Diabetes Winter 2013 by Diabetes New Zealand

Diabetes Winter 2013

Living well with diabetes

Real life:

“I lost 25kg and reversed prediabetes” EXPERT ADVICE Kids and night-time checks

Kidney care

It could save your life

ONE IN FIVE KIWIS AT RISK OF DIABETES

DIABETES AND YOUR MOOD Breakfast ideas + exercise myths + grow your own microgreens

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 25 no 2 Winter 2013

INSIDE winter 2013 4 5

From the President From the Chief Executive

Upfront

News, views and research

Treatment

8 Kicking ketones into touch 29 Nurse prescribing Focus

10 Diabetes rates rising Living with diabetes

12 Butch's story 30 Changing diabetes:

cyclist Aaron Perry

Care and prevention

14 Look after your kidneys 18 Stress and diabetes Profile

16 Professor Merlin Thomas Gardening

17 Grow your own microgreens and mushrooms

Consumer

20 Talking glucose meters Food

21 Portion control 22 Breakfast treats Families and chidren

24 Checking your child at night Let's get active

26 It's never too late to start exercising

28 Six myths about exercise and the over 60s

Diabetes Youth NZ

32 Introducing your new

Community

33 Obituary: Lin Jackson The last word

34 Chasing a cure

President

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 369 636 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 PRES I DENT

Thoughts from a South Sea island I am lucky enough to have just returned from staying with friends for 10 days in Fiji. While I was determined to leave behind my work ie all things diabetes – apart from my own – the will did not always prevail. I knew that as with other Pacific Islands there is a high incidence of diabetes. In only June last year the Fred Hollows Foundation opened a purpose-built diabetes eye clinic at the Pacific Eye Institute in Suva, such is the need. I couldn’t help but note therefore – not far from the airport – the familiar golden arches of surely the world’s most ubiquitous restaurant. Followed by the widespread availability of sugar-laden fizzy drinks (almost no sugar-free varieties apparent). It was distressing to witness on the day we

spent with a delightful Fijian woman and her two-year-old daughter, whom my friend has gotten to know, that lunch for the baby was Fanta and fries with copious tomato sauce on the side. Perhaps out of ‘guilt’ we gave her as much fruit as she could eat. Having visited the local markets the day before, we saw that the island’s produce was expensive. While we could afford and couldn’t get enough of the local pawpaw, pineapple and bananas, not to mention the herbs, spices and vegetables, the devastating hurricane in December had rendered many of these things out of the reach of families where the breadwinner probably earned not a lot more than $3-$4 an hour. I learned from Izzy, a Fijian man who, in teaching me how to make the local dish of Kokoda, said that in the villages it is usual to use sea water in the marinade for the fish. I admitted surprise to which his simple response was ‘there is no salt in the villages.’ Of course but given

that salt is as toxic to good human health as sugar, I winced yet again at the inevitability of the development of illnesses like diabetes in Pacific Island populations as they are forced to move from their traditional ways of eating and living. I couldn’t help but note that those who took up residence poolside in the loungers from morning till dusk, placing repeated food orders with the wait staff, bore more of a resemblance to beached whales than those who got out early each day (the only time when it was cool enough) for a walk or run in one of the most beautiful and friendly places on earth. Bula Vinaka Fiji – we shall return!

Chris Baty National President

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 369 636 to find out more.

DIABETES | Winter 2013

FROM THE CHIEF EXECUTIVE

Plotting a safe course through rough seas Over recent months you will have read about the things we are trying to do that will change Diabetes New Zealand to make it fit for the future. Like everyone, we have to think about what we do, how we do it and why? We, like all charities, are being challenged by the current economic climate and the changing world view of volunteering. This is why it is important we have a clear story and direction that can be explained to everyone – individuals, families, communities, employers and government. Three years ago we decided to embark on a journey of change to bring together our local branches to form one organisation. Since then we have been building a ship (planning the journey), making us seaworthy (shaping the organisation) and gathering provisions (looking at our resources). Doing this has helped us think critically about where we are going and how we will get there. It

will take time, effort and resources – more than we currently have – but we need to keep sailing towards the horizon. So where are we heading? Our mission is to ensure ‘every person with diabetes in New Zealand has the support needed to live full and active lives’. This is supported by our vision ‘diabetes: contained, controlled, cured’. How we achieve this is through a range of activities that increase public knowledge of diabetes and Diabetes NZ as well as promoting self-care, advocating for better services, encouraging research and ensuring we have robust management and governance. As you can see there is quite a bit to do. However we have three main priorities we think will make a real difference in tackling the challenges ahead. First is the engagement platform – an innovative online resource, which will provide peer support for people with diabetes and training for those who work with them. Another priority is to support our branch staff and volunteers, who deliver local support and education programmes. Thirdly we want to deliver a sustained awareness

programme to educate people about diabetes.

How can you help? One of the easiest ways to support us is through Donate your Desktop. Download a simple application and you will see a different advert on your desktop every day – 75 per cent of the money from advertisers will go directly to one of Donate your Desktop’s partner charities. That’s where you can choose us! Find out more at donateyourdesktop.co.nz. Or consider changing to Just Energy (www.justenergy.co.nz) as your power provider. For every supporter that signs up to Just Energy under its community support programme, Just Energy will make a payment to Diabetes NZ. Thank you for supporting us – even small contributions will make a huge difference.

Joe Asghar Chief Executive

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 an instant $20 donation:

0900 DIABETES (0900 86369)

Winter 2013 | DIABETES

UP FRO NT

NEWS, VIEWS AND RESEARCH

Weight loss halves diabetes deaths

Stem cell hope for the blind

The loss of just 5kg across a whole nation led to a 50 per cent drop in type 2 diabetes deaths and a one-third reduction in heart disease, a study of Cuba has revealed. The international research study, published online in the British Medical Journal, studied the population-wide weight loss in Cuba during a severe economic crisis between 1991 and 1995, which led to food and fuel shortages across the whole country.

Scientists in Ireland are hoping stem cells are the answer to saving the sight of people with diabetes – by treating vision loss and its cause. Millions of people with diabetes are at risk of diabetic retinopathy, which causes the blood vessels in the eye to become damaged and can cause blindness.

The team, led by Dr Manuel Franco, found the incidence of diabetes declined from 1991 to 1995, when the average Cuban lost 5kg of weight. Subsequent economic growth saw this trend reverse – diabetes rates and related mortality returned to pre-crisis levels in 2002 and increased by 42 per cent between 2002 and 2010.

Researchers from Queen’s University, Belfast, want to grow bone marrow stem cells in the lab and transfer them to patients in the hope they will repair blood vessels in the eye. The €6 million REDDSTAR study is being carried out by scientists in Ireland, Germany, the Netherlands, Denmark, Portugal and the US.

Olive leaf extract cuts diabetes risk Fresh olive leaf extract ‘appreciably’ reduces some risk factors for developing type 2 diabetes, say researchers from the University of Auckland’s Liggins Institute. Principal investigator Prof Wayne Cutfield said supplementation with olive leaf extract for 12 weeks during a recent clinical trial improved the way insulin was secreted and worked in overweight middle-aged men at risk of developing diabetes. “The changes were of a similar magnitude to those achieved with commonly-prescribed diabetes medication metformin, suggesting these results could have clinical relevance for patients with type 2 diabetes,” he said. There has been little previous scientific evidence to support the centuries-old use of olive leaf as a remedy for ill-health, including diabetes.

New class of diabetes drug approved A once-a-day diabetes medication that uses a new way of lowering blood sugar – by flushing it out in a patient’s urine - has been approved by the US Food and Drug Administration. Invokana (canagliflozin), has been approved for adults with type 2 diabetes. Regulators highlighted the fact that the drug, made by Johnson & Johnson, was the first in a new class of medications. It blocks the kidneys from reabsorbing sugar causing it to be eliminated in the urine. The company will be required to conduct follow up studies to monitor the drug’s safety, including the risk of heart problems, cancer, pancreatitis and liver abnormalities.

DIABETES | Winter 2013

Pancreas size and t1 diabetes Two recent studies suggest that a smaller pancreas may be an early marker of type 1 diabetes. Alistair Williams and colleagues in Bristol found that pancreatic volume was 26 per cent less in those with recent-onset diabetes. A second study by Campbell-Thompson and colleagues from Gainesville found the mean pancreatic weights were 44.9 g for those with diabetes, compared with 81.4 g for the control group. Pancreatic weight varies within a healthy population but these studies suggest the disease process that leads to the development of type 1 diabetes may include changes to the pancreas before the onset of hyperglycaemia, opening up an exciting new area for research.

Kidney disease biggest threat Keeping your kidneys healthy could be the best way to extend your life if you have diabetes. The University of Washington study in the Journal of the American Society of Nephrology looked at mortality rates in over 15,000 adults with and without diabetes. Researchers found that 11 per cent of those with type 2 diabetes, but no kidney disease, died during the 10-year study, compared with 31 per cent of those with diabetes and kidney disease. The death rate for people without diabetes was eight per cent.

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TREATM ENT

KETOACID OSIS Q&A

Kicking ketones into touch Diabetic Ketoacidosis (DKA) is a serious complication faced by people with diabetes. It is usually caused by the body starting to run out of insulin and is most likely to affect people with type 1 diabetes but can also affect people with type 2. Here are some common questions about ketoacidosis.

What is diabetic ketoacidosis? Ketoacidosis develops when your body doesn't have enough insulin and can't use glucose for fuel. Your body will start to break down fats to use for energy. Problems arise if the body breaks down a large amount of fat in a short period of time - waste products called ketones are produced. Ketones are acids, for example nail polish remover (acetone). High levels of ketones can cause a great deal of damage in your body. Imagine having nail polish remover in your bloodstream!

What causes ketoacidosis? It is caused by an underlying condition or illness. This might include having an acute illness (such as flu), pregnancy, inadequate insulin administration, stroke, cocaine use or heart condition. People with undiagnosed diabetes may develop diabetes ketoacidosis – it is a symptom that your body does not have enough insulin.

What symptoms might ketones produce? Symptoms typically evolve over a 24-hour period and include: abdominal pain, vomiting, dehydration, deep laboured

DIABETES | Winter 2013

breathing, confusion and sometimes coma. Your blood glucose levels will also be high.

What does having ketones mean? Having ketones means your body needs more insulin. When you are sick or injured your body becomes resistant to the action of insulin your insulin can't work properly. Your body needs more energy (and insulin) to fight infection or heal from an injury.

When should I test for ketones? Ketones are very easy to test for. When your body is high in ketones it tries to get rid of them very quickly. It does this by pushing them out in your urine. You should test for ketones when your blood glucose is more than 17mmol/L OR if your blood glucose is climbing and you feel unwell, OR if you are injured and your blood glucose levels are increasing.

How do I test for ketones? You can test yourself for ketones using special urine or blood test strips, which are available on prescription.

When should I be concerned? A small amount of ketones is usually OK (0.6 to 0.9 mmol/L as recorded on the blood ketone test strip or small amount on a urine ketone test strip). If you have small amounts of ketones and are unwell, you should keep a careful eye on the level. Get help from a health professional if they continue to rise. You need to act quickly to bring the ketone level down if you are

showing a moderate or large amount of ketones (>0.9 mmol/L on a blood ketone strip or moderate/large on the urine ketone strip). You should ALWAYS contact your doctor or diabetes nurse specialist if you have a moderate/ large amount of ketones. If you cannot get immediate advice you should go to the nearest hospital emergency department.

What else can I do? If your ketones are raised, but not too high, you can: • Drink water. If your ketone levels are small or moderate and you are feeling well, you need to start drinking a large amount (two to three litres) of water.

• Take more insulin. You need to take more rapid or short-acting insulin. If you have not been taught how to do this (and what dosages to take) you must get help and guidance on this from your diabetes team. Don't take extra insulin unless you know how to dose for sickness. Ask the team for a sick day plan to have at home should you need it.

• Test your blood and your urine. You should test your blood glucose and ketone levels every one to two hours until the ketones are cleared and your blood glucose levels are coming down. *Thanks to diabetes nurse specialist Pauline Giles for advising on the content of this article.

Dexcom G4TM - The Latest Technology in Continuous Glucose Measurement Now Available in New Zealand Do you use insulin? Do you want to improve your glucose control? The Dexcom G4TM updates your glucose level every 5 minutes so you can track your glucose continuously day and night. Monitor your highs, lows and target ranges and how fast you are getting there to help you take the guesswork out of your diabetes management and enable better treatment decisions. •

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For more information or to arrange a trial to see the for yourself, please contact us on 0508 634 103 W www.nzms.co.nz P 09 259 4062 E nzms@nzms.co.nz Dexcom G4TM is indicated for use in patients 2 years of age and over. Always read the manufacturer’s instructions and use strictly as directed. 1 Dexcom G4™ User Guide, May 2012. LBL-011277 Rev 04, LBL-011346 Rev 02. 2 Freckmann G, Baumstark A, Jendrike N, Zschornack E, Kocher S, Tshiananga J, Heister F, Haug C. System Accuracy Evaluation of 27 Blood Glucose Monitoring Systems According to DIN EN ISO 15197. Diab Tech & Thera, Vol 12, No 3, 2010.

FO CU S

FIRST RELIABLE NATIONAL D IABETES FI G URES

Diabetes rates rising – one in five Kiwis at risk Researchers have published the first reliable evidence of the prevalence of diabetes and prediabetes in New Zealand. The number of people with diabetes is likely to rise significantly in future years unless effective prevention strategies are introduced. Caroline Wood reports. The number of people with diabetes is high and rising in New Zealand – and this should sound alarm bells for policy makers and health providers. This is the stark message to come from a landmark University of Otago study, which provides the first evidence-based figures for the number of people with diabetes and prediabetes in the general population. Seven per cent of New Zealanders have diabetes and a further one in five face the prospect of getting the condition in the future, according to

the study, which was published in the New Zealand Medical Journal in March. Worryingly only half of the younger adults with diabetes in the study knew they had diabetes – for every participant under 45 years with diagnosed diabetes, there was another person who was undiagnosed. Diabetes was the sixth leading cause of death for all New Zealanders in 2009 and the fourth leading cause of death for Maori. Health costs for treating diabetes are rising in line with the increasing number of people being diagnosed. The true burden of diabetes has historically been under-estimated in New Zealand because no‑one knows exactly how many people have diabetes – diagnosed or undiagnosed. Estimates have previously been based on assumptions and modelling and haven’t been very reliable. To try to plug the knowledge gap,

Key study findings

1 2 3 4 5 10

Seven per cent of the population has diabetes and one in five adults are at risk of getting it. The number of people with diabetes has risen over time since 1967, when figures were first recorded – study confirms this for the first time. The level of undiagnosed diabetes is worryingly high among younger (working age) adults. Only half of those adults under 45 knew they had diabetes. Prediabetes is high among Pacific (24 per cent) and Maori (20 per cent). Effective evidence-based prevention strategies are urgently needed to stem the diabetes tide.

DIABETES | Winter 2013

Lead researcher Dr Kirsten Coppell, Edgar National Centre for Diabetes and Obesity Research

researchers from the University of Otago analysed thousands of blood samples collected from participants in the 2008/09 Adult Nutrition Survey. They checked the HbA1c levels of each participant. Dr Kirsten Coppell, Professor Jim Mann, and colleagues from the university’s Edgar National Centre for Diabetes and Obesity Research, were able to see how many respondents had diabetes (diagnosed or undiagnosed). They were also able to check the samples for prediabetes, an important predictor for future diabetes rates. “These data, when compared with the first measurement taken in 1967,

Research confirms worrying levels of diabetes NZ adults aged 15 years and over Overall diabetes prevalence

Men

Women

Obese

14%

Pacific – diabetes

15%

Pacific – prediabetes

24%

Maori – diabetes

10%

Maori – prediabetes

20%

Prediabetes overall

19%

Prediabetes (35-44 age group)

20%

Prediabetes (45-54 age group)

25%

Prediabetes (55-64 age group)

45%

FI RST RELI A BLE NATI O NA L DI A BETES FI G URES

FOCUS

Why don’t we know how many New Zealanders have diabetes? It is not known exactly how many people have diabetes in New Zealand. There has been a lack of reliable data on the prevalence of the condition among adults and children. The Government’s Virtual Diabetes Registry, established 10 years ago, provides some limited data. It counts people with diabetes by analysing six national databases (hospital admissions, attendance at diabetes outpatients or retinal screening, diabetes medication, HbA1c testing and mortality). It doesn’t capture people with undiagnosed diabetes, or prediabetes, nor does it distinguish between those with type 1 or type 2 diabetes. The four national health surveys undertaken since 1992 include self reports of doctor-diagnosed diabetes – but do not capture people who are undiagnosed, or those with prediabetes. The University of Otago research using blood samples from the 2008/09 Adult Nutrition Survey, allowed researchers to collect reliable data on the rate of diagnosed and undiagnosed diabetes, as well as prediabetes, among a representative sample of New Zealand’s population.

provide convincing evidence that the prevalence of diabetes in New Zealand has increased over time,” says lead author Dr Kirsten Coppell. “It provides for the first time reliable estimates of diabetes and prediabetes prevalence in New Zealand.” She said the number of people with prediabetes, on top of an already high prevalence of diabetes in the general population, should be of major concern to policy makers. People with prediabetes have glucose levels above the normal range but have not yet gone on to develop full-blown diabetes. The study found an ‘alarmingly’ high number of working age adults had prediabetes (see table left). The 7.5 year probability of these people developing type 2 diabetes is 41 per cent. The risks are even higher for those who are overweight, have high blood pressure or cholesterol. “The implications of increased diabetes-related morbidity, mortality and health care costs are considerable,” Dr Coppell added. “Implementation of effective, evidence-based diabetes prevention studies is urgently required to reduce the increasing cost of the diabetes epidemic.” Dr Coppell and colleagues hope to attract funding for further research into the effectiveness of dietary intervention at GP level for those with prediabetes.

Winter 2013 | DIABETES

LIV ING W ITH D I A B E TE S

BUTCH' S STO RY

“I cut out sugar, lost 25kg,

and kicked prediabetes into touch”

Tourism manager Butch Bradley decided he was not going to go the way of his dad who lost his eyesight to diabetes. After being diagnosed with prediabetes, Butch ditched his unhealthy diet with spectacular results. Caroline Wood reports.

“I was breaking down a lifetime of bad habits but it was easier than I thought”

“The future wasn’t looking too great,” says Butch Bradley, describing the moment his doctor sat him down and told him that unless he started to eat more healthily, he was going get type 2 diabetes – just like his dad before him. It was a wake up call for Butch, Director of Regions and Operations for Māori Tourism NZ. He spent the next few months researching diets and healthy food, looking at traditional Māori foods, and came up with his own eating plan. In August 2011, he turned his back on a lifetime of bad habits – ditching sugar, salt, processed foods and flour – replacing them with healthy fresh foods. Within a week Butch was feeling better and free from cravings. “My dad had diabetes, at his heaviest he was 21 stone and even though he lost a lot of weight, he lost his eyesight, so when I had a couple of check ups and the doctor said you have the signs and symptoms, I took it very seriously. The doctor said ‘it’s up to you’. It was diet in my case,” he said. “I removed all flour and processed food from my diet and started more of a living food diet. I started reading the labels and cutting out

DIABETES | Winter 2013

sugar and salt. I found that if it was light or fat free it often had more sugar and salt in it. I looked into how food was processed and made. I started food combining. Getting rid of sugar was critical. “Now it’s a way of life, not a diet, it’s the way I eat. If I eat a bit of cake I don’t bash myself up because I am eating well and healthily overall. “My dad was a good incentive, my wife is very supportive and I have four children and seven grandchildren so I figured I owed it to them – the future didn’t look very great but diabetes is one of those afflictions you can do something about.” Over a 15-week period, Butch lost 25kg and is down to about 90kg. He started to become more physically active. His blood sugar has returned

to normal. His cholesterol halved from 10 to 5. His previously high blood pressure is now normal. And he has stopped taking a reflux drug that he had been using for 10 years. “At the next check up my doctor didn’t believe it, he asked for a second set of tests with more comprehensive blood work,” says Butch. Now Butch is eating foods that had never appealed to his palate before. And his food cravings are now healthy ones – for example mung beans, mushrooms and sprouts. “I was breaking down a lifetime of bad habits but it was easier than I thought. It’s really sobering when you read about type 2 diabetes. For me it’s a modern affliction, but it’s simple to change, it really is,” he added.

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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.

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C ARE A N D PRE VE NTI O N

LOOK A FTER YO UR KI DNEY S

Anyone with diabetes can get kidney disease Diabetes and high blood pressure are the most common causes of kidney disease, and people often have both. It is important to get diagnosed early, according to Kidney Health New Zealand. Chronic (long-term) kidney disease caused by diabetes always affects both kidneys and does not go away. Rather, it may get worse over time and can lead to kidney failure. If the kidneys fail, the choices available to the person include going on dialysis, getting a kidney transplant or conservative treatment. About half of the 2,500 Kiwis on kidney dialysis have diabetes. But it doesn’t mean that everyone who has diabetes will get kidney disease. There are things you can do if you have kidney disease to slow down the damage (see the Helping yourself panel opposite). Kidney disease can be treated, and the sooner you know you have it, the sooner you can get help to keep your kidneys working for longer. Most kidney diseases do not cause

DIABETES | Winter 2013

any symptoms until the late stages, but your doctor can do some simple tests to see if you have kidney disease. Professor Kelvin Lynn, Medical Director of Kidney Health NZ, said: “I’d encourage people to be proactive, ask your GP to test your kidneys for signs of disease, ask what you can do to lessen your risk and be aware of the different treatments available so you can discuss these with your doctor. “It is important that patients manage their diabetes well and keep their blood pressure well controlled. There is evidence that using ACE inhibitors to control blood pressure

Professor Kelvin Lynn, Medical Director of Kidney Health NZ

can help slow kidney damage in people with diabetes.” You can contact Kidney Health New Zealand’s helpline for advice and information about any aspect of kidney care – from diagnosis to dialysis – by calling 0800 543 639 or visit www.kidneys.co.nz.

Do I have kidney disease? Most kidney diseases do not cause any symptoms until the late stages but your doctor can do some simple tests to see if you have kidney disease. The main tests are: •

A blood pressure check – high blood pressure can be caused by kidney disease or can cause kidney disease.

•

A urine test for protein – leaking of protein from the kidneys is an early

sign of kidney damage in diabetes. The more damage to the kidneys the more protein they leak. •

A simple blood test to measure creatinine levels – this test is used to measure overall kidney function or the estimated Glomerular Filtration Rate (eGFR).

You can ask your GP for these tests at your next annual diabetes check.

LOOK A FTER YO UR KI DNEY S

CARE AND P RE V ENTION

Why am I more at risk of kidney disease? Diabetes is the most common cause of chronic kidney disease in New Zealand. Māori and Pacific Island people with diabetes have an increased risk of getting kidney disease. Over a long period of time diabetes causes damage to the filters in the kidney. As the kidneys get more damaged they are not

able to clean or filter the blood properly. Wastes and extra water build up in your body making you feel sick, tired and breathless. Imagine your kidney as a sieve, and the holes of the sieve are slowly blocked up. At first the sieve will still work but over time as more of the holes become blocked the sieve will stop working. You could say that

kidney failure happens in the same way. Chronic kidney disease is not usually curable. The good news is that if your doctor finds out early that you have a kidney problem, there are a number of ways to help slow down the disease.

Helping yourself – 10 ways to reduce the risk If you have diabetes you should be tested once a year to see if the disease has damaged your kidneys. Your doctor will do a kidney check, which will include a blood test, urine test and check of your blood pressure. Following these tests a kidney doctor may want you to have further tests to find out more information. Understand the blood tests your doctor orders and what the results mean. This is an important way of knowing what is happening to your kidneys.

Keeping your blood pressure under control is vital if you want to avoid kidney disease. Ask your doctor what your blood pressure should be and what you can do to keep it at a safe level. Lifestyle changes such as losing weight, exercising, stopping smoking, eating less salt and drinking less alcohol can help lower your blood pressure. You can also ask your doctor if you should be prescribed medicines to control your blood pressure, (for example, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) that can help slow the damage to the kidneys in people with diabetes.

Make healthy food choices. It is important to follow the eating plan given out by your dietitian. If you are overweight, lose weight. This should also help your blood sugar control and blood pressure.

4 5

Avoid becoming ‘dry’ (dehydrated), especially when you are sick.

Stop smoking or don’t start smoking. Only drink small amounts of alcohol.

Make sure you do some regular physical activity (like walking).

Control blood cholesterol levels with diet and medication as needed.

Do not take anti-inflammatory painkillers, such as Nurofen or Voltaren, as they can cause kidney damage. Use paracetamol.

Have urine infections treated immediately.

It is important to keep good control of your blood sugar levels to help slow the kidney damage. Agree on target blood sugar levels with your doctor and check your blood sugar levels regularly. You may need to adjust your diabetes medicine – talk to your doctor about this.

*Article based on information contained in the pamphlet Chronic Kidney Disease and Diabetes, reproduced by kind permission of Kidney Health New Zealand. For more information go to: www.kidneys.co.nz.

Winter 2013 | DIABETES

P RO FI LE

PROFESSOR MERLIN THOMAS

Diabetes is not a punishment Managing diabetes needn't be complicated but it is essential, says Professor Merlin Thomas. The diabetes clinician and award-winning medical researcher was educated in New Zealand but now works in Australia. Prof Thomas spoke to Caroline Wood while on a whistle-stop tour to promote his new book Understanding Type 2 Diabetes. As a young graduate, Merlin Thomas knew very early on in his medical career where his interests lay. His experience with aboriginal patients in Australia made him realise he wanted to specialise in diabetes – specifically the treatment and management of diabetic complications. Brought up in Canada, Thomas went to school in Wellington before graduating with distinction in medicine from the University of Otago in 1992. He soon realised that some of the most challenging patients were those with diabetic complications. In Australia he started working with kidney transplant patients, including those who were blind through diabetes. This led to a PhD in preventing diabetes complications and his future career path was set. Thomas is now a clinician scientist at Baker IDI Heart and Diabetes Institute, in Melbourne. He works extensively with patients and their doctors, as well as undertaking ground-breaking research. He is currently looking at breaking the links between sugar and the damage it causes in the body – such as

DIABETES | Winter 2013

“Diabetes is not a punishment, it can be a really rewarding opportunity to improve your health.” Prof Merlin Thomas

kidney failure, amputations and blindness. “Over the last decade the sheer number of people with diabetes has exploded. One hundred million people in China, 60 million in India, it’s just mind-boggling and it’s occurring in our lifetime,” he said. “It’s about cheap calories. We are eating far more than we are expending in physical activity and it’s going around our waist. Between a quarter and a third of the over 60s are going to get diabetes – that is what the signs are telling us.” Thomas jumped at the chance to write a book on how to manage type 2 diabetes and prevent complications, drawing on all he had learned over the past two decades. “I wanted to get down all of the things that I thought people should know about diabetes, all of the little practical things that we can do to look after our bodies and spirit. “The whole purpose of the book is to refute the notion that diabetes care is solitary, repetitive and futile. Diabetes is not a punishment, it can be a really rewarding opportunity to improve your health.”

Thomas’s advice is easy to understand and practical. He covers all aspects of diabetes care, including those that sometimes get missed – how to look after your mood, sex life and sleep. “You can make changes little by little, find a way to do it that suits your lifestyle,” he adds. Diabetes and my mood – see p18

Prof Thomas's key messages for the newly-diagnosed 1. Not everyone develops complications, most people lead full and happy lives, it’s not a death sentence, it’s not the end of the world, you do not have to punish yourself. 2. Little changes make a big difference. Act now to control your a) glucose b) waistline c) blood pressure d) cholesterol. If you can get these under control, we know you can have the benefits now and for decades afterwards. 3. Diabetes doesn’t mean you need to stop doing the things that you want to do. It’s an opportunity to look at your life, for example what you are eating, or how you are interacting with people, and do something different.

M I CRO G REENS A ND M US H RO O M S

GARDENING

Grow your own without leaving the house You don’t have to give up gardening because the weather is cold and wet outside. Gardening expert Rachel Knight explains how to grow nutritious sprouts, microgreens and mushrooms in your own home. Sometimes the weather isn’t right for outdoor gardening. Sometimes you don’t have access to a garden. Sometimes you want to try something new to get your kids interested in growing things. Here are three things you can grow without venturing outside.

Sprout your own Grow your own sprouts from seed on your kitchen bench. Put a tablespoon of seed in a jar, rinse the seeds with water twice a day and drain it off. In about a week you’ll have something fresh, crunchy and nutritious to add to your salad, sandwich or stir fry. Many seeds produce delicious sprouts and they all have a slightly different flavour. Some are quicker to grow than others. You can buy some sophisticated sprouting equipment but a clean glass jar with a piece of muslin over the top, secured with a rubber band, will be perfectly adequate. Once your sprouts are at a size you like, store them in the fridge for a day or two. Try a few different varieties to find a taste and texture that suits you best. You can buy packs of mixed seed if you have trouble choosing just one.

Seven seeds for sprouting Alfalfa Broccoli Clover Lentils Mung beans Peas Radishes.

Fun with fungi The only time that fungus in your laundry is a good thing is when you start growing your own mushrooms. Choose from standard button or field mushrooms, or choose to experiment with more unusual types such as oyster and shiitake mushrooms. You can find kits at garden centres, farmers’ markets or on-line. They should come with detailed instructions to grow some fresh, fascinating fungus with very little effort and in a very small space – either a bucket or a bag.

Microgreen magic You might have grown mustard and cress on a windowsill when you were younger, but now ‘microgreens’ have become the essential edible garnish to meals at the best restaurants. They’re quick to grow because you pick them when they’re little more than seedlings, waiting only until they’ve grown their first ‘true’ leaves. Radish, pak choi and mustard are some of the fastest to grow, but any seeds you use for sprouting, or salads, can be used for microgreens. A thin layer of damp potting mix spread in a flat container with drainage holes will be enough to sustain the seedlings. Put them on a bright windowsill and keep them warm. Spray with a handmister to maintain moisture levels. When they’re big enough to eat, snip or pinch the plants off carefully above the surface of the soil so they stay clean. It’s best to grow different varieties separately and mix them after harvesting, as they may grow at different rates. Select a mixture of leaves to give yourself a range of flavours, colours and leaf shapes.

Seven seeds ideal for microgreens Beetroot Cress Mizuna Mustard Pak choi Rocket Wheat.

Winter 2013 | DIABETES

C ARE A N D PRE VE NTI O N

STRESS A ND DI A BETES

Diabetes

and my mood Stress is a killer and having diabetes is really stressful, says Professor Merlin Thomas. Finding your own way of dealing with this stress is just as important as any other component of your diabetes care. The following extract is taken from his new book Understanding Type 2 Diabetes. Effective management of diabetes is much more than biology and chemistry. It also means keeping your chin up and maintaining and optimising your mental wellbeing. This is not always easy. Having diabetes is challenging. There are complex treatments, targets and goals, successes and failures. This often results in a range of emotional responses that are as different as the people who experience them.

Broadly, these responses can be classified into eight different reactions:

1 Anger and frustration • ‘Why me?’ • ‘It’s not fair!’ • ‘How can this be happening to me?’ • ‘I hate my diabetes.’

2 Denial/ridicule/rejection/ disbelief • ‘I feel fine.’ • ‘This can’t be happening to me.’ • ‘It’s not that serious.’ • ‘It’s only a touch of ...’

3 Guilt/self-blame • ‘I caused this mess.’ • ‘It’s all my fault.’ • ‘I deserved this.’

4. Bargaining • ‘I have to do this now.’ • ‘If I do this, then ...’ • ‘I’ll do anything for ...’ • ‘I don’t care what it takes.’

5 Withdrawal/nihilism/feeling overwhelmed/defeated/ fatigued/resigned/hopelessness • ‘It’s all too hard.’ • ‘What’s the point?’ • ‘Why should I bother to keep taking these/doing this?’ • ‘The harder I try the harder I fall.’ • ‘Stop the world I want to get off!’ • ‘I don’t care any more.’

6 Depression/negative thinking/ low self-esteem • ‘I’m not worth the effort.’ • ‘They should just let me die.’ • ‘I’m stupid.’ • ‘I’m a bad person.’

7 Stress/distress/anxiety/fear/ dread • ‘What will happen now?’ • ‘What will I do if ...?’

8 Acceptance • ‘I’m okay with my diabetes.’ • ‘I have a plan.’ • ‘It’s just the way it is.’ • ‘I’ll just have to get on with it.’

Receive $10 off Understanding Type 2 Diabetes (RRP $32.99) by Prof Merlin Thomas. Go to www.exislepublishing.co.nz and type in DiabetesNZ at the checkout to get your discount.

DIABETES | Winter 2013

STRESS A ND DI A BETES

These different reactions are often called defence or coping mechanisms. They are perfectly normal. Part of coping with type 2 diabetes will inevitably involve experiencing some or all of these different emotional responses. They are not stages. There is no particular order or requirement to experience any of these reactions. But at the same time, it is sometimes important to acknowledge and express these feelings as a way to move forward. You can also use these emotions as a trigger for change. However, sometimes these emotions can get the better of you. This is often described as being ‘stuck in a rut’. And this is when the stress of diabetes begins and when problems seem to magnify the longer you are stuck there. One of the most important differences between people who are able to survive their diabetes and those who succumb to its many challenges and complications lies in their ability to cope with illness and rebuild again and again. Finding your way out is a personal journey, but one you shouldn’t need to make alone. Your diabetes care team will know what you are going through and have many resources available that can help. The best way to prevent stress from diabetes is to cultivate your relationship with your diabetes care team, and work with them to create and achieve common goals. Some of the things they may get you to do include:

Disclosure Putting into words what you are feeling and letting others share your concerns can sometimes help you to know what you are really feeling. Talking to your diabetes management team, your family and friends will always make a difference. Even just communicating

CARE AND P RE V ENTION

GIVEAWAY

We have three copies of Understanding Type 2 Diabetes by Professor Merlin Thomas to give away. It offers clear and effective guidance on all aspects of diabetes management by one of the world’s top experts in the disease. Email admin@diabetes.org.nz with your entry using the phrase Understanding T2. Please submit your entry no later than 31 August 2013.* *Terms and conditions apply, please see www.diabetes.org.nz

with yourself by keeping a personal diary can be a useful way to conceptualise your feelings.

Self-awareness Focus on the triggers that set you off. Find out what’s making you angry or upset and when. Understand the things that make you feel good and find a way to go there when you’re stuck.

Exploration Have a look at what other people with diabetes are experiencing. Read the blog or internet journal of someone else with type 2 diabetes. Attend group sessions where you hear about what other people are doing to keep control and how they are coping. Borrow new ideas or new recipes that might work for you.

Goal realignment Many of the challenges of diabetes come from unrealistic and unnecessary expectations. It is always important to realign your goals and aim to control what is in your control. This is where close contact with your diabetes management team will make a real difference and allow you to have a dynamic and evolving plan for coping with your diabetes.

Planning The best way to know where you should be going is to have a map. By establishing comprehensive plans and routines and following

them closely, it is much easier to track your progress and never feel lost. Make your intentions clear to ensure you are in control of where your management is going. As you become more and more familiar with where you are, it also becomes easier to step off the map for brief periods and try new things, as you always know your way back.

Accenting the positive The impacts of any stress can be modified by changing the way it is perceived. If you think you are stressed, then you are. But when you think you have the resources to cope, then stress is no longer a threat. Some of this ‘stress resilience’ comes from confidence and coping skills. Some also comes from a positive outlook. All these can be cultivated and fostered. Stress-resilient people may have the same stressors (e.g. diabetes) but they expect everything will be okay, rather than a problem. They are better able to deal with stress because they know they can. A number of studies have shown that simply learning to ‘accentuate the positive’ in everything you do is associated with reduced stress and less heart disease. Optimism can be learned with practice and become part of your life. * Extract from Understanding Type 2 Diabetes by Professor Merlin Thomas, Baker IDI Heart and Diabetes Institute. RRP $32.99. For details see www.exislepublishing.co.nz Winter 2013 | DIABETES

CO N S U M ER

TALKING GLUCOSE METERS

‘Booming’ blood glucose meter upsets blind users Visually-impaired users of talking glucose meters may not be checking their bloods as often as they should because they are embarrassed by the loud voice that ‘reads’ the test result when they are out in public. Caroline Wood reports.

“I just don’t test in public and that’s bad for my diabetes control especially because I can’t feel my hypos.”

Lee Kennard has a potentially life-threatening condition called hypoglycaemia unawareness – she doesn’t realise when she has low blood sugar. One minute she feels fine, the next she is on the floor and colleagues are calling an ambulance. It is vital for her to be regularly checking her blood sugar but Lee has stopped testing at work or in public because she is embarrassed by her talking blood glucose meter – because it reads the test result in a loud voice and has no volume control. Lee, from Palmerston North, has had type 1 diabetes since childhood and is visually-impaired as a result of multiple sclerosis. She was given a SensoCard Plus audible glucose meter several years ago. The instructions and values displayed on screen are spoken in clear and simple sentences by the meter’s ‘voice’. But Lee says the meter is too loud to use in public and there is no headphone jack. “It has no volume control and it irritates my hearing. I can’t use it in the office and I have to hold it away from me when I use it at home. I travel a lot overseas and don’t feel I can use it even in a hotel room, people can hear it through the door, she explains.

DIABETES | Winter 2013

LEE KENNARD

“I just don’t test in public and that’s bad for my diabetes control especially because I can’t feel my hypos.” Lee’s diabetes team picked up the issue at a recent case review and reported their concerns to the New Zealand Society for the Study of Diabetes (NZSSD) and Diabetes New Zealand. Up to 240 other visually-impaired people with diabetes are thought to be using the same meter. Lee says she has spoken to two other users who also complained about the loudness of the unit. Pauline Giles, a diabetes nurse specialist and chairperson of the NZSSD nurse specialist section, said: “Some users are unhappy with the lack of volume control on the meter. They feel they can’t use them in public. It reads the blood test result in a booming voice. “It is a real problem – if people think they are too noisy, we are concerned they won’t check their blood glucose often enough.”

“If this is a wider problem, we may need to talk to Pharmac about getting it changed. We don’t want this to be a barrier for people who are blind.” Anyone who has diabetes and is visually impaired can ask the Royal New Zealand Foundation of the Blind for an audible blood glucose meter. Spokeswoman Miriam Stettner said approximately 240 of the same brand of meter had been issued. “They are fairly loud, there is no headset jack and no volume control. It’s hard to muffle the sound. I have had a couple of clients comment on this but they didn’t have to test in public,” she said. *Have you had a similar problem with your audible glucose meter? Contact editor@diabetes.org.nz.

PO RTI O N S IZE M ATTERS

FOOD

Perfect portions Research shows that people will eat more when they are presented with a larger portion of food on their plate. Here are some tips on how to reduce portion sizes.

Try these ways of limiting portion sizes • Plate patrol Plate sizes have crept up over the years and those used today are estimated to hold up to 400 calories extra per meal. Using smaller dishes at home is an easy way of reducing the amount of food you eat as you typically eat what is in front of you. Fill half your plate with healthy veggies and salad, a quarter with healthy lean protein and the other quarter with carbohydrates, such as brown rice or pasta.

• Stash serving dishes Sit down to eat without putting the serving dishes on the table in front of you – it’s too tempting to have seconds. Serve what you want onto your plate and leave the serving dishes on the kitchen bench. Leftovers can be frozen for another meal – saving you the effort of having to cook that day.

Portion control and type 2 diabetes Portion control is important when you are eating with diabetes, as there is a stronger focus on managing carbs, fat and calories in your diet. If you can get into the habit of following a consistent meal pattern throughout the day, with proper portions, it will help keep your blood sugar from spiking or bottoming out. Research shows that eating smaller portions can help you lose weight and reduce diabetes complications. Portion size will vary between individuals, depending on gender, activity level and age.

Serving size versus portion size: Is there a difference? A ‘serving’ is the amount of food recommended in consumer education materials and on the back of food packets. A ‘portion’ is the amount of a food you choose to eat at any one time — which may be more or less than a serving. Source: US Academy of Nutrition and Dietetics

• Snack attack Buying big family value packs is a great way to save money. Avoid the temptation to eat direct from the bag – decant the chips or biscuits into smaller containers and keep them in the cupboard instead of the big bag. Don’t keep unhealthy snacks in the house, or if you do have them put them out of view and keep them for special treats.

A handy guide for healthy portions Watching the amount you eat is a simple way to cut back on calories, lose weight and live more healthily. But it can be very time-consuming to measure out your food using cups, scales or measuring spoons. Here is a simple guide to using your hands to get the correct healthy portion size.

Carbs

Protein

(eg.cooked rice or pasta) One cupped hand

The palm of your hand

Margarine or Butter The tip of your thumb

Baking

Snacks

(Slices and cakes) Two of your fingers

(Chips, popcorn, crackers) Two of your cupped hands

Winter 2013 | DIABETES

FO O D

B RE A KFAST TREATS

Eating for diabetes can be exciting and fun Australian chef, TV personality and food commentator Michael Moore was diagnosed with diabetes at the age of 35. A decade later he suffered a severe stroke and this inspired him to change his eating habits and embark on a campaign to help people with diabetes eat fabulous food.

Michael Moore believes you do not have to eat boring food if you have diabetes and his first recipe book Blood Sugar was intended to shine some light into the ‘gastronomic wilderness’ of diet food. Last year he launched a new restaurant in Sydney called O Bar and Dining, which is underpinned by the Blood Sugar eating philosophy. His second recipe book Blood Sugar The Family has just been published and is full of everyday inspiring recipes for any family facing the challenges of diabetes and healthy eating. The book includes lots of tips for how to use healthy ingredients, such as whole grains, pulses, seeds and alternative sweetening options, such as agave syrup. Many of the recipes would be ideal for entertaining and are certainly not boring. Desserts are not left out – the not-so-naughty chocolate cake that is low fat, low GI, high protein and low sugar looks fabulous. Here are two of Michael’s delicious breakfast/brunch recipes. Bon appetit!

DIABETES | Winter 2013

B RE A KFAST TRE ATS

FOOD

Baked chilli eggs with chickpeas, spinach & shaved ham The paprika and chilli will stimulate your metabolism and get your body moving — it’s a perfect spicy kick start to your day.

2 tablespoons olive oil 1 medium onion, finely diced 1 clove garlic pinch smoked paprika ½ teaspoon dried chilli flakes 4 ripe tomatoes, chopped 1 x 10oz (300g) can of organic chickpeas sea salt and pepper 2 cups fresh spinach leaves 8 large eggs 6oz (175g) finely shaved smoked ham grainy bread, toasted, optional to serve (not included in carb exchange) Serves 4

1. Preheat oven to 360°F/180°C. In a medium-sized non-stick frying pan heat one tablespoon of the olive oil and fry together the onion and garlic until light brown. Add a pinch of the paprika, chilli flakes and the chopped tomatoes. Cook on a low heat for 15 minutes until a rich sauce has formed. 2. Add the chickpeas and cook a further 20 minutes. Season with sea salt and fresh pepper, and add more chilli to taste. 3. In 4 small ovenproof dishes or ramekins, divide the spinach leaves and spoon over the hot tomato chickpea mix. Using the back of a serving spoon make a well on the top. Crack two eggs into each well. If you like your eggs really spicy, sprinkle some chilli flakes or fresh chilli on the eggs at this point. 4. Drizzle the top with a few drops of olive oil and bake for approximately 12 minutes until the eggs are cooked to your liking. Place shaved ham on the top and serve with some hot grainy bread, toasted.

Roasted field mushrooms with crumbled feta & garlic I like to add some rashers of grilled bacon, shaved ham or poached eggs.

8 large field mushroom caps 1 clove of fresh garlic 2oz (60g) butter 4oz (120g) low-fat feta cheese ½ bunch lemon thyme 1 cup of fresh baby spinach leaves 4 slices of soy linseed bread, toasted optional sea salt and pepper Serves 4

1. Preheat oven to 360°F/180°C. Peel and remove stalks from the mushrooms. Heat a non-stick frying pan and cook mushrooms together with sliced garlic and butter for approximately 5 minutes. 2. Turn mushrooms onto a roasting tray and sprinkle with lemon thyme and crumbled feta. Bake in oven for 12 minutes, until cooked and tender and the cheese begins to melt. 3. Toast the bread and spread with a little butter. Place some of the spinach leaves on each slice and spoon on the hot mushrooms and cheese. Serve in the middle of the table, to share.

™

*Extracted with permission from Blood Sugar: The Family by Michael Moore, published by New Holland, RRP $55.00.

Winter 2013 | DIABETES

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

NIGHT CH ECKS

Checking your child at night Clare Cheetham is the mother of two boys Henry, three, and Oliver, one. The family lives in Mangere Bridge and Clare teaches part time at a school in Remuera.

Night-time checks can be a fraught issue for families especially those with very young children. Clare Cheetham tells her personal story. Our family has discovered crisp white sheets are over rated. Nothing spoils the look more than little blood smears across the sheets like marmite spots. That’s the night blood checks for you. Sheets aside, night blood checks can be a complete pain for both parents and the T1 but a necessary part of the 24-hour routine we must follow to keep our loved ones as healthy as we can. Henry, our T1, is three-and-a-half years old (and was diagnosed at the age of two). We had an eightweek-old baby as well, so as you can imagine not much sleep was happening in our house – and still doesn’t to be honest! We try to check him at least once in the night (between 12am-4am) but more if he’s had a strange 10pm reading or has woken and is unsettled. I figure that if we can at least get him mostly stable during the night, that’s 12 hours out of the 24 that we are winning the game. That moment before the number

DIABETES | Winter 2013

flashes up you think ‘what’s his dinner digestion been like; how much exercise has he done; is he getting sick?’ It’s a never-ending conversation in your head. We started on a pump last December after nearly one-year diagnosed, and for our family that has been a good decision. Corrections used to be a major problem for us during the night as it would mean an injection. They caused such a drama we would really dread having to do it and would even avoid it hoping he’d ‘come down eventually’. He would cry and protest enough with the two to three injections during the day, the thought of unsettling him in the night just seemed like punishment for everyone. I know that doesn’t sound very responsible but we do our best, and now on the pump corrections are as simple as pushing a few buttons. There have been many times during the night when the alarm goes off for a blood test that I have really negative feelings towards diabetes. I want to just rebel and let it rest, just to shut the door on it. It can feel so consuming during the day that having it all continue on into the night just feels too much. Those are the nights my husband takes over or I pull myself together and just get

on with it. Some mornings I have forgotten if I even got up to check his bloods and have to look back on the meter to see what his number was!

"There have been many times during the night when the alarm goes off for a blood test that I have really negative feelings towards diabetes. I want to just rebel and let it rest, just to shut the door on it.”

N I G HT CH ECKS

FAM I LI E S A ND CH ILD REN

The expert’s view By Dr Craig Jefferies, Starship Hospital’s paediatric endocrinologist and Clinical Director Diabetes and Endocrinology

Once in a blue moon we will have both kids fast asleep and bloods are steady but you still stir and have the ‘need’ to test. It’s almost like your brain can never turn off. I’ve had conversations with other mums of T1 kids who have a sixth sense when their child is low during the night and know when to check. I’m not fortunate to have developed that yet but we have learned his unconscious signals that blood levels might not be right. His breathing changes, he gets very fidgety (like having a bad dream), sometimes groans and starts to sweat. These signs aren’t attached specifically to ‘low’ or ‘high’, as fidgety can mean a high but the next night it could be a low! One thing we have definitely learnt from managing diabetes is that nothing is ever a given. Night checks are definitely easier than they used to be as I think Henry moved into the acceptance stage and just knew he had to have it done. He usually stays asleep or briefly protests by tucking his

hands under his body or pillow. I sometimes just say ‘it’s just mum doing your bloods’ and it can all be over and done with in minutes. I do wish that I could give his tiny little fingers a complete rest though. The little black dots that show up after swimming or a bath are just another visual reminder of the physical scars of the constant pricking and prodding. It’ll be a long time before we will hand over responsibility to Henry to do blood checks during the night. I’m not expecting him to be able to wake or set an alarm to check. We know, as parents, that is our job. I’m sure that in years to come when he does take over I’ll still wake, still worry and still wonder – ‘what are his bloods doing?’. In the meantime, it’ll be strong coffee at breakfast, the odd afternoon sleep and paper, scissors, rock with my husband to who gets up to do the check – we are in this for the long haul whether we like it or not.

Night checks are an important part of caring for your child with diabetes. The exact time of the night to check will depend on why you are checking in the first place, and there are a few myths about what happens at night.

Common myths

1 2 3

My child always wakes up when they are low. If my child’s blood glucoses are ‘high’ going to bed then they will be fine. There is an exact time to check that will detect all hypos.

I usually suggest the following: • If you need to be up at night, then use this time to check on your child, and do a glucose check if at all unsure. • If your child has had a bad hypo that day or had a lot of exercise (school sports etc), then you should check. • The nadir of glucose is usually about 1am-3am, so if they are stable from bed to 1am then they should be fine. • Be very very cautious about giving extra insulin in the early hours of the morning.

Winter 2013 | DIABETES

LE T ' S G E T A CTI VE

EXERCISE FOR O LDER PEO PLE

It’s never too late to start exercising It’s really important to keep exercising as you get older. Diabetes nurse Tess Clarke and Dan McNaughton, owner of the Results Room Gym in Wellington, explain the benefits of exercise in older age.

The first thing to remember is that you’re never too old to get active. The good news is you can still make noticeable improvements in strength, balance, posture and fitness. Regular exercise plays an important role in managing type 2 diabetes and can have many benefits for people with type 1 diabetes too.

Exercise and type 2 diabetes Getting some regular exercise is especially important for people of all ages with type 2 diabetes. You should aim to do at least 30 minutes of moderate exercise on most days of the week. If this isn’t manageable for you, don’t be defeated! Research now suggests that engaging in shorter periods of exercise throughout the day that add up to 30 minutes can have just as many health benefits.

Often it’s getting started that’s the hardest part of increasing your level of physical activity. You are never too old to begin doing some regular exercise and it benefits your health in so many different ways, including: • improving blood glucose levels • helping reduce or maintain weight • lowering blood pressure • reducing the risk of heart disease • improving circulation • increasing energy levels • reducing stress and improving mood • improving sleep.

Exercise and type 1 diabetes Engaging in any sort of exercise adds another challenge to managing your type 1 diabetes, however most people find that doing regular physical activity improves their sleep and makes them feel healthier, happier and less stressed, as well as bringing most of the benefits listed above. It’s important to remember that exercise will make your body cells more sensitive to insulin and this effect may continue for up to 24 hours after you exercise. Frequent testing is essential for managing physical activity safely when you have type 1 diabetes. If you are starting a new exercise programme, talk to your diabetes specialist or diabetes nurse specialist before you begin. They will help you learn how to manage your blood glucose during exercise and will teach you how to adjust your insulin doses and carbohydrate intake for physical activity.

DIABETES | Winter 2013

EXERCI S E FO R O LDER PEO PLE

LE T ' S G E T ACTIVE

Getting started Have a thorough medical check up and consult with your diabetes team before starting any new exercise routine. This is especially important if you have had diabetes for several years or have any diabetes-related complications, such as heart disease, eye disease or nerve damage. Discuss with your doctor or diabetes nurse types of exercise that may be appropriate for you.

Ask for a Green Prescription A Green Prescription is a referral written by a doctor or nurse that will allow you to access support from a local fitness provider to help you increase your physical activity. The Green Prescription will take into account your current fitness, health concerns and diabetes management plan.

Tips for exercising with diabetes You will be more prone to having low blood glucose levels during or after exercise if you take insulin or some types of oral diabetes medication. Make sure you always have some quick acting and long-acting carbohydrate with you in case you have a hypo. Exercise with someone who knows you have diabetes and knows what to do if you have a hypo. If you are exercising alone let someone know when to expect you back and carry some identification that shows you have diabetes. Be careful exercising when your insulin is having its peak effect. Wear supportive shoes and practise good foot care.

Types of exercise suitable for older people Whatever exercise you choose, make sure it’s an activity you enjoy. That way you’ll be more likely to stick with it! Try one or more of the following: • • • • • • • •

walking swimming or aqua aerobics riding a stationary bike dancing pilates or yoga climbing stairs golf, tennis or bowls varied resistance exercise with a personal trainer.

Busting some myths about exercising in old age – see p28

Winter 2013 | DIABETES

LE T ' S G E T A CTI VE

MYTHS ABOUT EXERCI S E A ND TH E OVER- 60s

Busting 6 myths

(about exercise and older adults) You are never too old to start exercising, despite what you might think. Diabetes nurse Tess Clarke and personal trainer Dan McNaughton help bust some common myths about exercising for the over 60s.

Myth: There’s no benefit in exercising at my age Reality: The benefits are huge

whatever your age and regular exercise can improve your quality of life – and be life extending. Physical activity reduces your risk of a huge number of health conditions including Alzheimer’s disease and dementia, depression, heart disease, colon cancer, high blood pressure, stroke and cancer. Don’t forget the most important one for you – improvements in insulin sensitivity and blood sugar control. Better control of your disease means more independence later in life.

Myth: I’m more likely to injure myself because I am older Reality: You’re more likely to injure

yourself without exercise – at any age. With regular exercise of a suitable type you’ll improve balance, build strength, increase endurance, and can prevent or slow loss of bone mass. Exercise also improves your range of joint movement, which helps with the body’s tilting and righting reflexes – preventing trips, falls, and associated injuries.

DIABETES | Winter 2013

Myth: Gyms are expensive and not for retirees

together will offer the most all round benefits and health improvements.

Reality: People of any age can and

Myth: I can’t move much, so I can’t exercise

do benefit from going to a gym. A good gym will provide you with the right support to get you going. Find a skilled personal trainer to help you get started on an exercise programme. Exercising with a trainer will make the gym environment a lot less intimidating and ensure better results. The trainer will tailor an exercise programme to a level that is suitable for you. They will show you how to do the exercises and can provide on-going supervision and help with motivation.

Myth: Cardio is the best type of exercise for improving diabetes Reality: Studies have shown that a

combination of aerobic exercise and resistance training is significantly better for controlling blood sugar than either type alone. An exercise circuit involving weights and cardio

Reality: You can still exercise if you

have limited mobility of any kind. There will always be an option to move in some way. Pick up a suitably challenging set of weights, stretch, engage in light boxing pad work, or do chair-aerobics.

Myth: Elderly people shouldn’t exercise – they should take it easy Reality: Exercise is beneficial at any

age. Research shows no matter what your age, everyone can expect to see a range of health benefts. It only takes 30 minutes a day and it should enhance your quality of life. *The Ministry of Education has published a fact sheet on exercising for the over 65s. See http://tinyurl.com/ch53zgo

NURS E PRES CRI BERS

TREATMENT

Nurse prescribing project rolled out nationally There are now specialist diabetes nurse prescribers at seven district health boards following the success of a trial that won praise from patients and practitioners alike. Caroline Wood reports. The number of diabetes clinicians able to prescribe drugs to patients has effectively doubled with the national roll-out of a registered nurse prescribing scheme. There are now an extra 15 nurse prescribers working in specialist diabetes centres and GP practices across the country, who are able to prescribe diabetes medicines to their patients without having to get a GP or endocrinologist to sign the script. Nurse prescribing in diabetes care was successfully trialled with 11 registered nurses and 1,300 patients in four demonstration sites last year. Eligible nurses have to pass strict criteria and undergo specialist training before they are allowed to prescribe medicines such as insulin

and metformin for type 1 and type 2 diabetes, as well as medications for associated conditions such as high blood pressure and cholesterol. The benefits of the nurseprescribing model, which has been used successfully in the UK, include improved patient safety and better diabetes care. Nurses have more time than doctors to explain the medications and how they should be taken, which means patients are more likely to take their medications as directed. Dr Helen Snell, who is project manager for the roll-out, said: “The number of doctors who specialise in diabetes is extremely low in this country. The nurse prescribing project has effectively doubled the number of diabetes clinicians who can prescribe diabetes medicines in New Zealand. One of the key benefits is timeliness, it’s not just that patients are receiving the right medication in the right dose – they are also receiving it immediately at the same time they are seeing their diabetes nurse. They don’t have to make another appointment with their GP or medical specialist.

Since January this year 15 nurses have become diabetes nurse prescribers for Hutt Valley, Auckland, Mid Central, Wanganui, Northland, Counties Manukau and Southland DHBs. Patient feedback was due to be analysed in May as part of an evaluation of the roll-out, which is set to continue beyond the current implementation stage. The New Zealand Society for the Study of Diabetes, which led the roll-out, will continue to work with The Nursing Council of New Zealand on the scheme. Anyone who is interested in becoming a diabetes nurse prescriber can contact Helen Snell for more details on 06 3508114 or at helen.snell@midcentraldhb.govt.nz.

Keep your feet warm and toasty. Never have cold feet again. The Nu-Klear Multi Mat is a slim line heating mat designed to keep your feet comfortably warm. Whether working in an office or snuggled up at home the ambient heat generated by the multi mat will keep your feet, from your toes to your ankles, toasty and warm. And, the Multi Mat is not just a foot warmer. It has many other uses, such as, a wardrobe airer, shoe dryer or even a plant propagator. For more information phone us on 09 4466435 or visit our website at www.nuklearproducts.co.nz

Winter 2013 | DIABETES

LIV ING W ITH D I A B E TE S

CYCLIST A A RO N PE RRY

Changing diabetes

DIABETES | Winter 2013

CYCLI ST A A RO N PE RRY

LI V I NG WITH DI ABE TES

“I want to show people that we may have diabetes but we are not going to let it hold us back.” — Aaron Perry

Cyclist Aaron Perry has embarked on a life-changing journey combining professional riding with raising diabetes awareness around the world. Aaron is the first New Zealander to join Team Novo Nordisk – a professional cycling team consisting entirely of athletes with type 1 diabetes. Aaron spoke to Caroline Wood before he flew to the US. Aaron Perry first started riding a bike at the tender age of six, catching the cycling bug and going on to make it his career and passion – first mountain biking and then road racing.

headquarters of what was then Team Type 1, which included many riders with diabetes. He had been following the team’s progress and wanted to ask them for some tips on riding and diabetes, in particular using a continuous glucose monitor. To his surprise they wrote back asking about his riding history and statistics, this was followed by a phone call and before he knew it, Aaron was on a plane to Europe for tests and training camps in Spain and Italy. An official invitation to join the team on a two-year contract followed.

Even when Aaron was diagnosed with type 1 diabetes at 16 years old, he didn’t let it derail his determination to stay in the saddle. He went on to represent New Zealand in mountain biking competitions in 2005 and 2006.

Aaron, 25, flew to Atlanta, Georgia in April. He will train and compete for the team, which is now called Team Novo Nordisk and made up solely of athletes with type 1 diabetes. It is the first professional team of its kind in the world and an important part of the team’s ethos is that the members engage in awareness raising events whenever they compete. The idea is to ‘inspire, empower and change diabetes’.

Last year Aaron, 25, from Rotorua, had been taking a break from competitive cycling when he decided to email the US

“I thought what a fantastic opportunity. They are passionate about cycling and diabetes and so am I,” said Aaron.

“I want to raise awareness about diabetes in New Zealand and change the perception that you can’t do things if you have diabetes. You absolutely can. “I want to show people that we may have diabetes but we are not going to let it hold us back.” When Aaron was diagnosed with diabetes as a teenager, he was already a serious rider. The first thing he asked his doctor was whether he could still achieve his dream – to ride professionally. “I felt gutted and confused but I didn’t let it get to me and kept going. There wasn’t a lot of advice out there so I struggled a bit for a while. A lot of people didn’t know I was diabetic, I didn’t publicise it," added Aaron. “The Team Novo Nordisk guys are such a good bunch, it’s an amazing environment to go into, having lots of people with diabetes around me. “I think it will be very supportive, we will work together towards finding the best possible way to manage diabetes while maximising our own physical riding capability.” Aaron is the first New Zealander to join Team Novo Nordisk. You can follow his progress online at: www.teamnovonordisk.com

Winter 2013 | DIABETES

Introducing your new President Hi everyone. My name is Renata Porter and I am very fortunate to have just been elected President of Diabetes Youth NZ. While I find it a little overwhelming to be sitting in this space, I am excited for the future of DYNZ. A little about me, I am a mum of two and have been married to my husband Michael for 14 years. Both of our children have type 1 diabetes. My daughter is 19 years old (diagnosed at four) and my son is 13 (diagnosed at nine). I have sat on the Diabetes NZ Auckland Youth Committee for almost four years and have been a part of DYNZ for three. During this time I have had the pleasure of working with some great people, both locally and nationally. And I have met quite a few of you along the way. Having two children with type 1 has given me great insight into the condition that affects our children. However, as I have worked

DIABETES | Winter 2013

with volunteers from around the country and spoken to many families I realise this is not a onesize-fits-all disease. People manage differently, work differently and need different levels of support. It astounds me sometimes to think there are so many families I can relate to. However, at any given event, I can meet a family and through discussion realise that what they do on a daily basis to ‘manage’ is completely different to what we as a family do – and it still works. That’s a testament to our local organisations – they support us in our similarities and our differences. It's definitely made me truly appreciate the hundreds of volunteers we have in this country dedicated to making our children and families feel well supported. I believe this will be a year of shifting focus for DYNZ. It’s my goal to ensure that we now more than ever put additional effort into supporting our local organisations. That said, we can't afford to lose sight of the national activities we carry out year after year. It's definitely going to be a year of finding balance – between serving the country as a whole and ensuring each local area receives the individual support they need.

Luckily at our AGM we had two new volunteers step forward. I am happy to announce that Pete Duncan, from Invercargill, and Steph Mills, from Nelson, are joining the DYNZ committee. It's wonderful to have new people as they bring a fresh perspective and new energy. And I am thankful for this given the goals I have put in front of DYNZ this year. In signing off, I would like to thank Hayden Vink for his service as President over the past two years. His continued effort in bringing us closer to Diabetes NZ and his consistent representation of our committee at both a national and local level have done DYNZ a huge service. Thank you Hayden.

Renata Porter

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

Diabetes Youth New Zealand

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O B ITUA RY

COM MUNITY

The ‘face of diabetes’ on the West Coast Lin Jackson was a dedicated member of Diabetes West Coast for over 20 years supporting everyone she could, as well as educating children about diabetes. Lin Jackson was a tireless diabetes volunteer. She received a Diabetes New Zealand Life Member award in 2004 and was also a life member of Diabetes West Coast. She had served as secretary of Diabetes West Coast for 15 years before her death at the age of 69 last December. She used to visit members in their own homes to give them support and loved speaking to children, educating them about diabetes. Lin was a dedicated diabetes advocate for over two decades, earning her



the sobriquet ‘the face of diabetes on the West Coast’. Lin will be fondly remembered for her work in schools, where she used to dress up in a Buzzy Bee costume for the children. She also promoted the Books in Schools project, which went to every school in the district, and was subsequently adopted in other areas throughout New Zealand. Friend and president of Diabetes West Coast Elaine Jolly said: “Lin was one of the key people in our group and she has left a big gap. Lin went out of her way to visit many schools to speak to the children about diabetes. She will be greatly missed by all who knew her.”

Branch secretary Patricia Stanley added: “She was the face of diabetes on the West Coast, she did so much for the advance of diabetes knowledge here and we just hope we can carry own her work in some way.” Lin is survived by her husband Colin, four adult children and nine grand children.

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Winter 2013 | DIABETES

THE L AS T WORD

YOUR DAY WILL CO M E

Chasing a cure for type 1 Families affected by type 1 diabetes have launched a fund-raising drive to raise money for stem cell research – in the hope it will one day lead to a cure. Caroline Wood reports. The Chasing a Cure for Type 1 fundraising page was launched on Facebook in January as the focus of a community-based fund-raising drive. It is being coordinated by Sandra Grant, of South Otago, who has type 1 diabetes. The group is raising money to help fund ground-breaking stem cell research being carried out by the Spinal Cord Society of New Zealand in Dunedin. Diabetes covered the exciting research being undertaken by Dr Paul Turner (see the Winter 2012 issue), which could lead to a cure for type 1 diabetes. Sandra said: “I have been living on insulin injections for 21 years and my husband for 23 years (we met

at a Diabetes Youth camp 18 years ago). In all our time with diabetes, this is the most realistic chance we have seen for a cure. Plus, it has the potential to cure other auto-immune diseases. “Being from a part of the country where we know that if we want something we have to make it happen ourselves, I decided to do some fundraising. I started fundraising by having some tee shirts made to sell. “I realised I needed to do more. I have continued selling my tees, auctioned items on Trade Me, run a sweepstake and taken over the admin role on the Chasing a Cure for Type 1 Diabetes Facebook page. I have worked hard at finding potential funding sources and inspiring other ordinary Kiwis to believe in a cure and start fundraising.” Sandra has inspired families from across New Zealand to join the fundraising effort. She has also joined forces with type 1 diabetes

fundraisers from the UK to create a song to sell to raise funds for the research. UK musician Shane Board raises money in the UK for diabetes research (see www.pop4diabetes. co.uk). He agreed to let Sandra, who contacted him via the internet, to use one of his songs. Sandra then asked her brother-inlaw Christchurch DJ Maestro B (aka Brent Silby) to create a remix of Shane’s song “Your Day Will Come” – and he has come up with a unique Kiwi version of the song that is now available for downloading. “It’s a great song and I am really grateful to Shane and Brent for their support and the time they have given to creating it. Please download the single and help us find a cure for t1 diabetes,” added Sandra. You can listen to the song and download it for US$3. Go to http:// audiodreams1.bandcamp.com/ track/shane-board-your-day-willcome-maestro-b-classic-houseremix

On the net… Check out the Chasing the Cure for Type 1 Diabetes facebook page http://tinyurl.com/c5acxkk Find out more about the Pop 4 Diabetes charity fund in the UK www.pop4diabetes.co.uk Listen to the Kiwi remix of “Your day will come" on Bandcamp… http://tinyurl.com/acrrvco … and then listen to the original of “Your day will come" by Shane Board http://tinyurl.com/bxp25bp

DIABETES | Winter 2013

IMPORTANT MESSAGE To all People who Test for Blood Glucose and/or Blood Ketones

Optium / FreeStyle Optium

luc ose

ne o t e k

FreeStyle Optium Blood Glucose Test Strips: An agreement with Pharmac has been reached to continue funding FreeStyle Optium Blood Glucose Test Strips for eligible users. Funding will continue after 1st March 2013 for those who received both Optium Blood Glucose and Optium Blood Ketone test strips on prescription prior to 1st June 2012.* FreeStyle Optium Blood Ketone Test Strips: Prescription access remains available and continues for all people with diabetes, maximum of 20 strips per prescription, regardless of which meter they use for glucose testing.* FreeStyle Optium Meter: is able to be prescribed for ketone testing where the patient has had one or more episodes of ketoacidosis and is at risk of future episodes. One meter per patient will be subsidised every 5 years.*

M E D I C A

L I M I T E D Blood Glucose Monitoring System

www.medica.co.nz 0800 106 100 PO Box 303205 North Harbour 0751 TAPS NA6142 *www.pharmac.govt.nz Accessed February 2013. Always read the label and follow the manufacturerâ&#x20AC;&#x2122;s instructions. FreeStyle Optium is indicated for use for people diagnosed with diabetes. FreeStyle and FreeStyle Optium are trademarks of the Abbott Group of companies in various jurisdictions. Information contained herein is for distribution outside of the USA only. MSE130402040759

A 24-hour insulin that I can take once a day? 2

“Sweet...!”

Lantus® (insulin glargine) is now fully funded for Type 2 diabetes mellitus patients requiring insulin.1,2 For thousands of Kiwis, this will be something to smile about. Lantus® is a long-acting basal insulin. ‘Basal’ is a term used to describe the slow, steady release of insulin needed to control your blood glucose between meals and overnight. Lantus® provides a continuous level of insulin over 24 hours, similar to the slow, steady (basal) secretion of insulin provided by the normally functioning pancreas. This means that only one dose of Lantus®, given at the same time each day, is needed for 24-hour basal control. 2,3 How is Lantus used in people with Type 2 diabetes? In Type 2 diabetes, Lantus is given by subcutaneous injection once daily and can be used in combination with oral diabetes medications and/or with short or rapid acting insulin as instructed by your doctor. 2,4,5 Talk to your doctor about whether Lantus® could be right for you.

References: 1. February 2012 Pharmaceutical Schedule Update, Pharmac. 2. Lantus Data Sheet, August 2010. 3. Goykham S, et al. Expert Opin. PharmacoTher 2009; 10(4):705-718. 4. Fulcher G, et al. AMJ 2010; 3(12):808-813. 5. Nathan D, et al. Diabetes Care, 2009; 32:193-203. Lantus® is a Prescription Medicine that is part of the daily treatment of Type 1 & Type 2 diabetes mellitus. Do not use if allergic to insulin glargine or any of its ingredients. Precautions: for subcutaneous (under the skin) injections only, do not mix or dilute. Close monitoring required during pregnancy, kidney or liver disease, intercurrent illness or stress. Tell your doctor if you are taking any other medicines, including those you can get from a pharmacy, supermarket or health food shop. Interactions with other medicine may increase or decrease blood glucose. Side Effects: hyper or hypo glycaemia, injection site reactions, lipodystrophy (local disturbance of fat metabolism). Contains insulin glargine 100U/ml. Use strictly as directed and if there is inadequate control or you have side effects see your doctor, diabetes nurse or educator. For further information please refer to the Lantus® Consumer Medicine Information on the Medsafe website (www.medsafe.govt.nz). Sanofi, Auckland, freephone 0800 283 684. Lantus® is fully reimbursed when prescribed by a medical practitioner. Pharmacy charges and doctors fees apply. TAPS PP1903

GLA 12.02.001