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Hello, I'm Norman Swan.
Welcome to another program in our series on type 2 diabetes.
Today we're talking about primary prevention and early detection,
and what to do when you find a problem.
Type 2 diabetes affects over 7% of the Australian population
aged 25 years or older.
For every person diagnosed, there's one person who goes undetected,
and that's a recipe for complications in almost every organ in the body,
but you already know that.
This program looks at new NHMRC evidence-based guidelines,
and we'll be talking about prevention and early diagnosis, as I said.
As usual, there are a number of useful resources available
on the Rural Health Education Foundation's website:
Now let's meet our panel.
Ashim Sinha is the director of Diabetes and Endocrinology
at the Cairns Base Hospital and its Diabetes Centre,
and is also Associate Professor and Senior Research Fellow
at James Cook University. Welcome, Ashim.
Thank you, Norman.
Mark Harris is a general practitioner
and director of the Centre for Primary Health Care and Equity
at the University of NSW.
- Welcome, Mark. - Good evening, Norman.
Alan Barclay is a practising dietician with Diabetes Australia
and researcher at the University of Sydney.
- Welcome, Alan. - Thank you.
Welcome to you all.
Mark, we are dealing with an epidemic.
I know we've said it, but let's remind ourselves of the statistics.
The prevalence of diabetes is increasing in Australia,
but worldwide we're seeing a steady rise
in the number of people with diabetes.
That's related not only to the ageing of the population
but the shift in our lifestyles.
That's happening in developed countries like Australia,
but also in less developed countries,
especially in the Asian region.
It's the most rapidly rising disease in the region.
NORMAN: What about the prevalence
of abnormal glucose tolerance?
MARK: That's certainly very high.
We look at about 7.5% of people having diabetes,
but there's another 10.5% of people
who have impaired glucose tolerance,
and about another 5% or 6% of people
with impaired fasting glycemia.
So we're looking at over 20% of the population over the age of 25
either with diabetes or who are at a high risk of diabetes.
NORMAN: It's not evenly spread through the population, is it?
No. We know that diabetes is...
In Australia, the prevalence of diabetes is greater in low socioeconomic groups,
and that's largely associated with the incidence of obesity.
Here we can see in this graph,
a graph of diabetes-related deaths
by looking at different socioeconomic quintiles,
with the most disadvantaged having the highest rate.
Then what we call a social gradient,
as you move up the social classes to a lower level of diabetes.
NORMAN: A disease of poverty? - Yeah.
That's reflected in the death rates and prevalence rates as well.
Alan, you've tracked it by geography.
We have indeed.
We've done geospatial maps
of the prevalence rates of diabetes in New South Wales,
which we believe are broadly applicable to the rest of the country.
Going from lightest to darkest is increasing diabetes prevalence.
This is the 2000 map, the National Diabetes Services Scheme data
from the year 2000, and the 2001 census data.
You can see the dark points in the middle and to the west.
Then we move forward to the 2007 data,
and you can see quite an increase in the number of regions
with the darker colour.
So the diabetes prevalence rates are rising dramatically,
particularly in the west and far west of New South Wales.
We do believe this is very similar in other parts of the country.
Ashim, a lot of that will be reflected in other parts of the country.
- Your experience would be that it is? ASHIM: Yes, absolutely.
The prevalence of diabetes in the Indigenous communities
across Far North Queensland and elsewhere in the country
is almost three times that of non-Indigenous Australians,
rising to 25%, 30% in some populations.
The most recent study that was done in Darwin
in urbanised Indigenous Australians, the prevalence rate is 17% to 20%.
We're seeing the disease more and more in younger people,
and particularly in children.
Frame these guidelines for us that we're basing our discussion on, Mark.
The guidelines are really for the prevention of diabetes.
Also, there's another guideline for the early detection of diabetes.
Basically, we're seeking to prevent diabetes before it can occur.
We're talking about primary prevention of diabetes.
We can think about that in the general population.
We're interested in reducing the incidence of type 2 diabetes
in the whole population through general-population measures,
particularly around diet and physical activity and overweight
and amongst high-risk groups.
This is particularly relevant to clinical practice
increasing the... offering interventions for people
who we judge to be at particular risk of diabetes.
We'll come back to that in a moment.
Let's go to the results of our poll to find out where you base yourselves.
Blue is rural, yellow is remote, red is metropolitan and green is regional.
Most of you identify yourselves as rural,
then you're evenly split between metropolitan, remote and regional.
I want to give you your second poll question:
So why don't you answer that question, and we'll come back to that.
We've got our first question in,
which comes from Marisa Pilla in Queensland - your area, Ashim.
'I wonder if we're missing the boat with our potential diabetic patients.
I've had a few patients whose pathology has changed immensely
from 12 months earlier.
However, the levels were just within the guidelines for fasting blood glucose.
They were told, all is well.
Twelve months later and all are now at early-stage diabetes.
Could we not have intervened earlier and prevented this from occurring?'
Ashim? North Queensland question.
Might as well go to a North Queensland specialist.
Yes, I think it's very difficult to draw where the line is.
The clock starts to tick very early.
Where we have set an arbitrary figure of 7 for diagnosis of diabetes,
we also know that people with impaired glucose tolerance
and impaired fasting glucose, which is called pre-diabetes,
are at equal risk of cardiovascular disease.
If you are in the high-risk group and if you have facets of high risk,
intervention should start as early as possible,
even if their blood glucose is not within the so-called diabetic range.
How often is it that you see it speeding, it's a speedy change?
Well, it is seen quite commonly.
Where we come from, we see quite often
that things change dramatically within 12 months to 18 months.
That's not uncommon to find, from being normal to...
Once your beta cells are clapping out, you're on the margin.
Beta cells can drop off very fast.
That's a well known pathological term - clap out.
Harrison's textbook describes it well.
Alan, how preventable is it, really, type 2 diabetes?
There's good evidence that we can prevent almost three out of five cases
of type 2 diabetes through lifestyle intervention.
So very good evidence indeed.
Mark, it's about twice as effective as medication, doing that?
Yeah. Surprisingly, we've found that diet and physical activity,
getting people to lose weight
in the various studies that have been conducted overseas -
Finland, US, China and India -
all of them demonstrate that, particularly the ones
where they've had a comparison with metformin, for example,
that lifestyle change is more effective than drug therapy.
When you can do it?
When you can do it.
You've just described a situation where
people who are least able to take control of their lives in Australia
because there's so much going on, they're on Struggle Street,
are they able to take this on?
It's possible. It's difficult.
The Finns recognise this.
I was talking to Tuomilehto.
He recognised that it's difficult.
We need to make extra effort with people from low socioeconomic backgrounds,
but it's possible.
We don't have to get people to be The Biggest Losers
and lose mega amounts of weight.
It's a relatively small amount of weight that we need
in order to really achieve that dramatic reduction in risk,
especially in high-risk people.
- Alan? - Absolutely.
Small changes add up.
We're only asking people to lose between 5% and maximum 10% of their body weight,
which is not a huge ask.
A small reduction in their total kilojoule intake,
around about 2,500 kilojoules per day on average,
will certainly help people to lose a half to one kilogram per week.
It's not, as Mark said, The Biggest Loser.
It's quite a moderate amount.
You can do that through small, incremental changes to your diet
and increasing regular physical activity, rather than dramatic changes.
People can achieve those, it has been shown.
What about exercise, Mark?
Isn't exercise easier to do than changing your diet?
I thought evidence was stronger, particularly with weight training.
There was a Melbourne trial which showed weight training
was very good at preventing it.
Certainly exercise is an important part of prevention.
These things are a bit of a chicken-and-egg situation.
One of the impediments to people doing exercise
can be that people who are morbidly obese, in particular,
can find it difficult to achieve adequate levels of physical activity.
They're the people that tend to be very sedentary
and very at risk of developing diabetes at a young age.
But the evidence around physical activity is very strong.
We need to be finding ways of tailoring not just diet,
but physical activity programs to people's needs.
That's going to be very different
depending on people's life circumstances.
We're talking about two things in this program -
population and individual interventions.
If you look at population interventions
to change the community rather than people who are at risk,
tough ask, particularly in Aboriginal and Torres Strait Islander communities.
It is a very difficult thing.
You have to look at the whole dynamics of the society that we work in.
There are many, many other social problems
and financial problems et cetera.
Asking people to exercise often becomes a very big ask.
One of the points that I want to emphasise,
and I don't know whether the other panel members will agree with me,
is that yes, weight loss is very important,
but the message I try to give to patients is
that even maintaining their current weight is very important.
Even if they maintain that weight and not gain the weight,
it does have beneficial effects in the long-term progression of the disease.
In gestational diabetes,
the recommendation in the NHMRC guidelines is,
don't bother identifying women at high risk.
This is a waste of time.
You're going to miss up to 50% of women with gestational diabetes.
You've got to screen every pregnant woman at 26 weeks for diabetes.
The question is, when we move away from population interventions
to change community, how we design exercise,
the stuff we talk about all the time,
and look at individual interventions to try and prevent diabetes,
if we go for a high-risk strategy,
Alan, do we know how many people we're going to miss?
No, I couldn't answer that question. Mark might be a better person.
Yeah, it is difficult.
We will miss a percentage of people.
One of the reasons that we are designing simpler methods of screening people
is to try and pick up as many people as possible.
- We're going to talk about that later. NORMAN: In a minute, actually.
The guidelines recommend a screening strategy,
an intervention strategy to identify people that are high-risk,
and presumably people who are pre-diabetic?
Yeah, we're interested in identifying people with pre-diabetes, diabetes
and people who have equivalent risk.
That's why we've moved from our previous recommendation
in the general population, which was to screen people from the age of 50 up
and some other groups at an earlier age,
to really try to bring that age down quite a bit to 40,
and screening them using a diabetes-assessment tool.
NORMAN: This is an absolute-risk tool?
MARK: Yeah, the AUSDRISK tool, which is based on the AusDiab study
and really calculates people's risk.
You get a risk score based on your answers to a set of questions.
NORMAN: A heck of a lot younger than that
if you're Aboriginal or Torres Strait Islander.
MARK: Yeah, Aboriginal and Torres Strait Islander, we're talking about 18 and up.
There are some other groups as well that have equivalent risk.
We're recommending that people be screened with that from the age of 40,
and Aboriginal people from 18,
and that those people who have a risk of 15 or more,
not only should they have a fasting plasma glucose
to determine whether they've got diabetes
or possibly impaired glucose tolerance,
but also that those people, regardless of their glucose,
require an intervention -
require a lifestyle and physical-activity intervention
of the sort we were talking about earlier.
That's where we've got the possibility of intervening early
and picking up some of those people missing previously.
Let's take a couple of questions.
Karen, I think is her name, has asked,
'Could you name some of the studies in primary prevention?'
The studies that are probably best known,
the original study was a Chinese study.
Pan was the first author of the paper that announced that to the world.
There's been a study in Finland, a Tuomilehto study.
There was the US diabetes-prevention trial
and the Indian study, which was another large study.
All of these studies focused on people who were high-risk
and had impaired glucose tolerance and impaired fasting glycemia,
and trying to prevent those people from going on to develop diabetes.
Otherwise we're looking at at least two thirds of those people
over a ten-year period going on to develop diabetes.
We were able to prevent, as we said earlier,
about 60% of those people from doing so.
The results of our poll 2 are in.
Most of you claimed to have
either a comprehensive or moderate understanding.
A couple of questions coming in by our webcast.
From David Menzies, a general practitioner in Victoria -
'Current diabetes-prevention initiatives are struggling to attract participants,
especially in the younger age groups.
How do we convince young, busy people that are at risk
to adopt lifestyle change when they perceive themselves as healthy?
The AUSDRISK is picking up people,
but they're self-selecting out due to lack of urgency.'
That's a very good question.
People don't really recognise the symptoms having any immediate effect.
It's a long-term condition where they'll be having complications
10, 15, 20 years down the track.
We can focus on the initial feelings of feeling better, more energy,
a general feeling of wellbeing and quality-of-life things.
So accentuate what people will feel are immediate benefits
and maybe then talk about complications.
NORMAN: How do you motivate people, Ashim?
One of the important things people forget...
NORMAN: Do you shout at them?
We are far too glucocentric.
In today's world, in 2009,
I would define diabetes as a vascular disease
in which hypoglycemia plays an important role.
People don't realise that even if they have sugars in the normal range,
that you can still end up getting severe cardiovascular complications.
That has been well seen both in the IFG and IGT state.
That is one of the biggest motivations - that it's not just the glucose,
it's the other systems in the body that are being affected.
I think that's the way to go.
That's how I talk to my patients, that diabetes is a vascular disease.
- Mark? MARK: Yeah, this is a challenge.
As we move away from the somewhat artificial situation of a trial -
and they've found this in Europe
as they've tried to take what they learned in the Finnish study
and apply it at a European whole-population level -
they've had the same difficulty.
Some of it is a question of logistics -
getting people to programs, enrolling them and linking them up.
That's something that we've got to do a lot more work
at getting to work seamlessly.
Motivation is a big part of it.
This is a key role for the GP, for the practice nurse,
for the diabetes educator, the dietician, others in the community,
to really work with people using motivational interviewing strategies
and help them to make a decision to make a change.
That's not something that's easy to do,
and it's probably not something that for many people
will occur in one consultation.
It will be slow water torture.
You really have to keep returning to this and say,
'Last time we saw you, your risk was high.
You haven't yet got diabetes but it's only a matter of time
if we don't do something about it.'
So keep revisiting it and keep encouraging people.
This is a long-term problem,
and it's a long-term strategy we'll have to have to deal with it.
We'll come back to the algorithm later
about what you do when your AUSDRISK is high,
to signal part of that assessment is your cardiovascular risk
and intervening then.
Presumably you've also got to apply
what are the cardiovascular absolute-risk tools too.
Yes, absolutely. Diabetes cannot be assessed separately
from any cardiovascular risk.
Any cardiovascular-risk tool that we use has to be applied simultaneously.
Another question from Queensland -
'Is there any evidence that people who do shift work
are more prone to diabetes and stroke
because of the changes required of the body,
or is it simply that they choose the wrong foods,
and that becomes a risk factor?'
There's an association with lack of sleep and diabetes risk.
There's an association between sedentary lifestyle and poor diet
with diabetes and diabetes risk.
It certainly puts people in a higher risk category,
given the way most shift work works.
But it's not something that's not changeable.
It is possible to work in shift work
and to still engage in enough physical activity and have a reasonable diet.
That will make a big difference to your risk.
I might go to our next poll question, which is:
We'll come back to that later.
Beverley Smith asks, 'Are ***-positive patients a high-risk group?'
There has been some wonderful work done from this part of the world,
particularly from St Vincent's Hospital in Sydney.
- The protease inhibitor story? - Right.
With *** and lipodystrophy syndrome,
what you see from Professor Don Chisholm's group,
where they have shown that
patients with *** have the same sort of metabolic facets
as you would see in the metabolic syndrome -
central adiposity, dyslipidaemia, dysglycemia, et cetera.
So yes, the answer to your question is, they are at high risk.
Particularly, some of the medications may also interact with
this metabolic syndrome configuration.
And if they change the HAART make-up,
the highly active antiretroviral therapy, is it reversible?
I don't know. I have no straightforward answer to that question.
Certainly when you are treating these patients,
you've got to treat the metabolic factors as well, and that's what we do.
NORMAN: Now, our first case study.
Joe is 27 years old.
He comes to see you, Mark.
He's a truckie, a smoker,
likes a few drinks at the weekend.
There's a family history
of type 2 diabetes.
He's overweight, verging on obese.
He comes for his annual medical that
he has to have to maintain his licence.
He's certainly at risk of developing diabetes, maybe not immediately,
but certainly over the next 10 to 15 years
he's at risk of developing diabetes.
It depends on his level of obesity, particularly his central obesity.
I'd want to be assessing his weight, his body-mass index,
his waist circumference.
Looking at all those other risk factors which are part of the AUSDRISK tool,
such as his ethnicity and his diet and physical activity...
And there are additional risk factors we didn't talk about
that aren't part of the risk factors.
Yeah. He won't have polycystic ovary disease.
He'd probably thump you if you suggested it.
If he's had a cardiovascular event, that puts him in a high-risk category.
I'd want to really assess his risk factors,
his overall risk of both cardiovascular disease and diabetes.
I'd have a real discussion about that with him
rather than leap in and do a fasting blood glucose straightaway.
One of the problems with him is that if we do a fasting blood glucose,
as was pointed out in one of the questions earlier,
is that he might well have a normal glucose, but he's still...
That's the value of the absolute-risk tool?
Yeah. He still may be at risk of developing diabetes
over the next 10 or 15 years.
We need to look at him and say,
if you're 40 and you've got these same risk factors,
what's your risk score?
What are your chances of having diabetes or at least pre-diabetes,
and what's that going to mean?
It's a very multidisciplinary GP, Alan,
so he refers young Joe to you for lifestyle modification.
Absolutely. Being a man, we wouldn't be focusing so much on his weight,
but getting him into shape,
getting him to lose a few pounds so he looks a bit buffer,
focusing on a moderate reduction in his kilojoule intake
making simple changes so he can implement them into his everyday life.
Pretty tough if you're driving a truck.
I was just about to say that. On the road, long hours.
Restaurants in rural and remote areas maybe don't have the best choices
that we would be recommending.
They've got Chiko Rolls. What are you complaining about?
Something like one of those plug-in refrigerators
that you can stick into the cigarette lighter would be a great tool for him.
He could put in sandwiches, snack foods,
something from home,
some fresh filtered water,
because it doesn't have a taste,
unlike some tap waters.
Things he can have on the go.
Also, getting him to try
a reduced-alcohol beer
rather than regular beer.
Cutting back,
but not telling him not to drink.
That would be unlikely at his age.
Maybe trying to stick to
two standard drinks a day if he can
and not save it all up for Saturday night.
The other thing is getting him out of the truck
and doing some physical activity.
Maybe walking around the truck to inspect it, make it look inconspicuous.
Going for a walk at lunchtime, or before or after his drive.
There are lots of little things you can incorporate into his lifestyle
without putting him on a diet as such.
Motivating him, Ashim? A 27-year-old who thinks he's invulnerable.
Well, difficult, but we've got to do it.
I just did a quick AUSDRISK score on him,
and he's in the moderate-risk group.
His chances of developing diabetes is 1 in 20, fairly high.
You could hang the threat of, one day he might be on insulin,
which is not a great idea for a truck driver.
We don't like to use insulin as a threat as endocrinologists.
Absolutely not. This is part of the normal course of diabetes.
Thank you for correcting me.
So your objectives are moderate weight loss, is that right?
Absolutely. We need to lose 5% to 10%
of the initial body weight.
So if he's 100kg, just 5kg or 10kg.
We're not going for The Biggest Loser.
It's not 10, 20, 30kg
within a few weeks,
it's .5kg, maybe up to 1kg a week.
The other important thing to point out -
we know that people do well if they see
a practitioner on a regular basis.
If they see the doctor, the dietician,
the physiotherapist,
the diabetes educator,
all the team working together
providing consistent advice
will help the individual to comply
with our recommendations
and to keep up those behavioural changes
for the long-term.
That's really important.
And as well, some telephone contact, Mark.
If you're in a truck, I suppose you're dealing with a mobile phone.
But some people are trying to intervene.
The important point here is the consistent message that Alan brought up.
Whoever is giving those messages has to be consistent.
In a real-life situation, we see
people get different messages from different sources.
That's very important.
Which weight-loss diet is better? Alan, you've looked at that.
There's plenty on offer.
Many. A new one every week, I think.
Our group looked at four
of the more popular ones in Australia
over the last couple of years.
You'll recognise these.
The one is yellow is
really a standard weight-loss diet
that most people up until recent times
would have been recommended.
It's high in carbohydrate, low in fat,
moderate in protein.
The blue one is the low-GI diet,
which is essentially the same
as the high-GI diet,
except the carbohydrates that are chosen
are the low-GI options.
The high-protein diet is essentially
the CSIRO Total Wellbeing Diet,
very popular in Australia.
The green one is the Atkins-style diet.
Despite what people might think,
the low-GI diet and the Wellbeing Diet
were almost equally as good
and better than the Atkins-style diet,
and definitely an improvement
over the standard weight-loss diet.
Both of them lead to a fairly
significant decrease in fat mass,
which is very important.
It's not just about losing weight,
it's what you're losing that's important.
Losing body fat is most important.
The other factor that sets the two apart
is that the high-protein diet caused
a slight increase in LDL cholesterol
relative to the low-GI diet.
It is worth pointing out
that in this trial,
people were provided with lean meat.
It wasn't fatty meat, it was lean meat,
but they still had that slight rise
in LDL cholesterol.
So overall, the low-GI diet was a superior system
for losing weight for these people.
Another question has come in, also from Queensland -
'Considering how many children are now obese,
should we be screening them also?'
It's a good question.
The evidence points otherwise.
Where people have done screening for type 2 in children,
the EEL has not been great.
Experts believe that children actually don't remain in a state of pre-diabetes
for a long time.
You have normal glycemia one day, and within a short span of time
they develop frank diabetes.
So we don't have a definite answer to that question,
whether we should screen children.
In some work that we did in the Torres Strait and has now been published,
we have shown that 44% of Torres Strait children have got some aspects
of metabolic syndrome.
In that particular very high-risk group, what we have tried to introduce
is screening for diabetes as a part of their routine health check,
and not as anything different.
That brings us to the very interesting question,
what would be the best screening tool?
In the new guidelines, people have suggested
point-of-care testing with glucometers as well as somewhere down the line,
once we get agreement about the HbA1c methodology,
probably the point-of-care testing with glycohemoglobin
will facilitate matters and will be easier to do from a finger prick.
But at this stage, it is evidence-free territory
that screening for children for type 2 really hasn't shown much help.
The most important thing we need to do with children
is to assess their levels of physical activity and their diet,
and to really talk through with the parents about what we can do with that.
That's not very sexy, but it's what we need to do.
It's the most evidence-based thing we can do with children.
I think you've got a dietary checklist for people.
Yes, we certainly have. Just a few points to jot down.
Eating regular meals throughout the day is important.
People who are overweight tend to skip breakfast and sometimes even lunch
and have the gut-buster meal in the evening,
which starts at five and goes till eight o'clock at night or longer.
It's important to spread that food throughout the day as much as possible.
I recommend three main meals. Snacks are a bit of an extra.
A lot of people eat them out of habit.
It's an easy way of cutting out that 25% of calories I talked about earlier -
just by dropping those snacks altogether.
As you saw from those diabetes-prevention studies,
reducing total fat intake was the primary goal.
Because fat is the most energy-dense,
it's one of the easiest ways of reducing the kilojoule intake in the diet.
There are lots of lower-fat products out there in the market.
We're not saying have a no-fat diet.
That's impossible, and definitely unpalatable.
We're saying eat quality fats instead of the saturated and trans fats
that you find in a lot of processed foods.
Have the healthy poly- and monounsaturated fats
like you'll find in olive oil and canola oil and products made with those.
Most people think diabetes and developing diabetes
is related to sugars, but there's very little evidence for that.
What people need to do is avoid both refined sugars and starches.
It's the refined ones that are the problem.
Foods like milk and yogurt are quite high in sugar, as is fruit,
but the sugars in those foods isn't as bad for you as a lot of the other ones.
Having high-fibre foods will fill you up,
and often they're the whole-grain ones, so they're more slowly digested.
Getting back to the main point
is to have carbohydrate at each of those main meals,
so at least breakfast, lunch and dinner.
Lastly, to make sure that those carbohydrate foods are the low-GI,
or low glycemic-index options.
They're the best ones to have if you've got a risk of diabetes.
Let's look at our, I suppose you'd call it the second case study.
This is moving on to the topic of exercise.
There is randomised control trial evidence
that exercise can make an enormous difference.
There are prospective studies showing that
exercise can abolish the risk of diabetes,
and a randomised trial in Melbourne
showing that weight training can reduce the progression to diabetes
in people with pre-diabetes.
This is a program developed by Diabetes NSW
and it's titled the Beat It program.
It targets fitness trainers,
developing exercise resistance and cardiovascular training,
in this case, we'll show you people with type 2 diabetes,
but it certainly would work with people at risk of it.
My name is Bronwyn Penny.
I'm an exercise physiologist and a lifestyle-programs manager
with Diabetes Australia NSW.
The Beat It program was designed by myself
for exercise professionals,
such as personal trainers and exercise physiologists.
It's an education program about diabetes and exercise
and how to suit the needs of somebody with diabetes or people at risk.
WOMAN: One. Away you go.
From some research that we looked at,
we know that a lot of people with diabetes are exercising in a gym
under the care of personal trainers.
The problem with personal trainers is that their understanding of diabetes
is not necessarily at a level that provides a safe environment.
The trainer-training program covers some of the severe complications -
hypoglycemia,
exercising with high blood glucose levels as well, so hyperglycemia,
and looks at some of the long-term complications
that can affect people with diabetes
that will in turn affect their ability to exercise safely.
Away you go!
You've got a minute left.
BRONWYN: There are some programs out there that do similar things.
There is lots of gentle exercise for older adults.
All the research and evidence base suggests
that people with diabetes are more than capable and safe
for doing higher intensity physical activity,
and that they get better results
in terms of blood glucose control and diabetes management.
So our program combines aerobic physical activity
and quite heavily loaded resistance training.
WOMAN: How is that feeling? Alright?
BRONWYN: The other difference between this program and a lot of other programs
is that it's underpinned by a behavioural-change approach.
When somebody comes along to do the program,
they're involved in an initial physical-activity consultation
which does not only look at their health status and those types of things
but discusses their goals, their barriers to exercise,
because we know that people get better results when those aspects are included
as part of a program.
This leg has to be free.
You can wobble, but the moment you start to jump around, you're out.
BRONWYN: We piloted the program to see how effective it was
in a few sites, one of which was Bundanoon,
at the Solar Springs Health Retreat.
We had some really brilliant results down there.
When Diabetes NSW approached us about doing the program,
I initially thought, where are they going to find 24 diabetics in Bundanoon?
We're just a little village an hour and a half south of Sydney
with 1,500 people.
I was so surprised at the initial information session that we had
that 50 people turned up.
It was just incredible that in a little community like ours,
there were so many people that we could potentially help.
Away we go.
We started with two groups of 12 participants
meeting twice a week for 12 weeks.
Because that was so successful
we've continued those classes on a regular basis.
And two. Last one.
Have a rest.
No, we won't. Stand up. And have a rest.
Before I did the program,
I knew that diabetics had a problem to do with their blood glucose levels
to do with lack of insulin production,
but I didn't know there were so many complications.
What the program taught us initially was all the complications that may occur.
Also we looked at exercise contraindications,
'cause there's some things diabetics can't do.
Put it up a bit more, that'd be great.
We learned that they have conditions such as peripheral neuropathy,
which is a lack of sensation to the feet.
So we have to be really careful where they place their feet.
We don't want them to trip or fall.
The other thing was because many diabetics have heart conditions,
they might be on medication that lowers their heart rate or their cholesterol.
So we can't measure their heart rate as we would in a normal class
to see how hard they're working.
We've got to use a scale of perceived rate of exertion.
The great thing about the Beat It program is that it is affordable
because it is a class situation.
You're not paying exorbitant personal-training fees.
It can be done in any facility.
It can be done in a hall
as long as the facilitators have Dyna-Bands or little hand weights.
Do some bicep curls.
When we deliver the training package to personal trainers,
you have to have your Cert IV personal training certificate.
It's delivered by accredited exercise physiologists,
accredited practising dieticians and diabetes educators.
They're getting all those aspects when they come to a training program.
The program has been extremely successful.
We did quite thorough testing before the program -
clinical testing and also functional testing.
The results have been fantastic.
We not only have seen a lower blood glucose level,
also exercise helps with weight management,
and weight loss is particularly important to diabetics.
If they can manage their weight, in a lot of cases,
they can manage their diabetes.
We have a participant, Grant, who has had fabulous results.
His blood glucose and his blood pressure have both dropped,
and his aerobic fitness has increased.
GRANT: Certainly the HbA1c has dropped down from 8.9 down to 7.3.
My insulin doses were increasing, and now my insulin doses are decreasing.
As my control is improving,
I may even be able to drop some of the medication as well.
The great thing is, I'm much more motivated
to get out and do the exercise.
I now walk four to five days a week.
I'll do some of the exercises that we've been shown to do at home.
I'd looked at joining gyms before in the past.
My problem was, you feel inadequate when you look at the bright young things.
Coming here with a like group of people, that was great.
Everybody's in a similar situation, so we're all motivating each other.
The other aspects you look at is the social and emotional wellbeing.
They're things you can't always quantify through a physical activity test.
We do an SF-36, which is a general health and wellbeing survey.
We showed some really dramatic improvements in the quality of life
that people experienced after finishing the program.
Mark, would that work for people at risk as well, people with diabetes?
Yeah. Exactly that sort of program is what would be appropriate intervention
for people with high diabetes risk, people with IGT or IFG.
Let's go to the answers of our third poll question:
The answer is, the overwhelming majority do it annually.
Nobody does it third-yearly.
Somebody said it depends on the patient,
and six-monthly is the other group.
What do the guidelines say?
The guidelines say that we ought to be screening the population
every three years, for example from the age of 40,
in terms of using the AUSDRISK tool and so on.
Once people are identified as being high-risk,
so having an AUSDRISK score above 15,
we really need to be following it up on an annual basis.
So our audience is well informed.
A question from Roscoe Taylor in Tasmania -
'Looking at the longer-term outcomes for weight-loss programs,
do we really have good evidence that sustained weight loss occurs
for periods longer than, say, 12 months?'
There are some studies that go beyond 12 months,
but they're not as large a number of them as we'd like.
There certainly are a number of trials
that have gone up to five years, for example.
The biggest evidence comes from the Finland study.
The Finland study is still going, and people are continuing to lose weight.
It's gone beyond five years.
Without continuing intervention?
Yeah, with just the lifestyle intervention that people have done.
The Finland study is a five-year follow-up
without further interventions, and still showing weight loss.
A question from Brian Bowring in Tasmania -
'Is there a need for a diabetes risk-factor assessment
via general practitioner or nurse, an MBS item for it,
that would include evidence-based assessment,
such as the AUSDRISK assessment questionnaire?'
Yes, I think so.
There's already an item number for GPs doing an assessment
in people who have completed the AUSDRISK tool.
This whole area of risk assessment
is something which is ideally suited to the role of the nurse.
I don't think it replaces the GP.
There's still some things that the GP will need to do
once people's risk has been assessed.
Working through the risk assessment with patients
is something that would be ideal for a practice nurse to do.
The problem that we've got is that
that's really only available for people at the moment
between 40 and 50, and it should continue to be available.
It should be available for some younger groups who are at risk as well.
Let's say you put somebody on a lifestyle program.
What sort of monitoring, apart from repeating the AUSDRISK tool every year,
would you be doing on somebody to monitor their progress?
This is somebody who's got a risk score of 15?
That's not diabetic, you're just putting on a lifestyle program.
How will you monitor them? What parameters?
You need to repeat their AUSDRISK tool,
but you want to do annual fasting glucose.
Some of those people, despite your best efforts,
maybe because they're unable to follow the lifestyle program,
will go on to develop diabetes
or measurable impaired glucose tolerance or impaired fasting glycemia.
Let's go through the protocol now.
Let's remind ourselves about who gets screened, the AUSDRISK again
and also those extra risk factors,
then what happens with your blood-sugar testing.
The first thing is to screen everyone from 40 up.
NORMAN: Or 18 up if you're Aboriginal.
If you're an Aboriginal or Torres Strait Islander, from 18 years of age.
All those people should have the AUSDRISK score assessed.
If they've got a score of 15, they need to be tested with a fasting glucose
and be referred to a lifestyle program, regardless of their fasting glucose.
So even if they've got a fasting glucose of 4 and a risk score of 15,
they get referred to a lifestyle program of some sort.
There's a number of other groups at high risk,
independently of their AUSDRISK score -
anyone who's had
a previous cardiovascular event,
such as myocardial infarction or stroke.
Women with a history
of gestational diabetes.
Women with polycystic-ovary syndrome.
Patients on antipsychotic drugs,
for example, olanzapine or risperidone.
And those who've had a previous
impaired-glucose tolerance test
which has been abnormal or have
impaired fasting glycemia previously.
All those people we can regard
as being at high risk and warranting
yearly, at least, follow-up,
assuming they don't yet have diabetes.
Some people are arguing that rather than a fasting blood sugar,
you do a glucose challenge, which is not a glucose-tolerance test
but another form of screening.
The guideline says a fasting blood sugar if you've got a high AUSDRISK score.
The current evidence is in favour just of fasting blood glucose.
The only situation where we will do a formal oral glucose-tolerance test
is when your fasting blood glucose is between 5.5 to 6.9.
That's the only situation where we'll do an OGTT -
not a challenge test, but a proper 75g glucose-tolerance test.
Your fasting blood sugar comes back at under 5.5. What do you do?
If you have a high risk factor, you have to repeat it
and make sure you don't base your assessment on one single blood test.
If it is 5.4 and your risk screening is high,
you've got to repeat.
We know that there is a day-to-day variability in fasting glucose.
You are giving somebody a diagnosis,
or no diagnosis, for the rest of their life.
You've got to make sure, just like what we do for diagnosis of diabetes.
If we have one sugar more than 7, we make sure that the sugar is repeated.
You've answered that for diabetes. If it's over 7, repeat it.
Then it's a diagnosis of diabetes.
- If it's 5.5 to 6.9? - We'll do an OGTT.
I certainly in my practice do an OGTT in that situation.
- If that's marginal, repeat in a year? - Yeah.
We've got somebody on a lifestyle program.
When would you think about drugs, metformin for example?
Metformin will probably lower their weight
and make them more insulin-sensitive.
I think it's a second-best choice.
First of all, it's not actually approved by the TGA
for diabetes prevention in Australia.
More importantly, the evidence is that
diet and physical activity and weight reduction
is a better strategy.
It's a more effective strategy at preventing diabetes.
NORMAN: If they do it. - If they do it.
I think we shouldn't be fatalistic about this.
One of the things which influences how effective we are
are our outcome expectations as clinicians.
We need to be positive about it.
It's still our first choice.
Try to get people to lose weight.
Using medications to lose weight can be effective,
but the problem is, people often regain the weight
when they stop the medication.
Again, it may be worth a trial in some patients.
One of issues here, Ashim, is that it's a line in the sand
where we say it's diabetes.
It's pretty arbitrary.
There's more and more evidence coming out
that anything over 5, you're really at risk of microvascular complications,
including a macrovascular one.
We might be in a situation of talking ten years from now
that they've redefined diabetes as 6.5.
Yeah, we're just drawing arbitrary lines.
Coming back to drugs again, we have to dissect what the drugs do.
Do they actually prevent diabetes or do they delay the progression?
The diabetes world is coming to grips with that.
- Either is OK, isn't it? - Yeah, either is OK.
I think it's more towards delaying the progression
rather than preventing the disease.
NORMAN: Isn't that true of lifestyle as well?
That's right.
The other question is, you've said, where do we draw the line?
The clock starts to tick very early.
Macrovascular disease has been shown in people
even with normal glycemia.
The George Institute did a trial suggesting
that if you've got a diagnosis of diabetes,
you should certainly just be on statins and antihypertensives
regardless of your level of cholesterol or blood pressure.
What's the story with pre-diabetes in primary prevention
in terms of when you would start a statin or an antihypertensive?
I don't think we have any evidence for that in pre-diabetes at this stage.
MARK: We have to look at people -
the point you made earlier about looking at people's cardiovascular risk.
- Cardiovascular absolute risk? - Absolute-risk score.
The problem is, that's driven by whether you say people have diabetes or not,
'cause that increases their risk.
But certainly someone who has impaired glucose tolerance
and has a borderline absolute-risk score,
I'd be erring on the side
of putting them on an antihypertensive and a statin.
A question from Catherine Jones in Casino in northern New South Wales -
'Would AUSDRISK really be beneficial in aged care?'
I think it's useful at any age, really.
What age is it validated to?
It's only validated, because of the AusDiab study, up until the age of 70,
so we don't have much evidence beyond that.
The problem in aged care, you've got cognitive problems and so on,
and your scope for preventing people from eventually developing diabetes
may be less.
Either AusDiab risk score or preferably I'd go straight to a fasting glucose
in people in aged care.
We're talking about particularly people over the age of 75.
I have no desire to bankrupt the Australian health-care system,
but what about bariatric surgery as primary prevention?
I think we've got to be very careful with the bariatric surgery story.
While the data shows that particularly from the Swedish obesity study,
that people in a certain category, particularly BMI more than 50,
have been shown to decrease mortality, which is the most interesting data,
as well as reversing diabetes, it cannot be a panacea for everybody.
As you said, the Australian system will go bankrupt.
Lifestyle should still be the first choice.
It's more the bypass operations.
There is the question of what surgery you should do.
There are surgeries which decrease the volume of the stomach
versus surgeries which have other kinds of action.
The Roux-en-Y bypass has been suggested as probably the preferred mode
of weight-reduction surgery in people with morbid obesity, more than 50,
whereas people who are less morbidly obese
can have the gastric Lap-Band.
This is the new operation, unproven so far -
a sleeve, a metabolic thing.
The whole question of bariatric surgery is whether it's cost-effective.
There is a very recent study, just published, from the UK,
which does show that it is cost-effective.
Then again, we have to look at the particular scenario
where we are going at.
It's very difficult for clinicians.
You certainly see the benefit, particularly of Lap-Band surgery.
You also see people who liquefy their eggnogs.
You also see the effect that that has on people's lifestyle long-term.
If we're going to use bariatric surgery in people who are morbidly obese,
we want to do it at a young enough age where we'll get real benefit
in terms of preventing diabetes and cardiovascular disease.
We need to think that if we do that on a 30-year-old,
our case example from previously, that if you did it at that age,
you're going to have to manage that person for the rest of their life.
That's significantly difficult.
The thing about Lap-Banding is, there's no exit strategy.
You've got to maintain them forever. Job for life.
So the key message is, don't forget primary prevention.
Screen your patients.
What are your messages for people to take home, Alan?
Take on a diet, make small changes to achieve long-term goals.
Small amounts of weight loss by changing your diet
in a small way that's achievable.
- And sustainable. - And sustainable.
The evidence for general practice in particular
is that we can be most effective with that high-risk group.
It's finding the people who are high-risk
and trying to offer a lifestyle intervention to those people,
as well as obviously ruling out diabetes.
As well as advocating for population-based changes.
And all the other things we've talked about.
NORMAN: All of the above, plus. Ashim?
As an endocrinologist, I think we should be working more closely
with our general-practice colleagues.
Just because we are specialists, we don't have to take that step
of not looking at prevention.
Diabetes is no longer an epidemic, it's now a tsunami.
I think primary prevention is the way to go.
Early detection, early treatment and treating diabetes as a vascular disease
is the way forward.
Thank you very much to you all.
I hope you've got a lot from tonight's program on type 2 diabetes
and primary prevention, case detection and early diagnosis.
This series of four programs, which is what it will be,
will be available in December free on DVD.
If you want to order the set, visit the Foundation's website at:
rhef.com.au
If you're interested in obtaining more information about issues we've raised,
there are a number of resources available
on the Rural Health Education Foundation's website.
I'll say it again:
Including links to all the new type 2 diabetes guidelines.
Don't forget to complete and send in your evaluation forms,
and please register for CPD points by completing the attendance sheet.
It's fantastic that so many of you were involved.
Thanks for all your questions.
I'm Norman Swan. I'll see you next time.
Funded by the Australian Government Department of Families, Housing,
Community Services and Indigenous Affairs.
Captions by Captioning & Subtitling Internationa�