Diabetes Living well with diabetes
Winter 2014
Diabetes time bomb
Cases to double in 20 years
Are you getting the DIABETES CARE you deserve? TREATING DEPRESSION
Diabetes in history The Renaissance
SUCRE BLEU Diabetes in India not so sweet
Cycling Picton to Bluff (aged 66)
handy salt guide + project energize + winter nosh
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Diabetes: the national magazine of Diabetes New Zealand | Vol 26 no 2 Winter 2014
INSIDE winter 2014 Gardening
Diabetes Youth
14 Ten winter tasks
33 Newly diagnosed info
Care and prevention
16 Are you getting the diabetes care you deserve?
Families and children
packs launched
Research
34 Vitamin D and type 2 diabetes clinical trial
18 Sam's story: Making the most of life with diabetes
Diabetes in history
20 The Renaissance and after
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Treatment
22 Dealing with depression From the Chief Executive From the President
Upfront
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News, views and research
Focus
10 Healthcare atlas reveals diabetes time bomb
Living with diabetes
12 Ron’s story:
Spinning the wheels
Let’s get active
24 Project Energize Food
26 Healthy gourmet eating 29 Slash the salt Community
30 Sucre Bleu: Diabetes in India not so sweet
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32 Global retinopathy study
COVER PHOTO: LAKE MATHESON, MT COOK
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: admin@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
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Changing attitudes towards living well Have you noticed the increasing discussion in the press over processed foods, fizzy drinks, fast food and the risks the population is facing from non-communicable diseases, namely type 2 diabetes, cardiovascular disease and cancer? We all know the risk factors for diabetes and heart disease but often avoid doing anything until the symptoms appear. Sometimes I wonder if these conditions grew on the ‘outside’ whether we would deal with them sooner. In the last 12 months you might have seen the increased coverage about the need for people to have regular heart and diabetes checks. Diabetes New Zealand felt it was important to get behind this programme to try and help people stay well and avoid complications. The programme also
helps identify those with prediabetes and provides an opportunity for individuals to talk to a health professional and get some advice on living well. Of course, in the 8,760 hours that exist a year we make our own choices and often only do the right thing just before our next check up – it’s human nature. That’s why health promotion agencies are seeking to change attitudes to healthy living so that these behaviours become part of everyday life and not just something you do before a check up or when the symptoms of disease appear. Over the past few years, with very limited resource, Diabetes NZ has been trying to do our bit to ‘lift the game’ by contributing to the national food and nutrition debate to change attitudes towards living well. Through this, we have built relations across the sector with other charities, community groups and non-governmental organisations and worked together to deliver similar health-promoting messages. We have worked with the Health Promotion Agency and the Heart Foundation
to promote the heart and diabetes checks. We also launched our first long-term awareness campaign Will you be killed by your sofa? We have partnered with the New Zealand Society for the Study of Diabetes and the Refract Group to develop an interactive video on prediabetes (see www. healthmentoronline.com); continued our parliamentary presentations, which help MPs learn more about diabetes; and have worked alongside the Auckland YMCA to pilot an exercise programme for people with diabetes. Our website now gets about 300,000 hits annually and we take well over 20,000 calls a year from people with diabetes. Changing attitudes to healthy living is a big challenge but we will continue to do what we can with what we have – thank you to all who support us.
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.
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DIABETES | Winter 2014
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FROM TH E PRESIDE NT
Raft of positive diabetes initiatives under way There are now nearly a quarter of a million1 people with diabetes in New Zealand. That’s about one in 18. It is not that long ago it was one in 20. We are not the only country wrestling with diabetes and I remain convinced something can yet be done here to slow its growth and high prevalence. And for those for whom it is too late, every effort must be made to reduce the chances of developing the destructive complications of the disease. It can seem like not much is happening here in New Zealand. I acknowledge my good luck that in my work as President, representing those with diabetes, I get to know about stuff going on. But I know this is harder for others and in talking with Caroline, editor of this magazine, we are going to try and bridge this knowledge gap through these pages. There is a lot of good work going on at national and local level to develop better diabetes services. You will 1
previously have seen mention of the Diabetes Care and Improvement Packages in each district health board region, where diabetes services are developed according to local needs and priorities. DHBs are encouraged to involve consumers in the development and evaluation of these services. I am thrilled at the recent release of the Quality Standards for Diabetes Care (see p16). This is an especially impressive piece of work and, while not everywhere will be offering everything, they are an agreed benchmark against which consistency can be measured. So often things go wrong when we are admitted to hospital and do not receive adequate care for our diabetes. An in-patient audit has been undertaken across New Zealand hospitals with the intention of developing national guidelines to minimise this risk. Last year guidelines were developed for the management and care of gestational diabetes, the incidence of which is also increasing. Their release is imminent. An Atlas of Healthcare Variation in Diabetes has been done (see p10), as has a care pathway for foot care and
assessment for people with diabetes in primary care. Recently work has been done on confirming the number of children diagnosed with type 1 diabetes (1,103 aged 0-15) with a view to extending the paediatric diabetes register beyond 15 years. Also new in paediatric care is the development of diabetic ketoacidosis (DKA) guidelines for treatment. There is also a raft of work going on for those with prediabetes. Much of this is about local initiatives, which are being piloted and tested prior to possible national roll out. And there are three shared care pilots, which will trial different ways of multi-disciplinary healthcare teams working with long-term condition patients (with a diabetes focus). This is but a brief outline of some of the recent activity and we hope to bring you more in future issues. Let us know if there are any of particular interest. Keep warm and well.
Chris Baty National President
243,125 as at December 31, 2013, Ministry of Health
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)
Winter 2014 | DIABETES
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UP FRO NT
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NEWS, VIEWS AND RESEARCH
Diabetes New Zealand AGM and Conference Day 2014 Save the date for Saturday 8 November because this year we’re doing things a little differently. We’re taking the best bits of conference, condensing them into a single day, and incorporating our Annual General Meeting. The date is set and the venue is booked. Now it’s up to you. Don’t miss out on an informative, inspiring and interactive day – make a note in your diary and register now! Attendance is free for all financial members of Diabetes NZ. Non-financial (supporting) members and non-members are also welcome to attend the event for a small admission fee. Registration on the day may be possible, but seats are limited so best to book in advance and secure your place. More information and registration forms are available on our website www.diabetes. org.nz or call 0800 DIABETES (0800 342 238) for a paper copy. Full details of the day will also be published in the next issue of Diabetes. Any enquiries should be directed to Pat Bent on 021 134 6576 or email dt_pat@yahoo.com Conference Day details: Saturday 8 November 2014 from 9.30am - 4pm at Wellington Airport Conference Centre. Morning tea, lunch and afternoon tea provided. Pat Bent Conference Organiser
Good news for coffee drinkers Previous studies have suggested a protective effect of regular coffee consumption on the risk of developing type 2 diabetes. This study by Ding M et al pubished in Diabetes Care in February 2014, found that compared with nil or rare coffee consumption, the risk of developing diabetes decreased as daily coffee consumption increased up to six cups a day. The benefits were also seen for decaffeinated coffee, suggesting the coffee beans may contain compounds that have beneficial effects on glucose metabolism, rather than the effect being caused by the caffeine.
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DIABETES | Winter 2014
Vigorous exercise ‘snacks’ better Short bursts of vigorous exercise before meals controlled blood glucose better than one continuous 30-minute session of moderate activity, according to a University of Otago study. Nine participants with insulin resistance (a marker for diabetes) were asked to complete three different exercise routines: six 1-minute bouts of intense exercise before breakfast, lunch and dinner; a similar programme but with resistance exercises replacing some of the vigorous activity; and a less active 30 minutes of moderate intensity walking before dinner. The two intense routines reduced three-hour post meal glucose levels by an average of 12 per cent, in contrast to no improvement from moderate exercise. The reductions persisted the following day. The study by Monique Francois and colleagues was published in Diabetologia in May 2014.
Complications worse in t2 youth Youth with type 2 diabetes exhibit complications sooner than youth with type 1 diabetes, according to a new study. Researchers studied young people aged 1–18 years with either type 1, type 2, or no diabetes. They found the risk increased among the type 2 cohort, who also had diagnoses of renal and neurological complications appearing within five years of diagnosis. Major complications such as dialysis, blindness and amputation began to manifest 10 years post diagnosis. The research by Dart AB et al, was published in Diabetes Care in February 2014.
Funding change for Optium meters Pharmac is now funding Optium meters for ketone testing for people using insulin pumps. The change will allow patients on an insulin pump to be eligible for funded Optium meters for the purpose of blood ketone testing. The change came into effect on 1 January 2014.
NZMS Point of Care rebranded NZMS Point of Care, suppliers of the Animas Vibe insulin pump, Dexcom continuous glucose monitoring system and Diasend diabetes management software, is now NZMS Diabetes. The company logo and name have changed but they offer the same products, service and friendly team. You can contact NZMS Diabetes (a division of New Zealand Medical and Scientific Limited) on 09 259 4062 or visit www.nzms.co.nz.
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NEWS, VIEWS AND RESEARCH
Diabetes cases up
Stem cell breakthrough
The number of people living with diabetes in New Zealand rose by 7.7 per cent during 2013. The Ministry of Health’s Virtual Diabetes Register estimates there were 243,125 people living with type 1 and type 2 diabetes at the end of December 2013. The district health boards supporting the highest number of people with diabetes are: Counties Manukau (37,140), Waitemata (28,843) and Auckland (25,697). See p10 for more details.
A woman with type 1 diabetes donated skin cells, which were changed into stem cells using a similar technique to the one used to clone Dolly the Sheep. Scientists were able to prompt the stem cells to form into pancreatic beta cells.
Flu risk higher in PWD Working age people with diabetes who contract flu were six per cent more likely to require hospital treatment for complications compared with adults without diabetes. A Canadian population-based study, published in Diabetologia in January, provides ‘the strongest available evidence for targeting diabetes as an indication for influenza vaccination, irrespective of age’. Influenza vaccinations are free for New Zealanders with diabetes until the end of July. See your doctor or nurse.
The US study published in Nature in April has widereaching future implications. Patients could potentially have a pancreatic beta cell transplant created from their own skin cells. The cells would match genetically and, unlike current transplant therapy, there would be no need for immunosuppressive drugs to stop the transplant being rejected. The technique is still in very early stages, and the scientists have not yet tried implanting the newly created beta cells into someone with type 1 diabetes.
Chinese herbal medicine hope
Dairy study surprise
Patients with prediabetes were given Tianqi capsules containing 10 Chinese herbal medicines, or a placebo, for 12 months during a randomised clinical trial. Compared with the placebo, Tianqi was associated with a significantly lower rate of progression to diabetes (32 per cent) and a great proportion of patients with normal glucose tolerance. There was no significant difference for change in bodyweight. No severe side effects were reported. The study by Lian F et al was published in the Journal of Clinical Endocrinology and Metabolism in January 2014.
Researchers looked at the relationship between low dairy intake and weight gain. Observing 3,440 participants from the Framingham Offspring study over 17 years, they found three or more servings of dairy was associated with less weight gain and a marginally smaller increase in waist circumference when compared with a low dairy intake.
Blood pressure retinopathy risk The observational study looked at blood pressure and HbA1c measurements of nearly 5,000 patients with type 1 and type 2 diabetes over 20 years. It found an association between poor glycaemic control and high blood pressure and the progression of diabetic retinopathy. Significantly, they also found that intensive management to reduce systolic blood pressure and HbA1c was associated with a regression of mild retinopathy. The study by Liu Y et al was published in Diabetes Care in December 2013.
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DIABETES | Winter 2014
“The difference was only 100g a year, so hardly stunning, but perhaps most importantly when considering other health issues, such as calcium intake and osteoporosis, there is no evidence of harm in greater dairy intake,” commented Wellington endocrinologist Dr Jeremy Krebs. The study by Wang H et al was published in the International Journal of Obesity in February 2014.
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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
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DIA B ETES ATL AS OF HEALTHCA RE VA RI ATI O N
Atlas highlights New Zealand’s diabetes time bomb New Zealand’s first Diabetes Atlas of Healthcare Variation has been developed to help improve the quality of care for the rapidly increasing number of people with diabetes. Caroline Wood reports. A record 243,000 New Zealanders had diabetes by the end of 2013, according to the latest Virtual Diabetes Register. About 90 per cent have type 2 diabetes. A further half a million people are believed to have prediabetes (defined as having an HbA1c of between 41-49 mmol) and be at risk of developing type 2 diabetes. If the current trend continues the number of people with diabetes in New Zealand is expected to double in the next 20 years, according to the
first Diabetes Atlas of Healthcare Variation. That would put a huge pressure on existing health services. The aim of the diabetes atlas is to investigate the quality of care currently provided to people with diabetes. The information is presented regionally so it is easy to see any differences between district health boards (DHBs). The idea is that over time the information will help improve the quality, equality and efficiency of diabetes services nationwide.
The atlas will be published online by Health Quality and Safety Commission New Zealand, which has developed a number of diabetes health indicators to track people’s care, including disease management and the rate of complications due to diabetes. The information is presented in the form of an ‘atlas’– a map of New Zealand divided into regions by DHB. Clinicians, health practitioners and members of the public can search the data by health indicator and drill down to detailed information based on age, ethnicity and region. You can see a range of health indicators, such as how many people
The Diabetes Atlas of Healthcare Variation will show how district health boards are performing relative to one another.
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DIABETES | Winter 2014
DI A BETES ATL AS O F H EA LTH CA RE VA RI ATI O N
are being prescribed insulin or metformin and blood pressure medications, the rate of admissions to hospital for diabetic ketoacidosis or hypoglycaemia, the rate of lower limb amputations, and the number of hospital bed days occupied by people with diabetes. The atlas also looks at regular monitoring of HbA1c and other important health markers. The atlas has its limitations – it can’t split people by the kind of diabetes they have (although an estimated 90 per cent of the 243,000 PWD have type 2). It can’t look at things like how many people are screened for diabetic retinopathy or end stage renal failure/renal dialysis because of a lack of available data. Health Quality and Safety Commission senior analyst Catherine Gerard, who has developed the diabetes atlas, says it is part of an international movement to develop health atlases using health ‘indicators’ to allow comparisons to be made geographically.
She said: “The atlas allows DHBs to benchmark their performance nationally across a wide range of indicators; to identify DHBs that are performing well in certain areas; and to identify areas where there is the potential to improve the quality of care for people with diabetes. “If we look at how health services are delivered regionally and we see there is a large variation, that tells us something is going on. Although the atlas does not suggest an ideal rate, observing wide variation suggests this may be an area worth exploring.” For example, if a DHB has twice the national average hospital bed occupancy for people with diabetes, that would indicate an area that needs investigating to find out why it was happening and make service changes. The figures used are actual numbers (not standardised) and will be updated regularly. The atlas is due to be published online in July, see www.hqsc.govt.nz.
Diabetes Atlas of Healthcare Variation: Key messages* Prevalence • One in six people aged 65 years and older have diabetes. • Pacific people have a significantly higher rate of diabetes than all other ethnic groups affecting nearly nine out of every 100 people.
Medication • On average five out of 10 people with diabetes regularly receive either metformin or insulin.
Complications
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• On average 4.5 out of 10 people with diabetes received medications to lower blood pressure and reduce the risk of kidney disease. • The rate of lower limp amputation increased significantly with age, with 82 per cent occurring in those aged 45 years and over. This was a rare complication affecting 0.2 per cent of the diabetes population in a year.
Hospital admissions • Two DHBs had consistently lower rates for hospital admissions for diabetic ketoacidosis. • Ma¯ori, Pacific and Asian people occupied significantly more bed days proportionately than European/other. * Based on 2012 figures
Winter 2014 | DIABETES
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LIV ING W ITH D I A B E TE S
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RON'S STO RY
Spinning the wheels
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Pensioner Ron Harding has been ticking off numerous physical challenges at home and abroad since he was diagnosed with type 1 diabetes in his 40s. Most recently he pedalled over 1,000 kilometres from Picton to Bluff with his wife Chalo. Ron, 66, from Blenheim, shares his story because he wants to inspire others with diabetes, particularly young people, to pursue their own physical goals and challenges.
I was in a low gear, standing on the pedals, leaning forward, going downhill, and still the bike was hardly moving. The southerly hammering the east coast of the South Island was making it tough here in the Kaikouras. The leg from Blenheim to Camden Station in the Molesworth should have taken us five hours. It took nine. And this was only day two of our 19 day trip. The weather in early March is usually fairly settled and balmy, and we had planned on it being ideal conditions for the trip. It was ambitious: my wife Chalo and I were cycling over 1,000 kilometres from Picton to Bluff, and I’m a 66-year-old pensioner, a heart attack
Worldwide adventurers: Ron and Chalo have walked and cycled all over New Zealand, Nepal, South-east Asia and the Pacific.
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DIABETES | Winter 2014
survivor, and I have type 1 diabetes. I was ticking off another item on the bucket list. I’m a determined sort of person (some of my mates say stubborn) and if someone tries to tell me I cannot do something, it will get done. The bike expedition was the latest in a number of challenges I have set myself since I was diagnosed. I try to make sure that having diabetes does not change my lifestyle or direction. As long as I maintain good control I will be able to maintain my fitness. As long as I maintain my fitness I will be mobile and living my choices. So control of my diabetes is priority no.1. I am and have always been slim – only 65kg – and was quietly proud
RO N' S STO RY
of my fitness and excellent health. Then in 1990, when I was in my 40s, I started experiencing the symptoms well known to readers of this magazine, and was eventually diagnosed as a type 2. I kept good control with diet and medication but in May 2007, after a whole week in which I seemed to be losing everything, the local hospital diabetic clinic re-diagnosed me as a type 1, and introduced me to the insulin pen. I continued to work as a builder five or six days a week, often up to 12 hours per day. And I set myself new challenges: Chalo and I have backpacked through Nepal, Tibet, Vietnam, Laos and Cambodia. We frequently visit Thailand. Temperatures of 35 degrees plus, day after day, with no refrigeration, can make for particular problems. After one particular stinking hot day in central Thailand, when I couldn’t get my glucose levels down, I threw out the insulin. But it turned out I had contracted typhoid (dodgy water supply). Good service from a Thai hospital, some antibiotics and a new cartridge in the pen, saw me come right. Four years after my type 1 diagnosis, I was training for the 165km ‘Round Lake Taupo’ cycle challenge. I had a strange burning, prickly sensation at my left nipple. I put up with it for four days and two more training rides before I went to the emergency centre and was told I had had a heart attack. The Taupo challenge never happened as I was bundled into an air ambulance, flown to Wellington and had a stent inserted. Seven days later I was back on my bike, but taking it easy for a while. This isn’t a travelogue, so I won’t give a day-by-day, blow-by-blow (and believe me it did!) description of the Picton to Bluff ride, but I will offer some first-hand information that may be of interest to other people with diabetes thinking about
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getting into exercise to improve their lifestyle. My approach has always been determined, but thought through, and based on discussions with doctors, specialist nurses, dietitians and my good friend Colleen, who has had type 1 diabetes for over 50 years. She is also a keen cyclist and traveller, and her advice is well founded on practical experience (together with a group of good mates we have cycled the Otago, Waikato and Hauraki trails, and have circum-cycled Savai’i, the largest island of Samoa).
“Having diabetes will not adversely change my life or direction. Maybe it even drives me to do physical challenges I would not otherwise have tried.” I admit that when I was first getting into cycling challenges, and started significantly increasing my training distance and time, I didn’t have great control of my blood glucose levels. I was talking about my plans at my local bike shop, and someone suggested I should talk to Ingrid, a New Zealand cycling champion, and as it happens, a specialist dietitian at the diabetic centre. She helped me understand and appreciate the importance of carb counting. She also put me right on the need to replace electrolytes quickly, so electrolyte drinks are now an essential part of rehydrating. During our Picton to Bluff ride, we were self-supporting. There was limited room in the bike panniers, so apart from a few basics and emergency rations, food was what we could buy along the way. I had to
LI V I NG WITH DI ABE TES allow for our intake of café food during the day, and anticipate the little enthusiasm we had to cook in the evening. The South Island ride took us 19 days. We rode 1,111 kilometres. In Bluff, we had the mandatory feed of oysters and cycled 30km back to Invercargill where we officially ticked it off as ‘completed’. Over the next three to four days my blood glucose levels fluctuated dramatically. I could not get back to my target. The sudden end to the sustained period of serious exercise, vastly different diet and irregular meal times, all combined to throw me a curve ball. However, during the bus and train journey back north and return to something more like my routine, everything fell back into place. The bike trip was hard. We ached and our thigh muscles burned for the first few days but it came right. At times, the weather was unfriendly. Some of the hills seemed hostile. A couple of the beds were positively unyielding! But each day the post-exercise glow was welcome, and a sense of accomplishment could be quietly savoured. Was it worth doing? Too right. Even if no one else particularly noticed, Chalo and I proved something to ourselves. Having diabetes will not adversely change my life or direction. Maybe it even drives me to do physical challenges I would not otherwise have tried. There is plenty of help out there. I have always benefited from tapping into many sources of advice – technical from medical people, and practical, based on personal experience, from other people with diabetes. So here’s mine: try spinning those wheels – have a go. I’m already thinking about the next one. Taupo again? Hmmm...
Winter 2014 | DIABETES
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GARD EN I N G
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WINTER JOBS
Ten winter tasks to get set for spring When it’s cold and wet outside it’s hard to get motivated to get out in the garden. If the sun comes out though, even half an hour spent outdoors in winter can pay huge dividends when it warms up in spring. Here are gardening expert Rachel Knight’s top 10 winter tasks for your edible garden.
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Sow green manure
There’s usually space in our gardens in winter to sow some lupins, broad beans or mustard. They’ll protect the soil as well as adding organic matter to it. You can either chop the plants in with a spade or pull them out and use them as ingredients for your compost heap.
Work out what went well last year and what you want to change. Too many beans? Not enough carrots? Short on salad? Plan for yourself and your family and the time and space you have.
Mustard is an ideal green manure crop
DIABETES | Winter 2014
Rake all those leaves to add to your compost pile
Prioritise the things you love and add a couple of extras for luck!
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Make compost
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Clean your tunnel house or cold frame
Keep collecting all your garden and kitchen waste to make compost to spread in spring.
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Read the seed catalogues
Seed catalogues provide lots of inspiration and information, even if you mostly buy seedlings from the garden centre. Sowing seeds is cheaper and gives you more varieties from which to choose.
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Divide your rhubarb
Split each clump into three with a spade every three to five years for a bumper crop. Dig a big hole and fill it with compost before replanting. Give away spare pieces to a rhubarb-loving friend.
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Plan your summer garden
Spread some mulch
Bare soil is bad soil so use whatever you’ve got to cover it. Lawn clippings, straw, seaweed or compost spread on the surface now will be pulled down into the soil by worms and other organisms. You’ll keep the worst of the weather and weeds at bay and by spring you’ll have richer soil as a result.
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If you have a tunnel house or cold frame, give it a good scrub with soapy water and rinse well to get rid of any mould and let the sun shine in. Consider building a simple cold frame out of a recycled window and some scrap timber.
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Set some mouse traps
Mice will be searching for seeds and shoots in spring so keep their numbers in check with a few peanut-butter baited traps.
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Plant your garlic
The middle of the year heralds the start of the new season and is the traditional time to get garlic started.
Plant a fruit tree
Winter is the best time to plant fruit trees as they’re dormant. It’s surprising what you can fit into even a small garden. Perhaps a climbing grape or an espaliered apple, peach or pear.
*Rachel Knight blogs on growing and eating your own fresh, healthy food, see www.thekitchengarden.co.nz.
C ARE A N D PRE VE NTI O N
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KNOW YO UR RI G HTS
Are you getting the diabetes care you deserve? The Minister of Health has approved new standards to improve the quality, consistency and access to health care for people living with type 1 or type 2 diabetes across New Zealand. The 20 standards cover diabetes treatment, self-management and education. We are publishing them in full in a handy ‘cut out and keep’ format for future reference. Caroline Wood reports. The concept of patient-centred care is at the heart of new national quality care standards designed to ensure everyone with diabetes – type 1 or type 2, young, old, poor, rich, rural, urban, Pasifika, Māori, Asian or Pākehā – has access to the same comprehensive and equitable health care, regardless of where they live in New Zealand. The 20 standards were drawn up by the National Diabetes Services Improvement Group (a Ministry of Health group made up of representatives from across the diabetes sector, including specialists, GPs, nurses, dietitians, podiatrists, national/ primary health officials, Diabetes New Zealand, and Diabetes Youth). They were approved by the Minister of Health in April and the ministry sent the standards to every district health board in the country in May for consideration as part of their planning for local diabetes services. Diabetes New Zealand president Chris Baty sits on the group that drew up the guidelines. She said the quality standards are an important step forward for people with diabetes and should result in people being able to consistently access diabetes services, such as podiatry and dietitian advice, wherever they live in the country. She said: “It should ensure that everyone can access a minimum standard of care that doesn’t depend on their local postcode. I think it will be really significant because so often around the country we hear of people who can’t get proper access to important services, such as nutritional information or podiatry care. If everyone knows what they are entitled to, they can ask about it when they see their diabetes doctor or nurse. “It's important to note that not all of these services will be available in all areas straight away. It may take some time to have podiatrists available in all places, for instance,” she added.
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DIABETES | Winter 2014
KNOW YO UR RI G HTS
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CARE AND P RE V ENTION
Quality standards for diabetes care Here are the standards of diabetes care you should be able to access in your local area.
Basic care, self-management and education 1. People with diabetes should
receive high quality structured selfmanagement education that is tailored to their individual and cultural needs. They and their families/whﾄ］au should be informed of, and provided with, support services and resources that are appropriate and locally available.
2. People with diabetes should receive personalised advice on nutrition and physical activity together with smoking cessation advice and support if required.
3. They should be offered, as a
minimum, an annual assessment for the risk and presence of diabetesrelated complications and for cardiovascular risk. They should participate in making their own care plans, and set agreed and documented goals/targets with their healthcare team.
4. They should be assessed for the
presence of psychological problems with expert help provided if required.
Management of diabetes and cardiovascular risk 5. People with diabetes should agree
with their health care professionals to start, review and stop medication as appropriate to manage their cardiovascular risk, blood glucose and other health issues. They should have access to glucose monitoring devices appropriate to their needs.
6. They should be offered blood
pressure, blood lipid and anti-platelet therapy to lower cardiovascular risk when required in accordance with current recommendations.
7. When insulin is required it should be initiated by trained healthcare professionals within a structured programme that, whenever possible, includes education in dose titration by the person with diabetes.
8. Those who do not achieve their
agreed targets should have access to appropriate expert help.
Management of diabetes complications 9. All people with diabetes should
have access to regular retinal photography or an eye examination, with subsequent specialist treatment if necessary.
10. They should have regular
checks of renal function (eGFR) and proteinuria (ACR) with appropriate management and/or referral if abnormal.
11. They should be assessed for
the risk of foot ulceration and, if required, receive regular review. Those with active foot problems should be referred to and treated by a multidisciplinary foot care team within recommended timeframes.
12. Those with serious or progressive complications should have timely access to expert/specialist help.
While in hospital 13. People with diabetes admitted
to hospital for any reason should be cared for by appropriately trained staff, and provided access to an expert diabetes team when necessary, They should be given the choice of self-monitoring and encouraged to manage their own insulin whenever clinically appropriate.
14. Those admitted as a result
of uncontrolled diabetes or with diabetic ketoacidosis should receive educational support before discharge
and follow-up arranged by their GP and/or a specialist diabetes team
15. Those who have experienced
severe hypoglycaemia requiring emergency department attendance or admission should be actively followed up and managed to reduce the risk of recurrence and readmission.
Special groups 16. Young people with diabetes
should have access to an experienced multidisciplinary team including developmental expertise, youth health, health psychology and dietetics.
17. All patients with type 1 diabetes
should have access to an experienced multidisciplinary team, including expertise in insulin pumps and CGMS when required.
18. Vulnerable patients, including
those in residential facilities and those with mental health or cognitive problems, should have access to all aspects of care, tailored to their individual needs.
19. Those with uncommon causes
of diabetes (e.g. cystic fibrosis, monogenic, post-pancreatectomy) should have access to specialist expertise with experience in these conditions.
20. Pregnant women with
established diabetes and those developing gestational diabetes should have access to prompt expert advice and management, with follow-up after pregnancy. Those with diabetes of child-bearing age should be advised of optimal planning of pregnancy including the benefits of preconception glycaemic control. Those not wishing for a pregnancy should be offered appropriate contraceptive advice as required.
Winter 2014 | DIABETES
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FAM I LI ES A N D CH I LD RE N
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SAM'S STO RY
Making the most of life with diabetes Sam was two years old when he was diagnosed with diabetes. He is now 21, a talented sportsman with a love for the outdoors living and working in Canada. But it hasn't always been easy. Mum Cheryl Heta, from Auckland, tells their story. This is Sam’s story, and I am Cheryl, his mother. At the young age of two a frightening thing happened in our household. My mother, Sam’s grandmother, was staying with us and commented on Sam’s thirst and regular wet nappies. She suggested I ask my GP about diabetes when I visited him next. Heavily pregnant with my second child, I took Sam to my next antenatal check up. Fortunately we had a diligent, supportive GP who listened to my concerns about Sam’s behaviour and what my mother had said. So along with the necessary antenatal checks for me, there were blood tests for Sam. I remember that day so clearly, Sam’s blood glucose reading of 31 meant an immediate trip to Starship Hospital. Our world did a 360-degree fast spin. We were asked about any family diabetes history but there wasn’t any there. It seemed that Sam had developed the condition as a result of an immune breakdown and this may have followed a common cold or virus. He was diagnosed with type 1 diabetes and admitted to Starship acute unit. Funnily enough I went into labour during his admission. My mother accompanied me to Waitakere Hospital maternity unit to deliver my baby, leaving dad to stay with Sam at Starship. We kept both hospital units busy but they were very supportive. A sudden change in our family had been thrust upon us and
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DIABETES | Winter 2014
like many other parents of newly diagnosed children, there were lots of questions about why and how. Diabetes didn’t run in either my or Sam’s father’s family. A steep medical learning curve presented itself and this involved the wider whānau. Carbohydrate counting, blood glucose tests and getting used to insulin injections quickly became part of our everyday household routine. The first year was the hardest, as Sam cried through the finger tests and insulin injections and all I wanted to do was swap his condition to me. Educating and empowering the wider whānau was a bit of a challenge but we had close friends who stepped up to the mark. They learned what was required and offered us respite care when we needed it. Being a pragmatic person, I was determined not to wrap Sam in cotton wool and I wanted our life to be the same as if we weren’t living with diabetes. The Diabetes Youth groups were a great support, as it was important to share experiences with other families and for Sam to see other children doing the same as he was. At the age of eight, Sam and his younger brother went through a family change, which saw them single parented by mum, staying with their dad every second weekend. This contributed an additional stress on Sam’s condition that resulted in a short hospital stay. I remember feeling like the worst parent on earth as I couldn’t prevent
the stress he was feeling at the time. Thankfully we were supported by a great paediatrician and the staff at the diabetes unit in Nelson Hospital. There have been scary hypoglycaemia moments that have occurred throughout Sam’s life, with the most recent one being Christmas Eve 2013. Even at 20 years old one must continually remember to manage one’s condition well and unfortunately Sam does not always have a good awareness of when his blood sugars are going low. Healthy good food wasn’t a problem for us but carbohydrate counting took some getting used to. As a sporty, active parent, I encouraged both my boys to do the same and happily transported them to their various sporting events. Living with diabetes does not prevent you from achieving what you want; it may just be a little more challenging. The Nelson lifestyle meant we could afford to do lots of activities at little cost. I believe a healthy mind, body and soul lead to a positive wellbeing and attitude. Sam developed into a B grade squash player, a senior basketballer, a top soccer player and at the age of 17 represented New Zealand as a Junior Black Sox softball player in the Trans Tasman Championships in Australia.
S A M ' S STO RY
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FAM I LI E S A ND CH ILD REN
“I did not like having a son diagnosed with diabetes, I couldn’t change it, but my attitude was to accept it and go about making the most of life.” Cheryl Heta
After finishing college in 2010, not letting his condition hold him back, Sam decided he wanted to be a voluntary student abroad working in an outdoor education camp for children. That dream was nearly dashed when he broke his leg while playing softball. The break was so bad he had to have a rod inserted inside his leg, from his knee to his ankle and four bolts. Sam was still determined to get to Canada in March 2011 so
he took extra care to manage his diabetes and sought help from his physiotherapist. He attended a gym under the guidance of a good personal trainer who empathised with Sam’s condition and his desire to heal and make his leg strong. With this support, and Sam’s attitude, it allowed him to become part of the Global Latitude Student Abroad programme and he was given an employment opportunity at Camp Jubilee in Canada. Sam is now in his third year in Vancouver and during his three ‘off ’ months he returns to New Zealand to work for Cable Bay Adventures in Nelson.
There is a quotation that springs to mind, which reflects our story, and one that I refer to in many a situation: “If you don’t like something, change it. If you can’t change it, change your attitude” (Maya Angelou). I did not like having a son diagnosed with diabetes, I couldn’t change it, but my attitude was to accept it and go about making the most of life. Diabetes definitely contributed to the path Sam took but the result to date is what every mother wants. Through adversity Sam has become the confident and kind young man we see today and I am very proud of him.
Rocking it: Sam Church has a love of travel and the outdoors. Winter 2014 | DIABETES
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DIAB E TES I N H ISTO RY
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THE RENA I SS A NCE A ND A FTER
The sweet taste of serum The early origins of our current understanding of diabetes can be traced to discoveries made by European scientists in the Renaissance and the 1700s. In the second of our occasional history of diabetes series, Caroline Wood looks at what the early physicians knew about diabetes from the Middle Ages to the end of the 18th century.
The ancient Egyptians were the first to describe the clinical features of diabetes mellitus 3,000 years ago, saying the condition was marked by “too great emptying of the urine.” Ancient physicians gave us the name ‘diabetes’ (see Diabetes in Antiquity, which featured in our Winter 2013 issue). Little attention appears to have been paid to diabetes by physicians in the Middle Ages as it must have been quite rare. Arab physicians accepted the theoretic and therapeutic knowledge handed down by the ancients and were unaware of the sweet taste of diabetic urine. The Byzantine physician Actuarius (13th century) treated diabetes with rosewater. Latin physicians made little progress in identifying or treating the condition. “During the Renaissance, a renewed interest in the scientific, cultural and artistic successes of ancient civilizations took hold, spurring medical advances throughout Europe for the next 200 years,” says Jackie Rosenhek, in her article about the history of using urine to diagnose disease (uroscopy). Diabetes was a still relatively rare condition during the Renaissance but one that was being studied, with more than 100 authors concerned with diabetes and writing about it over the period from 1500 to 1670. One of the most notable Renaissance physicians was Paracelsus – Aureolus Theophrastus Bombastus von Hohenheim
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DIABETES | Winter 2014
Paracelsus
(1493-1541) – who was born in Switzerland and credited with establishing the role of chemistry in medicine. In keeping with other physicians of the time, Paracelsus diagnosed his patient’s ailments by a detailed examination of their urine, including tasting it. He was purported to carry a sample of urine in a specially-designed pouch, which he wore around his neck. Paracelsus allowed the urine of patients with diabetes to evaporate and observed a white residue. He incorrectly thought it was salt and proceeded to attribute excessive thirst and urination in these patients to salt deposition in the kidneys. ‘Diabetes is nothing other than an excessive eagerness to pass urine, and the cause of this malady is excessive heat of the kidneys,’ he postulated. Steam baths should prevent this dangerous salt formation, he concluded. It wasn’t until 1670 that Thomas Willis (1621-1675), a doctor and
THE RENA I SS A NCE A ND A FTER
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DI AB E TE S I N H ISTORY
Paracelsus diagnosed his patient’s ailments by a detailed examination of their urine, including tasting it. He was purported to carry a sample of urine in a specially-designed pouch, which he wore around his neck.
scientist in Oxford, was the first to notice the sweet taste of urine of patients with diabetes. He referred to diabetes as the ‘pissing evil’ and noted that in patients with diabetes ‘the urine was wonderfully sweet, as if it were imbued with honey or sugar. He was the first to add the word ‘mellitus’ (derived from the Greek word for honey), to diabetes to distinguish it from diabetes insipidus, a different condition that doesn’t have glucose in the urine. He proposed the sweetness first appeared in the blood and was later found in the urine.
Thomas Cawley in 1788 was the first to suggest a link between the pancreas and diabetes. However, it would be another 100 years before the significance of this link was realised.
Diabetes diagnosis breakthrough It took more than 100 years before the next significant breakthrough in the search for the cause of diabetes. In 1776 British physiologist Matthew Dobson (1735-1784), from Liverpool, actually measured the concentration of glucose in the urine and found it to be increased in patients with diabetes. His experiments conclusively established the diagnosis of diabetes in the presence of sugar in the urine and blood. By this time diabetes was no longer considered a rare ailment. In Experiments and Observations on the Urine in Diabetics, Dobson was the first to show that the sweettasting substance in the urine of patients with diabetes was sugar. He gently heated two quarts of urine to dryness. The remaining residue was a whitish cake, which Dobson wrote ‘was granulated and broke easily between the fingers; it smelled sweet like brown sugar, neither could it be distinguished from sugar, except that the sweetness left a slight sense of coolness on the palate’. Dobson noted the ‘sweet taste of serum’ in these individuals and thus discovered hyperglycaemia (high blood sugar). He put forward the theory that diabetes was a systemic disease rather than that of the kidneys. He noted that some people with diabetes die within weeks, others have it for several years. In 1788, British surgeon Thomas Cawley was the first to suggest a link between the pancreas and diabetes after he observed that the pancreas of a patient who had died of diabetes had stones in it and tissue damage.
It was to be a century before the significance of this clue was appreciated. A decade later, in 1797, Dr John Rollo, a Scottish military surgeon, printed Notes of a Diabetic Case. He realised that diet played a role in diabetes and developed a high protein, low carbohydrate diet and prescribed anorexic agents such as digitalis and opium to suppress appetite in patients with diabetes. This diet apparently relieved the glycosuria (excess of sugar in the urine) of two diabetic patients. Look out for the next in our occasional History of Diabetes series: the 19th century scientists who laid the groundwork for the discovery of insulin.
Sources “The Main Events in the History of Diabetes Mellitus” by Jacek Zajac et al from the book Principles of Diabetes Mellitis (L Poretsky, ed), 2010. Diabetes Mellitus from Antiquity to Present Scenario and Contribution of Greco-Arab Physicians Hamid ALI et al, International Society for the History of Islamic Medicine, 2006. Diabetes and its Medical and Cultural History (Prof Dietrich von Engelhardt (ed) 1989. “Liquid Gold” by Jackie Rosenhek published in Doctor’s Review, September 2005. Bittersweet: A Study of Diabetes, The University of Texas Health Science Centre, 2008. Understanding diabetes, a Biochemical Perspective, RF Dods, 2013.
Winter 2014 | DIABETES
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TREATM ENT
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D IABETES ON MY MIND
Dealing with depression Identifying and managing depression is an important and underrecognised part of diabetes care, writes diabetes clinician and scientist Professor Merlin Thomas. He explains what to do if you are feeling low and gives a clear explanation of the different treatment options available.
Depression is a serious and common problem for people with type 2 diabetes. It is common for everyone to feel low at times during their life. But depression is a disproportionate and pervasive mood that interferes with your ability to function. It can affect your relationships, your work, your sleep and many other aspects of your health and wellbeing. Depression can also affect your diabetes control, the likelihood of complications and their impact. Not everyone with diabetes will become depressed, no matter how bad their illness gets.
Certainly, women are twice as likely to become depressed as men. Single people are more at risk than married ones. At the same time those people who stay socially connected with their family and friends have a lower risk of depression. Depression is not a simple illness. It is sometimes difficult to see it for what it is against a background of other problems in people with type 2 diabetes. However, identifying and managing depression is an important and under-recognised part of diabetes care.
Like any other illness, depression can be treated. Effective treatment of depression will also mean better diabetes control.
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DI A BETES O N MY M I ND
One way to identify those people who could be depressed is the Patient Health Questionnaire-2. It asks only two simple questions:
stress management are also key components. These sessions can be delivered to you alone or as part of a group.
1. Have you often had little interest or pleasure in doing things over the past month?
Participation in physical exercise programmes, or increasing your physical activity in a social setting (such as walking the dog, golf, walking groups, tennis, etc.), can also significantly improve symptoms of depression in some people and have a range of other benefits for your overall health.
2. Have you often been bothered by feeling down, depressed or hopeless over the past month? Most people suffering from depression will answer yes to one or both of these questions. If this is you, then it is worth talking to your doctor or other members of your diabetes care team about the need for further evaluation. About half of those with positive responses will turn out not to be depressed, but it is still important to ask your doctor or specialist for their formal assessment.
Treating depression Depression is not something you have to put up with. Like any other illness, depression can be treated. Not only will this make you feel and function better, the effective treatment of depression will also mean better diabetes control. A number of different treatment options are available that will be suited to different people and different clinical situations. Doctors will first try to use treatments that don’t involve taking pills. The most widely used of these is psychotherapy (also known as counselling). This can be very effective in many people with depression. The response rate is roughly similar to that of taking antidepressant pills, although when combined they may be even more effective than either alone. There are many different forms of psychotherapy, but most involve structured weekly sessions delivered by trained therapists to retrain thinking and behaviour or develop new coping skills. Relaxation and
Many people with depression also need antidepressant pills to help them out. Each of these medications acts in a different way to balance disturbed chemistry in the depressed brain. Medications include: • Selective serotonin-reuptake inhibitors (SSRIs). These are often used as the first-line drug treatment for depression, especially in those over 60. • Serotonin–norepinephrine reuptake inhibitors (SNRIs). These may be particularly useful for patients with chronic pain due to nerve damage associated with diabetes. • Tricyclic antidepressants (TCAs). These agents are effective but may have significant side effects, especially in those with heart problems.
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TREATMENT
About half of those treated with any given antidepressant show a positive response, often within as little as a month of treatment, although it may take a few more months for a full response to occur. Once a remission is achieved, antidepressants are usually continued for a further 6 to 12 months, as stopping too soon can increase the risk of recurrence. In those who do not respond initially, a trial of an alternative antidepressant or combination of medicines, with or without psychotherapy, is often undertaken. Where needed, the actions of antidepressants can sometimes be augmented by other medications, such as lithium or anticonvulsants. There are a number of different supplements and over-thecounter herbal remedies that are advertised to help treat the symptoms of depression in some people. However, their effectiveness is variable, and most people experience little or no benefit from them. *Talk to your healthcare provider and ask for help if you think you might be depressed. See www. depression.org.nz for further information about managing depression.
• Monoamine oxidase inhibitors (MAOIs). These older agents also work in some patients, but require close monitoring and a special diet to prevent side effects, so may be less suitable for those with type 2 diabetes. Antidepressants do not blunt normal emotional reactions or turn you into a zombie. Antidepressants also do not lead to dependence or addiction. However, many of these medications do have significant side effects, so are used only where having depression is a worse alternative.
Extracted from Understanding Type 2 Diabetes by Professor Merlin Thomas, Baker IDI Heart and Diabetes Institute. RRP $32.99. To purchase a copy, see www.exislepublishing.co.nz.
Winter 2014 | DIABETES
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LE T ’S G E T A CTI VE
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PROJECT ENERG IZE
Homegrown healthy kids initiative goes global Project Energize has been proven to reduce obesity and improve physical fitness in Kiwi school children. It is now being replicated in Ireland as other countries seek to find answers to the current worldwide obesity epidemic. Caroline Wood reports. Project Energize is a Kiwi success story. It began nearly a decade ago as a trial in a few Waikato schools. Children were encouraged to learn about being more physically active and eating healthily, while being monitored for their weight and fitness. Passionate and committed ‘Energizers’ (trained nutrition and physical activity specialists) visited each school to give advice and a tailored programme to help the kids (and their whānau) become Kiwi success story: Ireland is trialling its own Project Energize scheme. Photo: Margaret Tiddy
healthier. They hoped it would help the children become more active and eat better as a result. Nearly 10 years later the results are in and they are ‘impressive’ according to a leading diabetes expert. A formal evaluation of Project Energize (see panel right) shows significant weight loss and improved fitness levels among the children who took part. Commenting on the evaluation, Wellington endocrinologist Dr Jeremy Krebs, who was not part of the study, said: “The results are impressive, with very meaningful reductions in the rates of overweight and obesity and improvements in physical fitness. Perhaps more impressive is the universal nature of the response cutting across gender, ethnicity and socioeconomic status. This is vital if we are to really see long-term benefits.”
By long-term benefits Dr Krebs is referring to one of the aims of the programme, which is to reduce the children’s risk of developing type 2 diabetes and other longterm health conditions as adults by encouraging them to adopt lifelong healthy eating and exercise habits. With diabetes increasing rapidly worldwide, the hunt is on to find ways of reducing the risk of developing the condition. The success of Project Energize has captured the attention of other countries, which are also struggling to deal with obesity in children and adults. Ireland is trialling its own version of Project Energize in County Cork, where it is called Project Spraoi. Members of the Project Energize team have been supporting their Irish counterparts to help set up their scheme. Stephanie McLennan, Project Energize project manager, said: “It’s very exciting because we know we have a fabulous product and we have nine years of experience on how to take physical activity and nutrition into school settings. We have done a lot of research on how to engage children and families and we think it’s the right thing to do, to share that knowledge.”
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PRO J EC T ENERG IZE
‘Energizers’ work with schools, teachers and parents, giving physical fitness and nutritional advice and helping implement health and fitness programmes. The aim is to improve nutrition and physical activity levels, reduce obesity rates and reduce diabetes and cardiovascular risk factors. More than 44,000 primary and intermediate schoolchildren are now part of Project Energize.
Impressive results In 2011, compared with controls, the younger and older Project Energize participants had measurable (or meaningful) changes in: • Prevalence of obesity and overweight – reduced by 31 per cent and 15 per cent respectively. • Body Mass Index – decreased by three per cent and 2.4 per cent respectively. • Time taken to run 550m improved by 13.7 and 11.3 per cent respectively. Project Energize was equally effective for boys and girls, Māori and non Māori and by socioeconomic status.
Back in New Zealand, all 244 Waikato primary and intermediate schools have been ‘energized’ and the scheme is now being trialled in Northland and Counties Manukau. The team has also developed a version of the programme for the under-5s and is piloting a project whereby an ‘Energizer’ works with local medical centres to help patients adopt healthier lifestyles.
3 Waikino Primary School After taking part in the Energize Bikewise obstacle course, the year 3 and 4 students were given a technology challenge to create bike obstacles for the school. This was used at a whānau TRYathlon event where 10 parents had a go too.
3 St Joseph’s School, Te Kuiti A ‘Boys Club’ was established with interested boys being invited to join with their parents’ permission. Every two weeks Energize took the boys for rough and tumble type games in a supervised environment. The club was a success and the school is now working towards the boys’ dads running the club.
3 Club Energize Hamilton Energize organised Club Energize Triathlon Training for children in Hamilton earlier this year. Over three mornings in January, children learnt the basics of triathlon in preparation for school triathlons and the Weetbix TRYathlon. They also received nutrition information, including taking home the Energize ‘Eat to Compete’ nutrition tip sheet. Similar programmes will now be used in Hamilton and other districts.
3 Karangahake School Energize initiated a ‘nude’ food day at Karangahake School and it’s now organised every term by the school. Children came dressed up as their favourite snacks that don’t come from a packet, including a blueberry (see photo left) and a banana.
Academic Leader of Project Energize, Professor Elaine Rush, who led the formal evaluation, said: “Project Energize has made, and continues to make, a huge difference to the Waikato community. “Children and their children are our future and an investment of $45 per child per year is small compared to the short and longterm gains. I would like to see it extended throughout the country and in all spheres of life.”
LE T ’ S GE T ACTIVE
Some Project Energize success stories
Project Energize Project Energize began in 2005 and is funded by the Waikato District Health Board, Sport Waikato and AUT University, Sport NZ, Te Korowai Hauora o Hauraki, Te Kohao Health and South Waikato Pacific Islands Community Services.
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3 Te Kura Kaupapa o Harataunga
Project Energize: Kids have fun while learning to be healthy and active.
Cooking sessions with Energize are now a regular feature on the term calendar. Last term the children created their own sushi. One girl had never eaten it before. The students really enjoy the sessions and loved the sushi for lunch. Winter 2014 | DIABETES
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FO O D & RECI P E S
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HEALTHY GOURMET EATI NG
Simple, healthy (and delicious) Christchurch dietitian and food writer Julie Leeper set out to write a cook book with recipes that look and taste decadent but are also good for you. Nosh is all about healthy eating, it’s not a fad diet, there are no special foods to avoid or eat. Every recipe is designed to help maintain a healthy weight and a healthy heart, as well as being good for peole with diabetes.
Special offer for Diabetes readers Special offer: Diabetes readers can buy a copy of Nosh for $30 (normal retail price $34.95). Sales of more than 50 books at this special rate will result in a $5 per book donation going to Diabetes New Zealand. You can buy the book from www.nosh.net.nz.
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DIABETES | Winter 2014
Mini ham wrapped meat loaves The thought of meat loaf conjures up, for me, some anaemic, unexciting looking food. These mini meat loaves wrapped in ham look like they’ve come out of some trendy delicatessen – and they are full of vegetables and flavour.
Preheat the oven to 180°C (160°C fan). Lightly grease a loaf tin (13 x 23 cm) or 6 (½ cup) mini loaf tins. Place the kidney beans into a sieve and place under running cold water. Drain then place in a large bowl and mash. Finely slice the onion. Leaving the skin on the carrot, finely grate. Add the onion, carrot, red pepper or sun dried tomatoes, fresh and dried herbs, mince, corn, mustard, first measure of tomato and Worcestershire sauces, stock, oats and the egg to the kidney beans. Mix well.
1 cup canned kidney beans 1 medium red onion 1 medium carrot ¼ cup diced red pepper or sun dried tomatoes 2 tablespoons chopped fresh herbs such as parsley 1 teaspoon dried mixed herbs 400 grams lean mince such as topside or premium ¼ cup frozen whole kernel corn 1 teaspoon mustard powder 2 tablespoons tomato sauce 2 tablespoons Worcestershire sauce 2 teaspoons beef stock powder ½ cup rolled oats 1 medium egg white 12 slices shaved ham 2 tablespoons tomato sauce 2 tablespoons Worcestershire sauce 2 tablespoons hot water Garnish (optional) 6 fresh sage leaves
Lay strips of the shaved ham in the bottom and up the sides of the tin/s. Lightly pack in the meat mixture and bake for 15 minutes. Combine the second measure of the tomato and Worcestershire sauces with the hot water. Mix to a smooth paste. Spread over the top of the loaf or loaves. Cook for another 10 minutes for the mini loaves and another 30–35 minutes for the large loaf. Leave in the tins for 5 minutes then remove. Serve warm, upside down, and garnished with sage leaves. Serve with some crusty bread and a leafy green salad. *Gluten-Free: Use gluten-free mustard powder, tomato and Worcestershire sauces and stock powder. Substitute the oats with gluten-free breadcrumbs. Serves 6 NUTRITION PER SERVE (NOT INCLUDING SIDE DISHES): Energy: 960kj/ (230 cal), Carbohydrate: 16g, Fibre: 3.8g, Total fat: 7.7g, Saturated fat: 2.4g, Sodium: 1339mg, GI: Low
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FOOD & RECIPES
Corn and cheese topped potatoes These potatoes have less fat than a baked potato served with butter or sour cream – and much more flavour.
4 medium potatoes
Preheat the oven to 200°C (180°C fan).
light spray oil
Scrub the potatoes. Spray with oil and bake for 50–60 minutes or until cooked.
2 spring onions or 1 small red onion ½ medium red pepper 2 rashers lean bacon or 2 slices ham (optional) ½ cup canned cream-style corn ½ cup low fat cottage cheese ½ teaspoon French onion soup powder sprinkle grated parmesan cheese to garnish (optional) 8 sprigs fresh herbs
Slice the onion, red pepper and bacon finely. Cook in a non-stick frying pan until browned. Remove from the heat and add the corn, cottage cheese and soup powder. Mix well. Slice the potatoes in half lengthwise. Spread over the topping and sprinkle with the parmesan cheese. Bake for a further 10–15 minutes until browned. Serve with some sprigs of herbs. *Gluten-free: Use gluten-free cream style corn, cottage cheese and soup powder Serves 4 NUTRITION PER SERVE: Energy: 799kj (191 cal), Carbohydrate: 30g, Fibre: 4.3g, Total fat: 2.4g, Saturated fat: 1.1g, Sodium: 323mg, GI: High
*See overleaf for Julie's fabulous banana and prune loaf recipe.
Winter 2014 | DIABETES
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FO O D
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H E A LTHY GOURMET EATING
Banana & prune loaf Nuts and seeds add a different texture in baking. They are high in fat (and kilojoules), but the fat that is predominant in them is beneficial for heart health.
¾ cup dried prunes 1 teaspoon baking soda ¾ cup boiling water 1 cup plain flour 1 tablespoon baking powder 1 cup wholemeal flour ¼ cup lightly packed brown sugar ¼ cup castor sugar or equivalent sweetener 1/3 cup chopped walnuts 2 medium whole eggs ½ cup low fat milk 2 (250 grams) bananas 2 tablespoons vegetable oil
Preheat the oven to 180°C (160°C fan). Line a loaf tin (13 x 23 cm) with baking paper. Chop the prunes into small pieces and place in a bowl. Sprinkle over the baking soda and water. Leave for 10 minutes. Sift the plain flour and baking powder. Add the wholemeal flour, brown sugar, castor sugar or sweetener and nuts. Beat the eggs with the milk. Mash the bananas and add the oil. Combine all the ingredients together gently. Do not over mix. Place in the loaf tin and bake for 45–50 minutes or until cooked. Leave in the tin for 5 minutes then place on a cooling rack to cool. Best eaten fresh (1–2 days) or frozen and then reheated in the microwave. 15 Serves NUTRITION PER SERVE: Energy: 617kj (148 cal), Carbohydrate: 23g, Fibre: 2.0g, Total fat: 4.6g, Saturated fat: 0.6g, Sodium: 140mg, GI: Medium
Julie Leeper has always had a passion for cooking. Julie worked for nine years as a community dietitian. She was one of the first dietitians in New Zealand to run supermarket tours and work with chefs, winning public health awards for these initiatives. Julie has also worked as a food writer and provided dietetic advice for the food and hospitality industry. She is currently in private practice. Her belief is that food should not only be healthy, it should also look and taste great – hence NOSH!
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REDUCI NG STRO KE RI S K
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FOOD & NUTRITION
Slash the salt Strokes are more common in people with diabetes and their impact is greater. Reducing salt lowers high blood pressure, which is a major risk factor for stroke. Here are the Stroke Foundation’s top tips for slashing the salt.
SALT GUIDE
How much is too much? The maximum daily intake for adult Kiwis is 2,300mg of sodium or one teaspoon of salt.
Did you know that the maximum daily amount of salt recommended for adult Kiwis is just one teaspoon a day? And that’s from all sources, not just the salt you sprinkle on your food. In fact most salt is hidden in processed foods, such as breakfast cereals, cheese, deli meats, pizza, sauces, soups, bakery products and packaged ready-to-eat meals, snacks and takeaways. Mark Vivian, chief executive of the Stroke Foundation, says: “The research shows that if you stop using salt at the table or in cooking it would only affect 15 per cent of your overall salt intake. Most of your salt comes from processed foods, such as breakfast cereals and deli meats. “The reason why salt is so important is that it is associated with high blood pressure so reducing your salt will reduce your blood pressure and high blood pressure is the single biggest risk factor associated with stroke.”
What is salt? Salt is made up of 40 per cent sodium and 60 per cent chloride. It's the sodium in salt that can be harmful to health. Only a tiny amount of sodium is needed to help regulate fluids and blood pressure. Too much sodium in the diet can raise blood pressure and lead to strokes, heart attacks, kidney disease, stomach cancer, osteoporosis and other conditions. The maximum daily amount of salt recommended for adult Kiwis is 6g (equivalent to 2,300mg of sodium). The Stroke Foundation recommends several ways to reduce your salt intake, including: • E ating more fresh foods and using less salt in cooking and at the table. • C hecking the nutritional panel and choosing lower sodium options (see right). • E ating less fast foods, takeaways, processed meats and sauces. • Using herbs, spices and other seasonings instead of salt.
LOW-SALT FOODS Less than 120mg sodium per 100g. These are good choices.
MEDIUM-SALT FOODS 120 to 600mg sodium per 100g. These foods are OK most of the time, but try to choose foods from the lower end of this range. Limit these foods if you have a salt-related health problem (such as high blood pressure).
HIGH-SALT FOODS More than 600mg sodium per 100g. Limit these foods.
Check the label A nutritional food label must list how much sodium (salt) is in the product. A simple rule of thumb is to check the amount of sodium per 100g in the product. A low-salt product contains less than 120mg of sodium per 100g. Nutritional label: Servings per package: 3 Serving size: 80g Quantity per serving
Quantity per 100g
Energy
290kJ
360kJ
Protein
3.0g
3.7g
Fat, total
1.0g
1.2g
Saturated
0.1g
0.1g
Carbohydrate
10.5g
13.1g
Sugars
2.7g
3.4g
Dietary fibre
2.9g
3.6g
Sodium
95mg
115mg
Potassium
270mg
335mg
This product is a good low-salt choice: it contains less than 120mg of sodium per 100g
For more information about stroke and reducing salt intake see stroke.org.nz.
Winter 2014 | DIABETES
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D IABETES IN IND IA
Life in India is sweet – unless you have diabetes Erin Little is the American founder and Executive Director of Sucre Bleu, a community-based organisation working to improve the lives of people with diabetes in Bangalore, India. She is an International Diabetes Federation Young Leader in Diabetes and represented the US at last year’s Melbourne World Diabetes Congress. Carrie Hetherington found out about Erin’s inspirational work in rural India when she interviewed her for Diabetes.
Your organisation Sucre Bleu sounds like an incredible venture, what kind of projects are you running at the moment? Our main programme is called Peers for Health. We partner with existing healthcare institutions, and train their patients and caregivers in rural and urban poor communities on how to screen, diagnose, and provide care and follow ups for diabetes, hypertension, and cardiovascular disease, also known as non-communicable diseases. Here in India, there is often a lack of compassion and medical care for people with diabetes, and stigmas are high.
Erin Little (third from left) with members of the Sucre Bleu team in Bangalore, India.
How long have you had diabetes? I was diagnosed at the age of 11. I’m now 27, so 16 years and counting. You’re originally from America, but you're now living in India – why did you decide to move halfway across the world? India had been on my heart and my mind since I was roughly seven years old. When I was old enough to get a passport, I bought a 10-year visa just to encourage myself to follow my dream. I knew this was a part of my journey. It was something I needed to do to become my best self. Did you face any opposition from the community when you began or did they welcome your new diabetes initiative? We emphasise the power of relationships and generally work with individuals who have lived their entire lives in the same community. A lot of time and attention goes into assuring we have full support from the entire village before we start. We begin with the spouses and families of the patient and caregiver, the local village leadership, and we complete due diligence on the people that we bring into the programme. It's not just about throwing a health care worker into the field, but really building their leadership capacity. Having diabetes yourself, I can imagine you have been a role model and inspiration for some of the young children and families. How do people react to you? I think the patients are very curious about why I have chosen to do this, but it's really them who are my inspiration. Many type 1 children in India die before they are diagnosed,
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DI A BETES I N I NDI A
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COM MUNITY
and many don't survive past the age of 25 due to the challenges associated with care here. A month ago we had a mother come up to some of the team, and confess she wanted to kill her daughter who was type 1 and then kill herself because she had no support or access to diabetes care. Since then she has received treatment, her daughter excels better than the other members of her family and the mother wishes her sons were more like her daughter! I think as a type 1 myself, I feel a sense of connectedness with other diabetics, almost a sense of family. So at the end of the day it's less about inspiration and more about sharing one another’s struggles and empathising – whether it’s because you feel terrible from having a high blood glucose reading, or you’re going blind at the age of 10 from not having access to insulin. I think we all want to know there is a safe place where we can be understood for who we are without always having to explain it.
What has it been like for you living with type 1 in India? There is a lot of stigma here with being diabetic, even more with type 1. People don't understand the disease, so you get a lot of goodintended people trying to cure it. Here getting married is a huge issue for girls with type 1– so many people assume I cannot (or do not intend to) get married. After 22 is considered too old by many standards. I think it has been easier to maintain my type 1 here in India
Many Indian children with diabetes die before they are diagnosed.
than in the US due to the cost of the medicines and the fact I do my best to ensure I am a healthy role model – I go to the gym and eat right. The hardest thing was moving from Bombay to Bangalore – to an almost entirely vegetarian culture with a heavy carb-based diet.
Have Sucre Bleu and India changed your life in a positive way? I have been incredibly humbled through this entire experience. I have seen the best and the worst of myself, and I think it has been very cathartic for me to be here. I was a punk rock kid, and have always been a rebel of some kind, and a lot of that had to do with having a disease thrown at me and never accepting it. When I first moved to India I couldn't keep my weight under control, and had a very hard time even keeping a schedule because I was sick about 50 per cent of the time. Dr. Srikanta, my clinical partner, asked me to speak about what life was like as a diabetic in front of his entire staff. No one
had ever asked me this question, definitely not in the US. I cried for almost an hour. I was so moved that anyone cared! Sixteen years and no one ever asked what it was like to have diabetes or to manage all the challenges associated with the disease. I think when you see how powerful the human spirit is, and the genuine kindness of those around you here in India, it gives you peace. Peace to accept things and let go. Patience to believe that change is possible. Resilience to see that you have been given a gift and have a duty to live up to your full potential as a human being.
Although it can be so frustrating, what is the best part about having diabetes? It always gave me a reason to skip class. But don’t tell my teachers that… *Find out more about Sucre Bleu’s work in India on www.sucreblue.org. You can also follow Erin’s work via Facebook or Twitter.
Winter 2014 | DIABETES
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INTERNATIONAL D IABETES FEDERATI O N
Global project aims to stem diabetes-related blindness A project has been launched to assess the awareness, treatment and implications of diabetic retinopathy worldwide. Results are intended to inform decisionmaking and policy development around this common and serious complication of diabetes.
with known type 1 and type 2 diabetes worldwide – ranging from 11 to 45 per cent.
Retinopathy is one of the most common complications associated with diabetes and one of the major causes of adult blindness. Up to 11 per cent of adults with diabetes have diabetic macular edema, a specific type of diabetic retinopathy. There are large variations in the estimates of retinopathy prevalence in people
Project partners, the International Federation on Ageing and the International Diabetes Federation, working with the New York Academy of Medicine and the International Agency for the Prevention of Blindness, will gather evidence on knowledge, policies, standards of care, and supportive services for retinopathy across 40 countries. “Unless we act now to stem the diabetes epidemic and provide joined up services that enable
people with diabetes to be checked and treated for diabetic retinopathy then the number of blind people in the world will increase dramatically in forthcoming years,” said Peter Ackland, Chief Executive of the International Agency for the Prevention of Blindness. The project will culminate in a barometer report and a compendium of resources designed to increase awareness, as well as to inform policy and practice related to diabetic retinopathy and vision loss across countries. *See www.idf.org.nz for details.
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DIABETES | Winter 2014
Launch of newly diagnosed packs well received I am pleased to report Diabetes Youth New Zealand has begun sending out the first of our Newly Diagnosed Packs to our local societies and district health boards. It is the culmination of a two-year effort and we are excited to finally see it in action! The idea was first mooted a few years ago during a Diabetes Youth workshop attended by local groups around the country. Everyone thought it would be a good idea to deveop a ‘standard’ newly-diagnosed information pack for families across the country as they begin their journey with diabetes. The pack would cover the basic materials needed by a newly diagnosed young person, while assisting in off-setting costs to the local societies. Local societies could add extra materials as they saw fit or send the pack on its own if they preferred. Last year we decided to change our fundraising strategy so these packs could come into being. We
changed our Yellow Balloon Day campaign with the Lions Club to the ‘Newly Diagnosed’ campaign and I am happy to say it was well received. Each pack costs $60 for us to make up and through the Lions Clubs we have raised approximately $14,000 in order for us to be able to send them out free of charge. We have estimated that 300 packs will be needed in 2014 for all the newly diagnosed children and young people in New Zealand. I would personally like to thank everyone who has helped Diabetes Diabetes Youth New Zealand sent Youth in putting these packs out the first of these packs to local together. I would also like to thank societies and to district health the Lions Club for their donations boards across the country in April. and support as well as Pharmaco Each child receives a blue backpack for the donation of the parent containing: manuals and flip charts and Sanofi • information booklet for the donation of the MediKidz • parent manual comic books. • flip chart for schools • supply carrying case If you would like to donate to the • MediKids diabetes comic book Newly Diagnosed Packs, you can • pen with quick reference hypo find Diabetes Youth New Zealand information on Fundraiseonline.co.nz. In the • diabetes log book message section, please note that • temporary wallet medical you wish to have the funds go ID card. directly to the Newly Diagnosed Packs. To date, we have sent out 118 packs and I am happy to say that the feedback has been nothing but positive. Societies are thankful for the assistance and families are happy to know there is support for them. We have put a workstream in place to monitor the packs’ effectiveness and ensure that we continue to expand the packs and offer relevant materials and items to the families we support. We welcome any and all feedback as this will only help to support our efforts.
For more information, please send an email to contact@diabetesyouth.org.nz.
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
JOIN YOUR LOCAL SUPPORT GROUP BY VISITING
General enquiries: contact@diabetesyouth.org.nz Phone: (09) 623 2508
FIND US ON FACEBOOK AND TWITTER
www.diabetesyouth.org.nz
RES EA RCH
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L ARGE-SCALE VITAMIN D CLI NI CA L TRI A L
Can vitamin D prevent type 2 diabetes? A large US clinical trial hopes to provide a definitive answer to the question of whether a simple vitamin pill could lower the risk of developing type 2 diabetes. Caroline Wood reports. Researchers have begun the first large-scale clinical trial to investigate if a vitamin D supplement helps prevent or delay type 2 diabetes in adults with prediabetes. The Vitamin D and Type 2 Diabetes (D2d) study will include about 2,500 people. Funded by the American National Institutes of Health, the multi-year study is taking place at about 20 study sites across the United States.
Based on observations from earlier studies, researchers speculate that vitamin D could reduce the diabetes risk by 25 per cent. The study will also examine if sex, age or race affect the potential of vitamin D to reduce diabetes risk.
Its goal is to learn if vitamin D – specifically D3 (cholecalciferol) – will prevent or delay type 2 diabetes in adults aged 30 or older with prediabetes. People with prediabetes have elevated blood glucose levels that are higher than normal but not high enough to be called diabetes. They are at a high risk of developing type 2 diabetes. “This study aims to definitively answer the question: Can vitamin D reduce the risk of developing type 2 diabetes?” said Dr Myrlene Staten, D2d project officer at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. “Vitamin D use has risen sharply in the US in the last 15 years, since it has been suggested as a remedy for a variety of conditions, including prevention of type 2 diabetes. But we need rigorous testing to determine if vitamin D will help prevent diabetes. That’s what D2d will do.” “Past observational studies have suggested that higher levels of vitamin D may be beneficial in
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DIABETES | Winter 2014
preventing type 2 diabetes, but until this large, randomised and controlled clinical trial is complete, we won’t know if taking vitamin D supplements lowers the risk of diabetes,” said Dr Anastassios G Pittas, the study’s principal investigator at Tufts Medical Center, Boston. D2d is the first study to directly examine if a daily dose of 4,000 International Units (IUs) of vitamin D – greater than a typical adult intake of 600-800 IUs a day, but within limits deemed appropriate for clinical research by the Institute of Medicine – helps keep people with prediabetes from getting type 2 diabetes. Based on observations from earlier studies, researchers speculate that vitamin D could reduce the diabetes risk by 25 percent. The study will also examine if sex, age or race affect the potential of vitamin D to reduce diabetes risk. Half the participants will receive vitamin D. The other half will receive a placebo – a pill that has no drug effect. Participants will have check-ups for the study twice a year, and will receive regular health care through their own health care providers. The study will be double-blinded, so neither participants nor the study’s clinical staff will know who is receiving vitamin D and who is receiving placebo. The study will continue until enough people have developed type 2 diabetes to be able to make a scientifically valid comparison between diabetes development in the two groups, likely to be about four years. *See www.d2dstudy.org for more information about the study.
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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