SA JOURNAL OF DIABETES & VASCULAR DISEASE DRUG TRENDS

ADVANCE PUBLICATION • 8 APRIL 2011 1

NOD gets a big nod at annual meeting

An innovative programme compiled by the Nurses on Diabetes (NOD) executive com-

mittee rung in positive changes for nurse-led education in South Africa at the sixth NOD congress held in Gauteng in February 2011. Supported financially by the Novo Nordisk and Roche Accu-Chek teams, the topics on diabe-tes were presented in crystal-clear talk-show format.

The clinical presentations by experts in the field of paediatric and gestational diabetes were chaired by the Nurses on Diabetes mem-bers, complementing the talks with practical questions and answers relevant to daily prac-tice.

Learning from your peersSetting the scene for ‘Learning from your peers’, four diabetes nurse educators from around the country, participating in conversa-tional style with host Cathy Haldane, presented ‘One hundred years of diabetes education in South Africa’.

The Diabetes Education Society of South Africa (DESSA), the senior participant in diabe-tes education in South Africa, with its formal links to the Society for Endocrinology, Metabo-lism and Diabetes in South Africa (SEMDSA) and the Department of Health and DEATE, supported its younger NOD counterpart, with positive participation from Laurie van der Merwe and its senior executive.

Sr Lyn Starck, with 40 year’s experience from Groote Schuur Hospital, described how her car was her consulting room. ‘At that time, there were only two to three diabetes edu-cators in the Western Cape and we had no facilities for education. There were no glucose-monitoring devices, no strips. We boiled urine to determine glucose levels, which today, as we know, bears no relation to actual blood glucose levels.’

‘But we had a passion to drive for change. I once convinced a hospital administrator that it was time to go for a less-painful bloodletting lancet by asking her for two fingers to test the old and newer device. The order for the new device was approved the next day!’

Walking this sort of tough road has also been the experience of Nana Maseka from Roche, with more than 25 years of experience in diabetes education. ‘You must have perse-

verance as a diabetes educator; you must have the spirit of the hunter, and educate, re-edu-cate, and educate again and again.’

Sr Jen Whittall from Bryanston has personal experience to add to her passion for diabetes education, and focuses on the education of families with a diabetic child. ‘When my son was diagnosed with diabetes in 1978 at 18 months of age, I, a nursing sister from a sur-gical background, knew about amputation in diabetics. I was determined to ensure that my son had the best treatment available.’

Again, in 1978, the tools available were paltry. This determined young mother fasci-nated Prof Bonnici. ‘We set up a blood-testing laboratory at home and in 1978 did multiple, six to eight blood tests a day – seeking to avoid the highs and lows. We had one of the first mobile meters from the United States that became available in the early 80s.’

‘Today, I believe every patient has the right to the best treatment available. My goal is to help the patient reach his full potential, as free of complications as possible’, Sr Whittall stressed.

Laurie van der Merwe, responsible for professional education of nurses in DESSA, pledged the organisation’s commitment to get a formalised training course in place, ulti-mately approved by the Nursing Council of South Africa. ‘We have presented DESSA train-ing courses in diabetes, and in April, we will launch the practical side of this four-day formal training. The practical training will take eight months, to be completed in a maximum period of 18 months, and will be practice-specific. It will allow nurses to be registered as diabetes nurse educators.’

‘The DESSA committee is planning to pre-sent their own conference in 2012/2013. We need to be moving forward with determina-tion’, Laurie noted.

Education is key to diabetes management‘We believe it is vitality important to under-stand the patient and then education can be truly effective. We also know that scare tactics do not work, as they disempower patients. For this reason, Roche has developed the friendly but cheeky campaign “Have you checked your sugar, Sugar?” to encourage self-monitoring of blood-glucose’, Dr Atkinson noted.

The Accu-Chek range aims at providing the correct tools to bring accurate information that can be acted upon by the patient and the diabetes care support team. ‘We launched the CONNECT programme last year and this year’s support for the DISC workshops and lectures at this NOD conference continues this effort to add value to the diabetes educator’s practice’, Dr Atkinson added.

Novo Nordisk, with a full portfolio of modern insulinsZella Young from Novo Nordisk noted the rela-tionship between Novo Nordisk, as the leading diabetes care company in South Africa, and Roche, with its excellent relationships and com-petence in patient education. ‘They are ideal partners to meet the objective of long, full and healthy lives for South African patients.’

Novo, a Danish-based company, was the first company to develop commercial insulin in 1923, following Banting and Bests’ discovery of insulin in 1921. Nordisk, a second independ-ent Danish company, initiated insulin products in 1925. These companies merged in 1989 to form Novo Nordisk.

‘True learning comes from other educators’ – Cathy Haldane, Roche

‘Bright ideas for smarter choices’ – Accu-Chek Active System

‘To drive change in dia-betes, we must continue to lead’ – Zella Young, Novo Nordisk

‘Have you checked your sugar, Sugar?’ Experienc-ing a different conversa-tion with patients – Dr Mary Atkinson, head of Roche Diabetes Care SA

Lyn Starck and Nana Maseka.

DRUG TRENDS SA JOURNAL OF DIABETES & VASCULAR DISEASE

2 ADVANCE PUBLICATION • 8 APRIL 2011

Gestational diabetesPresenter: Goolam Mahyoodeon, Chris Hani, Baragwanath Hospital and Glenwood Hospital, JohannesburgNOD commentator: Lionel van Wyk, diabetes educator, Johannesburg

Gestational diabetes (GD) is carbohydrate intolerance with variable severity, occur-ring usually in the second half of pregnancy, although it can appear earlier. Gestational diabetes occurs in 1–14% of pregnancies, depending on factors such as ethnic group, diet, body mass index and a family history of diabetes. In South Africa, selective screening for gestational diabetes is normally done only on high-risk patients.

Patients at higher risk for developing dia-betes in pregnancy are those with persistent glycosuria, those who had gestational diabetes during a previous pregnancy, those who have close family members with diabetes mellitus, mothers with previous big babies, unexplained foetal loss, obesity, and being of Asian descent.

The HAPO (Hypoglycaemia and Adverse Pregnancy Outcome) study1 examined 23 000 pregnant women using a 75-g oral glucose tolerance test (OGTT) challenge between 24 and 32 weeks. Maternal glucose levels were correlated with increased adverse pregnancy outcomes, defined as big babies, caesarean delivery and neonatal hypoglycaemia. Results showed an increased risk with increased maternal hyperglycaemia that was less than the levels of diabetes mellitus, but no clear demarcation of a particular level at which risk starts.

‘Interestingly, it has recently been proposed that a single fasting plasma glucose value higher than 5.1 mmol/l following a 75-g OGTT defines increased neonatal risk and gestational diabetes. This has not yet been adopted by any key international diabetes societies’, Dr May-hoodeon noted.

Principals of care in gestational diabetes• Early referral to specialist centres• A team-approach of care is essential (diabetes

educator, physician and dietitian)• Patient-focused approach• Early ultrasound and screening for genetic

abnormalities• Care continues into and beyond the post-

partum period.

Key management protocol• Diet of 2.5 kCal/kg• Folate and iron supplementation• Self-monitoring of glucose levels – as often as

six times daily• Good glucose control; 4–7 mmol/l range is

required• Evidence for glibenclamide and metformin

usage if glycaemia is moderate, but many patients will still progress to insulin usage

• Regular insulin and short-acting insulin are used

• Regular weekly or bi-weekly visits.

Excellent results are obtained at Chris Hani Baragwanath Hospital with a rigorous self-monitoring glucose programme, Dr Mahyood-een pointed out. ‘Insulin is stopped immediately post-partum and delivery is timed using the principal of minimising risks associated with prematurity weighed against the increased risk of periods of hyperglycaemia. Neonatal moni-toring for neonatal hypoglycaemia is essential.’ Excellent outcomes are possible if the patient is well managed by a competent team.

Lionel van Wyk, diabetes educator comments‘We see the patient frequently, at least monthly. If she is a type 1 diabetic patient on a pump, I see her weekly. You need to involve a dieti-tian who works with the individual patient and even takes cravings into account in her advice and support of the mother-to-be.’

‘Only type 1 diabetics would use an insulin pump. The learning curve in gestational dia-betes is too steep for the use of pumps unless there are exceptional risks. A multi-disciplinary approach is essential.’

Incretin therapy Angela Murphy, Sunward Park Medical Centre, Johannesburg

‘The diabetes challenge is to choose the right treatment for the right patient’, Angela Murphy stated at the outset. The most ground-breaking potential of GLP-1 analogues/ago-nists is regeneration of the β-cells, which has been shown to occur in animal studies.

The incretins GIP and GLP-1 are produced in the gut and provide an important regula-tory system in the post-prandial state. ‘GLP-1, as released by L-cells in the distal gastrointes-tinal tract, also decreases gastric emptying, an important factor assisting in weight manage-

ment, improves systolic blood pressure and has been shown to be neuroprotective, with the exciting potential of improving cognitive func-tion’, ”Dr Murphy noted.

The evidence from laboratory studies that GLP-1 can stimulate the production of β-cells and decrease the rate of β-cell death could offer a revolution in diabetes care. There are two types of incretin-based therapies that are available in South Africa, the GLP-1 agonists, which are more resistant to metabolism than the original human hormone, and the DPP-4 inhibitors that inhibit the breakdown of GLP-1.

Liraglutide (known internationally as VIC-TOZA®) has a pure GLP-1 effect and increases the levels of GLP-1 to super-physiological levels, with the advantage of very significant weight loss. DPP4-inhibitors such as sitagliptin, vildagliptin and saxagliptin result in an increase in both GLP-1 and GIP-levels, all within the physiological range. They are weight neutral but can be taken orally, whereas GLP-1 ago-nists have to be given as a subcutaneous injec-tion, as they are peptides.

‘The big advantage of these agents is that they only act in the presence of glucose and patients are very, very unlikely to experience hypoglycaemic events’, Dr Murphy noted. Liraglutide has been shown in the LEAD series of trials with all oral antidiabetic agents and against placebo, to significantly lower HbA1c levels by up to 1.6%. Nausea, a complication of exenatide and to a lesser extent a compli-cation of liraglutide, seems to be transitory, although it does account for major withdraw-als in clinical trials.

Soundbites on improving insulin usage in the young and in gestational diabetesLarry Distiller and Michael Brown

Using case studies to exemplify treatment choices, Drs Larry Distiller and Michael Brown provided one-liners that should be part of every diabetes-care educator’s vocabulary.• Insulin works if you take it!• Understand the type of insulin you are using

‘Remember, as the bulge develops, aim for the legs and arms for insulin sites’ – Lionel van Wyk

‘The one aspect that will make liraglutide a signifi-cant therapeutic tool is weight loss’ – Dr Angela Murphy

‘We must understand the mechanism of these drugs to use them appro-priately in type 2 diabe-tes patients’ – Dr Angela Murphy

‘Pregnancy is a time of rapid physical and emo-tional change, which can be alarming. Developing gestational diabetes is a

challenge for both patients and diabetes educators’ – Dr Mahyoodean

SA JOURNAL OF DIABETES & VASCULAR DISEASE DRUG TRENDS

ADVANCE PUBLICATION • 8 APRIL 2011 3

• Type 1 patients are healthy people without insulin

• Analogue insulins are insulins of choice• Any indication of poor eating behaviour in

teenage girls needs psychological evalua-tion

• There is too much focus on food in diabe-tes; diabetes is an insulin problem

• Don’t dictate, negotiate• Gynaecologists should not be treating dia-

betes; diabetologists don’t deliver babies• Teach patients to eat correctly; do not pre-

scribe a diet.

DISCover yourself as a diabetes educator‘We need to have a high level of introspection as to how our behaviour may resonate with our patients’, noted Debbie Hinnon, nurse educator from Wichata, Kansas, in her presen-tation with colleague Sam Thompson from LQ Performance Strategies, Indianapolis, Indiana. Their visit to South Africa, sponsored by Accu-Chek, focused on DISC, the Discovery wheel, which is an easy-to-understand tool of natural and adaptive behavioural strategies.

Firstly, all NOD delegates attended a work-shop to identify their individual behavioural styles (Fig. 1) and then were shown in par-ticipative lecturing style how to use this tech-nique. Debbie pointed out that experienced diabetes educators intuitively interact with their patients. ‘However, even experienced and successful diabetes educators can use this DISC technique to support their intuition.’

‘It is important to note that this technique was developed by William Marston in the USA in 1928 and has been successfully evaluated in

most cultural settings across the world’, Sam pointed out. The take-up by nurse practition-ers and physician’s assistants in the diabetes field has been excellent, as the awareness of self-behavioural style allows the educator to be aware of the patient’s style and adjust to it so as to mirror the patient and communicate more effectively.

Continue walking – the DNE Glamorgan programmeMadelein Young and Jeannie Berg

Diabetes specialist nurse Sr Madelein Young and pharmacist Jeannie Berg are among the first South African diabetes educators to undertake the postgraduate course for diabe-tes nurse educators offered by the University of Glamorgan in the UK. There is no comparable course offered locally.

It offers considerable rewards, but they both underscore that it is something that needs to be taken one step at a time as, in addition to being ‘interesting and ‘amazing’, it’s also ‘addictive’ and ‘exhausting’. ‘You get so addicted to the research and to learning so much, that you start to eat, breathe and sleep the course’, warns Jeannie. ‘No matter how long you’ve been involved with diabetes care, there is always something new to learn’, she says.

Taking it one step at a time allows partici-pants to juggle work and family commitments. The course takes the form of a part-time, online, distance-learning programme and par-ticipants can log on from anywhere at any time and interact with other students. It runs over one calendar year and comprises six modules, each of six weeks’ duration. In between each module there is a two-week break.

After an initial two days of introductory lectures, either in South Africa or the UK, the participants are split into groups of 10 to 15 individuals each, usually from different back-

grounds. ‘So there is true multidisciplinary interaction’, says Madelein. A tutor supervises each group.

People from different countries participate in the course, which adds another valuable dimension. ‘There is much to learn from their different experiences and outcomes’, contin-ues Madelein.

Madelein and Jeannie are currently half-way through the course. ‘It’s exhilarating’, says Jeannie. ‘Every week it gives me the opportu-nity to reflect on how I’m coping and how my knowledge and understanding of diabetes is growing. I’m learning more every day and feel that I’m growing both as a diabetes specialist nurse and as a person’, concludes Madelein.

Education techniques and guidelinesLaurie van der Merwe and Buyelwa Majikela-Dlangamandla

When it comes to educating patients about their diabetes, ‘nurturing and supportive’ beats ‘prescriptive and judgemental’. This was the key advice given by diabetes nurse educa-tors, Srs Laurie van der Merwe and Buyelwa Majikela-Dlangamandla. ‘It’s not about lectur-ing and dictating; rather you need to combine a variety of methods so that you meet the patient halfway and meaningfully influence their knowledge and health behaviour’, says Laurie.

She also underscored the importance of interaction. ‘What people say and do is what they remember best. Don’t just show them how to use an insulin pen. Let them play around with it themselves.’

Buyelwa cautions that it’s important for educators to be aware of their own attitudes and that their approaches needs to be tailored

Types of behaviourD = Directness/dominanceI = InfluenceS = SteadinessC = Conscientiousness

Note: The more flexible and adaptive behaviour is closer to the centre of the wheel. The further to the periphery, the more effort is required to move from one style to another.

Wheel

Figure 1. The DISC concept.

DC

S I

From left to right: Sam Thompson from LQ Performance Strategies, Indianapolis, Indiana with Cathy Haldane from Roche and Debbie Hinnon, nurse educator from Wichata, Kansas.

Laurie van der Merwe and Jen Whittall.

DRUG TRENDS SA JOURNAL OF DIABETES & VASCULAR DISEASE

4 ADVANCE PUBLICATION • 8 APRIL 2011

to the stage at which the patient is. Educators should be guided by the following principles, grouped under the acronym ‘RULE’:• Resist the righting reflex• Understand motivations• Listen• Empower.

Find the power button in your youthHester Davel and representatives of Youth with Diabetes

Sr Hester Davel of the CDE notes that coun-selling and guiding teenagers with diabetes comes with its own set of unique challenges. She highly recommends a book called The Five Love Languages of Teenagers, by Gary Chap-man, which has helped her significantly. ‘It’s important to know which of the five love lan-guages is paramount in an individual context, so that you can help that patient optimally’, she says. The languages are:• words of affirmation• physical touch• quality time• acts of service• gifts.Hester and Dr David Segal founded Youth with Diabetes in 2005. Diabetes youth leaders are trained in counselling and leadership skills and then help to facilitate the diabetes camps run under the auspices of the CDE. Four of them shared their experience of diabetes at the NOD conference:

Step up! The Structured Testing Program (STeP) studyDebbie Hinnen, Mid-America Diabetes Associ-ates, Wichita, USA

To date, studies have shown conflicting results when it comes to the effectiveness of blood glucose self-testing and monitoring, espe-cially in type 2 patients not on insulin. Given the importance of evidence-based practice, the STeP study, sponsored by Roche and pub-lished recently in Diabetes Care, was under-taken among type 2 insulin-naïve patients and primary-care doctors to address the question definitively.

The study made use of the simple Accu-Chek 360-degree View paper-based tool, which allows patients to create a seven-point glucose profile over three consecutive days. Patients record and graph their test results, along with details of meal sizes and energy levels. ‘My favourite part of this tool is the question that appears at the bottom, “What did you learn?”’, says Debbie Hinnen, who was a co-author of the study.

Patients undertook the exercise prior to each quarterly visit to their primary-care doctor. The aim was to assess the effectiveness of blood glucose testing in poorly controlled type 2 diabetics. A total of 483 non-insulin-treated patients participated. Those in the structured-testing group (STG) made use of the Accu-

Chek 360-degree View, while those in the active-control group (ACG) received usual care with random blood glucose testing. Both arms had access to point-of-care HbA1c assessment.

The patients had been diabetic for approxi-mately seven years, and the average HbA1c level was 8.9%. The doctors were relatively young, having been in practice for an average of seven to 10 years.

‘All patients showed a drop in HbA1c by month 12’, observes Debbie. ‘However, the STG experienced an even bigger drop, and this was most marked in those who were meticu-lous in filling in the Accu-Chek 360-degree View form and keeping their doctor appoint-ments. The significant drop in every point on the seven-point profile shows that a tool like the Accu-Chek 360-degree View, when used in a collaborative way with both patient and physician fully engaged in the process, can result in a significant improvement in the patient’s glycaemic control.’

As a result of their self-monitoring, the STG experienced three times as many medica-tion changes, lifestyle changes or combined changes as the ACG. In addition, the STG used fewer blood glucose strips, meaning that they obtained superior results with less-frequent testing. Both groups experienced an improve-ment in depression and diabetes-related dis-tress, but once again the results were more marked in the STG.

‘The beauty of the tool is its simplicity and its use of highlights and colours. The colours help the patient to sort out the many pitfalls and difficulties associated with numeracy and measurement and enable them to see the dif-ference the exercise is making and the efficacy of the treatment’, says Debbie.

Concluding, she reiterated that those in the STG experienced a significantly greater improvement in HbA1c by month 12 than those in the ACG. Likewise, they experienced greater improvements in depression and diabetes-related distress.

J Aalbers, Special Assignments Editor, Peter Wagenaar, Gauteng correspondent

1. HAPO study Co-operative Group. Hyperglycaemia and adverse pregnancy outcomes. N Engl J Med 2008; 858(19): 1991–2002.

‘Motivation is fundamen-tal to change’ – Laurie van der Merwe

‘Nobody cares how much you know until they know how much you care’ – Debbie Hinnen

‘I’ve been diabetic for 13 years and I was one of Hester’s worst patients, always crooking my testing strips and my HbA1c readings. Hester’s warning that I might not be able to have children if I didn’t get my diabetes under control was a wake-up call for me.’ – Jackie

‘Diabetes connects those who have it on a spiritual level. I have something inside me that can empower me if I let it. Don’t be shy to grasp your diabetes with both hands. I’m proud to be a diabetic.’ – Jason

‘Diabetes camps are the perfect way to learn about diabetes, as well as a great opportunity to help others. Diabetes is a manageable condition if you have good support and self-control. Thanks to having diabetes, I’ve met many wonderful people I’d otherwise never have got to know. I even won a car in a diabetes art competi-tion.’ – Kerry

‘When I was diagnosed with type 1 dia-betes at age 10, I didn’t realise the inten-sity of what I would have to live with. I resented being seen as a diabetic first, and as a person second. As a teenager, your image is more important than your health, and between grades 6 and 10, I suffered numerous hypos, subsequently waking up in hospital. The diabetes camps inspired a light in me to help others out of their dark-ness – and to make them realise that, like me, they are not alone.’ – Gareth