ORAL PRESENTATION TIMETABLE
SESSION 1 Wednesday 21, APRIL 1345-1500
# - Time
01.
1345-1400
Lead Presenter
Simon THORNLEY
Page 10
Title
TRACKING DIABETES FROM LINKED
NATIONAL HEALTH RECORDS: DO THEY
AGREE WITH PRIMARY CARE DIAGNOSES?
Affiliation
SPH -University of
Auckland
02.
1400- 1415
Emmanuel JO
Page 10
ADMISSIONS TO NEW ZEALAND HOSPITALS
FOR PEOPLE WITH DIABETES: 1999-2008
Ministry of Health
03.
1415-1430
Grace JOSHY
Page 11
DIABETES SURVEILLANCE IN THE WAIKATO:
THE REGIONAL DIABETES INFORMATION
SERVICE PROJECT
Waikato Clinical School
04.
1430-1445
Corina GREY
Page 11
A COMPARATIVE ANALYSIS OF DIABETES
PREVALENCE IN PACIFIC PEOPLES AND
EUROPEANS ASSESSED ROUTINELY IN
PRIMARY CARE
SPH -University of
Auckland
05.
1445-1500
Grace JOSHY
Page 12
NON-TRAUMATIC LOWER EXTREMITY
AMPUTATIONS IN THE WAIKATO 2000-2008:
IMPACT OF DIABETES
Waikato Clinical School
ABSTRACT ORAL PRESENTATIONS
01.
TRACKING DIABETES FROM LINKED NATIONAL HEALTH RECORDS: DO THEY AGREE WITH
PRIMARY CARE DIAGNOSES?
Simon Thornley,1 Craig Wright,2 Roger Marshall,1 Gary Jackson,3 Paul L Drury,4 Susan Wells,1 James Smith,5
Wing Cheuk Chan,3Romana Pylypchuk,1 Rod Jackson.1
1Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland; 2Ministry of
Health, Wellington; 3Counties Manukau District Health Board, 19 Lambie Drive, Manukau City; 4Auckland
Diabetes Centre, Auckland District Health Board, Greenlane Clinical Centre; 5Auckland Regional Public Health
Service, Greenlane Clinical Centre, Auckland
Aim: To assess the validity of an algorithm for estimating the prevalence of diagnosed diabetes using linked national
health records.
Methods: We measured the agreement between a diabetes diagnosis (using an algorithm based on appearance on
national lists of drug dispensing, outpatient attendance, laboratory tests (HbA1c) and hospital diagnoses) and a primary
care diagnosis in a cohort of nearly 54,000 adult New Zealanders. Participants were selected by their general
practitioners for a cardiovascular risk assessment using the PREDICT™ decision support system.
Results: The primary care cohort had a prevalence of recorded diabetes of 20.9% (11,266/53,911), similar to our listderived prevalence of 20.1% (10,837/53,911). Of the participants with a diagnosis of diabetes in primary care, 86%
(9,719/11,266) were similarly diagnosed by the list algorithm, indicating that about one in seven people with a primary
care diagnosis had not been either admitted to hospital, seen at outpatient clinics, prescribed diabetes drugs or
undertaken regular HbA1c tests. Conversely, 10.3% (1,118/10,837) of the people who had a diagnosis from the four
lists, did not have a corresponding PREDICT record of diabetes. The kappa statistic measure of agreement was 0.85.
Conclusion: Estimating the prevalence of diagnosed diabetes based on appearance on any one of four routinely
collected national databases shows good agreement with primary care records. Our findings suggest that linked health
data can provide a timely and efficient method for tracking prevalence of diagnosed diabetes in health care systems
where such data is individually linked.
02.
ADMISSIONS TO NEW ZEALAND HOSPITALS FOR PEOPLE WITH DIABETES: 1999-2008
Emmanuel Jo, Sandy Dawson, Pauline Giles, Paul L Drury.
Ministry of Health, Wellington and NZSSD Inpatient Study Group
Recent studies in New Zealand (NZ) suggest that up to 25% of people admitted to hospital may have diabetes, though
are often not recognised and/or coded as such, a situation recently worsened by an Australasian coding decision in mid2008. Our aim was to examine recent national data on admission rates and the major clinical causes. We have thus
analysed Ministry data on the number of patients admitted each year between 1999-2000 and 2007-08 with diabetesrelated conditions (using ICD9 and ICD10 codes). Admissions have been recorded for specific diabetes problems such
as ketoacidosis (DKA) and hypoglycaemia – more likely to be coded correctly - as well as the macrovascular
complications. We have also “corrected” these figures to 1999-2000 levels assuming a 5% annual increase in national
diabetes prevalence.
1999-2000 2007-08 Change
absolute
absolute absolute
(%)
45037
67347
+50%
617
848
+37%
1168
2679
+129%
4430
5472
+24%
19992000
basal
45037
617
1168
4430
2007-08
Change in
“corrected” rate (%)
All diabetes codes
45583
+1%
Ketoacidosis
574
-7%
Hypoglycaemia
1813
+55%
Acute Coronary
3704
-16%
Syndromes
Stroke
1830
2154
+18%
1830
1458
-20%
Amputation
507
518
+2%
507
351
-31%
Other atherosclerosis
1231
4649
+277%
1231
3147
+155%
Diabetes was only coded in 6.0% of 757,000 NZ admissions in 1999-00 and in 7.4% of 904,000 in 2007-08 suggestive of
massive under-reporting. The overall increase in admission numbers is consistent with the increasing prevalence but,
within this, there appears to be clear evidence of:
 Increasing rates of admission with hypoglycaemia, usually a primary coding
 Reduced rates of all major cardiovascular events, especially amputation
 Markedly increased rates of admission with less specified atherosclerosis
We conclude that current statistics substantially underestimate the scale of the problem, but that there are important
clinical trends in the causes and rates of admissions.
03.
DIABETES SURVEILLANCE IN THE WAIKATO: THE REGIONAL DIABETES INFORMATION SERVICE
PROJECT Grace Joshya, Peter Dunnb, Ross Lawrensona
Waikato Clinical School, University of Auckland, Hamilton, New Zealand;
Service, Waikato Hospital, Hamilton, New Zealand.
a
b
Waikato Regional Diabetes
Background: Robust reliable regional level diabetes surveillance data is needed for better planning and provision of
diabetes services at DHB level. Current systems fall short in their ability to access the true number of people diagnosed
with diabetes in a timely fashion, coverage of diabetes care programmes like “Get Checked” and retinal screening,
interventions aimed at patients at risk of complications, the impact of diabetes and its complications on health service
utilisation and mortality trends among diabetes patients.
Methodology: The RDIS project, a partnership between the Waikato DHB, Pinnacle Group Ltd and Waikato Clinical
School, has established a database of known diabetes patients using existing primary care and secondary care
datasets.
The Waikato Regional Diabetes Service (WRDS) provides secondary diabetes service including mobile retinal screening
in the Waikato DHB region. Patients are screened every two years and the register is thought to be 90% complete.
Waikato Primary Health (WPH) is the largest PHO in the Waikato area with over 11,000 people diagnosed with diabetes.
Pinnacle Group Ltd provides “Get Checked” data management for WPH and Te Kohao Health, accounting for 97% of
reviews in 2007. The initial RDIS database was setup using PHO coded diabetes database, Pinnacle’s “Get Checked”
database, the WRDS retinal screening database and Waikato DHB in-patient management system. Data will be updated
quarterly.
Results: The database currently contains over 17,000 people with diabetes. Coverage of the “Get Checked” review
programme and the retinal screening programme were audited using the database.
Discussion: The development of the RDIS database provides a model for the development of a regional diabetes
register using routinely collected data from both primary and secondary care. It will be used to closely follow up the
quality of diabetes care and will provide the much needed estimates of incidence, prevalence, service utilisation and
health outcomes.
04.
A COMPARATIVE ANALYSIS OF DIABETES PREVALENCE IN PACIFIC PEOPLES AND EUROPEANS
ASSESSED ROUTINELY IN PRIMARY CARE.
Corina Grey, Sue Wells, Tania Riddell, Romana Pylypchuk, Andrew Kerr, Dudley Gentles, Roger Marshall, Paul
Drury, Raina Elley, Shanthi Ameratunga, Rod Jackson.
Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland.
Aim: To describe differences in diabetes prevalence between Pacific peoples and Europeans, and between five Pacific
ethnic subgroups, assessed in routine primary care practice by PREDICT, a web-based clinical decision support
programme for assessing and managing cardiovascular disease (CVD) risk.
Methods: Between 2002 and January 2009, CVD risk assessments were conducted on 39,835 Europeans and 10,301
Pacific peoples aged 35-74 years with and without a prior CVD event using PREDICT. The Pacific cohort was
comprised of 4933 Samoans, 1724 Tongans, 1366 Cook Island Maori, 880 Niueans and 1398 people identified as ‘Other
Pacific’ or ‘Pacific Not Further Defined’. Prevalence of diabetes was calculated for Europeans and the total Pacific
group, and for each of the Pacific subgroups. Age- and deprivation-adjusted risk ratios were calculated using Europeans
as the reference group in the Pacific/European analysis and Samoans as the reference group in the Pacific subgroups
analysis.
Results: Pacific versus European Analysis: In this cohort, 10% of European men and women were diagnosed with
diabetes, compared to 28% of Pacific men and 36% of Pacific women. Pacific men were 2.6 times more likely, and
Pacific women 3.3 times more likely, than their European counterparts, to be diagnosed with diabetes. (Risk ratios and
95% confidence intervals 2.61 [2.45-2.78] and 3.33 [3.13-3.55] respectively).
Pacific Subgroups Analysis: Among Pacific subgroups, Tongan women and Niuean men and women had the highest
prevalence rates of diabetes (ranging from 37% to 41%). Compared to their Samoan counterparts, Niuean men were
31% more likely, and Niuean and Tongan women 17% and 26% more likely, to be diagnosed with diabetes. (RRs and
95% CIs 1.31 [1.15-1.48], 1.17 [1.04-1.32] and 1.26 [1.15-1.39] respectively).
Conclusions: This cohort highlights significant disparities in diabetes prevalence between Pacific peoples and
Europeans, and much smaller differences between Pacific subgroups. Diabetes remains a key contributor to health
inequalities between Pacific peoples and Europeans in New Zealand.
05.
NON-TRAUMATIC LOWER EXTREMITY AMPUTATIONS IN THE WAIKATO 2000-2008: IMPACT OF
DIABETES
Grace Joshya, Peter Dunnb, Paul Haggartc, Alan Fletcherd, Ross Lawrensona
a Waikato Clinical School, University of Auckland, Hamilton, New Zealand; b Waikato Regional Diabetes
Service, Waikato Hospital, Hamilton, New Zealand; c Vascular Surgery, Waikato Hospital, Hamilton, New
Zealand; d Medical Student, University of Aberdeen, United Kingdom
Background: There is a lack of longitudinal data on diabetes related amputations in the Waikato. The aim of this study
was to look at the impact of diabetes on non-traumatic lower extremity amputation (LEA) procedures in the Waikato.
Methods: Retrospective review of non-traumatic LEA discharges from the Waikato DHB hospitals during 2000-2008.
Data were linked with the Waikato Regional Diabetes Service database. Diabetes coding on admissions and diabetes
status recorded on the WRDS database were used to determine diabetes status. End stage renal disease (ESRD) status
was determined using electronic patient records, searching for dialysis treatment or kidney transplant. One year of data
from vascular surgery database was used to validate events. Trends in LEA discharges over the years were examined
using BPCHART software. Logistic regression was used to estimate the likelihood of diabetes and ESRD co-morbidities
among LEA patients.
Results: There were 1264 non-traumatic LEA discharges from 2000-2008, among 804 patients. Procedures among
diabetes patients accounted for 686 (63%) of the 1093 discharges among Waikato DHB domiciled patients.
Of the 698 distinct patients who were domiciled within the Waikato DHB region, 370 (53%) had diabetes as indicated by
discharge diagnosis codes or registration with the Waikato Regional Diabetes Service. Among the 121 (20%) Maori
patients, 73% had diabetes and 26% had end stage renal disease. Among adult patients (aged>20) with major LEAs,
Maori were more likely than Europeans to have diabetes and ESRD co-morbidities. [Age and gender adjusted odds
ratios 5.6 (3.0,10.6) and 8.5 (3.8,18.9) respectively].
No significant change in trend in the number LEAs among people with diabetes was observed during the study period.
Figure 1. Number of non-traumatic LEA discharges among people with diabetes in the Waikato: 2000-2008
100
90
80
70
Minor
60
Major
50
Total
40
30
20
10
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
Conclusion: Nearly two-third of non-traumatic LEA procedures was among diabetes patients. Further investigation into
the incidence of LEAs is being carried out.
SESSION 2 Wednesday 21, APRIL 1530-1630
# - Time
Lead Presenter
06.
Jinny WILLIS
1530-1545
Page 14
07.
Gemma STOTT
1545-1600
Page 14
Title
Affiliation
TYPE 1 DIABETES IN CANTERBURY
CHILDREN AND ADOLESCENTS: 1970-2009
Christchurch Hospital
HOW TO INCORPORATE DAFNE INTO
ROUTINE CLINICAL PRACTICE
Waitemata DHB
08.
Martin De BOCK
1600-1612
Page 15
09.
Rab BURTUN
1612-1622
Page 15
10.
Pui Ling CHAN
1622-1632
Page 16
06.
INSULIN PUMP THERAPY IN CHILDREN AND
ADOLESCENTS WITH TYPE 1 DIABETES: THE
AUCKLAND PAEDIATRIC DIABETES
EXPERIENCE 2002-08
Paediatrics -University of
Auckland
WHICH PATIENTS ARE BEST SUITED TO A
PREMIX ANALOGUE INSULIN REGIMEN?
AUDIT OF CLINICAL RESPONSE IN PATIENTS
WITH TYPE 2 DIABETES
Waitemata DHB
INSULIN ERRORS IN A HOSPITAL SETTING
Waitemata DHB
TYPE 1 DIABETES IN CANTERBURY CHILDREN AND ADOLESCENTS: 1970-2009
JA Willis1, RS Scott1, B A Darlow2 on behalf of Paediatric and Adult Diabetes Services, CDHB
1Lipid & Diabetes Research Group, Christchurch Hospital, Christchurch, New Zealand; 2Department of
Paediatrics, University of Otago, Christchurch, New Zealand
Background Type 1 diabetes is an autoimmune disorder thought to be precipitated by environmental factors in
individuals with permissive genotypes. The incidence of the disease is increasing in many populations. The prevalence
of high-risk HLA genotypes has decreased over time in type 1 diabetes cases, suggesting that environmental factors are
contributing to increasing disease penetrance. The objectives of this research were to ascertain and characterise every
new case of type 1 diabetes in individuals aged less than 20 years normally resident in the Canterbury geographical
region from1970 to the present day.
Methods Prospective ascertainment of all incident cases commenced in this region in 1982. Prior to 1982, incident
cases were ascertained retrospectively from hospital records. All cases presenting from 1970 to the present day have
been ascertained. Clinical and demographic data were collected at diagnosis. Age and sex specific annual incidence
rates were determined from five-yearly census population denominators.
Results For the years 1970-2009, there were 744 new type 1 diabetes cases (381 males, 363 females) aged 0-19
years diagnosed in the Canterbury geographical region. The incidence ranged from 2.40 cases to 28.60 cases/100 000
person years. Mean (SEM) incidence rates for the age groups 0-4 years, 5-9 years, 10-14 years, 15-19 years were
11.81 (1.38), 15.13 (1.61), 21.75 (2.12) and 10.49 (1.37) cases/100 000 person years respectively. The increase in
incidence rate over the four decades was 0.55 cases/100 000 per year (P<0.0001), representing a three-fold increase in
the mean incidence rate per decade. The greatest increase in attack rates occurred in 0-14 year olds. The cohort was
predominantly European, though increasing numbers of Maori and Pacific Island children have presented in the last
decade.
Conclusions The rate of presentation of type 1 diabetes in Canterbury children and adolescents is rapidly increasing.
Temporal trends reflect those observed in other countries. The highest risk is still associated with European ethnicity,
though there is an increase in individuals identifying with ethnicities traditionally associated with lower risk.
07.
HOW TO INCORPORATE DAFNE INTO ROUTINE CLINICAL PRACTICE.
G Stott, E Sumpter, Catherine McNamara
Diabetes Services, Waitemata District Health Board, Auckland.
Background: DAFNE is recommended by NICE in the UK as best clinical management for patients with Type 1
Diabetes. We have been running DAFNE courses at WDHB for eighteen months. Consumer response indicates that we
should incorporate DAFNE into routine clinical practice. To determine the feasibility of doing this we have costed the
program and analysed one year clinical data so far.
Methods: The DAFNE team currently comprises 6 DAFNE educators, a part-time administrator and 2 physicians.
DAFNE graduates are invited to a rolling program of follow-up which is currently being piloted. Clinical contact is
recorded on PIMS and CVDIS.
Results: We have delivered 18 courses (152 patients) with 100% attendance. Principal DAFNE goals to improve
quality of life and reduce severe hypoglycaemia have been achieved (PAID score reduced 50%, hypos reduced by
70%). Lipids, creatinine and HbA1c have all improved. Mean improvement in HbAlc at one year is 0.1% but this
includes patients who have improved from overly tight control. Course costs per patient include salary for educator time
allocated to a pre-course assessment, 5 day course, follow up rolling programme, preparation and stats collection and
email support, one year follow up clinic and 30% overhead. This calculates to $466 per patient. Compared to clinic
setting if a patient sees a nurse twice per year, dietitian and consultant once a year, this calculates to $236 per patient.
Conclusions: Initial outlay costs for the course are feasible given that when comparing the amount of time the patient
has alongside a clinician, 50hrs for the DAFNE programme (including FU) compared with 3.67hrs standard care, the cost
benefit: is $9/hr of clinician time for DAFNE and $64/hr for standard care. Increased patient autonomy, which is another
key goal of the DAFNE program, will reduce patient dependency on one to one clinic visits.
08.
TITLE: INSULIN PUMP THERAPY IN CHILDREN AND ADOLESCENTS WITH TYPE 1 DIABETES: THE
AUCKLAND PAEDIATRIC DIABETES EXPERIENCE 2002-2008.
Martin de Bock1, Peter Reed2, Jean Ann Holt2, Grace Harris2, Caroline Adamson2, Wayne Cutfield1, Fran
Mouat2, Paul Hofman1, Alistair Gunn3 & Craig Jefferies2.
1 Liggins institute, University of Auckland; 2 Starship Children’s Health; 3 Department of Physiology, University of
Auckland.
Aim: To examine the clinical impact of insulin pumps in the Paediatric Diabetes service at the Starship in children and
adolescents with type 1 diabetes mellitus (T1DM).
Methods: A retrospective audit of the Starbase Paediatric Diabetes database for Auckland. The recorded clinical data in
T1DM seen diabetes service from 1 January 2002 to 31 December 2008 was included. Data at each 3-month clinic visit
was recorded in the Starbase database: age, duration of diabetes, duration on pump, height, weight, BMI, insulin dose,
severe hypoglycaemia and DKA date. All pump patients were on an insulin pump for >12 months. A comparison was
also made to an age/sex matched group who were not on pumps. Retrospective ethics was obtained.
Results: 621 subjects of which 74 used insulin pump, with a total of 6691 clinic visits were included. The mean age at
pump start was 10.2 years (2.75 - 16.1 years). Average time with T1DM prior to pump start was 4.25yrs (0.5y - 11.75
years). There was equal sex distribution, and the majority were European (93%).
Pump patients had a peak improvement in HbA1c of 0.54% at 18 months post pump start, using -0.18U/kg/day of
insulin, and were -0.1SDS on BMI.
Comparing pump children to matched non-pumpers, there was a difference in HbA1c even before pump start (-0.32% at
12 months from diagnosis), which persisted (-0.41% at average time of pump start) and was accentuated over the length
of follow-up (-0.6% at 10 years from diagnosis)
DKA and Hypoglycaemia rate appear to be reduced on insulin pump, final statistics awaited.
Conclusions: Insulin pump therapy is an increasingly popular method of insulin delivery in the paediatric population,
and can be safely instituted with a dedicated insulin pump team even in very young children. Their metabolic control is
maintained at an acceptable level, while the non-pump subjects had a persistent decline in HbA1c
09.
WHICH PATIENTS ARE BEST SUITED TO A PREMIX ANALOGUE INSULIN REGIMEN? AUDIT OF
CLINICAL RESPONSE IN PATIENTS WITH TYPE 2 DIABETES
R Burtun, N Cunningham, M Choe, S Young, R Cutfield, Catherine McNamara
Diabetes Services, Waitemata District Health Board, Auckland.
Background: In the secondary care service at Waitemata DHB, we estimate that approximately 50% of insulin- treated
Type 2 patients referred to us have an Hba1c > 8%. The potential benefits of premix analogue insulins over premixed
human insulin or basal insulin regimens, include better compliance because it can be taken immediately with food, less
hypoglycaemia and reduced weight gain. To test this hypothesis, we audited the 6 month clinical response of patients
started on Humalog Mix insulins between October 2008 and April 2009.
Methods: We agreed specific clinical criteria for commencement on Humalog Mix. Baseline and follow up data
including HbA1c, weight and compliance were recorded. The new insulin regimen was started in clinic by a Diabetes
Specialist Nurse.
Results: 34 clinic patients were commenced on Humalog Mix insulin (~40% New Zealand European, 20% Maori, 20%
Pacific Island and 20% South East Asian). 12 patients were previously on oral hypoglycaemic medications alone with
mean baseline HbA1 of 10.2%. 22 patients were already on insulin (10 on basal and 12 on premix), mean HBA1cs 9.7%
and 9% respectively. HbA1c in the insulin naïve patients improved to 7.9% and to 8.3% in the insulin treated groups.
However, a significant proportion of patients did not comply properly with insulin at baseline and/or follow-up (N=10).
Another 6 patients were lost to follow- up. Data on weight was incomplete but in the majority of recorded cases
remained stable.
Conclusion: Premix analogue insulin improved control in 38% of our patients and appears to have a role in the
intensification and also initiation of insulin therapy. However, problems with compliance and follow-up persisted. Future
strategies which include treatment algorithms and dietetic as well as cultural and social support, may be beneficial in
helping insulin treated patients to achieve target HbA1c levels.
10.
INSULIN ERRORS IN A HOSPITAL SETTING
J Mulvey1, PL Chan2, C McNamara2, M Choe2, S Young2, R Cutfield2
1Inpatient Pharmacy, 2Diabetes Services, Waitemata District Health Board, Auckland.
Aims/Background: Unfamiliarity with new insulin preparations and “mixes” amongst hospital staff, together with insulin
timing errors, food delay and inaccurate drug history, have caused a number of insulin prescribing and administration
errors in hospital wards. This clinical governance issue has prompted the Diabetes Team at WDHB with the help of
Pharmacy to raise awareness about different insulin preparations and also conduct a review of insulin errors and
concerns during 2009.
Methods: Pharmacists record all medication errors on a database. The number of errors recorded is dependent on the
level of pharmacist participation on post-acute ward rounds. We analysed the insulin errors recorded from January 2009
to January 2010, relating to prescribing, administrating and documentation. We feel that they reflect the majority of
events.
Results: Seven cases were identified where patients were given Humalog instead of a Humalog Mix (25 or 50), and
one when a patient was given Humalog instead of Humulin 30/70. Most of them were recognised early with adverse
events prevented, though in 2 cases significant hypoglycaemia occurred. Common insulin errors included: insulin not
being charted when known to be on insulin, errors of dose and timing, GIK transfer errors (stopping the GIK without
usual/new regimen being charted), and omission of insulin from discharge scripts.
Conclusion: Enhanced awareness about different insulins including Humalog Mix insulins, accurate medicine
reconciliation at admissions and greater involvement of the diabetes team should improve patient safety where insulin
prescription and administration is concerned. In view of the shortage of Diabetes Nurse Specialists, we see the hospital
pharmacists as an important resource to reduce insulin errors. Many diabetes patients themselves may be able to
manage their insulin better than hospital staff.
A repeat review by the Pharmacy after 6 months will hopefully demonstrate a positive impact of updated educational
resources and information.
SESSION 3 Thursday 22, APRIL 0915-1015
# - Time
11.
0915-0930
Lead Presenter
Kirsten COPPELL
Page 18
12.
0930-0945
13.
Simon YOUNG
Page 18
Jill ARNOLD
Title
COMPARISON OF TREATMENTS AND
CARDIOVASCULAR RISK FACTORS AT
DIAGNOSIS OF TYPE 2 DIABETES AND AT 5
YEARS FOLLOWING PARTICIPATION IN A
REGIONAL DIABETES QI INITIATIVE.
IMPROVING DIABETES CARE: A WEST
AUCKLAND PACIFIC CLINIC 1999-2008
PRIMARY CARE NURSES WALKING THE TALK.
Affiliation
ENCDR
University of Otago
Waitemata DHB
South Auckland
0945-0955
14.
0955-1005
Page 19
Ravi SUBRANIAM
Page 19
15.
1005-1015
Belinda IHAKA
Page 20
11.
THE EFFECT OF INTENSIVE PODIATRY CARE
ON CLINICAL STUDY ENROLMENT RATES OF
SLOW HEALING DIABETIC FOOT ULCERS.
Counties Manukau DHB
WAEWAE TAPU: PODIATRY ASSESSMENT IN
NZ - WILL THIS MAKE A DIFFERENCE?
AUT University Auckland
COMPARISON OF TREATMENTS AND CARDIOVASCULAR RISK FACTORS AT DIAGNOSIS OF TYPE 2
DIABETES AND AT 5 YEARS FOLLOWING PARTICIPATION IN A REGIONAL DIABETES QUALITY
IMPROVEMENT INITIATIVE
Kirsten Coppella,, Janet (EunHwa) Leea, Sheila Williamsb, Jim Manna.
a Edgar National Centre for Diabetes Research, Dunedin School of Medicine, PO Box 913, Dunedin.
b Department of Preventive and Social Medicine, Dunedin School of Medicine, PO Box 913, Dunedin.
Aim - to compare intermediate outcome measures at diagnosis and after 5 years amongst a cohort of new type 2
diabetes cases (T2DM) participating in a regional diabetes quality improvement initiative.
Methods - 1,108 new T2DM cases enrolled on the Otago Diabetes Register and diagnosed between 1997 and 2002
with recorded clinical and biochemical measures at diagnosis and at 5-years were identified. Age at diagnosis was
calculated for each individual, who was assigned to one of four age groups: <40 years, 40-59 years, 60-79 years and 80100 years. Cardiovascular risk was estimated using the National Heart Foundation 5-year Cardiovascular Risk Charts.
Means and standard deviations or percentages were calculated for variables of interest for the four age groups. Pvalues for differences over time and among the groups were calculated.
Results - the <40 year age group were obese and had the worst risk factor profile at diagnosis compared with the older
age groups. Improvements in clinical and laboratory measures were evident in all age groups at 5 years following
diagnosis, particularly the <40 year age group, who demonstrated statistically significant improvements in many
modifiable cardiovascular risk factors: weight decreased from 97.7±38.5kg to 91.0±43.8kg, P<0.001; systolic blood
pressure from 128.4±14.9mmHg to 115.8±39.2mmHg, P<0.001; total cholesterol from 5.4±1.1mmol/l to 4.9±0.8mmol/l,
P<0.001; triglycerides from 2.6±3.6mmol/l to 1.9±1.5mmol/l, P=0.001). However, in this group the greatest deterioration
in HbA1c was observed (from 7.3±1.9% to 7.9±1.7%, P<0.001) despite intensification of medication. Estimated 5-year
cardiovascular risk remained almost unchanged in all age groups.
Conclusions – good diabetes management, principally in primary care, can lead to improvements in most modifiable
cardiovascular risk factors in T2DM patients at 5 years following diagnosis. Targets for glycaemic control and weight are
less readily achieved amongst young age groups. Prevention of obesity, especially at young ages, provides the most
promising means to avoid the serious consequences of diabetes.
12.
IMPROVING DIABETES CARE: A WEST AUCKLAND PACIFIC CLINIC 1999-2008
S Young1, R Cutfield1, E Howard2, Sara Morton2, G Donald3
1. Waitemata DHB 2.Diabetes Project Trust 3.Westfono Clinic
Background Since 1999 The Diabetes Project Trust West Auckland audit has included a large practice with a
predominantly Pacific enrolment in West Auckland. This population faces significant socioeconomic challenges. Our aim
is to track quality of diabetes care since 1999.
Methods: The audit method has been previously described. Standard performance measures are collected. Results are
later fed back to the practice. Seven audit reports were available for review for the period 1999-2008.
Results: The practice is approximately 90% Pacific. The 2008 pass showed data collection and recording was as good
as or better than the whole region data and exceeded 90% in most cases. There was a massive improvement in the rate
of eye screening from only 16.9% in 1999 to 78.4% in 2008. Cardiovascular risk factor treatment improved significantly
over the ten years. Mean systolic BP dropped from 143 in 1999 to 130 in 2008. ACE inhibitor/ARB use rose from 28% in
1999 to around 80% in 2008 (versus 70% for the region). Mean total cholesterol dropped from 5.8 to 4.6. Improvement in
glycaemic control over the ten years was small. The mean HBA1C in 1999 was 8.6% (9.0% in 2000). In 2008 the mean
HBA1C was 8.3%. Metformin use rose from 38% in 1999 to 79.6% in 2008 and insulin use rose from 10% to 25%. The
use of glitazones was low at around 5%. The rate of nephropathy in 2008 was 14.8% and ESRF was 2.4%.
Discussion:
1. Marked improvements in data collection and some outcome measures have been helped by the audit process
plus improved clinic processes. .
2. The improvement in eye screening rates is likely due to the mobile retinal screening service.
3. Improving glycaemic control in this patient group is an ongoing challenge.
13.
PRIMARY CARE NURSES WALKING THE TALK.
Jill Arnold PG Dip Advanced Nursing.
Chair South Auckland Chronic Care Nurses Cell Group
Introduction In 2007 a group of nurses working in high deprivation areas of South Auckland initiated a professional
development cell group.
Aims The primary aim was to improve the quality of nursing care to patients with chronic diseases, primarily diabetes.
Secondary aims were to foster collegiality, and provide professional practice support amongst nursing peers. The
endpoint was to increase the number of nurse-led clinics.
Methodology: Preplanning, creating resource group, meeting, consultation, service-delivery of evidence-based nurse
specific chronic disease management. All sessions were evaluated, group members were encouraged to design and
plan sessions.
Rules: It was important for our autonomy and transparency that the group was independent of political affiliations, PHOs
and DHBs. Support from these groups was obtained during the planning/consultation phase. The group was guided
exclusively by their peers. This emphasis on nursing practice was to uncover the meaning of delivering effective holistic
nursing care to these complex patients with multiple co-morbidities.
Results: Attendees now number 45-50 per session. Education sessions are conducted by health professionals with
session delivery, NZ guidelines and evidence-based. These are underpinned by the excellent CMDHB chronic disease
management programme.
Conclusions Funding constraints and reallocation of Services to Improve Access (SIA) funding continue to hinder
nursing opportunities for nurse-led clinics.
There is a need to support primary care nurses working in isolated situations in increasingly autonomous conditions. If
we are to retain this most important sector of primary care nurses all efforts should be made by PHOs to encourage
nurses into nurse-led clinics.
Nurses completing post-graduate studies need to develop practical working knowledge to complement the theory
attained from such papers as applied science and long term condition papers.
Within our group there were only three nurses out of forty-five nurses conducting independent nurse-led clinics. This
imbalance needs to be addressed.
14.
THE EFFECT OF INTENSIVE PODIATRY CARE ON CLINICAL STUDY ENROLMENT RATES OF SLOW
HEALING DIABETIC FOOT ULCERS.
Dr. Ravi Subramaniam Dr. Ajith Dissanayke, Dr. John Baker, Roger Greach.
Diabetes Service Middlemore Hospital CMDHB Auckland.
Aim: This paper describes our recent 8 months experience with the impact of intensive podiatry care on identifying
suitable patients for enrolment into a clinical trial.
Methods: We retrospectively reviewed the impact of the eligibility and run-in criteria on the success of finding subjects
suitable for enrolment in a study of slow healing diabetic foot ulcers. The protocol called for: an initial assessment of
eligibility at the first screening visit then subjects found suitable progressed to a 2-week screening run-in period, which
consisted of two further clinical visits. During this run-in period, compliance with ‘standard-of-care’, which included
orthotic boot offloading and debridement of the target ulcer was assessed in addition to monitoring changes in ulcer
surface area and depth with the Silhouette Mobile Device. At the end of the screening run-in period, subjects whose
diabetic foot ulcers decreased by <30% in surface area were classified as “slow healing” and were eligible for the study.
Outcomes: Data will be presented on the prevalence of apparent slow healing ulcers in the Middlemore Hospital
Diabetes Clinic population. In addition a summary will be given of the characteristics of the 50% of patients that showed
>30% improvements in wound size accomplished solely though 2 weeks of intensive podiatry care compared to those
that were less responsive. These preliminary data suggest there maybe an unrecognised pool of diabetic ulcer patients
that could benefit rapidly from short course intensive podiatry therapy alone.
15.
WAEWAE TAPU: PODIATRY ASSESSMENT IN NEW ZEALAND – WILL THIS MAKE A DIFFERENCE?
Ihaka B , Rome K , Brown, J., Garrett, N.
Lecturer, School of Podiatry, AUT University, Auckland
Background: Maori are over-represented in diabetes associated morbidity and mortality rates in New Zealand,
including foot pathology [1]. Given that podiatry can contribute a significant role in the early detection of imminent
diabetes-related foot pathology, we describe how podiatry plays a key role in the interdisciplinary management of the
disorder.
Aim: The presentation explores the implementation of a podiatric assessment tool and preliminary findings with the
objective to improve diabetes related lower limb outcomes for Māori.
Methods: We developed a diabetes podiatry assessment tool informed by evidence based practice. Patients were
recruited from two Māori health provider sites based in Auckland. All patients meeting the inclusion criteria were invited
to participate. Sixty participants were recruited from two different Primary Health Organisations to participate in the
study. Patients were assessed using the diabetes podiatric assessment tool.
Results: The median age of the cohort was 54 years (IQR: 45.5-61.5 years old). The median duration of diabetes was
15 years (IQR: 7-25 years old), and the median BMI was 35.7 kg/m2 (IQR 32.9-41.9 kg/m2). Forty two percent (42%) of
patients displayed poor glycaemic control (>8% HbA1c continuously); and the majority of patients displayed risk factors
for diabetes related to cardiovascular disease (49% hypertension & 55% dyslipidemia). Thirty-two percent (32%) of
patients displayed findings in their assessment to warrant a six-month review, and 58% displayed predisposing foot
lesions such as callous, corns and fungal infections.
Conclusion: An evidence-based approach using a specifically-designed podiatric assessment tool could be widely
applied by primary care health podiatrists in the detection of imminent diabetes-related foot pathology and to support
disease management. This assessment tool would be of particular benefit to communities including Maori, where the
incidence of diabetes and its complications is higher [2].
Acknowledgments: The authors gratefully acknowledge The HRCNZ project funding (05/286) for this research.
References
1. New Zealand Guidelines Group: Management of Type 2 Diabetes, Wellington; 2003.
2. Simmons, D: The epidemiology of diabetes and its complications in New Zealand. Diab Care, 1996,3:371-375.
SESSION 4 Thursday 22, APRIL 1100-1200
# - Time
18.
1120-1130
Lead Presenter
Cheri HOTU
Page 22
Zaven
PANOSSIAN
Page 22
Renate KOOPS
Page 23
19.
1130-1140
Rebekah JAUNG
Page 23
20.
1140-1150
David SONG
Page 24
21.
1150-1200
Ole SCMIEDEL
Page 24
16.
1100-1110
17.
1110-1120
Title
A NOVEL MUTATION OF HNF1A ASSOCIATED
WITH MODY 3
METFORMIN – THINK TWICE BEFORE YOU
STOP
Affiliation
Auckland DHB
COUNTER-REGULATORY HORMONE
RESPONSE TO INSULIN TOLERANCE
TESTING IN THE DIA-06 STUDY:
APPARENT TRANSMISSION OF TYPE 1
DIABETES BY BONE MARROW
TRANSPLANTATION
SPINAL COMPRESSION FRACTURES DURING
HYPOGLYCAEMIA IN INSULIN-TREATED
PATIENTS
CALCIPHYLAXIS
Counties Manukau DHB
Auckland DHB
Auckland DHB
Auckland DHB
Hawkes Bay DHB
16.
A NOVEL MUTATION OF HNF1A ASSOCIATED WITH MODY 3
C. Hotu1, P.Drury1, N.McGrath2, D.Song1, R.Marquis-Nicholson3 R. Murphy1,4
1Auckland Diabetes Centre,2 Northland Health Diabetes Service, Whangarei2, 3Dept of Pathology, Auckland
City Hospital, 4Dept of Medicine, FMHS, University of Auckland4
The most common cause of monogenic beta cell disorders is a mutation in the hepatocyte nuclear factor (HNF)-1α gene
(HNF1α), also known as maturity onset diabetes of the young (MODY3). We describe a family with a novel mutation in
HNF1α. The 26 year old female proband was given the presumed diagnosis of type 1 diabetes at 17 years when she
had incidental hyperglycaemia detected during presentation of a flu-like illness, however no glucose-lowering therapy
had been required due to no deterioration in her glycaemic control. Her mother was insulin-treated for a presumed
diagnosis of type 1 diabetes since age 15 years. Her brother was diagnosed with a “lazy pancreas” at 6 years, “prediabetes” at 13 years and commenced on insulin therapy at 21 years.
Investigations to clarify the proband’s diagnosis of diabetes included HbA1c 7.1% (<6.0), post-prandial C-peptide
1100pmol/l (300-2350), serum insulin 13.8mU/l (5-13), concurrent plasma glucose 5.9mmol/l (fasting <5.5), glutamic acid
decarboxylase (GAD) antibodies 162U/ml (<10), and IA2 antibodies <15U/ml (<15). Despite her positive GAD
antibodies, given her own and family history of atypical diabetes, a search for a monogenic cause began. To distinguish
between a glucokinase defect and a transcription factor defect, a 75g oral glucose tolerance test was performed.
Fasting plasma glucose pre and 2-hour post glucose load was 4.5mmol/l and 11.3mmol/l respectively. Her low fasting
plasma glucose and large 2-hour increment was not in keeping with a glucokinase defect. Her concurrent urinary
glucose levels pre and 2-hour post glucose load were respectively <0.5mmol/l and 27mmol/l. This was consistent with
the lowering of renal threshold of glucose, typically seen in HNF1α mutation carriers.1 Sequencing of HNF1α revealed a
novel mutation in exon 1 in the proband and all her affected family members.
1. Stride A et al, Diabetes Care 2005;28:1751-1756
17.
METFORMIN – THINK TWICE BEFORE YOU STOP
Zaven Panossian, Paul L Drury, Tim Cundy.
Auckland Diabetes Centre, Green Lane Clinical Centre, Auckland District Health Board.
In clinical trials in type 2 diabetes metformin is reported to reduce HbA1c by 0.8 – 3 % (median 1.3%), but in practice
metformin can sometimes be much more effective. We describe eight patients in whom discontinuation of metformin
resulted in dramatic deterioration in glycaemic control; in 6 cases metformin was later reintroduced with significant
improvement.
The patients (4 women, 4 men; age 50 – 87 years) had type 2 diabetes for a median of 13 years; 6 also took
sulphonylureas and 3 took insulin. The reasons for discontinuing metformin were renal impairment (5), cardiac failure
(1), chronic liver disease (1) and gastrointestinal side effects (1). Stopping metformin was associated with a significant
rise in HbA1c over 3-12 months ranging from 3.5% to 7.1%. The mean increase was 5.0% (from 7.6 to 12.6%, P <
0.001). This was associated with a mean weight gain of 3.5kg and mean increase in insulin requirements of 20units/day.
After review of the reasons why metformin was stopped, we were able to reintroduce it in 6 patients producing significant
decreases in HbA1c over 4–12 months ranging from 1.7 to 7.9 %. The mean change was 3.8% (from 11.2% to 8.1%, P
< 0.01).
We conclude that in some cases metformin withdrawal can have a much greater detrimental effect on glycaemic control,
weight and insulin requirements than is commonly appreciated. There is continuing debate about the indications for
metformin withdrawal, and almost certainly the current recommendations are too conservative - the risk of lactic acidosis
is very low in the absence of concurrent illness causing acute tissue hypoxia. There is an emerging consensus that
metformin can be continued in renal impairment unless the GFR is <30 ml/min/1.73m2. However, we have concerns that
the MDRD formula commonly reported by New Zealand laboratories may underestimate GFR in obese patients.
18.
COUNTER-REGULATORY HORMONE RESPONSE TO INSULIN TOLERANCE TESTING IN THE DIA-06
STUDY
Renate Koops, John Baker
Middlemore Hospital, Auckland
Objective: Patients with long-standing type 1 diabetes and a history of recurrent hypoglycaemia frequently become hypo
unaware and lose the normal physiological response to hypoglycaemia. Insulin tolerance tests (ITT) were performed at
all participants in the DIA-06 study pre-transplantation to determine their counter-regulatory hormone response to
significant hypoglycaemia.
Design: A week before the transplantation of porcine islet cells, participants underwent an ITT to measure counterregulatory hormones. The test took place in a safe environment with experienced endocrinology staff attending.
Participants were given 0.15 U/kg Novorapid iv, blood glucose levels were measured every 15 minutes, blood samples
for adrenalin, glucagon, ACTH, cortisol and glucose were taken every 30 minutes and symptoms were recorded. Target
blood glucose level was <2.3 mmol/l on the HemoCue, a device specifically designed to accurately measure low blood
glucose levels.
Results: The glucose responses to ITT for 4 participants with longstanding type 1 diabetes and hypo-unawareness are
shown in the figure. Counter-regulatory hormone results indicate absent glucagon response, attenuated adrenergic
response, and attenuated cortisol/ACTH response. Individual results will be presented at the meeting
Conclusions: Patients with longstanding type 1 diabetes and hypo-unawareness showed impaired normal physiological
response to hypoglycaemia.
19.
APPARENT TRANSMISSION OF TYPE 1 DIABETES BY BONE MARROW TRANSPLANTATION
R Jaung, J Wu and T Cundy
Auckland Diabetes Centre
We describe the case of a woman who developed evidence of type 1 diabetes 8 years after receiving a bone marrow
transplant from her sister who had type 1 diabetes. The patient was diagnosed with acute myeloid leukaemia at the age
of 20 and went into remission after chemotherapy.
She subsequently became pregnant for the first time. The
pregnancy proceeded normally, without evidence of gestational diabetes, but with relapse of her leukaemia. Four
months after delivery she underwent marrow ablation therapy, followed by allogeneic bone marrow transplantation
(BMT). The donor was her younger sister who had had type 1 diabetes from the age of 6. When tested 2 years after
BMT (age 24) the patient was negative for anti-GAD and IA2 antibodies. At the age of 29 she became pregnant for the
second time. Gestational diabetes was diagnosed early in pregnancy and insulin treatment was required from 15 weeks
gestation. Her anti-GAD and IA2 antibodies were strongly positive (52 and 8.7 u/ml, respectively [normal ≤1]). An early
postpartum glucose tolerance test was normal, and although she retains islet cell antibodies, she remains off insulin 5
years later.
A number of other reports describe type 1 diabetes developing in subjects receiving BMT from relatives who had type 1
diabetes (Table), but there are also cases similar to ours where permanent type 1 diabetes has not yet developed
despite persistent islet cell autoantibodies.
Recipient
age –sex
Lancet 1998
Lancet 1998
Lancet 1998
26-F
22-F
22-M
haematological
diagnosis
MDS
AML
Lymphoma
islet cell
autoimmunity
Yes
?
No
Diab Care 2002
6-F
Aplastic anaemia
Yes
Ped Trans 2009
This case
7-M
30-F
Aplastic anaemia
AML
Yes
Yes
Donor
time – BMT to
diabetes
4yrs
2yrs
No diabetes
after 8yrs
No diabetes
after 23yrs
3yrs
No diabetes
after 8yrs
age – sex
30-M
8-F
24-M
9-M
?-F
19-F
20.
SPINAL COMPRESSION FRACTURES DURING HYPOGLYCAEMIA IN INSULIN-TREATED PATIENTS
David Song, Paul L Drury
Auckland Diabetes Centre, Greenlane Clinical Centre, Auckland
Spinal compression fractures as a result of seizures induced by hypoglycaemia are a recognised, but apparently rare,
complication of hypoglycaemia in insulin-treated patients, first reported in 1985. We report a case and suggest that it
may be more common than previously thought.
A 63-year old groundsman was diagnosed with type 2 diabetes in 1994 and started on insulin in 1996. He has been on
a multiple insulin regimen for several years (mostly twice daily Protaphane and once-to-twice daily Novorapid). Clinic
letters record relatively frequent hypoglycaemia and he was previously known to have hypoglycaemia unawareness,
often asymptomatic till glucoses were below 2.5–3 mmol/L. He was admitted in 2009 after presenting with severe, acute
back pain. This followed an episode of unconsciousness with a preceding glucose of 4.4 mmol/L after which he had no
recollection. There was no clear history of falling or trauma. X-rays showed a partial T11 compression fracture and
degenerative change throughout the spine. Subsequent investigation revealed mid-normal bone density. He had no
other risk fractures for osteoporosis, no previous peripheral fractures and was on no relevant medication. His pain settled
with analgesia. He later recalled a previous spinal fracture 4 years previously, again apparently related to hypoglycaemia
and loss of consciousness. . At that time he was admitted for 4 days and required opiate analgesia.
Such fractures are well documented in epilepsy, tetanus and electroconvulsive therapy but are not well recognised in
diabetes. We have seen four such patients over the past 10 years; all are male, ages range from 18 to 63 and all had
suffered frequent hypoglycaemia and/or unawareness. One Asian patient had moderate osteopenia with mild Vitamin D
deficiency.
We therefore suspect that this complication of hypoglycaemia may be under-recognised - it may have become more
common with intensive glycaemic control and lower targets.
21.
CALCIPHYLAXIS
Ole Schmiedel(1), Pip Rutherford(2), Drew Henderson(3)
Hawke’s Bay Hospital, Hastings
Diabetic ulcers are a common and are associated with significant morbidity and mortality. The majority of these ulcers
are of ischemic, neuropathic or mixed etiology, however a small number of ulcers have different causes.
We present a 61 year old female with type 2 diabetes, hypertension, renal impairment (CKD stage 4), stroke and atrial
fibrillation (on warfarin). She developed severe pain over an ulcerated area at the lower leg. The ulcer started as a
mottled brownish bruise without the patient having sustained any trauma. The lesion developed into a black eschar with
raised edges and an ulcerated centre. However, the ulcer characteristics were not those of venous or arterial aetiology
and the question was raised whether this lesion could represent calciphylaxis.
On examination, there was no evidence of pressure damage, and the peripheral pulses were present with a strong
triphasic signal on Doppler. Swabs from the ulcer showed colonization with gram positive cocci and bacilli. Antibiotic
treatment was started and surgical debridement under local anaesthesia was performed. The histology showed murally
calcified small blood vessels consistent with the diagnosis of calciphylaxis.
However, except for being diabetic and having chronic renal impairment, she had none of the classical risk factors for
calciphylaxis such as hyperparathyroidism or abnormal normal calcium and phosphate metabolism. Therefore, after
review by the renal team, management with a calcium chelator such as sodium thiosulphate was not considered to be
appropriate. The only modifiable risk factor was her treatment with warfarin.
Warfarin interferes with vitamin K metabolism and there is evidence that vitamin K dependent proteins such as Feutin A
are inhibited by Warfarin. Feutin A has been shown to reduce the degree of calcification and a Feutin A knock out model
has shown significant calciphylaxis.
Warfarin was switched her to Aspirin, however two weeks after the change the patient presented to hospital with a
transient ischemic event. Special authority approval was obtained for the use of enoxaparin. After six months the wound
improved significantly, having reduced in size from 6 x 9 cm to roughly 1cm in diameter. The pain eased and the patient
had no hospital admissions since commencement of therapy.
Calciphylaxis is a syndrome of vascular calcification, thrombosis and skin necrosis. It is generally seen in patients with
advanced renal disease (CKD stage 5). It often leads to chronic non-healing wounds, amputations and can be fatal.
Calciphylaxis, a rare but serious disease, needs clinical acumen in diagnosis, optimal wound care, treatment of infection
and specialist level care to achieve optimal outcomes.
SESSION 5 Friday 22, APRIL 0915-1030
# - Time
22.
0915-0930
Lead Presenter
Brandon
ORR-WALKER
Page 27
Title
LET'S BEAT DIABETES - NEARLY 5 YEARS ON
WHAT HAVE WE ACHIEVED AND WHERE ARE
WE GOING?
Affiliation
Counties Manukau DHB
23.
0930-0945
24.
0945-1000
Dane BAKER
Page 27
Kate SMALLMAN
Page28
GETTING TO WORK WITH OUR WORKERS
Diabetes Projects Trust
A NEW INITIATIVE IN DIABETES PREVENTION
- GARDENS 4HEALTH
Diabetes Projects Trust
25.
1015-1030
26.
1030-1045
Richard COOPER
Page 28
Lynn RANDALL
Page 29
THE ART OF DIABETES
Counties Manukau DHB
PROMOTING INSULIN STARTS IN PRIMARY
CARE: WORKING COLLABORATIVELY TO
CREATE AN EDUCATIONAL DVD
Harbour Health PHO
22.
“LET’S BEAT DIABETES”: NEARLY 5 YEARS ON WHAT HAVE WE ACHIEVED AND WHERE ARE WE
GOING?
Orr-Walker, Brandon
Let’s Beat Diabetes, Counties Manukau DHB
Type 2 diabetes (T2DM) is a rapidly growing problem across developing and developed nations, and has a predilection
for ethnic minorities, immigrant populations and those of lowest social-demographic standing. While the risk of
developing T2DM and associated complications rise with age, in high-risk populations it is increasingly affecting people
at younger ages. This poses significant challenges to health system resources and capacity, the burden of disease will
cause considerable morbidity in coming years. Counties Manukau DHB has large minority populations (exceeding 50%),
high immigration, high population growth, and high proportions living in deprived circumstances. It has the highest
population rates and number of people with diabetes of any DHB in NZ.
T2DM is a multifactorial condition, but the epidemiology favours significant environmental influences interacting with
intrinsic (including genetic) factors. Many of those environmental influences are beyond the usual domain of health
bodies (e.g. DHB’s) charged with a mandate of the health of their populations, such as the food environment, built
environment, education, knowledge and attitudes, and cultural practices.
“Let’s Beat Diabetes” (LBD) arose from a DHB and local diabetes team initiative to engage the community through
Partnership, Protection and Participation (Treaty of Waitangi principles), and aims to reduce the development of
diabetes, reduce complications of diabetes, and improve the quality of life for people with diabetes. Whilst much of its
focus is on Type 2 Diabetes, Type 1 Diabetes is also included, and LBD’s framework, approach, community engagement
and agency and industry partnership are well suited for a broader strategy as outlined in the “2008-2013 Action Plan for
the Global Strategy for the Prevention and Control of Noncommunicable Diseases” (WHO, 2008). T2DM can be a useful
lens to look at population health (including latent development of CVD and lifestyle associated cancers), and clinical
practice has been a prototype of multifactorial risk assessment and management. The first 5 years of LBD will be
summarised concentrating on the design, key achievements, and challenges ahead.
23.
GETTING TO WORK WITH OUR WORKERS!
Dane Baker (NZRD)
Diabetes Projects Trust
It is well known that Diabetes is one of the major health risks facing New Zealanders and indeed the rest of the world.
Gaining access to the workplace provides a vital vehicle to promote health awareness to those at risk of diabetes,
overweight / obesity, inactivity and poor diet. If appropriate messages can be consistently communicated to those at risk
it can hopefully lead to prevention or delay to the onset of diabetes throughout our communities.
The aim of the Diabetes Projects Trust (DPT) “Healthy Workplaces Program” is to increase the awareness, knowledge
and skills of those in the workplace in relation to diabetes and obesity prevention. A flexible program currently exists
which is dependent on the level of buy in from workplaces. A variety of education tools are available and consist of
presentations (20mins – 1 hour +), displays, screening and risk assessment, 1 on 1 nutrition consultations, provision of
resources and on site environmental scoping and recommendations / support, all of this is provided for no cost to the
workplace. The program works closely with and promotes other existing community based organizations such as the
“ARPHS Heartbeat Challenge”, Green Prescription and the Heart Foundation.
The program is currently being evaluated in combination with the DPT and the Manukau Institute of Technology. To date
3 work places (32 participants) have evaluated the program, results have been extremely positive with an overwhelming
response in terms of meeting expectations and being a useful tool for improving health for participants.
The program allows for interaction and contact with a multicultural workplace population who may be missed by
mainstream health providers. By doing so it significantly enhances the message of a healthy lifestyle to those in our
community to help reduce and delay the onset of diabetes and fight obesity.
24.
A NEW INITIATIVE IN DIABETES PREVENTION - Gardens 4Health
Richard Main, Kate Smallman, Karen Pickering
Diabetes Projects Trust
Gardening promotes physical activity, better nutrition, is socially and culturally important, and makes economic and
environmental sense. The risk of type 2 diabetes, cardiovascular disease, and some cancers is increased by being
overweight and inactivity. Gardening, not only increases activity and develops skills it also supplies fresh healthy food for
families and the community, thus helping to prevent type 2 diabetes and its complications. The Gardens4Health
programme had its beginnings in 2008 as a pilot called ‘Gardening for Health & Sustainability’ in the Counties Manukau
District Health Board (CMDHB) area, and was designed by CMDHB Lets Beat Diabetes (LBD) in extensive consultation
with stakeholders. Gardens4Health involves facilitating and supporting the creation of community garden plots with the
eventual expectation that these will translate into development of home gardens as skill levels of participants increase.
The Gardens4Health programme started its transition into community based charitable trust Diabetes Projects Trust
(DPT) in December 2009. It is run by experienced Project Manager Richard Main and is being rolled out across the
greater Auckland region in 2010, with funding support from MOH, CMDHB, WDHB and ADHB as well as product and in
kind from other entities and business.
To date, there are 18 community gardens in which the programme has been involved, and there have been spin-off
opportunities in the form of school garden projects and reported uptake of home gardening. Plans are underway for 12
more in early 2010. There are also links to other services such as training opportunities at a local Marae where students
can obtain training and qualifications in horticulture. In the long term the plan is that gardening becomes the norm,
physical activity and healthy eating is increased, and therefore the communities’ health is improved.
25.
THE ART OF DIABETES.
Cooper, Richard, PhD, Barratt-Boyes, Caran, Orr-Walker, Brandon MBChB, FRACP,
Whitiora Diabetes Service, Counties Manukau District Health Board
Indigenous populations, in particular Maori and Pacific, have a long tradition of passing on their knowledge orally and by
using many forms of art, music and poetry. These messages are well received and remembered. It is well documented
that indigenous populations have a predisposition to kinaesthetic learning. Whakapapa was always passed on orally with
the aid of carvings, kowhaiwhai, weaving and reference to the stars. The written word was a tool of colonisation and
whilst indigenous peoples learnt to read and write, their hearts belong to visual images and story telling. With a fine arts
background, and Maori and Pacific ethnicity I have used visual methods (demonstration and art) to help communicate
healthy lifestyle.
In 2006 a men’s group had been established by the Whitiora Diabetes Service, meeting collectively to offer them a
supported learning environment. They started with 4 participants that would meet each month. In 2007 we continued
with this group, growing this to 3 large proactive groups that meet at 3 different marae. Attendance has grown from120
people in 2007, 332 in 2008, and 987 in 2009.
In 2009 we focused on Nutrition. The men would select the type of food they enjoyed eating and I would cook it up with a
healthier option. We have also been able to grow vegetable gardens. This has had a flow on effect in their homes and on
their marae. Additionally, we have cut down a lot of the barriers that stop Maori men from going to the doctors, taking
their medications, been more active and cutting back on how much alcohol they drink.
This year we will be focusing on been more active. I attended a wananga by Dr Ihirangi Heke on Indigenous Games
learning traditional Maori games that I will be teaching. Insights and materials developed for this program will be
presented at the conference. We are holding an Art Exhibition on Whanau Ora, portraying artworks to do with health
issues in the whanau
26.
PROMOTING INSULIN STARTS IN PRIMARY CARE: WORKING COLLABORATIVELY TO CREATE AN
EDUCATIONAL DVD
Rachael Calverley RN & Lynn Randall RN
Harbour Health. Auckland
Aims It is estimated that 20,000 people in Waitemata have diabetes. During 2009, 8657 patients received an annual
review, of which 1877 had an Hba1c level over 8% and were considered ‘unmanaged’. This equates to 21%. Appropriate
and early insulin intervention seeks to address this priority area for our populations. Accessible and easy to use
resources to educate General Practice Teams to initiate and manage patients with type 2 diabetes on insulin have been
lacking.
Objectives Insulin is considered an effective and safe treatment option for Type 2 diabetes, but is sorely underutilised
in primary care. A stunning new DVD production to connect and coach the General Practice Team has incorporated
cross sector collaborative work to illustrate the crucial benefits of early insulin starts in reducing Hba1c levels.
Methods Multidisciplinary clinical expertise across the sectors has led this project and produced a high-quality
educational DVD. It exemplifies how great working relationships can enable a valuable resource to emerge onto the
primary care landscape. An unrestricted educational grant from a pharmaceutical company helped us to realise the
project.
Results An initial 300 DVDs have been produced; a successful launch and a General Practice team workforce are
engaged to change. The DVD production will be presented.
Conclusion This original project has demonstrated how successful collaborative connections can impact positively on
our workforce teams and clients alike. The resulting innovative resource has local, national and global implications for
the future management of diabetes in primary care aligning with better, sooner and more convenient health potential.
SESSION 6 Friday 22, APRIL 1100-1150
# - Time
27.
1100-1112
Lead Presenter
Kate SMALLMAN
Page 31
Title
Affiliation
AN EVALUATION OF A HEALTHY EATING ON A Diabetes Projects Trust
BUDGET PROGRAMME
28.
1112-1124
29.
1124-1136
Jill McCLYMONT
Page 31
Roberta MILNE
and Lynne
FERGUSON
Page 32
WEIGHT MANAGEMENT: NOT A LOST CAUSE
Waikato DHB
SOUTH AUCKLAND EXPERIENCE IN WEIGHT
LOSS: A COMPARSION OF 4 GROUPS
Counties Manukau DHB
30.
1136-1151
Justina E WU
Page 33
BARIATRIC SURGERY IN THE WAIKATO: THE
360º VIEW
Waikato DHB
27.
AN EVALUATION OF A HEALTHY EATING ON A BUDGET PROGRAMME
Kate Smallman, Diana Anderson
Diabetes Projects Trust (DPT), Manukau, New Zealand
Following the pilot programme called “Healthy Eating on a Budget, the train the trainer programme Cook’nKiwi, was
rolled out across Counties Manukau, Waitamata & Auckland regions from the beginning of 2009 with the approach being
to work through those working with disadvantaged & vulnerable families. The demand for Cook’nKiwi rose steadily
throughout 2009 exceeding the contract target.
The Cook’nKiwi programme has been successfully presented to staff and clients groups with evaluation carried out
indicating that both the content and interactive hands on style of delivery are well received. Knowledge questionnaires
are completed before and after the programme to access areas of need and the effectiveness. Knowledge
questionnaires show that participants battle with the concepts of number of servings and serving size of foods from the
different food groups. Overall there was an increase in the level of nutritional knowledge for participants on average by
21.4%. Average knowledge scores for staff and client groups were similar at 24.8% and 22.44% respectively.
The two hour follow up session to Cook’nKiwi offered 1 – 2 months after the initial programme is well attended. Time
restraint was the main factor in participants not returning. Sessions were evaluated by using a questionnaire post
programme. Staff used information such as reading food labels and healthy food choices when visiting clients. Lack of
client motivation and economic means were major challenges in initiating changes in diet. Material from the presentation
to use in facilitating training sessions for clients was requested.
Further development of the Cook’nKiwi programme offered to clients is underway with greater emphasis on the practical
application of nutritional principles taught for the successful change in eating patterns. A training package for staff from
various organisations to use when visiting clients needs to be offered to ensure greater accessibility to healthy eating
information.
28.
WEIGHT MANAGEMENT: NOT A LOST CAUSE
Jill McClymont
Adult Weight Management Programme - Waikato Regional Diabetes Service
While currently interest in Bariatric Surgery is high, it is important to remember that for the majority of people with obesity
this will not be a viable treatment option for reasons of personal choice, medical contraindication, or cost. Given the poor
press received by traditional dieting strategies, expectations of success with non-surgical interventions is often low.
Weight loss and maintenance is possible through non-surgical means but the challenge is to develop programmes that
engage people in change and achieve short and long-term success. The Adult Weight Management Programme is a two
phase, multidisciplinary, group education programme with a six week VLED period and twelve group education sessions
in the first 6 month phase and an 18 month follow-on phase. A recent revamp of the programme focused on ensuring the
programme was using principles from adult education and the psychology of learning, along with the use of humour and
novel teaching strategies to make the learning process more engaging. Results are similar to those achieved in earlier
programmes but attrition rates for the first phase of the programme have fallen from 35% to 21%. Of the 2009 cohort
who have completed the first phase of the programme (n=64; 52% female, 48% male, mixed ethnicity) 50% lost greater
than 10% of their baseline weight (mean: -15.1%, SD: 3.48 ) and a further 35% lost between 5-9.9% (mean: -7.7%, SD:
1.36). For those with diabetes (39% of cohort) mean HbA1c dropped significantly (p<0.01) from 7.9% (SD: 1.10) at
baseline to 6.8% (SD: 1.61) at the end of phase one. Only 19% had an HbA1c less than 7% at baseline compared to
76% at the end of phase one. Longer term data are not yet available for this group of participants but will ultimately be
compared with results from early programme formats.
29.
SOUTH AUCKLAND EXPERIENCE IN WEIGHT LOSS: A COMPARISON OF 4 GROUPS
R. Milne MHSc (Nursing), L Ferguson MSc (Nutrition)
Whitiora Diabetes Service Counties Manukau DHB
Aims: To help overweight and obese patients to loose weight and maintain weight loss.
Objectives: To monitor weight, HbA1c, cholesterol and blood pressure to assess effectiveness of the program.
Methods: Ninety-six obese and overweight patients with diabetes were referred for weight loss, 59 attended the first
session and 48 completed 20% of the program. Six enrolled in more than one group (18 male, 24 female). Average age
53 (range 33-65). Ethnicity - 14 Maaori, 8 Pacific people, 18 European, 2 Indian. The groups commenced in 2006 and
ran annually. The first 2 groups were similar. Patients used Optifast for 12 weeks followed by 8 weeks transitioning onto
an appropriate eating pattern. The program included education on relapse prevention, behaviour modification, coping
with change, activity, diabetes and healthy eating. The next 2 groups used the Stanford Chronic Disease Self
Management Program for 6 weeks followed by six weeks of education similar to previous groups. A small number of
group 3 went onto Optifast, whilst group 4 only did the 12 week program.
Results
Mean weight
loss
% Weight loss
Statistical
significance
0.007
Range of
weight
Baseline
95.1-173.8
Range of
weight end of
program
108.6-158
Group 1
8.64
5.3%
Group 2
5.58
4%
0.068
120-167.7
102.4-166
Group 3
1.26
3.7%
0.302
95.3-133.3
94-143.1
Group 4
1.46
1.1%
0.002
85.1-184.7
82.2-183
All
4.41
3.4%
0.000199
85.1-184.7
82.2-183
Medium HbA1c %
BP
Average
Baseline
BP
Average
end of
program
Statistical
significance
Systolic BP
Baseline
End of
program
Statistical
significance
Group 1
8.2
8.3
0.916
144/83
127/77
0.003
Group 2
8.45
7.95
0.059
124/69
130/79
0.370
Group 3
8.8
8
0.351
140/74
133/76
0.097
Group 4
8
7.45
0.072
126/75
122/73
0.200
All
8.2
7.75
0.023
132/76
127/76
0.048
Conclusions: Mean HbA1c (p-value 0.0.23) and Systolic BP (p = 0.048) reduced slightly. The group mean weight loss
was 4.41kg (p = 0.0002) which is comparable with other year long weight loss programs such as Atkins (4.7kg), Zone
(1.6kg) LEARN (2.6kg), Ornish (2.2kg) (Gardner et al, 2007, JAMA). This research demonstrated that weight loss can
occur using Optifast meal replacement, however learning to make permanent lifestyle changes remains difficult as
evidenced by weight gain following cessation of the program.
30.
BARIATRIC SURGERY IN THE WAIKATO: THE 360o VIEW
Justina E. Wu, David M. Schroeder , Bryan Gibbison, and Jill McClymont
Waikato Diabetes Service and Surgical Obesity Service
Public support for bariatric surgery to cure type 2 diabetes (T2D) has been rising. The Waikato Diabetes Service has
funded Roux en Y Gastric Bypass Surgeries for the past 4 Y (n=45). The efficacy and complications of the surgeries
have been analysed by chart review. The average baseline weights (BW) post-surgically were 74, 80, 76, and 84% at 1,
2, 3 and 4 Y, respectively. The surgery was less successful (< 10% of BW) in 27% of patients with 4% of patients losing
< 5 % of their BW. There was improved weight loss in patients who had surgery in 2008 and onwards after the initiation
of behaviour therapy. Patients < 50 Y/O were able to achieve greater weight loss than those > 50 years old. Quality of
life measurements improved up to 3 yrs after surgery as did metabolic parameters. There were significant improvements
in HBA1c, blood pressure, triglyceride levels, HDL-C levels, and CRP. There was a cure rate of 30% for T2D with a
decreased cure rate of in patients requiring insulin therapy before surgery (4%). Complications included minor infections
(7%), gout attacks (7%), renal colic (2%), OGD for obstruction (16%), abdominal surgery for adhesions (4%), transient
peripheral neuropathy (2%), and mild nutritional deficiencies (52% vitamin B12, 16 % iron, 29 % vitamin D, and 16 %
protein). 16% of patients required significant input from mental health services. For the majority of people, gastric
bypass surgery can successfully cause sustainable weight loss and improvements in metabolic parameters but at a cost
of nutritional deficiency and post-operative complications risks. Gastric bypass surgery patients will require life-long
medical, nutritional, and psychological/behavioural follow up to monitor/treat complications and increase the likelihood of
success. Careful selection and preparation of appropriate patients is absolutely paramount in ensuring that the benefits
outweigh the risks.
POSTER PRESENTATIONS
#.
P01
P02
P03
P04
P05
P06
P07
P08
Lead Author
Margaret DEMPSTER
Page 36
Kate SMALLMAN
Page 36
Karen PICKERING
Page 37
Rachael CALVERLEY
Page 37
Wayne JOHNSTONE
Page 38
Ross LAWRENSON
Page 38
Grace JOSHY
Page 38
Michele GARRATT
Page 39
P09
Vicki CORBETT
Page 39
P10
Natasha
CUNNINGHAM
Page 40
Veronique GIBBONS
Page 40
Shekhar SEHGAL
Page 41
P11
P12
P13
Brett SHAND
Page 41
P14
Amy LIU
Page 42
P15
Craig JEFFRIES
Page 42
Title
Affiliation
THE DIABETES DUTY NURSE ROLE - ENHANCING Auckland DHB
PATIENT CARE
TRIATHALON 5 YEARS ON!
Diabetes Projects
Trust
A WORD ABOUT STUDENTS..FORGOTTEN
Diabetes Projects
ASSETS
Trust
DIABETES SELF-MANAGEMENT EDUCATION:
Harbour Health PHO
PSYCHOLOGY – THE MISSING LINK
WHANAU ORA: A JOURNEY OR A DESTINATION?
Waikato DHB
HOW DO NEWLY DIAGNOSED PATIENTS WITH
TYPE 2 DIABETES IN THE WAIKATO GET THEIR
EDUCATION?
ACCESS TO RENAL SERVICES IN THE WAIKATO:
UPTAKE OF DIALYSIS TREATMENT
A STOCK TAKE OF NEW ZEALAND SECONDARY
CARE PODIATRY SERVICES FOR ACTIVE
DIABETIC FOOT COMPLICATIONS AND THEIR
RELATION TO AMPUTATION RATES
REFLECTION OF YEAR 1 OF THE WDHB
DIABETES MULTI-DISCIPLINARY TEAM FOOT
CLINIC
PHARMACY INPUT INTO INPATIENT REFERRALS
TO DIABETES SERVICE
Waikato Clinical
School
IDENTIFYING BARRIERS TO INSULIN INITIATION
FOR PATIENTS WITH TYPE 2 DIABETES
INEQUALITIES IN DIABETES MANAGEMENT PRESCRIPTION MEDICINES AND SOUTH ASIAN
DIABETICS IN THE CMDHB
IS GLYCAEMIC CONTROL AND
CARDIOVASCULAR RISK DIFFERENT IN
MORBIDLY OBESE SUBJECTS?
ALCOHOL ADVICE FROM HEALTH
PROFESSIONALS WORKING WITH PEOPLE WITH
TYPE 1 DIABETES
REAL-TIME CONTINUOUS GLUCOSE
MONITORING IN CHILDREN AT INSULIN PUMP
Waikato Clinical
School
Counties Manukau
DHB
Waikato Clinical
School
Waitemata DHB
Waitemata DHB
Waitemata DHB
Christchurch Hospital
Auckland DHB
Auckland DHB
P16
Renate KOOPS
Page 43
P17
Patricia LOFT
Page 43
P18
Rebekah JAUNG
Page 44
Peter K MWAMURE
Page 44
P19
P20
Jessie Roy GEORGE
Page 45
P21
Deborah HUTCHINGS
Page 45
P01.
INITIATION.
DOES CONTINUOUS GLUCOSE MONITORING
(CGMS) ASSIST MANAGEMENT OF BRITTLE TYPE
1 DIABETES OVER AND ABOVE STANDARD
INTENSIVE SELF-MONITORING OF BLOOD
GLUCOSE? AN AUDIT OF 6 PATIENTS STUDIED
PRIOR TO XENOTRANSPLANTATION
PSYCHOMETRIC EVALUATION OF CANDIDATES
FOR A TRIAL OF THE SAFETY AND
EFFECTIVENESS OF PORCINE ISLETS
XENOTRANSPLANTATION IN PATIENTS WITH
TYPE 1 DIABETES
TYPE 1 DIABETES PRESENTING IN PREGNANCY
ETHNIC SPECIFIC BIRTH CENTILES FOR BABIES
FROM THE WAIKATO: A CLOSER LOOK AT
DIABETES IN PREGNANCY
POSTNATAL MANAGEMENT OF WOMEN WITH
GESTATIONAL DIABETES: ‘BARRIERS AND
BRIDGES’
THE ASSOCIATION BETWEEN ADHERENCE TO A
MEDITERRANEAN DIET AND INDICES OF
GLYCAEMIC CONTROL
Counties Manukau
DHB
Counties Manukau
DHB
Auckland DHB
Waikato DHB
Waikato DHB
Auckland DHB
THE DIABETES DUTY NURSE ROLE - ENHANCING PATIENT CARE
Margaret Dempster, Paul Drury Cathrine Patten, Tricha Ball, Jan Black, Jane Wilkinson and Melanie Lubeck.
Auckland Diabetes Centre, Green Lane Clinical Centre, Auckland District Health Board.
The Auckland Diabetes Centre “duty nurse” service was developed as a 2008-2009 local initiative aiming to reduce
hospital admissions and delays to assessment and prompt diabetes treatment. The service is based at Greenlane
Clinical Centre aiming to provide improved access to the service for community health providers including GPs, practice
nurse and others as well as other Centre and DHB clinicians and people with diabetes and their families.
Aim: To report on the development of the rapid-response duty nurse service
Method: All clinicians in ADHB district hospitals and community have immediate access to the duty nurse exclusively
available for acute referrals and enquiries with access via a direct telephone line. Patients are usually seen on the same
day or next working day. Nurses at the Centre share the role with days allocated separate from their other
responsibilities; they have immediate access to doctors, dietitians, podiatrists and retinal screening. Details of each
contact are recorded in a specified detailed format.
Results: Between January and December 2009 there were 669 contacts. Data presented below is from October and
November 2009 and represents both internal (Centre, hospitals and ED) and external (GP, practice nurse, community)
contacts including the main reasons for referral.
Month
October
November
Internal
28
41
External
22
24
Total
Average per month
Total seen:
127
69
35
46
23
Number
% age
30
14
37
2
32
24
12
29
2
25
(including 12 patients seen twice)
Reason for Referral
Insulin start
Hypoglycaemia
Poor control(but not insulin start)
New Type 1
Other (equipment issues, education, podiatry, retinal screening, service
enquiries)
Conclusion: While we cannot be certain that we have reduced hospital admissions, the rapid responses have offered
timely intervention for those with urgent problems and appropriate access to other aspects of the diabetes service.
P02.
TRIATHLON 5 YEARS ON!
Kate Smallman RN, DNS, MSc
Diabetes Projects Trust, Otara, Auckland
Diabetes prevention is vital if we want to stem the rate of increase in type 2 diabetes. Research shows that prevention of
metabolic diseases is possible and benefits not only the person but also the economy of the country. So why is
prevention so hard? All you have to do is eat healthy foods, exercise for at least 30 minutes a day and maintain a
healthy weight! If it was that easy we would not have a job to do.
The aim is to motivate and keep ourselves active and to encourage others to start exercising. 5 years ago I did my first
triathlon. In 2005 80% of the Diabetes Projects Trust did the triathlon with me. The objective is: are they still exercising
and how do we keep the motivation going.
At the trust we are walking the talk. All staff are managing to complete some form of exercise on most days of the week.
This ranges from walking to marathon training. We have kept the momentum up with motivation and brief interventions.
A newsletter is regularly written. The Sports club was started a couple of years ago and the trust matches a contribution
that we put in. This helps with funding to enter events and buy equipment. We had a challenge with Diabetes Auckland
doing the feet beat challenge. A golden shoe was awarded to the winning team.
To conclude we have learnt that it is important that motivation continues after the starting of something new. We need to
continually congratulate people on their achievements. We need to translate this information to our patients. Let them
know that they are doing a good job and encourage them to do more and to carry on. This presentation will show how
we motivate our staff and the changes we would like to see in the world.
P03.
A WORD ABOUT STUDENTS…FORGOTTEN ASSETS
Karen Pickering1, Diane Bermingham1, Stephanie Johnston2, Helen Scott2
1Diabetes Projects Trust (DPT), Manukau, NZ; 2Manukau Technical Institute (MIT), Manukau, NZ
In this paper we describe how we are working towards our aim of developing a more student friendly culture within our
organization in order to ensure the best possible outcome for our staff and the students who spend time with us.
Students are often viewed as being extra work, and even potential hazards in the workplace rather than as individuals
who bring their own valuable skills, experiences and perspectives and being an investment in the future workforce. At
the Diabetes Projects Trust we have had some excellent experiences, we have also had very average and even poor
experiences with students from a variety of institutions and disciplines.
As part of a quality improvement process which has involved gathering information using a variety of methods including
observation, survey, and discussion, we have identified some key factors which may help make the student (and the
workplace) experience more successful. These factors include for staff, the relationship with the representative of the
learning institution (usually tutors) which increases constructive and honest dialogue, clear objectives being provided upfront, management recognition that organization staff may feel under pressure with increased demands on their time and
need support themselves and there must be administrative capacity at the time to cope. For students, knowing what to
expect before arriving, having someone to report to within the organization, having pre-planned suitable activities in line
with ability and interests, early identification of problems, and students express a desire to ‘belong’, feel welcomed and
included.
In conclusion, students do entail additional work however with support they have an important contribution to make both
professionally and through being members of a team. There are opportunities after positive placement experiences for
encouraging promotion of organizations interests (eg, healthy eating) by students in the future, as well as networking
over the longer term.
P04.
DIABETES SELF-MANAGMENT EDUCATION: PSYCHOLOGY – THE MISSING LINK
Rachael Calverley RN, Paul Carver, Olwen Shearer & Lynn Randall RN.
Harbour Health, Auckland
Introduction: Diabetes is potentially the biggest health catastrophe the world has ever seen. It is estimated that 20,000
people in Waitemata has diabetes (WDHB, 2009). Diabetes occurs in the context of life; in the midst of family,
relationships and work. Group education equips patients with valuable knowledge to self manage and prevent long term
complications along with its associated costs. The concept of self-management is gaining momentum; however
equipping patients with psychological coping strategies has been overlooked.
Objectives: The DAWN (2002) survey revealed that 70% of clinicians identified that psychological factors were crucial
to effective management. In line with current guidelines, Harbour Health recognised the gaping need to address a
person’s mood, anxiety, stress, relationships and motivation via an additional bio-psychosocial component to our self
care management programme.
Methods: Harbour Health adopted a wrap-around care model utilising the skills of a multidisciplinary team. This
Diabetes Self Management Education (DSME) team includes a nurse educator, dietitian, podiatrist, sports consultant
and expert patient; complimented by a behavioural component on goal setting and coping strategies delivered by a
health psychologist. Key improvements are indicated.
Results: These will be contextualized in a table format and indicate significant and sustained improvements in clinical
indicators and client knowledge.
Conclusion: Sustaining long term change through a multi-pronged team approach serves to incorporate the missing
link of health psychology to complement educational intervention and seek win- win cost effective solutions to a brighter
future for our clients.
P05.
Whanau Ora: A Journey or a Destination?
Wayne Johnstone*, Jacquie Kidd**, Erena Kara*, Rawiri Blundell*, Veronique Gibbons**, Ross Lawrenson**,
Kingi Turner*, Kay Berryman*
* Te Puna Oranga, Waikato District Health Board ** Waikato Clinical School, University of Auckland
He Korowai Oranga: the Maori Health Strategy sets the direction for Maori health development in the health and
disability sector. The overall aim of He Korowai Oranga is Whanau ora, which is defined as Maori families supported to
achieve their maximum health and wellbeing within both Te Ao Maori and New Zealand society (Ministry of Health,
2002).
Chronic disease is the major cause of death for Maori men (Ministry of Health, 2006).
The meanings assigned to whānau ora from pilot interviews with Māori men aged 40 > with an existing chronic disease,
including diabetes, and 3 hui with Kaumātua are explored. These interviews and hui sit within the wider research project
titled Oranga Tane Māori (Health and Well-being of Māori Men).
P06.
HOW DO NEWLY DIAGNOSED PATIENTS WITH TYPE 2 DIABETES IN THE WAIKATO GET THEIR
EDUCATION?
Ross Lawrensona, Grace Joshya, Yoska Eerensb, Wayne Johnstonec
aWaikato Clinical School, University of Auckland; bMedical student, University of Otago; cTe Puna Oranga,
Waikato District Health Board
Background: Whilst education is accepted as the mainstay of management for people with diabetes there are few
studies of what is delivered from a patient perspective.
Aim: to ascertain how patients with newly diagnosed type 2 diabetes in the Waikato receive their education, what
education they were receiving and what their views were of group education.
Methods: A cross-sectional survey of patients identified from the Waikato Regional Diabetes Service database. Patients
identified in one calendar year, having a diagnosis of type 2 diabetes and being aged between 20 and 89 years were
included in the survey. Patients were sent a four page questionnaire. Non responders were followed up by telephone.
Results: 333/667 patients (50%) responded. Seven percent of patients reported that they had not received any
education about diabetes at the time of diagnosis. Overall there was no difference between Māori and non- Māori in the
reported levels of diabetes education but the patient perceived knowledge score was significantly lower for Māori in all
aspects studied.
Conclusions: Patients appear to be receiving appropriate information about diabetes but there does appear to be room
for improvement in a number of areas. We believe that further research on the educational needs of Māori and ethnic
minorities within New Zealand is needed.
P07.
ACCESS TO RENAL SERVICES IN THE WAIKATO: UPTAKE OF DIALYSIS TREATMENT
Grace Joshya, Hanin Kananb, Margaret Fisherc, Peter Dunnd, Ross Lawrensona
a Waikato Clinical School, University of Auckland, Hamilton, New Zealand; b Student, University of Auckland,
New Zealand.; c Renal Unit, Waikato Hospital, Hamilton, New Zealand; d Waikato Regional Diabetes Service,
Waikato Hospital, Hamilton, New Zealand.
Aim: End Stage Renal Disease (ESRD) is a major complication among diabetes patients in New Zealand, especially
among Maori. Incidence of ESRD is usually estimated using new patients entering the Australia and New Zealand
Dialysis and Transplant (ANZDATA) registry database. There are concerns that among some patients with ESRD (e.g.
Maori and rural patients) may be less likely to access dialysis treatment. The aim of this study is to review the uptake of
dialysis among ESRD patients in the Waikato.
Methods: This is a retrospective review of all renal disease patients in the Waikato, who developed ESRD during 20032008. The list of new patients ANZDATA registry and electronic patient records indicating offer of dialysis treatment
following specialist renal assessment at the Waikato Renal Unit (WRU) were used to identify ESRD and dialysis
treatment uptake.
Results: 486 new patients from WRU entered the ANZDATA registry during the study period (2003-2008). A further 169
patients, without prior history of dialysis/transplantation, who attended their first renal assessment at Waikato Renal Unit
during the study period, were offered dialysis treatment. 91 of them subsequently started dialysis treatment. 78 patients
did not commence dialysis treatment until end of 2009.
Entered ANZDATA during 2003-2008
486
74%
Offered dialysis during 2003-2008
Started dialysis since 2008
Still Undecided
Rejected offer
169
91
33
24
14%
5%
4%
Deceased
Total
21
655
Dialysis Treated: 655 (88%)
3%
No Dialysis Uptake: 78
(12%)
Among them 30(38%) had diabetes co-morbidity, 35(45%) were Maori and 49(63%) were domiciled outside of Hamilton.
The profile of patients without dialysis uptake has been compared with those who commenced treatment.
Conclusion: Current results show that rates based on acceptance of dialysis/transplant alone may be an underestimate.
Uptake of dialysis continues to be an issue in the Waikato, especially among Maori. Uptake in the Midlands region is
being studied.
P08.
A STOCK TAKE OF NEW ZEALAND SECONDARY CARE PODIATRY SERVICES FOR ACTIVE DIABETIC
FOOT COMPLICATIONS AND THEIR RELATION TO AMPUTATION RATES
Michele Garrett1 ,Andrew Jones2 , Leigh Shaw3
1Waitemata DHB, 2Waikato DHB, 3Bay of Plenty DHB
Diabetic foot problems are among the most serious and costly complications of diabetes. The implementation of
structured foot services have been linked to lowering diabetes related lower limb amputations. There has been little
evidence to support this in the New Zealand setting as there has not been an overview of the podiatry services provided
by individual DHBs. The aim of this study is to do a stock take of services provided and analyse the provision of service
against the most recent diabetes related lower limb amputations rates.
Prior to this year there has not been a co-ordinated network for podiatrists employed in the provision of diabetic foot
services. The establishment of the Podiatry Special Interest Group (PSIG) affiliated to NZSSD has initiated this review of
services. A simple questionnaire asking for information on FTE details in relation to work with the high risk diabetic foot
and active foot complications was sent to podiatrists identified as working in this area. The data collected is being
analysed against the most recent lower limb amputation data supplied by the MOH.
Amputation statistics cannot be influenced by the provision of high end foot services alone. This information will provide
a starting place for further investigation of the correlation between the type, timeliness, appropriateness and accessibility
of services and the rate of end stage diabetes foot related complications and amputation.
P09.
REFLECTION OF YEAR 1 OF THE WDHB DIABETES MULTI-DISCIPLINARY TEAM FOOT CLINIC
Vickie Corbett – Diabetes CNS, Claire O’Shea – Podiatrist.
Waikato DHB
Background The Waikato Diabetes Regional Service multi-disciplinary foot team was established in July 2008 and
consists of Vascular Consultant, Diabetes Registrar, Diabetes and Wound care Nurse Specialist, Orthotist and
Podiatrists.
Aim /Objectives: To evaluate the first year of the Waikato Diabetes Regional Service multi-disciplinary foot team
(MDT). To identify the referral source and the time between the diabetic foot ulcer (DFU) developing and the referral
being made to the MDT clinic. To evaluate intervention of diabetes control and vascular interventions the effects this
has on DFU improvement.
Method: The database was established in January 2009 to review the components of the MDT clinic using Word excel.
Data such as diabetic control and vascular interventions were collected from initial referral, the WDHB health databases
and from the patient. Discharge data was gathered retrospectively from patient notes and databases.
Results:
 Total number of MDT patients 2009 was 94,
Females 28 (30%), Males 66 (70%)
Maori 31(33%)/European 47(50%)/Other 16 (17%)
4 deaths in 2009.
 The average first HbA1c was 8.3% and the discharge HbA1c 7.3%.
 The referrals received from Vascular team 27 (29%), DN 21 (22%), GP/PN practices 18(20%), Diabetes team
11 (11%), Podiatrists 11(11%), other 6 (6%).
 Currently it takes 6 weeks between the ulcer developing and the referral being made to the MDT clinic.
 Vascular interventions included angiogram/plasty+/- or bypass 33(35%) patients.
Conclusion: The goal in our first year of operation was to identify the referral source and timing of ulcer development
and presentation at the MDT clinic. Enabling strategies to be developed to increase knowledge and communication links
between the stake holders have improved patients outcomes.
As future data is collected, the team will explore and evaluate if improved glucose and blood pressure control has an
impact on healing times and identify patients who are at risk for the future.
P10.
PHARMACY INPUT INTO INPATIENT REFERRALS TO DIABETES SERVICE
N. Cunningham1, M. Choe1 , J. Pomfret1 and J. Young2
Diabetes1 and Inpatient Pharmacy2 Services, Waitemata District Health Board, Auckland, New Zealand
Introduction
Patients with diabetes make up at least 12% of our inpatients1. Unfortunately not all patients are referred to our service
therefore identifying patients who would benefit from a diabetes review remains challenging. We aim to determine if
ward-based pharmacists could be a means of identifying patients with diabetes.
Method: From 1-30 June 2009, ward-based pharmacists were asked to inform our service when insulin-using patients
were admitted. In addition to this referrals continued as previously. Referral criteria were available on the hospital
intranet and diabetes referral forms. The referral Data for these patients included length of stay, admitting service,
diabetes medications, HbA1c, and referral information.
Results: Total of 94 referrals were received. Referral criteria were met for 73 patients, 75% of referrals were from the
Medical Service, 43 (45.7%) referrals were made by ward staff, 43 identified by pharmacists and 8 referred verbally
mainly by doctors. Only 2 patients were referred by both ward and pharmacy. 74 patients had Type 2 diabetes, 35 on
one and 17 on two oral agents. 67 patients were using insulin. 27 patients using insulin were not referred by pharmacy.
65% of referrals were for education, 31% for education and advice. Mean age 61.4 years (SD 18.9), HbA 1c during
admission 9.2% (SD 2.3), length of stay was 10.9 days (SD 13.3; range 0-61), time from admission to referral was 4.5
days (SD 7.1) with no significant difference between referral sources (p 0.63) or use of insulin (p 0.23).
Conclusion: Pharmacists made nearly half of referrals to our service in June 2009, confirming them as a means of
identifying patients with diabetes which could be expanded in future.
1 Yip S. et al Audit on length of hospital stay amongst inpatients with diabetes at North Shore Hospital. Diabetes Res
Clin Pract 2008; 79:S109-S109
P11.
IDENTIFYING BARRIERS TO INSULIN INITIATION FOR PATIENTS WITH TYPE 2 DIABETES
Veronique Gibbons1, Sandra Rice2
1Waikato Clinical School; , 2Glenview Medical Centre
Background: Intensive management of patients with type 2 diabetes (T2DM) has been shown to be effective and has
led to wider use of insulin. Converting patients from oral medication to insulin is usually managed in primary care.
Aim: We aimed to identify the perceived barriers to starting insulin for patients with T2DM registered with a New Zealand
general practice.
Objectives: To explore accounts of living with diabetes and to identify perceived barriers to initiating insulin in patients
with T2DM.
Methods: The study was conducted in 2009 in one urban general practice in a large town (Hamilton, New Zealand) with
over 300 patients with type 2 diabetes. This was a qualitative study using thematic analysis of patients’ responses to
questions about barriers to the use of insulin.
Results: When insulin had been discussed, there was a realisation that diabetes is serious – tablets had not invoked the
same response. Insulin was seen as a handicap to socialising and travelling. The need for routine was limiting. There
was little insight into diabetes being a progressive disease.
Conclusions: This study provides the ground work for developing resources that will be of benefit to patients with
T2DM. There needs to be a greater emphasis on the disease being progressive.
P12.
INEQUALITIES IN DIABETES MANAGEMENT- PRESCRIPTION MEDICINES AND SOUTH ASIAN
DIABETIC PATIENTS IN THE CMDHB
Shekhar Sehgal MBChB (CMDHB) Brandon Orr-Walker MBChB , FRACP
Whitiora Diabetes Service, Counties Manukau District Health Board
Throughout the developed world ethnic minorities have a higher prevalence of diabetes; as well as a higher rate of
complications compared to the general population. This is a particular problem for Indians, who have poorer intermediate
clinical outcomes and a lower rate of meeting national diabetes targets, despite many global initiatives that attempt to
bridge the gap. This gap can be attributed to several factors such as variable prescribing practices.
Objective: In this study we analyze use of insulin, and oral hypoglycemic agents; comparing Indian with European and
Pacific (another high risk immigrant population) rates.
Results: The overall proportion of Indian patients using Insulin was 14%, compared to 24% for European (p=0.052) and
15% of Pacific Islanders. When patients were stratified according to glycaemic control only 14% of Indian patients with
poor control (HBA1c >=8.0) were prescribed Insulin, compared to 26% of European patients (p=0.025) and 22% of
Pacific (P= 0.1). Indian patients with poor control had a higher proportion of premixed Insulin than Europeans(10 vs. 2%,
p=0.017) and Pacific Islanders(1%,p=0.048 ), and were less likely to have basal and bolus insulin therapy than
Europeans(2 vs.19%, p=0.001) but not Pacific Islanders(2 vs.4%,p=0.34) . 32% of Indian patients were on no glycaemic
treatment, compared with 40% of Pacific(p=0.15) and 25% of Europeans(p=0.17). 20% of Indian patients with poor
glycaemic control were untreated similar to Europeans (15%, p=0.29) but less than Pacific (40%, p=0.008). Indian
patients were more likely to be on HMG-CoA reductase inhibitors (statins) than both Pacific(65% vs. 47%, p=0.015) and
European(65% vs. 48%, p=0.022).
Conclusions- Indian patients are less likely to be prescribed insulin than Europeans even when glycaemic control is
poor. Prescription rates of oral hypoglycaemic agents were similar between the two groups, and statin prescribing
higher, suggesting that engagement with medical care is not the limiting factor. Additionally, substantial proportions of
patients with suboptimal glycaemic control appear to be on no glycaemic medication. This treatment gap may be one of
the reasons that South Asian people with diabete are less likely to achieve national diabetes management targets.
P13.
IS GLYCAEMIC CONTROL AND CARDIOVASCULAR RISK DIFFERENT IN MORBIDLY OBESE
SUBJECTS?
Brett Shand1, Russell Scott1 and Peter George2,
1Lipid and Diabetes Research Group, 2Canterbury Health Laboratories, Christchurch Hospital, Christchurch.
Aim: Obesity is associated with increased cardiovascular risk and higher prevalence of chronic disorders such as
diabetes and systemic inflammation. The aim of this cross-sectional study in subjects attending an out-patient lipid
disorders clinic was to examine the relationship between increases in body weight from lean to morbid obesity, and
clinical and biochemical markers of glycaemic control and cardiovascular risk.
Methods: The following data were obtained from 3206 dyslipidaemic patients between 1996-2010; Anthropometry,
blood pressure, current medications, smoking history, presence of diabetes and glycaemic control (fasting glucose and
insulin, HbA1C), insulin resistance (IR) indices, plasma lipid profile, inflammatory markers (hsCRP and fibrinogen) and
plasma homocysteine concentration. For analysis, the data were stratified into six body mass index (BMI) groups (2025, n=669; 25-30, n=1403; 30-35, n=781; 35-40, n=239; 40-45, n=80; >45, n=34), followed by calculation of descriptive
statistics. Changes in the variables with increasing BMI were then examined using non-parametric one way ANOVA, with
the significance of differences between the BMI groups being determined by the Wilcoxon rank sum test.
Results: As anticipated, the prevalence of diabetes rose markedly with increasing BMI (20-25, 5.4%; 25-30, 8.0%; 3035, 18.1%; 35-40, 22.6%; 40-45, 22.5%; >45, 44.1%). In the BMI range 20-40 kg/m2, we observed a graded deterioration
in glycaemic and blood pressure control, IR indices, and the majority of the lipid parameters, associated with gradual
increases in the levels of plasma inflammatory markers. Exceptions to this trend were total and LDL cholesterol levels
which decreased marginally, and apolipoprotein B, Lp(a) and homocysteine levels which remained relatively unchanged.
None of the glycaemic, lipid or inflammatory parameters showed further deterioration in subjects with a BMI >40 kg/m2.
Conclusions: These results indicate both metabolic and inflammatory markers reach maximally abnormal levels in
patients with dyslipidaemia, even in the absence of morbid obesity.
P14.
ALCOHOL ADVICE FROM HEALTH PROFESSIONALS WORKING WITH PEOPLE WITH TYPE 1
DIABETES
Amy Liu, Nadia Lim, Daniel Howarth
Auckland Diabetes Centre, Greenlane Clinical Centre, Auckland, New Zealand
Alcohol ingestion is a common causes of fluctuating blood glucose levels in people with type 1 diabetes. This is due to
variables such as alcohol percentage, carbohydrate content, volume of alcoholic beverages consumed and physical
activity. However, there are no current guidelines for alcohol consumption in people with type 1 diabetes.
Aim: To investigate what guidance and advice New Zealand health professionals give regarding alcohol consumption, to
people with type 1 diabetes.
Methods: An online survey was conducted for health professionals working with the type 1 diabetes population, asking
what advice they give to their patients on insulin adjustment and carbohydrate intake when drinking alcohol. Structured
questions also asked what knowledge they had of national and international standards for alcohol and Type 1 diabetes.
Results: There were 41 responses in total (21 dietitians, 12 nurses and 8 doctors). Sixty-six percent of respondents
indicated that they educate all their type 1 diabetic patients regarding alcohol. Fifty three percent claimed that they were
aware of the current alcohol guidelines for patients with type 1 diabetes. However, currently we do not have any such
guidelines. The majority of respondents were not aware of any international guidelines and indicated that they provide
the general recommendations; to have food/carbohydrates with alcohol, drink in moderation and test regularly due to
increased risk of hypoglycaemia. There was limited knowledge of carbohydrate quantity, insulin adjustment and
carbohydrate intake provided. Ninety-three percent of respondents (90% dietitian 92% nurses and 100% doctors) felt
there was a need for more specific standards regarding alcohol consumption in patients with type 1 diabetes.
Conclusion: Results of this survey suggest a need for detailed guidance surrounding alcohol consumption for people
with Type 1 diabetes. Further research on insulin adjustments, carbohydrate quantities and alcohol consumption is
required.
P15.
TITLE: REAL-TIME CONTINUOUS GLUCOSE MONITORING IN CHILDREN AT INSULIN PUMP INITIATION
Craig Jefferies1,Jean Ann Holt1, Grace Harris1, Caroline Adamson1, Wayne Cutfield2, Fran Mouat1, Paul
Hofman2, Peter Reed1
1 Starship Children’s Health.2 Liggins institute, University of Auckland.
Aim: To see if Real-time CGMS (RT-CGMS) improves pump start and metabolic control long-term in children with type 1
Diabetes.
Objective: 1) To compare the metabolic control between children with RT-CGMS at pump start (intervention group) or
standard glucose testing at pump start (retrospective controls).
Methods: An intervention study (of CGMS in Pump children) with retrospective controls from the Starship Diabetes
Database. All subjects are already part of the registration/training list that has run since 2004, and currently starts ~20
children a year on insulin pumps. Comparison of the intervention group with RT-CGMS to the existing insulin pump
control data through the service. This RT-CGMS at insulin pump group have 2 periods of RT-CGMS; the first at pump
start, and then again between 4-6 weeks after. Comparison will be with HbA1c at time points 0, 3, 6 and 12 months
along with insulin dose, BMI SDS, Hypo rate (severe) and DKA). 20 RT-CGMS intervention cases compared to 40
retrospective controls will have over 85% power to detect a clinically significant difference in HbA1c of 0.8 (alpha = 0.05).
Results: Retrospective group: the mean HbA1c of 40 patients using pumps is 7.7 and SD is 0.9. At present 8/20 have
been recruited with from 3-6 months of follow-up available. Further analysis and recruitment will be available as the
study progresses. The patient satisfaction at pump start is improved, whether this translates to improved metabolic
control is to be seen.
Conclusions: RT-CGMS at insulin pump start appears to be a useful adjunct; further evaluation of results Is awaited to
see whether this translates to improvement in metabolic control.
Acknowledgement: NZSSD Novo Nordisk Diabetes Grant Scheme Award 2008
P16.
DOES CONTINUOUS GLUCOSE MONITORING (CGMS) ASSIST MANAGEMENT OF BRITTLE TYPE 1
DIABETES OVER AND ABOVE STANDARD INTENSIVE SELF-MONITORING OF BLOOD GLUCOSE? AN
AUDIT OF 6 PATIENTS STUDIED PRIOR TO XENOTRANSPLANTATION
Renate Koops, John Baker
Middlemore Hospital, Auckland
Objective: Patients with long-standing type 1 diabetes and a history of recurrent hypoglycaemia frequently become hypo
unaware and lose the normal physiological response to hypoglycaemia. Insulin tolerance tests (ITT) were performed at
all participants in the DIA-06 study pre-transplantation to determine their counter-regulatory hormone response to
significant hypoglycaemia.
Design: A week before the transplantation of porcine islet cells, participants underwent an ITT to measure counterregulatory hormones. The test took place in a safe environment with experienced endocrinology staff attending.
Participants were given 0.15 U/kg Novorapid iv, blood glucose levels were measured every 15 minutes, blood samples
for adrenalin, glucagon, ACTH, cortisol and glucose were taken every 30 minutes and symptoms were recorded. Target
blood glucose level was <2.3 mmol/l on the HemoCue, a device specifically designed to accurately measure low blood
glucose levels.
Results: The glucose responses to ITT for 4 participants with longstanding type 1 diabetes and hypo-unawareness are
shown in the figure. Counter-regulatory hormone results indicate absent glucagon response, attenuated adrenergic
response, and attenuated cortisol/ACTH response. Individual results will be presented at the meeting
Conclusions: Patients with longstanding type 1 diabetes and hypo-unawareness showed impaired normal physiological
response to hypoglycaemia.
P17.
PSYCHOMETRIC EVALUATION OF CANDIDATES FOR A TRIAL OF THE SAFETY AND EFFECTIVENESS
OF PORCINE ISLETS XENOTRANSPLANTATION IN PATIENTS WITH TYPE 1 DIABETES
Patricia Loft1, Joyce Fennell2, and John Baker3
1Centre for Clinical Research and effective practice; 2Auckland City Hospital, 3Middlemore Hospital, Auckland
Objective: To determine the usefulness of psychometric assessment tools to ascertain the suitability of candidates with
longstanding type 1 diabetes and a history of recurrent hypoglycaemia to cope with the rigour of the porcine islets
xenotransplantation trial.
Design: During the screening phase of the LCT/DIA-06 trial, candidates and their partners attended psychometric
evaluation by a registered Health Psychologist to determine suitability to participate in the trial. Candidates underwent a
structured interview using the Auckland Psychosocial Assessment Scale (TAPAS), and completed the Test of Memory
Malingering (TOMM), and Millon Behavioural Medicine Diagnostic (MBMD) scales. To date eight candidates and their
partners have undergone the psychometric evaluation.
Results: All psychometric tools were useful in identifying candidate suitability to participate in the trial, however the
MBMD was the most informative and comprehensive instrument as results corroborated with clinical impressions of the
candidates during the structured interview. The MBMD results were useful in identifying factors such as high levels of
guardedness and illness apprehension. Markedly, this scale identified high problematic compliance and spiritual
absence in most of the candidates, which highlights consideration for patient management.
Conclusions: The TAPAS, TOMM, and MBMD are effective psychometric tools to screen candidates for the LCT/DIA06 trial, with one candidate not accepted into the trial following the psychometric evaluation.
P18.
TYPE 1 DIABETES PRESENTING IN PREGNANCY
R Jaung, J Morgan, C O’Beirne, J Rowan, T Cundy
Diabetes Pregnancy Clinic, National Women’s Health, Auckland City Hospital
While it is not uncommon for type 2 diabetes to first present as gestational diabetes (GDM), this is an unusual presentation
for type 1 diabetes. Between 1992 and 2009 (18 years) we identified 13 women (age 15-37) with new or developing type 1
diabetes presenting as GDM. We have reviewed their presentation, pregnancy outcome and clinical course. Five of the
13 had needed insulin treatment for GDM in previous pregnancies. The mean pre-pregnancy BMI was 23 kg/m2. GDM
was diagnosed between 6 and 37 weeks (median 22) gestation. The mean HbA1c at presentation was 7.0% in the 10
women identified through routine screening at 24-26 weeks, and 10.3% in the 3 identified due to symptoms or glycosuria.
All were treated with insulin and delivered successfully (4 by cesarean section; including one pair of twins) at 37-39 weeks
gestation. Twelve of the 13 subjects had positive serology for islet cell antibodies, the one exception being a Laotian
woman who had a fulminant presentation with diabetic ketoacidosis in late pregnancy. Following delivery 7 subjects
required continuing insulin therapy, but 6 subjects did not require insulin immediately post-partum. Of the latter group only
1 had a normal post-partum glucose tolerance test. Four women needed to restart insulin 2 – 5 months postpartum, but 2
had long-term remission and did not develop diabetes until 3 years later. These newly diagnosed cases in pregnancy
comprised 3.5% of all type 1 diabetes pregnancies in the period 1992-2009. The proportion of cases of newly recognized
diabetes in pregnancy that had type 1 diabetes, rather than type 2, increased from 3% in 1992-1997 to 8% in 2004-2009.
P19.
ETHNIC SPECIFIC BIRTH CENTILES FOR BABIES FROM THE WAIKATO: A CLOSER LOOK AT
DIABETES IN PREGNANCY
Peter K Mwamurea, Grace Joshyb, Louise Wolmaransa, Peter Dunna
aRegional Diabetes Centre, Waikato Hospital, New Zealand, bWaikato Clinical School, University of Auckland,
Hamilton, New Zealand
Background: It has been reported previously that there are significant differences in mean birth weights between New
Zealand’s main ethnic groups. Ethnic specific birth centile charts were subsequently developed.
The term “macrosomia” has often been used non-specifically, with arbitrary cut off points, giving rise to the possibility of
misrepresenting true birth weights. Diabetes in pregnancy is known to adversely affect birth weight and has particularly
been associated with macrosomia.
Aims:
1. To generate ethnic-specific birth centiles for term babies (mothers without diabetes during pregnancy).
2. To explore where the offspring of diabetic pregnancies fall on the ethnic specific birth centile charts.
Methods: Birth data from the Waikato Hospital database from 2006-2008 (n = 7785) was used to generate ethnic
specific birth weight centiles. The frequency distribution of birth weight data from babies born to mothers who had
diabetes was compared to that of babies born to mothers who did not have diabetes. Multiple pregnancies, congenital
abnormalities, stillbirths and pre-term births were excluded. For Maori and European ethnic groupings, born at
gestational weeks from 38 to 41, sex specific centiles were generated and smoothed. The 10th and 90th percentiles and
the mean were calculated and then smoothed using a linear regression model.
Results: The mean birth weight from 38-41 weeks for the whole study cohort was 3529g.
The ethnic specific mean birth weights from 38-41 weeks were: European 3581g, Maori 3426g, Pacific Islander 3708g,
Asian 3359g and other 3426g.
Conclusion: Superimposition of the frequency distribution of birth weights from offspring of diabetic mothers showed no
significant deviation from birth weights of offspring of non-diabetic mothers.
P20.
POSTNATAL MANAGEMENT OF WOMEN WITH GESTATIONAL DIABETES: ‘BARRIERS AND BRIDGES’
Jessie Roy George
Waikato Regional Diabetes Service
Aim: Facilitate the postnatal management of women with gestational diabetes (GDM) by:
 Increasing practice nurse’s awareness regarding GDM post-natal follow up improving communication between
primary and secondary health care professionals.
 Enrol women at risk to annual or 2 yearly Oral Glucose Tolerance Test (OGTT)
 Increase uptake of 6 weeks postnatal OGTT.
Methods: Within the 6 months that the study was conducted, the following steps were implemented:
 A prominent marker in the Well Child book alerting the practice nurses that the child’s mother has had
gestational diabetes
 Communication via telephone with the practice nurse, providing them with full antenatal history and postnatal
follow ups.
 Copy of the discharge letter sent to General Practitioner and the practice nurse.
Results: After follow-up with practices that had the highest incidence of GDM cases, it was found that 10% of practice
nurses used the formulated guideline. However the bulk of the work has still remained with the Diabetes Nurse Educator.
In spite of this, there have been positive outcomes Marked increase in rapport between the DNE and the practice nurses.
 A recall system in the MEDTEC database for either an annual or 2 yearly OGTT.
 Increase in the number of women attending postnatal OGTT
 Early detection of pre or type 2 Diabetes.
Conclusion: The project is still in its infancy and is planned to be continued as a standard practice as early detection
and intervention has been proven to decrease the chronic complications of Diabetes.
P21.
THE ASSOCIATION BETWEEN ADHERENCE TO A MEDITERRANEAN DIET AND INDICES OF
GLYCAEMIC CONTROL
Author: Deborah Hutchings
Auckland Diabetes Centre at the Greenlane Clinical Centre, Auckland, New Zealand
Aims: Previous studies have shown that Mediterranean diets have a positive effect on cardiovascular health. Recent
evidence also indicates a favourable effect on type 2 diabetes. The purpose of the study was to review epidemiological
studies investigating the relation between indices of glycaemic control and consumption of a Mediterranean-type diet.
Methods: A systematic review was conducted investigating the relationship between a Mediterranean diet and
glycaemic control. The key words “Mediterranean diet”, “Diabetes” and “glycaemic control” were used in MEDLINE,
limited to humans and studies over the past ten years. The search focused on articles referring to the Mediterranean
diet as a whole and excluded studies regarding specific foods of this diet.
Results: Thirteen studies were selected that met the inclusion criteria. Prospective studies in people without type 2
diabetes have shown that adherence to a Mediterranean diet was associated with a significant reduction in the risk of the
developing type 2 diabetes, both in healthy participants and participants with cardiovascular risk factors or the metabolic
syndrome. All intervention studies reveal a positive effect of adherence to a Mediterranean diet on glucose metabolism
in participants with type 2 Diabetes or the metabolic syndrome. A Mediterranean diet showed more favourable effects
on glycaemic control compared with a standard low-fat diet, in patients with type 2 diabetes. In newly diagnosed type 2
diabetics, a low-carbohydrate Mediterranean diet had lower HbA1c levels and a delayed need for anti-hyperglycaemic
drug therapy compared with a standard low-fat diet.
Conclusion: Much evidence suggests that adherence to a Mediterranean-type diet can improve glycaemic control in
patients with type 2 diabetes and can reduce the risk of developing type 2 Diabetes. Further research is required to
determine whether a restriction of carbohydrates within a Mediterranean diet may be advantageous for patients with type
2 diabetes.