Jasmine
Thank you everybody for joining us, and welcome to this evening's webinar, Type 2 Diabetes Management and Support. My name is Jasmine, your RACGP representative for this evening, and we are joined by our presenters, Annabel Thurlow and Angela Blair. Before we get started, I would like to make an acknowledgement of country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to elders, past, present and emerging. I would also like to acknowledge any Torres Strait Islander and Aboriginal colleagues that have joined us online this evening. Let me introduce to you our presenters for this evening. Angela Blair is a credentialed diabetes educator for more than 40 years, and her passion continues to be supporting people living with diabetes. She is responsible for the development, delivery and review of many programs for children, adolescents and adults living with all types of diabetes. This has included training for health professionals both face-to-face and in the e-learning format. She is currently the Senior Clinical advisory for the Get Healthy service while continuing to work at CDE. Annabelle Thurlow is a diabetes educator for 35 years and a diabetes nurse practitioner for 16 years and is very, very passionate about diabetes. Her focus is on educating healthcare professionals and people living with diabetes, with a goal to make every person she sees feel more positive about self-managing their diabetes on a day-to-day basis. Some of her key achievements include piloting a diabetes telehealth program, looking after patients from as far afield as Alice Springs to Broken Hill, Pakistan and Nepal and insulin pumps Australia as a service dedicated to management of diabetes with insulin pumps and continuous monitors supporting people around Australia living with diabetes. By the end of this session, you should be able to discuss evidence that supports healthy eating, physical activity and health coaching for people at risk and living with type 2 diabetes, including older adults. Outline the importance of healthy eating and active living behaviours for people prescribed GLP-1 medication. You should be able to describe how the Get Healthy Service can support people at risk and living with type 2 diabetes, and how to refer patients and understand how the Get Healthy Service can support people at risk and living with type 2 diabetes and how to refer patients. Let me hand over to Angela.
Angela Blair
Good evening everyone and thank you for joining us. I thought I would start with just a few little points about diabetes, and I am sure most of you may know this, but there is roughly one person diagnosed with diabetes every five minutes in Australia and it is about 330 roughly people diagnosed every day. We use the National Diabetes Services Scheme statistics to actually demonstrate how many people are living with diabetes at the moment, and while it says here at the moment there is about just over 1.5 million in total, of which about 1.23 million are living with type 2 diabetes. It is a large group of people. In New South Wales, that number is around 20% of that figure, so New South Wales has quite a large. It is the second largest state or territory for type 2 diabetes. On the slide though it talks about a few factors that contribute to that, and one is that 95% of Australians actually say that they have an inadequate fruit and vegetable consumption, and I think that is something to keep in mind, and as well look at the one in two Australians who have either no or low exercise levels because both of these things, nutrition and exercise, both contribute to the development of type 2 diabetes, so we know where we are sitting. When we look at these figures, though of diabetes in Australia, we know that for roughly 1.5 million people living with it, there is about half a million people we know that are out there that are at risk or undiagnosed or may have prediabetes. It is quite a large group in our population that we should consider, and that is why we are talking about it tonight.
The first section we are going to cover is supporting people with lifestyle matters. I think we can all agree that on the importance of lifestyle in achieving better health outcomes for our patients. I mean, that goes without saying, there is so much research out there that underpins just how valuable it is, but we know that even if the medication is there, it is the lifestyle factors that go hand-in-hand with that that actually help manage diabetes and improve those blood glucose levels, which then in turn helps reduce the risk of diabetes related complications, as well as delay the need for increasing amounts or types of medication, including insulin to manage type 2 diabetes. Lifestyle changes positively also improve blood pressure, cholesterol and weight. They are key drivers for cardiovascular risk, and we know that cardiovascular disease is one of the leading causes of death for people with type 2 diabetes. Lifestyle is a very important component of how we manage diabetes. There is so much evidence that we could provide that supports early intervention through lifestyle in delaying or preventing the onset of type 2 diabetes in our at-risk community, especially those with prediabetes. Making healthier food choices and increasing physical activity can reduce the onset of type 2 diabetes by up to 47%, so find them early and get them started with lifestyle changes is important. The Diabetes Prevention Program, if you have heard of it, it is called DPP for short, started in 1996, in the UK, and it is the largest ongoing trial of people living with diabetes and looking at outcome measures. What that has demonstrated is that lifestyle changes outperform medication in preventing type 2 diabetes. That is just one of the great pieces of information that is flowed on from that, and unfortunately diet is the single largest modifiable risk factor, and that is globally, it is not just in Australia, it is around the world. We believe that by using motivational interviewing, brief interventions and referring on to allied health services such as dietitians, diabetes educators, exercise physiologists, psychologists, a range of health professionals are tools that you can use in everyday practice to support your at-risk patients in modifying their risk factors for either developing type 2 diabetes or delaying the onset of it, or if they have got diabetes to better manage it, and I think that is really important. The key lifestyle factors are, I am not going to talk too much about these, healthy eating goes without saying. We like to call it healthier eating now. A lot of the people we see will actually say, oh, but I already eat healthy. We have tried to change the narrative a little bit to say, well, we want you to eat healthier so we can get better health outcomes. Physical activity goes hand-in-hand. As you heard, I have been a diabetes educator a long time, seen lots of people, and really, often it is the physical activity that has the greatest impact for managing diabetes, and that includes very much strength-based exercise. It is so important for so many reasons, and I will talk about that in a couple more slides. Healthy weight alongside mental health wellbeing including stress management, but that also includes sleep. It includes mood, emotional well-being, so there are so many things to unpack in that one little box, and then the last one while it says alcohol reduction and cessation in pregnancy, it is also about smoking, recreational drugs, vaping and all the things that go along with that. When we look at lifestyle areas that we can focus on, it is really looking at those as a group, but the one that is not listed there that I would really like to point out is, is one that is a newer one that we are really starting to work with people in the diabetes space is sleep, and sleep is that thing that goes hand-in-hand with type 2 diabetes. It is one of those chicken and egg situations. Does the sleep apnoea come first or does the type 2 diabetes come first? And often it is one or the other and then it is a cycle. When people are reporting poor sleep habits, it is worth investigating. We know that some people turn up in their diabetes is quite well managed, but they are having their fasting blood glucose levels are still quite high. That can be because they are having that disrupted sleep overnight. Just put that on your target going forward.
I thought we quickly cover nutrition at a glance knowing that I am not an accredited practising dietitian, but as a diabetes educator, we focus very holistic when we are actually talking to people, so I thought I would throw in some of the things that I think about as a diabetes educator. We know that there are many diet options now, if you go on social media, if you look at the Apple News, for example, or any of the news that is out there, they are either talking about GLP-1 or they are talking about which diet does the best job. I wish they would talk more about which exercise does the best job as well. There are many options out there and people are going to come to you and they will have a preference, and our job is to work with that preference, but I am going to give you some very general guidelines that we use as educators, and that is focus on whole foods, foods that are high in fibre, drink more water because eating the fibre, you need the water to make it all work, choose low glycaemic index carbs, a great example is just switching from white rice to basmati rice is a low GI and stops those post-meal spikes, as does limiting those added sugars and refined carbs. We also want to look at people's general health and that is reducing their saturated fats and including those healthy fats in there, and they can keep people feeling fuller over the day as well. Moderate alcohol intake or if pregnant, none, and that can sometimes be a bit of a challenge, but it is it is part of still have to have some enjoyment in life, I guess, that is what many of my people I have seen have told me. My particular practical tips that I tend to use is if I am seeing someone that is newly diagnosed with type 2 diabetes, I like to focus on that simple swaps to start with, and that might be eating three meals a day as a start, it might be having breakfast where they might not have. It might be swapping their sugary soft drinks or their fruit juice to water, for example, so little things like that. Swaps can be a good place to start. There are first good goals to start with. If they can achieve those simple swaps, it usually helps them move on to some of the more nutrition goals that they need to set. I will just mention that there is a program at this point called type 2 and Me that is on the National Diabetes Services Scheme website, and we actually encourage our people that are newly diagnosed with type 2 diabetes when they are first registered on the NDSS to do this programme. It is full of videos and just simple steps for them to take to start managing their diabetes, and part of in that programme program, we talk about the swaps, but we also talk about the plate method and that is one really easy place to start. Look at your plate, half veggies whether it is breakfast, lunch or dinner, a quarter protein and a quarter carbs, and it is a really good starting point for many people. Menu planning, reading food labels is the next step, and often it is a great idea to refer them to the dietitian for just that personalised advice if they are really unsure of what to eat and the quantities that they need to have. The dietitian is best place to give that more specific information.
Physical activity. This is my favourite thing to talk about. Again, we are going to talk very generally, but the Australian guidelines for that that adult age range is for 150 minutes of moderate aerobic exercise per week, and how people can achieve that is walking, swimming whatever they choose to do. It is important to include that resistance training or weight bearing training because that builds muscles. We need it to be at least 2 to 3 times a week, depending on that person's ability because it does improve their insulin sensitivity, so it is the one thing that can help really bring down those blood glucose levels, and that can be as simple as getting some tins of salmon, for example, some water bottles filled with sand right through to going to do Pilates at a gym, and there is lots more options now out there for people to actually do some exercise programs. My practical tips when I see someone is to start small, getting them to do 10 minutes walk after meals can help with those post-meal spikes, but also it gets them started and it is not a huge commitment. Ten minutes is something that is achievable. Back in the day, we used to want them to do that whole 30 minutes, and for some people starting out on an exercise program, it is just not achievable. I try and tailor it to the person and what they want to do. Not everyone wants to walk. They might not live in the right area. Other people love swimming and they swimming might be their choice. A referral to an exercise physiologist or a physiotherapist can actually help as well if they want that more tailored approach, if they are not really sure what to do, if they cannot do that, there is a New South Wales Health has a website called Healthy Eating and Active Living, and on that website are some exercise options for people to start some little programs that they can start out with using and some other information that goes along with that to get them going. I like to also encourage them, I do not do it for them, but I like them to go out and find out what is in their local area that they can actually join. Sometimes just joining the local Pilates group or yoga group or there is a beach walking group can actually not only give them that exercise, but it can actually give them the social supports that they need with a community of like-minded people. I think that is really important as well. The next of course is achieving a healthy weight. Weights become a bit of a contentious topic at the moment because there is a lot of work being done around weight stigma and what those words mean that go along with weight. What we do know is that a 5% to 10% weight reduction can significantly improve outcomes, we know that, and it certainly can reduce the risk of going on to develop type 2 diabetes or altogether. We know that to achieve that, it has to be sustainable and realistic changes. Some people find it, I am using the word “diet”, but they find an eating plan that actually they cannot continue to achieve. They get hungry, they cannot find the foods. It is costly. There is a whole lot of issues around now getting the right eating plan for that particular person, and I think it is really important that we make it as simple as we can for people. We focus on reducing abdominal fat and that may or may not need them to be weighed as much. Certainly, a tape measure around the waist will tell you if that is being achieved, but so will their belt and their or their whatever waistband they are using can actually tell them because of that stigma I think we are really learning how to have a better conversation around weight with our patients. What I do, this is my particular way of doing it, I try and not use words like obesity, overweight things like that. I tend to talk about healthy weight. What is a healthy weight you would like to reach? Trying to encourage them to look at a number, it is more like, I just want to be smaller rather than saying I want to lose 10, 20, 30 kg. That is putting a number on it and then it is trying to achieve that number. Always ask permission if I am going to weigh someone, and they have got the right to say no, I do not want to be weighed, and then we look for some other way of getting that information. I have tried to focus on their health, not their appearance. I think I do not have to explain that one. I think social media has sorted that one out for us. I explore what they want what they want by just asking those open-ended questions like, what would you like to do to reach a healthy weight and things like that. Try and listen without interrupting, and it is really important to acknowledge their challenges but also acknowledge how they are progressing. Sometimes it is really hard when they are doing all the right things, but their weight loss is a little bit slow and they can become quite discouraged, and I think it is really important to encourage and say, look, your weight is stable rather than saying, oh well, you have not lost anything because it keeps them motivated, keeps them going, and so you are validating as it is written, they are validating their experiences, but my whole thing is focusing on small steps. I learnt that very on when I started as a diabetes educator when it was relatively a new thing that people are people and we have just got to work with them, but I think you will all agree talking about weight is a bit of a tricky topic these days.
Mental health and wellbeing. I think, we can talk about this in a number of ways, and I have added a few things around that. I think it is important to understand living with diabetes, it is a chronic condition and it is really quite relentless. If you are monitoring whether it is with CGM or a glucose monitor, you have to do it all the time, and people are always looking at those numbers and having a sense of I have done okay or I have not done very well, and it is their own judgement that can sometimes interfere with how they are actually managing their diabetes and how they feel about their diabetes. They are more likely to become anxious, become depressed, but more often than not, it leads to diabetes distress, which is they get to the point where they just go, oh, no matter what I do, it is not enough, and we have to reverse that thinking and try and say, well, let us start again, but let us look at little things that we can change and move on. I think it is really important to stress impacts glucose levels, and the more stressed over the day a person is, it can actually lead to above target glucose levels, and that is something that we need to be mindful of. My ways of looking at it is strategies, and I love that I have written down mindfulness meditation and relaxation techniques. I do not actually quite use those words, but we try and ensure that people think that there has to be fun in their day, that they are not just thinking about their diabetes all the time, and it is about finding things that give them a sense of feeling good about life and trying to incorporate some of their diabetes management into that, so if they are going out for dinner, they go out for dinner and they still enjoy it, but they can still manage their diabetes while doing that the same as connecting them in with support groups, people around them with like thinking, often people go to their local bowling club and they find that because of the age of most of the bowlers, they are not the only ones with diabetes, and it becomes almost a support group within a bowling group, but there is always the option to refer them to specialist mental health practitioners, the local psychologist or social worker for example, but part of that is, is that then the conversations around smoking and alcohol because they can be linked into those how people feel about their mental health as well and maybe using those as part of how they deal with their mental health, but it is important to know that smoking increases insulin resistance therefore and cardiovascular risk and diabetes related complications. One of the things that we have to find the right way of encouraging that cessation of smoking and vaping as well and the same with alcohol. I guess one of the important things is we try not to restrict alcohol for most people unless there is a reason to, but we know that alcohol consumption has an impact on weight, on blood pressure, on insulin resistance, and I cannot tell you how many people have said to me, but they tell me that a glass of red wine a day is good for my heart and you have to go, but a bottle is not. We have to be mindful of how we have these conversations. My method of supporting someone with lifestyle changes is to help them set their own Smart goals. It is really important to focus on what they want to change rather than what you think they want to change. It is really easy to go in and say you need to do this, this and this and that will make your diabetes manage manageable, but they might not be what is their agenda and what they want to do, and I think it is really important that we can have that conversation with them and get them on that path of what they want to change, and once they change one or two things, they often want to change more, so it becomes if I can do that, then I can do a bit more, I can do a bit of this. Not everyone, when they are newly diagnosed with type 2 want to monitor their blood glucose levels, and so there are other ways that you can get them to that point down the track, and probably they do not need to at first. It is down the track they need to. We use a lot of motivational interviewing as educators. It is something that we like to think we are good at because we want as I said, we want the person themselves to decide what they want to change, but it is really important as part of that is to explore what their barriers are because they can learn from their barriers. They can actually use those to actually do better with their goals. If we just ignore them, they will crop up and the person often then stops and we do not want that. We want them to know that it is not just going to be, oh, I have got a new goal and I am going to achieve it. I want everyone to stop for a minute and think about New Year's this year. How many people made a resolution, I am going to do this in this year like a commitment for 2025 and already did not. I have a friend that tells me every Saturday she eats whatever she wants because on Monday she is going to start eating healthy, but by Tuesday she is not. Goals have to have to be specific measurable achievable. The worst goal people can have is I am going to lose 20 kg because what are the steps? What are you going to do and how are you going to achieve that? Follow up, look at progress. Remember you have got lots of health professionals that can be part of the team, and that includes programs like type 2 and me, it can include programs like healthy eating and active living as well as the Get Healthy Service, and I think these are really good tools that you can use to support you with the patients that you see that need that support. Just to finish off this section, I thought we would have a quick case study, and this is someone that we have seen together. Mary is 48, identifies as female. She has a BMI of 32. Elevated fasting glucose and HbA1c of 6.3%. She lives alone and has a relatively sedentary lifestyle because of her job and then she is tired when she gets home. Her AusDRisk indicates a high risk of developing type 2 diabetes, and that is mainly due to her family history and her cultural background, and she is considered as having prediabetes at this stage, and so the intervention that we started with was nutrition and physical activity plan, and she made some goals around what she wanted to change in both of those, and she was referred to the Get Healthy Service to do that. Mary attended ten fortnightly coaching sessions over about a four-to five-month period. After six months, her HbA1c had improved. It was down to 5.6. She had experienced an 8% weight loss and that was mainly due to her increased physical activity levels. She did tweak what she was eating, but it was more around her physical activity, and the good news was that Mary was less isolated as well because she joined a local yoga and Pilates program, that she then met some women in her age bracket and started having coffee with them and things like that. She had a really good outcome. I am going to ask Annabel to join me now, and we are going to just got a few questions. I thought we would have a bit of a chat about. This is Annabel. So, Annabel, when we think about, and we have seen lots of people like Mary, but what would be your rationale for referring her to the Get Healthy Service?
Annabel Thurlow
Good evening, everybody. The rationale would be that Mary has been diagnosed with prediabetes. The HbA1c indicates that and actually she is 6.5+ would be type 2 diabetes. She is at the higher end of the scale there. Her BMI indicates that she is actually considered obese, and she admits to having a fairly sedentary lifestyle and a family history. Her risk for developing type 2 is relatively high. She was quite excited to be referred to this program and she committed to the ten sessions, which was excellent, something that probably encouraged her to attend it was that it is free and she was willing to attend and she did very well on it because she managed to reduce her HbA2c down to 5.8, still considered to be prediabetes, but much better than the previous HbA1c. The weight loss was quite significant. As Angela mentioned, at 5% to 10% weight loss reduces the risk of type 2 diabetes, reduces cardiovascular risk factors, reduces her risk of even about 14 different types of cancer, reduces the weight on her knees and hips, so overall it was very significant. I think the rationale is really to get her motivated and reduce many of her lifestyle risks. When she was spoken to, we asked her about her alcohol intake, and she indicated that she actually did not drink a great deal of alcohol, but there was something else that we brought up with her and that was, that she is 48 years of age, and we asked her whether she could be actually perimenopausal to which she said yes, but when we discussed it further, she was actually displaying signs of perimenopause, which we know increases insulin resistance. It can have sleep disturbance and mood which then impacts on her desire to exercise and maintain a weight loss program. She was really happy to talk to us about this. In fact, she was delighted to think that somebody was interested in the fact that she may have menopause and be going into perimenopause, and that she had no idea that it could impact on her risk of diabetes. That was news to her and that was a motivator for her to also attend that programme.
Angela Blair
That is really good. When we think about people like Mary, they are everyday people just out there, and knowing her risk is one is really important. Doing something about it for her meant that the next phase of her life is going to be a lot healthier than what it would have been.
Annabel Thurlow
Absolutely.
Angela Blair
We might move on now to the next section, which is Annabel is going to talk about lifestyle and the prescription of GLP-1 medications because they are certainly increasing in favour and popularity. I will hand over to Annabel now.
Annabel Thurlow
The GLP-1 have been an exciting addition to our glucose lowering toolbox. We know that a GLP-1 is a naturally occurring hormone in our gut, but it is blunted in people that have type 2 diabetes. We really are encouraging the use of GLP-1 in our patients with type 2 diabetes because we know that the medication will stimulate the release of insulin by working on the pancreas, therefore, lowering a person's blood glucose levels. We know that they reduce the release of glucose out of the liver, again, reducing a person's blood glucose levels. These drugs slow the gastric emptying and they reduce those post post-meal glucose spikes. The GLP-1 work on the appetite centre in the brain, which help to promote weight loss. This is really an added benefit. They reduce hunger and they increase satiety. I am often asked how soon will a person get that suppression of appetite? I find that it normally occurs within days of the person having their first injection. Because their appetite is suppressed, they have got reduced food intake. They really just do not feel like eating. They are not watching their clock and going "oh, it is it is 8 o'clock, I have to eat breakfast. It is 12 o'clock, I have to eat lunch". They are just not getting that feeling that they want to eat. I tell my patients, do not eat unless you are feeling hungry and do not eat overeat. I think majority of us have been brought up to eat what is on our plate. I encourage my patients to serve out a smaller meal, to eat it slowly, and if they feel they need more, then go back and get some additional food. But basically eat a smaller meal and they will find that they really do not need to go back because they are getting that appetite suppressing effect. Recent studies have shown that the GLP-1 has some cardiovascular benefits. It will actually reduce the systolic blood pressure, reduce the diastolic blood pressure, reduce inflammation and reduce dyslipidaemia. Currently, in Australia, we have a range of GLP-1 available. The first GLP-1 became available in about 2005, and that was actually a daily injection. That particular one that I am thinking of is no longer available on the Australian market. We do have one daily injection available still, liraglutide, and that is either Victoza or Saxenda. Victoza, we do not see very often now, and I believe it is in limited supply. The manufacturers are encouraging us as clinicians not to start any new patients on Victoza. If you have got patients already on it, certainly continue to use it, but do not start any new people on it. I am still seeing people start Saxenda, which is a daily injection. The person that I would start on Saxenda is that person who is really apprehensive about starting a weekly injection because of the nausea. Sometimes, it might be wise to start your patient on Saxenda just until you see whether they are going to develop nausea because it will be out of their system in a couple of days and they do not have to put up with the nausea for a week. The most common GLP-1 that we are using at the moment is Ozempic. Now Ozempic is PBS listed for type 2 diabetes for diabetes management. We have two different strengths in Australia, two different pens. One is the 0.25/0.5 and then we have the 1 mg. Of course, there have been some issues around supply and I find that it seems to be an area based thing. Some areas do not seem to have any issues and others do, but it is the only one that is PBS listed for diabetes management. Wegovy is available on the Australian market. It was launched in August 2024 and it is it is not PBS listed. It has been launched for weight management. Recent studies with Wegovy have shown some very positive outcomes, particularly in relation to reduction of waist circumference, reduction in HbA1c, cholesterol, systolic and diastolic blood pressure and also an increase around physical activity. It allows the person to increase their activity. Dulaglutide, Trulicity is still available on the Australian market. It is a once weekly injection and also it is PBS listed for the management of type 2 diabetes. Tirzepatide is probably the newest GLP-1 on the market and the brand name for that is Mounjaro. It is a weekly injection, and it is approved for weight loss in Australia. it is not PBS listed, but I know that hopefully it is going to be in the future. The benefit of combining a GLP-1 medication with lifestyle intervention is that it supports healthy weight changes. Often our patients, they feel, as Angela said, they are eating in a healthy way. We are encouraging them to eat in a healthier way. Sometimes their diet just needs tweaking, but with adding in the GLP-1, they often will see a more substantial weight loss, which is actually really a motivator to them. If a person makes changes to their diet, but they do not see a weight loss, it can be really discouraging and they think, "well, why am I giving up all those things that I really like when it is not doing anything" but by adding in that GLP-1, they see the weight loss, they see the reduction in their waist circumference, they see the reduction in their blood pressure, and that is a real motivator to them. We know that by improving their weight, they are going to get an improvement in their diabetes related and health outcomes. It can also reduce their medication dependency for long-term management. When we start a person on a GLP-1, if they are already on insulin, we will normally reduce that insulin. In fact, we often can get rid of, if they are on a long acting insulin, a basal insulin and a bolus or mealtime insulin, we can often get rid of that mealtime insulin, which is wonderful for the person. They may just have to have a small dose of long-acting insulin and then the weekly injection of the GLP-1. That really reduces the burden for the patient. Another aspect to consider is the financial impact that having all these injections has on the person. You are reducing that financial burden as well.
Angela Blair
Case study time. Just a quick case study because we are chugging along with time. Just quickly. Massimo is 68, BMI 29, diagnosed with type 2 diabetes five years ago, HbA1c 8.3, lives with his partner and still works part time. He has attended the local diabetes education class when he was first diagnosed and he is currently on metformin and a SGLT2, which he is not happy about because it has actually caused him some side effects, urinary tract infections. Intervention, review of the medication due to the side effects and as part of the annual cycle of care screening happened and the decision was made to change his medication as a result. His wife is very supportive around all of this. Again, it is around nutrition and physical activity plan and referral to the Get Healthy Service. The good news is after all that six months on, he has got an improved HbA1c. It is still not in target. However, he has got a 10% weight loss. He is doing really well. Again, that is probably the GLP-1, as well as he has increased his physical activity levels because he is mindful with his age that he does not want to lose muscle mass because he does not want to have some falls. He has been attending an exercise program for the last eight weeks. He is managing the weekly injections without side effects, which is also good news. Annabel, just quickly, why an GLP-1 rather than a different type of medication because there is quite a number of different classifications of diabetes medication at the moment.
Annabel Thurlow
I would consider commencing Massimo on the GLP-1 because his HbA1c was elevated. Therefore, he was at increased risk of developing diabetes related complications, retinopathy, neuropathy, nephropathy. Our goal is to avoid those complications. This gentleman, he was not doing much exercise. He had not attended a dietician for a while. His wife felt that she was doing everything right, but he found that when he attended the program, he actually gained a lot of knowledge, both he and his wife. Then we started him on the GLP-1 because he was getting side effects from the SGLT2. Now remember, the main side effects from the SGLT2 are UTI, thrush and for a man, balanitis. We are talking about GLP-1 tonight, but it is important when you talk to your patient on an SGLT2 that you do mention those side effects to your male patients and of course the UTI and the thrush to your female patients because they really do suffer and they often do not relate the two. He was getting side effects. We started him on the GLP-1. His HbA1c dropped down. It is still not where we really want it to be less than 7, but it is okay. The weight loss was good. The one thing I would really, really encourage here with this patient is that you advise him about increasing his intake of water, increasing his intake of fibre. Very, very important when we are putting a patient on a GLP-1 and also making sure that they are doing some resistance exercise, so encouraging them to Theraband, use light weights. Very, very important, so we avoid that muscle mass because if they think they are getting muscle wastage, they are not going to want to take the medication but we can overcome that. I would also look at Massimo's sleep habits like, is he sleeping well? How many times at night is he waking up? I would ask him about his intake of alcohol and just ensure that he is not drinking too much. If he does drink, make sure he is having a couple of drink free nights a week. Make sure he is not drinking too much soft drink, flavoured milks, orange juices, encourage him to be drinking the water. Ensure that he is having his eyes, feet, kidneys, hearing, teeth and a sleep study, if necessary, checked annually as per the recommendations in the annual cycle of care. I would be ensuring that he is being referred to have his eyes checked, his feet checked his. Those things that are mentioned in the annual cycle of care.
Angela Blair
Great. I think what we might do is just go to the next slide. What Annabel has given is a very complex and complete answer to that, so we might move on to the next slide.
Annabel Thurlow
This slide, while it is quite small here, even for me, it just shows how you can prescribe these medications. A GLP-1 can only be commenced in a patient with type 2 diabetes if they have had an inadequate response to an SGLT2. Now, if you start a person on a GLP-1, you should really stop the SGLT2 unless they are taking it for a cardiac or a renal condition. If you feel that you want to continue the SGLT2, you could prescribe it on a private prescription. The person starting on the SGLT2 also has to have an HbA1c greater than 7, or they have shown that they have been blood testing, and 20% of those blood tests over a certain period of time are greater than 10%. It is important that you look at those guidelines. They do not have to be on a sulfonylurea and a metformin, but they do have to have been on SGLT2. Angela, I would just like to also mention here that if the patient is taking a DPP-4 and you start them on an SGLT2, both are in the Incretin pathway, both the DPP-4 and the GLP-1. The DPP-4 should be stopped because it is of no benefit. Also, I wanted to mention because we are running out of time that if you are considering starting up a GLP-1 in a person that has a high HbA1c and they have had diabetes for a long period of time, there is probably nothing left in their pancreas. They really do not have additional insulin there to do anything, so those people need to be started on insulin therapy. Do not delay. Start them on insulin therapy. The DPP-4, the GLP-1, they all work better early on in the disease process, not when the person has had diabetes for 20 odd years. Be really proactive and get these people on these drugs. The GLP-1 can cause some nausea early on, but normally, after 1 or 2 injections, those side effects settle down. The common challenge is that they have a risk of reduced appetite. That is what these drugs are doing. They are reducing the amount that a person is eating. The main side effects we see are nausea. It can be just a couple of days or it can be for the first couple of injections. If the person is really feeling unwell, but they want to persevere, you could prescribe them ondansetron. I would not suggest you prescribe the Maxolon or Stemetil because that drug actually speeds up the gastric emptying and the GLP-1 slows the gastric emptying, so you have got two opposing teams there. Try and set some goals with your patients about what you expect. You do not expect them to lose 20 kg straight off. Just do those smart goals. The costs sometimes can be a challenge. They are expensive. Of course, the Ozempic is on the PBS, but the other weight management drugs are not and they are quite expensive. When you are starting a person on these drugs, you need to indicate to them that really they are a long-term drug. If they went on to insulin, they would know it was long term. These drugs are also long term. They are not just for a month or two. Sometimes, there is some fear around giving injections. That was where I would really encourage you to refer these patients to a credentialed diabetes educator where we can really help the patient get over that fear. It is a very, very easy process and a very, very small needle. As I have already mentioned about the muscle mass, we really encourage that weight resistance. In fact, we think that the drug should actually come wrapped in a Theraband so that the patient will start doing some resistance exercise straight away.
If the GLP-1 is stopped, the person will normally experience a change in their appetite. They will have increased hunger and this is where the weight gain comes back in. There is great potential to regain not all of the weight they have lost, but certainly I think on Ozempic, they say they will regain about 13% to 14% of the weight that they lost. There will be usually some emotional distress around that weight gain. We need to discuss that with the patient. Their blood glucose levels may increase. They have increased cardiometabolic risk factors due to an increase of their blood pressure and their lipids. If you have stopped some of the medication with a person who starts a GLP-1, please consider restarting it again because that will keep their blood glucose levels down. They may be concerned about how long they have got to take the therapy. They need to maintain the lifestyle changes that they implemented, that they learned in some of the programmes that Angela has mentioned and emphasise that the lifestyle interventions are very important. They need to continue on with those. Monitor their weight and their glucose levels and look at their HbA1c, fructosamine and their biochemistries.
Angela Blair
Okay. Back to me and we are going to go really fast because we are going to answer a couple of questions. You will be getting these slides in the pack. I am going to just go to the ones that talk about the Get Healthy Service, which I think is really important. The Get Healthy Service has been around since 2009. It is a great program. Diabetes Australia that is where I work is currently delivering the Get Healthy Service for New South Wales Health and I think the program itself is of value to you as a general practitioner because it is a program that you can actually refer anyone over the age of 18 to the service so that they can actually work out their health goals with a health coach, and we can support them to actually achieve those goals to improve their health. They can be living with diabetes. They can be living with hypertension, cholesterol. They are just wanting to become healthier. There are many reasons why they can be referred to us including, as I said, the people with diabetes. It is a program that once you refer the person to us, they can also refer themselves as well if you give them the information. Either way, it is really easy to be referred. The benefit is it is free. They get 10 coaching sessions and then they graduate. If they still have not quite achieved their goals or they want to start with some new goals, they can re-enrol and the whole process starts again. It is not just a one-off here we do it. It is ongoing, if they choose to have it ongoing. The good thing about it is they get to choose their coach. They get to choose the time they want to have those phone calls or video calls. We have supportive information. They get access to resources, webinars, Q&A sessions. There is lots of support around that program as well as the coaching calls. It is a really great program that can support you in general practice as a free service that people can actually access.
I will mention that you do get a lot of correspondence once you refer someone. We send you communication along the way on the person's progress if you choose to receive that. You get a progress report at the end once they have graduated. There is a bunch of ways that you can refer people. The best is if you are using Medical Director and Best Practice, it is actually inbuilt into the program. Just go to Specialist Referrals, you can actually auto fill in the referral and send it to us and we will do the rest. There is Website Referral, and you can just click on that button and enter the details and go through it. You can email in a referral. It is online but you can print it off and fax it if you would like to or you can email it through or the person can self-refer, which I think is a lovely way to do it, if they want to, on the website or they can ring us on the on the phone number, 1300-806-258 and we will do it all over the phone for them. Not everyone likes to use technology to do their referrals. If you have got a minute, remember you are getting this presentation. I would ask you to go through those slides about the Get Healthy Service if you want to know a little bit more about it. What you do need to know is it is a great service that can support you in getting the patients that you see started on their health journey. Thank you.