men's diabetic diet

hi, i'm warren snowdon, minister for indigenous health,rural and regional health and regional services delivery. it's my pleasure to introducethis program, produced by the rural healtheducation foundation and which is fundedby the australian government department of health and ageing. five years ago, approximately700,000 australians had diabetes. just three years later, the number hadjumped sharply to more than 818,000

or 4% of the population. the majority of those - 88% -were cases of type 2 diabetes. every day in australia, about 275 adultsdevelop some type of diabetes. there are on average10,600 deaths each year where diabetes is the underlyingand associated cause, which representsabout 8% of all deaths in australia. in indigenous populations,the figures are far worse. the prevalence of type 2 diabetes amongst aboriginaland torres strait islander people

is at least three times higherthan for non-indigenous australians. and incredibly,the rate of all types of diabetes amongst indigenous australiansin some remote communities is as much as ten times higher. yet, type 2 diabetes is considered to belargely a preventable disease. this program examinesevidence-based approaches to the management of diabetes, hypoglycaemic control anddiabetes-related complications amongst indigenous australians

and is part fourin a series of type 2 diabetes and the new nhmrc endorsed type 2diabetes mellitus clinical guidelines. this program will assist gps, aboriginalhealth workers, diabetes educators and all primary healthcare workers inproviding support and good care needed for indigenous australianswith type 2 diabetes. i commend this broadcast as a key toolin improving australia's performance on this important health issue. i strongly believe that a betterunderstanding of how to prevent, detect and diagnose diabetesin indigenous australians

will lead to improved health outcomesand life expectancy for all indigenous communities. thank you, minister. i'm norman swan. welcome to this, the fourth program ashe said, on type 2 diabetes guidelines and looking at diabetesin indigenous australians. and on behalf of everyone, i'd liketo acknowledge that we are meeting on the land of the wangal people. the wangal peopleare the traditional owners of this land and form part of the wider aboriginalnation commonly known as eora.

we also acknowledgeelders past and present and the descendantsof the wangal people. diabetes accounts for a significantproportion of the gap in mortality rates between indigenousand non-indigenous australians. and as the minister implied, this program focuses on a comprehensiveand culturally appropriate multidisciplinary approachto prevention, detection, diagnosis and managementamongst indigenous australians. now, if you're watchingon your computer,

you have the facility to type yourquestions in directly to the studio, just type your question in the livetalktext box below the slides. that also means of coursethat we can ask questions of you and here's one to get you going. tell us where you are located - in metropolitan, regional,rural or remote australia. and we'll come back to the answersto that in a moment. as usual, there are a number of usefulresources available to you on the rural health educationfoundation's website - rhef.com.au.

now let's meet our panel. dr pat phillips is the director of thediabetes centre and endocrinology at the queen elizabeth hospitalin adelaide and has been for many yearsat the forefront of diabetes research and treatment and overseas,the state diabetes outreach program. - welcome, pat.- thank you. what is the diabetes outreach programin your state in south australia? it's really around building capacityin rural and remote areas

so it's focusingon the health professionals and trying to give thema better capacity to deal with diabetesin their communities. so it's not parachuting in services, it's getting the local servicesto be able to do it better. the principle is thatif we can get the locals to do it, it's a bit like teaching someone to fishrather than giving them fish. norman: dr rob wayis a general practitioner at katungul aboriginal medical servicein narooma, nsw.

- welcome, rob.- thank you, norman. you'd have a few peoplein your community with diabetes? we have a few of our population, yes,with diabetes and perhaps a few with diabetes to come. norman: sumaria corpusis an aboriginal health worker and diabetes educator from darwin. - welcome, sumaria.- hello. and we're going to be talking aboutyour program in the top end shortly, which is you're quite actively going outinto communities

looking for peopleand helping people with diabetes. yep. norman: bernadette heenanis a credentialed diabetes educator and registered nursefrom far north queensland rural division of general practicein cairns. - so you're actually providing services.- that's right. we parachute in. and doing that.right, can't get away from it. again, we will come back to bothyour experiences and sumaria's later. so, pat, do you have anything to add tothe statistics the minister just gave?

i think that was a very fair summary,diabetes being very common and up to 50, 60, 70% in some aboriginalpopulations depending on their age. i think it was also a good point madeabout the complications and the excess mortalityin aboriginal people related to cardiovascular death andrenal disease, in particular those two. and i think the other commentwhich was really important was that it's a diseasethat unfortunately is so commonamongst the aboriginal population that you almost have to assumethat someone is going to get it

and start looking for itand treating it very, very early. bernadette, is it differentamongst indigenous people, aboriginal andtorres strait islander people, than in the general community? um, yeah, i think we notice it,certainly in the areas where i work. a lot of the clients that i,well, all the clients, most of them i see have got diabetes and there's certainlya much greater proportion in each of the communities that i go tothat would have diabetes

than you would seein downtown cairns, say, so... but how different is itfrom non-indigenous people? it's hard to know to what degreeit's a different disease in the sense that it's much more seriousthan in non-indigenous people because the indigenous peoplehave more risk factors so they have more hypertension,a lot of dyslipidemia, a lot of central overweight. it's also not clear alsowhether it may just be something that they are genetically predisposed to

and the third potential factor,or at least a third one, is the prenatal environment so that their intra-uterine environmentis often breeding a tendency towards diabetesmetabolic syndrome renal disease even before they are born. and instances of kidney disease,same with diabetes, is huge comparedto the non-indigenous community. very much so. so 30% of the population withtype 2 diabetes, non-indigenous,

may develop microalbuminuriaand potentially chronic kidney disease related to diabetes whereas it's 70, 80, 90% of theaboriginal people with type 2 diabetes and is a major causeof some of the other complications like cardiovascular disease. and that of course, rob,changes the way you look after people? that's right, i think we are lookingat everybody as a work in progress and we're just trying to make surethat we minimise the risk factors as soon as we canand actually, you know,

i think i treat everybodywalking through my door with an indigenous backgroundas pre-diabetic. sumaria, what impact doesall of this have on communities? it has a great impact 'cause they're notfunctional at a higher level, a lot of people go to town for dialysis so it's disruptingthe family everyday activities. and the support, there's no support. like, in the territory,they have to come, say, 800km to live in town and they can't livein their own communities

so they're taken awayfrom their homelands more or less. and how much awarenessdo you think there is? there's a lot of awareness but i thinkwe have to just do more promotion, health promotion,and start in the schools. how young is the youngest personwith type 2 diabetes you've come across in your communities,sumaria? - the youngest is a ten-year-old.norman: ten-year-old? yes and that's fromout in the remote area. and now she's about 12 now

and she's onoral hypoglycaemic medications and for that age, to have tabletsevery day is really hard. sure is. what's the youngestyou've seen, bernadette? nine years of age this year andshe started on metformin straightaway. norman: rob?rob: uh, 14. and that presentation waswith acanthosis nigricans so, yeah. so this is somethingthat not only happens more frequently, it happens at an earlier age? and it also means that the childrenwho develop their type 2 diabetes

should they survive, they get the metabolic consequencesof having type 2 diabetes and the duration of having diabetesthat occurs in type 1 diabetes. so they get the complicationsof type 1 diabetes and the complications of type 2 diabetes so they get a real,a really bad set of problems. and we have the resultsto our first poll question - where are you located? - and metropolitan - a third of you,regional - a third,

and rural - a third and, nobody's admitting to,well, a small percentage in fact are admitting to being in remote so it's a pretty... 8.3% and the... so welcome to you all. i just wouldn't mind just checkingyour level, your self-perceived level of knowledge. are you aware, do you think, of allthe risk factors for type 2 diabetes in indigenous australians?

yes, no, maybe a bit. let's go to our first case study. jim is a 30-year-old indigenous man with a wife and three kids, living in a remote community, he's unemployed, they share... the family shares a three-bedroom house with another family of four and all the four adults smoke.

there is one store in the community. jim enjoys playing cards, having a few drinks with his mates and occasionally goes hunting in the community toyota. jim's mum was diagnosed with diabetes at the age of 50. what's your assessment of jim, sumaria? jim's... with his mother being diabetic,it's a risk factor

and being inactiveis another risk factor and not workingand alcohol, smoking they're all risk factors soyeah, it's not too bright for jim. so if he's... even beforeyou do a single test on him, the assumption is he's pre-diabetic and he may already even be,have diabetes? yeah, most probably undiagnosed, yes. so if you don't have experiencedealing with aboriginal communities, looking after people in aboriginalor torres strait islander communities,

you might throw up your hands in horrorand say what could you possibly do? well, i am going to ask you. what can you possibly do about someonelike jim in your experience? just talk to him, give, tell himthe truth and see what he wants to do, like, you build up your rapportand inform him on his risk factors and what's going to happen to himand see what he wants to do about it. if he wants to start diet exercise, just small goals just to start withwould help. and what do you find motivates?

well, to motivate him,employment would be a start. getting the community involved,community-driven activities. norman: what does that mean, though? not taking the toyotawhen you're going out hunting or what? well, they can go out hunting more oftenusing the community's vehicle, doing community activitieswith other families. norman: do they get much exercisegoing out in the toyota, though? rather than sort of getting outand walking? no, they don't get much exercise butwhat i am saying is going out to a spot

and then go hunting from there, yeah. a lot of communitiesare starting to do that now - taking people outand just leaving them out there. how practical is looking for bush tucker and converting fromwhat might be a pretty unhealthy diet via the store to an expensive diet versus collecting your own bush tucker? there's a lot of bush tuckerout in the territory and it is, they can do it,it's just easier going to the shop.

i promote going back to bush tucker,hunting and gathering instead of just going to the shopand buying meat where it's much more healthierto have to walk, to have to work for it and they have to chase itso that's natural. one of the traps i had was a guy,one of my patients was telling me, 'oh, you only ate bush tucker,' and this is in tennant creekand what he meant by that was he ate a lot of kangaroo tail so he went down to the shop andhe got the kangaroo tail and ate that.

that's not bad, that's lean meat,isn't it, or is that pretty fatty? that's wherethe kangaroo stores all its fat. fat, oh, alright, so kangaroo tailis not a good idea. and how would you monitor jim, then? what sort of thingswould you be looking for in terms of, or getting him to monitor himself? would it be things like waistcircumference or you wouldn't even...? start with waist circumference. ask him to see if he can start30 minutes a day

and weight loss, look at weight lossand just set small goals and then he can grow on them. and make a change. norman: bernadette,what would be your approach? very similar, personalised to suit him. we'd give him a self-management folder and try and teach him a lot aboutbest blood pressure, what to aim for, we even encourage our clientsto self-blood-glucose monitor even if it's only before and aftera meal once a week

and we use lots of visual stuff so rather than having themwrite it in diaries, we get them to downloadtheir monitors to laptops so we use all the latest technology even if it's out on someone's verandahor out somewhere. we just take our laptops with usand so we do lots of pictures of, 'this is when your blood sugarsweren't so good and this is what's happening now' so there is alwaysbefore and after shots

and always positive stories,so positive role models. sumaria, you've developed some materialsto actually help you or detect the symptoms of diabetes? yes, we did this in darwinand it's how do you feel? and these are signs and symptoms. we've done five chapters so we went towhat now? i have diabetes, taking medications, doing bgls and just helps them understandwhat they're going through. and it's a good tooland it's on the web.

- so just show us a little bit of it.sumaria: ok. the first steps is being lethargic,sleepy, no energy and they can relate to that. and they say, 'oh, yeah,that's how i've been feeling.' some people are up all nightgoing to the toilet so the first thing you say is, 'how many times do you actuallyget up to go to the toilet?' and then, you know,that sends alarm bells. ok and then you can say,

well, going to the toiletif you get your blood sugars down, because your body is trying to get ridof that excess sugar in your body and it's making you get thirsty and the body is trying to get ridof the excess sugar so they are urinating it out. and if people want to get a hold of someof these materials, how do they do that? contact your local diabetes office or look on the webunder diabetes australia. let's talk now aboutyour more active prevention, pat.

what other more active thingscan be done? i mean, for example, is there any rolein aboriginal communities for obesity surgery? i guess, that's a questioni haven't thought a lot about because i would imagineit is very difficult to access and also very difficultto support the person through some of the things thatare associated with bariatric surgery so if you're going forthe malabsorptive surgery, for example, that really takes quite an investmentin terms of educational nutrition

and if it's lap banding,it's once again teaching people not to switch from solid to liquid foodwhich will just obviate the... so i'm not sure they would getthe sort of support after the surgery which is likely to make the surgerysuccessful. and is there any evidence that intervening in aboriginaland indigenous australians with their high risk of orhypoglycaemic agents or insulin early actually helps to minimise the course? there have been somenot totally well-controlled

but some intervention studiesand in particular relating to the kidney disease that i was talking abouta little while ago. and in northern australia,in the tiwi islands, there's a program which was organised bya doctor, wendy how, who... man: hoy.- hoy, who - thank you - who actually basically gave everyonean ace inhibitor, an angiotensin-converting enzymeinhibitor, because of the problems ofchronic kidney disease, hypertension

and showed a progressive decreasein both the total mortality and also the progressionof end-stage renal failure so it was, in that sense,historical controls but it was a demonstration thata - it was feasible to do this on a population-based scaleand b - it seemed to be effective. so what do the guidelines say? the guidelines suggest that an aceinhibitor is a preferred medication in type 2 diabetesif the person has hypertension. there's also been trialsin non-indigenous people

that an ace inhibitor has benefitsin those who have type 2 diabetes and one othercardiovascular risk factor. of course, everyone's gotone other cardiovascular risk factor so it's virtuallyeveryone with type 2 diabetes. that was the hope study with... it has been repeatedwith other ace inhibitors. there have not really beena lot of intervention studies which have been done in any sortof trial basis in aboriginal populations so the diabetes prevention program,for example,

was an american program and has beenrepeated in lots of other countries using metformin,other drugs have been used - the glitazones, acarbose,several other drugs have been used. norman: but not proven? not in the aboriginal population. in those populations they did reduce theprogression of pre-diabetes to diabetes. let's go to our first case study -oh, sorry, our second case study. this is a film case study. it involves greg,a 37-year-old indigenous man

who presents to western sydneyaboriginal medical service at mt druitt in new south wales. he's screen-diagnosed with diabetesand engaged in an intervention. let's take a look. i think once you've seenindigenous patients who are very young having diabetes, having heart attacks,having all sorts of vascular problems as we see in this setting, it really gets your radar working

and you have to applythe screening test at an earlier age than you would elsewhere. greg. this morning, actually,a patient of mine called greg is coming back to see me. i saw him last week,we were discussing diabetes 'cause he has a few family memberswith the disease and we did some tests in factand today he's coming back to have me tell him unfortunatelythat he does have diabetes.

oh, i hope you gotsome good news for me. well, look, yeah, last weekwe were discussing diabetes and... 'cause you were... greg is getting on into his late 30s,almost 40 now, quite a young manfor someone to be diagnosed with the mature onset type of diabetes. but being an indigenous man, he hasan extra layer of risk, we might say. he's not a big man, he's not the shapethat makes doctors think, 'well, that person's a suitorfor type 2 diabetes.'

but i guess it goes to show thatbeing indigenous and even just beinga little bit overweight, they are risk factors enoughto actively look for diabetes. can it go awayor is this going to be the answers? it's somethingthat will be with you for life. before we get too far aheadof ourselves, i'd like to go back to sort ofexplaining what diabetes is all about. it's very important to actually makesure the patient knows the consequences of having poorly managed diabetes

and, you know, so we're talking aboutproblems with the feet and problems with the eyes in particular but there are also problems as you knowwith the heart and kidneys and brain... that's a good starting base then to say,'well, what can we do about it and how can we prevent those thingsfrom happening?' you know, if we are going to moveforward now and manage this effectively, we want to involve some key peoplein helping you to manage it. it's important simply to havea very explicit, you know, listed plan of what's going to happen nextand with whom

so that everyone knows what is going onand nothing is overlooked. in the first instance, i referred gregto the aboriginal health worker whose specialty is diabetes and louise has a very good understandingof the disease and can talk to greg about thatin a way that he's, make it easier for him to understand that perhaps i wouldn't be ableto do so well. so he's in the waiting room now. so you want me to havea little chat to him and...

- if you could.- what have you been through with him? a bit about... apart from that,obviously being indigenous herself, she has that sort of innatecultural awareness and ability to attend to perhapsslightly different issues that would be differentfrom my perspective. just a question, did you understandwhat dr bill was talking about? yeah, i did, yeah, but just he told methere are ways of controlling it and so i just would like to talk aboutwhat things to eat now and...

ok, then, so... when a patient like gregor any of my patients come to me, i would normally talk to themabout diet changes, exercise and the complicationsthat diabetes can have in the long run if their diabetes is not managed. - did he put you on any medication?- not as yet. no, so that's good, so we're just gonnago on diet control at the moment. you got to try and focuson the first thing. like, greg today, really,about his diet changes

'cause it's a big shock to their system,like, they're coming in newly diagnosed and you try and tell themall these things, they're just gonna forget about itmostly 'cause they're stillin a bit of a shock, you might just have to explain ita bit more in simple terms. you know, your diet,well, next time you go shopping, you might want to look at this and say, well, you know,go at the back here and say, 'oh, on my shopping listi might choose from this today.'

you know, on the shopping listand your different choices... one thing too i do encourageis that they do get a glucometer so they can measure their sugar levels so they can keep an eye on itto see what's going on but you know a lot of our patientscan't afford it sometimes so... but they do come in hereand we can do it in here anyway if they don't, if they can't affordto buy their own glucometer. so what have you eaten this morning,greg? have you...? oh, this morningi had some vegemite on toast.

7.9 - that's still a little bit high. so is that all you had,vegemite on toast? oh, and a meat pie. well, once the patientsattend the service, you know, it's usually a team approach. we do have a lotof our visiting specialists come in like a podiatrist, a diabetes educator so that's all done but as for the eyes,we need to send them out. so you'll book me in for a week's time?

i’ll book you in for a week's timewith heather. - so i'll see you in a week.- yeah. we can only do so muchas health workers. most of it we try and encourage it,put it back onto the patients themselves like for self-management. by checking, buying a glucometer,checking their sugars, having regular check-ups, making surethey're taking their medications. - i'll see you next week.- thanks, louise. thanks a lot, have a good day.

we still have a lot of our patients thathave gone down the track and, you know, ended up on dialysis. it would be so niceto catch these patients early before it gets to that stage, i suppose. after all, i know things are not 100% but at least i am still going to be herefor as long as i can with the help ofthe aboriginal health workers here. greg's story from mt druittin new south wales. - how typical is that, rob?rob: it's very typical.

mind you, greg looks quite motivated and probably not too dauntedby his diagnosis whereas occasionally we find peoplewho are quite, quite upset, quite concerned about a diagnosis. and so i think with... i think bernadette was talking aboutemphasising the positive, the thing i would be making surethat greg knows is that it's great that we picked it upas early as we have. hopefully it's within a few monthsof his blood sugar popping up

so that we can startall these preventions. the guidelines that we're using here, this is a general practiceset of guidelines too, are they not? rob: yes and there's - i don't knowif we've got a slide of that coming up - but there's some excellentdiabetes management guidelines that cover pretty much most of thequestions that we're touching on today. just going backto the earlier point about screening, how regularly do you screen peoplein an aboriginal community? in an indigenous practice,i screen everybody

every time they walk through the doorso it's a set process they get. they get their weight,we measure their waist regularly and we check their sugarprobably every, at least once a month if they're popping in. norman: what about you, sumaria,what's your advice? we do waist-hip ratio, weight, bgl,blood pressure. do you use at risk tool with them ordo you just assume everybody is at risk? no, no. norman: you just assume it's everybody?

it's not designed, they never took itinto account for aboriginal people 'cause they've gotthe aboriginal and asians together and they're totally differentbody shapes and ethnic background so it doesn't work. and, bernadette, you try and personalisethe approach to somebody like this so that they've actually gottheir own book. yeah, we've got a self-management folderthat we use for people so we tend to take their photo and give them a whole bookthat's dedicated just to them.

it's full of lots of handouts and thingsthat are actually showing what their blood pressure is,what their blood glucose levels are, what their hba1c isand there's lots of handouts done by our doctors, dietitian,podiatrist, etc., on how they can actually lookafter things themselves so they're... norman: they even havean appointments book in there? yeah, there is an appointment book,yeah, with a whole ten or so people, we call it 'the mobwho help me look after my diabetes.' 'cause what we haven't saidbut a lot of people watching know it,

this is multidisciplinary team. multidisciplinary team,you can't do it any other way, yeah. so that's what this is aboutand the idea is that it is something big so our clients, it's harder to lose. the original patient held record, youput it in your wallet and you lost it. this is so bigthat it's hard to lose at home. and hopefully, clients will bring itwith them to other appointments so we've even had people turn upin cairns to see their specialist and they've brought their folderwith them

and the specialist has written a letterback to the gp up in the cape saying what happened on the day. and then you're also empoweringthe client so much because they're in chargeof that communication between a specialist and another doctor so it's very much tailored for themand we invent things as we need them. just before we go on, let's takethe results to that poll question - are you aware of all the risk factorsfor type 2 diabetes and half of you say yes

and the vast majority of you have thispartial knowledge and no is 12.5%. thank you for being so honest,the 12.5% of you, and we'll ask another poll question nowwhich is, 'does your service have a localindigenous diabetes education program to which it can make referrals?' yes, noor it's part of your own service. so let's hearwhat the answers are to that. what are the treatment options for greg? i mean, the guidelines saystart with lifestyle

but some people would arguewith aboriginal people, given their high level of risk, youmight move a little bit more quickly. well, actually, the americans and theeuropeans have both sort of adopted that second approach,that is, you've got type 2 diabetes, you counsel people on lifestyleand start metformin at the same time. in australia, we tend not to do that. we tend to use lifestyle first and then add in metforminfairly shortly thereafter. it does have the advantage,if you focus on lifestyle,

is that you're not taking their diabetesaway from them so that you've just been diagnosedwith type 2 diabetes and i give you a pill and say, 'take this pill andthat's all you have to do about it'. then the diabetes is now my problem - i'm prescribing the pills,you just take the pills and that's the endof your responsibility. and if the pills don't work,that's your problem, doctor. that's right.

but focusing in on the lifestyleengagement in the lifestyle and engagement in understanding diabetesand then using the medication, it might delay the medication, startingthe medication by a little while, but probably not much morethan weeks or a month or two. and in the contextof the type 2 diabetes, actually engaging the personin their self-management is really very important. and what about this incredibly high riskof kidney complications? i think there is a very strong case.now, i'm not a practitioner

who deals a lot with rural and remotepopulations of aboriginal people but there's a very strong case i thinkof in much the same way considering starting an ace inhibitorpretty well straightaway too because you can bevery, very confident that that person if they don't havehypertension already, they will get it and if they haven't gotkidney disease already, they will get that. and ace inhibitors have been shownto be good medications for hypertension and reduce the riskof chronic kidney disease.

and you don't necessarily haveto have hypertension to have them? - no.- rob, what's your practice? i'm also wondering...i mean, yes, i think so. i think that we should be, there'sevidence that both those medicines you know, delaythe onset of complications. the other question would be, should webe starting a statin at the same time? well, there is the...there've been, as you are implying, there've been several studies usingstatins in people with type 2 diabetes so there is the heart protection studyand there's a card study

and the a priori guess would be that that same benefitreply to an aboriginal population. although stronger for antihypertensives. sumaria, there's an affordabilityproblem here. you have all these doctorsthrowing around the scripts, people have actually got to payfor the drugs. um, in the territory,because they're remote, we're under the s100 so they getwebster packs from the local clinic and then their medication is reviewedevery three months.

so it's... and, say, if they've moved -that's the difficulties - or they come to town,they leave their medications at home and indigenous people out bushare always in and out of town so you just have to make surethey understand why they're taking the medicationsand to take the medications with them. we give them a little esky to taketheir insulin when they go fishing or they go bush so thenthey can take their insulin with them. just making things easy for themto take it with them. how aggressive are you with insulinin the remote communities?

we're quite aggressive with insulin because i look afterthe gestationals as well and this is young girlswith gestational diabetes and the only treatment for thatis insulin. so we have to look after their babyfor the whole term so, yeah, we have to be there,we have to... like, a lot of people say,'oh, it's impossible to get them to do four, five blood sugars a day' where,if you educate them on the realistic what's gonna happen to the babyif they don't, they'll do it.

and people say,'how can you have them on basal-bolus?' that's four injections a daybut they're willing to do it so the right information and being consistentin what messages you are giving them. i think that is really important. and what about non-gestational diabetes,people with just regular type 2? type 2, yeah, we do thatonce they're on maximum orals and then we'll start themon maybe a long-acting at night and it seems to work, yes.

so less of a problemthan you might imagine? yes, with the right information,right support you can. tell me a bit about your programin cape york for people like greg although greg'sin metropolitan sydney, really. yeah, what we have up there is we're part of an improvedprimary healthcare initiative and there's a group of uswho travel around together - gp, podiatrist, dietitian and a few other people -

and these are the areas that we cover. so we cover a few ofthe remote communities up cape york and the royal flying doctor servicecovers the other areas. and we try and cover the full spectrum of primary health care, comprehensive primary health careacross all the different... as well as just doingthe clinical areas, we go right through to tryingto educate and prevent and prevention in terms ofengaging with local shopkeepers, etc.

so, um... yeah, we tryand encourage the client to learn as muchabout their condition as possible. that's one of the large areasthat we're involved in and the key person to our whole project is our community engagement coordinator. no matter what we do, we don't go anywhere or engage in any activities, etc.,

without involving that person. and as you can seefrom the slide up there at the moment, our cec is the most important person. they're always indigenous so we have one ineach of the major areas we work - the weipa cluster, cooktown cluster and mossman gorge area. so if we were seeing someone like greg, then it would be our cec who would goout there and make the initial contact

if we were seeing himout in the community and invite him to come in and see usor we do home visits, whatever was appropriate. and we tend to be quite aggressivewith our management as well. norman: and your bookletprovides the care plan? yeah, it's the care plan, thecommunication document, the education and it's all best practice, there's no second best, second rate,it's all... yeah. good. let's take some questions nowfrom you.

kirsty fromcharles sturt university asks, 'how do you explain to someonewith little formal education what diabetes is and the importanceof regularly taking their medication?' bernadette? when describing what diabetes is,we would often draw things so we'd draw thingson a bit of scrap paper, maybe on a board, whatever's available, and do a basic drawingand show what happens. we use all sorts of things,big drawings on pieces of material

or the other day we started using a clear plastic containerwith little balls, green balls for glucoseand red ones for red blood cells and you fill it up with 20 green balls to show how clogged things becomewith glucose. we use lots of analogiesin our storytelling so whether it be blu-tack orchewing gum on a keyhole on a door and how, you know, talk abouthow the insulin won't work with that so we use, so we draw pictures,we also do blood...

you know, when we're drawing, puttingpeople's blood pressure into their book, if they happen to come on a daythat they forgot, they haven't taken their medicationthis morning, you put that little note in there so the next time they come andtheir blood pressure is in a good range, the person is learning straightawaythe relationship between taking your medicationsor not taking them and what it's having on their bodyand they're seeing it in a picture form so you don't have to readto use the books.

sorry, rob? can i just say, i think one thing thatdoctors often really get worried about is that understanding initiallyfor a patient and i think that comes with time and sometimes, i don't know,i found when i was young and keen, i really wanted to tell the patientall about diabetes up-front and i think and, really,i think i put people off and i think, really, keeping the messageas simple as possible so that people feel more in commandof what's happening is actually...

and then go with the patientas they want to understand more then, you know, you talk moreabout their condition and go into... and, sumaria, you've used thosematerials you were showing us earlier. yeah, i find more colour,the more they understand and just keeping your messages simpleand just grow on that. our next question comes from nataliein rural victoria, who asks, 'there's been mention of a traffic lightin the food labelling program in remote communitiesin western australia. has this been appliedin other communities?

can you comment onwhether you think this would assist?' yeah that's traffic light... it's actually a british system,isn't it? it started in britain. mm, i don't know,i'd have to ask the dietitian that one. but i know that sometimes they usegreen ticks and things like that in some other shops up the cape and i know it's still usedin some of the healthy food programs. a general practitioner from melbourneasks, 'should there be any differencebetween treatment approaches

between urban and remoteindigenous people?' which we have kind of answeredbut, pat, do you...? i think there are practical differencesbetween the two populations and one of the practical differencesis the availability of s100 medications in south australiaand some other states. i understand they're not availablein every state but this is a commonwealth program whereby the aboriginal peoplein rural and remote parts of australia can actually get their medicationfree of charge.

norman: but they don't in the city.- but they don't in the city. and when peoplefrom rural and remote come to the city, they no longer have accessto those medications. rob was telling me earlier that the program doesn't applyin new south wales so that would make a big difference to the rural and remote peoplein new south wales compared to those in south australia,for example, because new south wales, they're going to have to gettheir medication some other way,

south australia, they can get itthrough the s100 scheme. and is there any evidence that adherenceto medications is lower in the cities? i'm not sure thatthere's actually ever been done a trial but there's lots... it's reallya well-known phenomenon that people come to the cityand they don't get their medication because they no longer have accessto the s100. the aboriginal medical officersin adelaide are very, are continually lobbyingthe commonwealth to make the s100 drugsavailable to city people

and particularly to the rural andremote people who come to the city. a nurse in central queensland asks, 'is there a simple way,any simple way of assessing diabetes risk in indigenous people?would we use the ausdrisk tool?' i think you can certainly usethat tool and... norman: but sumaria reckonsit's not much cop. (laughs) that's right. no, well, it's not designedfor indigenous. they've got a different body frameto asians

so you can't just throw everyone inand say, you know, they're all, we'll just use this. as i said the best wayis waist-hip ratio. the jury may be out. personally, the way i would usethe risk assessment tool is to say, is to show people that if you're, say,like many of my patients, aboriginal, and you have a family historyof diabetes, you've already got five pointson your way to 15 points of being at the high risk.

however the other points, the otherrisk factors are actually things that you don't necessarily haveto have - you don't have to be a smoker, you don't have to actually, you can eat vegetables and fruiteach day, you can do some exerciseso you can actually... so it points out a way of showinghow you can change your behaviour - as much as anything else.rob: that's right. jane from the north coastof new south wales asks, 'how early should we start screeningaboriginal people for diabetes?' pat.

the comment was madeby the earlier speakers that they've seen childrenaged nine and ten and i think rob has the practiceof starting screening aged ten and that seems likea very reasonable thing. i think it's alsojust worth commenting here is that the teenage girls,it's particularly important to look out for early pregnancy because those girlsthen get gestational diabetes and that has adverse outcomes fortheir pregnancy but also for the child

so i think that group in the youngerwomen is a really important group. sumaria, what do you think? i think that's a good point, yeah. we have to, um, screen themat the age of ten and the younger women as welland get them prepared for pregnancy instead of unplanned pregnancy. those sorts of things have to beaddressed and reviewed as well, yes. let's get the resultsof your last question - does your service have a local

indigenous diabetes education program to which it can make referrals? answers - half of you, yes, half of you, no and a little bit of you say that it's part of your service. so then the next question for you is: we're not giving youa little bit of option here so let's see what your answersare to that.

let's go to our next film case study - the aunty jean's good health teamand it's built around the idea that better results forchronic disease management can be achievedif the community works together with the elders leading the way. the program is a comprehensive approach to improved self-managementin indigenous people. let's have a look. it's named after aunty jean morris who was a very much respected elderin the illawarra.

she did a lot of volunteer workfor the community over her lifetime and she passed away. permission from her family was soughtto use her photograph and her name as the good health team. i first came here,my sugar level was about 19. now it's dropped back downto four or five, you know. so it's good for me. aboriginal people don't go to the doctoruntil they have to. it's a last-minute thingwith the aboriginal people.

they won't go to doctorsbut coming up here, i know where i stand with my health. i think it's the creationof a culturally safe environment. most of the people have chronic illness and we look beyond the clinic rather than the prescriptive which is normally clinical focus which is normally givenin other programs. we look at abilities, not disabilities,

wellness rather than illness,strengths and really engaging people and letting them build uptheir confidence in self-managing and i think in that culturallysafe environment, it works really well. we're gonna push down and out and then back down. we saw the need whencaroline first came on to the program as the program manager. she'd done some background workin talking to other service providers and organisations and asking about

what they actually providedfor aboriginal people with chronic care or chronic conditions and she found that there wasa great big gap in service provision. some of the programs were eithertoo wordy and there was a lot of reading material and the other thing i guesswas isolation, they felt isolatedbecause they didn't have other crew peopleattending the program, etc. and some of them found it difficultso those were some of the findings

and we did some community consultations and asked the aboriginal communityin the illawarra and shoalhaven and their carerswhat they could identify as gaps in service provision to themas well. we invited a group of elders in theillawarra to help us put the framework and the flesh, i guess,of the program together. i'm one of the first and still attending and i was very down and very depressed. i used to hate to get upand face the day.

coming here every week, i've enjoyed it.it was something to get out of bed for. i'm not just sitting aroundwaiting to die now. i couldn't move on friday... i'm living a beautiful retirement. much better than what my mum did. they didn't have all this around thembut i have and i am very grateful for it. went to the wollongong specialistfor my kidneys and he said to me, 'well, i'm afraid i thinkwe'll have to take your kidney out.'

i said, 'you're not taking partsof my body, i'm not giving them away.' and he said to me,'well, get into exercises and so forth.' i started doing weights heremondays and tuesdays and then i went backand saw the doctor six months later and he was so thrilled. he said whatever i'm doing there,keep up the good work. he said he wished all his patientswould have been just as healthy, what i am now. some people are actually stayingout of hospital because of the program.

those people with really chronicand complex conditions come along and they're, you know,improving their flexibility and strength and learning to manage more. i do exercisewhich i've never ever done. i get up on a morningand i start walking. i've never ever done that, never. 'cause i used to sit homeand feel sorry for myself. but now i've got a life. i can walk further, i can swim better

and i can annoy a lot of peoplea lot better too now. i can touch my toes and do up my shoeseasy without puffing and blowing because since i've been doing this, i have also gone offthe asthma machine as well. i only use the puffers now because i wasan asthmatic when i first came here. woman: you have to have good nutrientsso that means you got to be eating the right thing. for diabetic people, your blood sugarsmust be under control... woman: they help us, they talk to youand explain everything to you,

you know, with your diabetesand things like that. my sugar level was just high, too. this means a lot to me. i wouldn't stop coming here'cause this is my family, my friends. so only foraunty jean's exercise classes, it's really put me on top of the world. the aunty jean's good health program. - rob, what do you think?rob: i think it's fantastic. my only concernwith this type of program

is that people go often enough to get that exercise regularlythroughout the week and my only concern was oneof the comments from one of the ladies is that she looks forward tothe aunty jean's program every week. i suppose, sumaria,if you look at it and you think, 'what are they actually doing there?they're moving their feet up and down. are they actually doing anythingsignificant?' but in fact that's actuallymovement against a background, not just for indigenous peoplebut for non-indigenous people too

where there's obviously,there's probably not very much movement in their lives. no, that's a good program. out in the remote areas,they don't think about, like, exercising because they think,'oh, we live a long way so we're exercising walking around.' norman: we're exercisingdriving the toyota. you know and stuff like that but, yeah. the communitieshave to start being community-driven

and start exercise programsin the communities and a lot of the problems is dogs. you know, getting bitten by dogsand stuff like that. and what we say is just take a groupof youse out and just go for a walk, you know, along the beach is beautiful and a lot of those areashave spectacular views. and it's just people supportingand just prompting people, i think. and your programis basically an outreach program going to those communitiesand has links to specialists, etc.?

yes, we do, we promote self-management,we give them the tools to make changes and ongoing education, supportand we do outreach from port keats over to borroloola so we've gotthe top end, so, yeah, and... - so you've spent your life in a toyota?- no, aeroplane. - too far to go.- yeah. and we do follow-ups with themand stuff like that so we're in contact with them. so, yeah, we're slowly doing it,we're only a small team but... i think we've got the resultsof your last question:

and three quarters of you are sayingyes and a quarter of you, no. let's just talk quicklyabout complications and the management of complications.rob? what's the... what should bethe approach here? i think it's prevention,i think we, you know, from diagnosis, we brief the patientthat because they have a condition which can affect many parts of the body, we are going to have many parts,many experts looking to prevent those problems occurring.

and i think we make surethey're off to the ophthalmologist for an initial visit, off tothe podiatrist, the diabetes educator and other people as needed, perhaps the endocrinologistif it's a young or an unusual case. pat, i mean, what about managementof complications and prevention? we spoke earlier about medications and i suppose we should really talkabout blood sugar control in this group and the medication regimes,just remind people what the approach is. for non-indigenous people, there's atablet which is called the type 2 tablet

which is recommended for all peoplewho have got type 2 diabetes and that's got metformin, statin,ace inhibitor and aspirin in it. and in an ideal world, everyone who has type 2 diabeteswould take those medications which are pretty evidence-basedin terms of reducing the risk. now, that would apply even moreprobably to the indigenous population but then you've got the problemthat you use four different medications, it's six differentmedication-taking occasions so it's quite a burden.

and i think in medication, one probably needs to say, 'so what's likely to give usthe best bang for our buck?' and i think we can bepretty confident with metformin, we can be pretty confidentwith ace inhibitors, pretty confident with insulin,they are three good medications and blood glucose control is important because of the microvascularcomplications. and if you don't develop neuropathy,you probably won't get foot problems

and if you don't develop nephropathy,your risk of cardiovascular disease is also very much less so glycaemic control and blood pressurecontrol are really important priorities because the blood pressurealso predisposed to the kidney disease. but the guidelines say no insulin until you've maxed outof your oral hyperglycaemics. well, that's not entirely true either. the americans and europeanshave recently come out with a guideline that says you start with metformin, yournext medication could be a sulfonylurea,

it could be insulin,it could be a glitazone, it could be one of the otherless commonly used medications. so i think people are recognisingthat insulin is very likely to be needed at some stageand earlier may not be a bad idea. and, sumaria, how well or badlydo people cope with hypoglycaemia particularly when you get on tothe sulfonylureas and insulin? we make sure they are self-monitoring,we don't put anyone on insulin unless they're self-monitoring. they do manage, we haveblind people doing insulin injections

and they count the clicks,those sort of tools, you know, we try and work out what's good for them and with the right information andthe right tools, people can do things. and in the top end and in cape york, what do you do about retinal screening,foot care, that sort of thing? we have a podiatrist who travels with us and plus, most of the health workersin any of the communities know how to dosimple assessment forms as well and there is an eye teamthat comes up a couple of times a year

up there as well. plus, we link in with the... the endocrinologist does a visitup there from the cairns diabetes centre and we also link inwith the cairns diabetes centre so if there is foot problemsor whatever, we telehealth in video conferencein to them as well. so we're in constant contactwith specialist areas as well for that. it's been fascinating,thank you all very much indeed. what are your take-home messages frompeople from the program? bernadette?

educate people as much as you can, keep it simpleso that you can empower them. yeah, 'cause if they can bethe boss of their diabetes, i think that's wherewe are going to see change is when the people feelthey are in control. make it a positive storyand no growling. norman: no growling.- no growling. no bullying,you're not a bully, sumaria. no, no, we don't do bullying.

i think it is just being consistent,being supportive and being truthful and, you know, everyone has got holesin their feet, they do muck up, they, you know, get off track, just have the patienceto help them back on track. yeah. norman: rob? treat the individual and, i think, bepositive about the story that they've... they're actually the peoplewho can control most of their risk factorsin their diabetes. norman: pat?

assume all peopleof aboriginal descent are very likely to get diabetes. i think, screen aboriginal people atregular intervals, for example, yearly. intervene activelyin so far as one can with metformin, ace inhibitors in particular and monitor for complicationsparticularly for neuropathy because that is the wayyou will prevent foot problems. thank you all very much andi hope you've enjoyed the program on type 2 diabetesin indigenous australians

and got a lot from it, i certainly have. this series will be availableof all four programs in december and that will be free on dvd. if you want to order,you visit the foundation's website and if you're interestedin obtaining more information about the issues raised tonight, there are a number of resourcesavailable on the website at rhef.com.au and that includes links to all the newtype 2 diabetes guidelines.

don't forget to completeand send in your evaluation forms and please register for cpd pointsby completing your evaluation form. i'm norman swanand i'll see you next time. captions bycaptioning & subtitling international funded by the australian governmentdepartment of families, housing, community servicesand indigenous affairs�