DPCA 2-4_entire issue

Diabetes
& Primary Care Australia
Vol 2 No 4 2017
The primary care diabetes journal for healthcare professionals in Australia
Free CPD module:
Psychological barriers
to insulin use
How barriers to treatment
intensification in people with type 2
diabetes can be understood
and addressed.
Page 139
Visit our suite of FREE e-learning
modules at pcdsa.com.au/cpd
IN THIS ISSUE
Low carbohydrate diets
How to approach a low carb
diet and what benefits might
be achieved.
Pages 130 and 133
Insulin pumps
The language surrounding
insulin pump therapy and what
you need to know.
Page 147
Telehealth
Can telehealth improve the
care of people with diabetes in
rural and remote regions?
Page 151
WEBSITE
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Contents
Diabetes
& Primary Care Australia
Volume 2 No 4 2017
@PCDSAus
Website: www.pcdsa.com.au/journal
Guest editorial
The importance of values, beliefs and intentions in diabetes management 129
John Furler comments on the importance of understanding the ideas, concerns and expectations of people with type 2 diabetes.
From the other side of the desk
Why I adopted the low-carbohydrate approach 130
Ron Raab shares his experiences of this approach to eating and the positive effects on his health that has resulted.
Articles
Low carbohydrate diets for people with type 2 diabetes 133
Adele Mackie reviews the evidence relating to the effectiveness of a variety of low carbohydrates diets for people with type 2 diabetes.
CPD module
Psychological barriers to insulin use among Australians with type 2 diabetes and clinical strategies to reduce them 139
For this issue’s free education module, Elizabeth Holmes-Truscott and Jane Speight draw on recent evidence of the causes of psychological
insulin resistance and discuss strategies to identify and address concerns about insulin therapy.
Articles
Insulin pump therapy – a new language 147
Traci Lonergan provides an overview of this therapy to familiarise primary healthcare professionals with the insulin pump basics.
Telehealth: making healthcare accessible for people with diabetes living in remote areas 151
Natalie Wischer describes how telehealth can be a useful tool in enabling people in rural and remote regions to access
best practice diabetes care .
American Diabetes Association 2017: a primary care overview of scientific sessions 154
Mark Kennedy highlights the most interesting and relevant of the scientific sessions for the American Diabetes Association’s Annual
Conference.
Editor-in-Chief
Rajna Ogrin
Senior Research Fellow, RDNS
Institute, St Kilda, Vic
Associate Editor
Gary Kilov
Practice Principal, The Seaport
Practice, and Senior Lecturer,
University of Tasmania,
Launceston, Tas
Editorial Board
Ralph Audehm
GP Director, Dianella Community
Health, and Associate Professor,
University of Melbourne,
Melbourne, Vic
Werner Bischof
Periodontist, and Associate
Professor, LaTrobe University,
Bendigo, Vic
Anna Chapman
Research Fellow, RDNS Institute,
St Kilda, Vic
Laura Dean
Course Director of the Graduate
Certificate in Pharmacy
Practice, Monash University, Vic
Nicholas Forgione
Principal, Trigg Health Care
Centre, Perth, WA
John Furler
Principal Research Fellow and
Associate Professor,
University of Melbourne, Vic
Mark Kennedy
Medical Director, Northern Bay
Health, Geelong, and Honorary
Clinical Associate Professor,
University of Melbourne,
Melbourne, Vic
Peter Lazzarini
Senior Research Fellow,
Queensland University of
Technology, Brisbane, Qld
Roy Rasalam
Head of Clinical Skills and
Medical Director,
James Cook University, and
Clinical Researcher, Townsville
Hospital, Townsville, Qld
Suzane Ryan
Practice Principal, Newcastle
Family Practice, Newcastle, NSW
Editorial team
Tracy Tran, Charlotte Lindsay
Editorial Manager
Richard Owen
Publisher
Simon Breed
© OmniaMed SB and the Primary Care
Diabetes Society of Australia
Published by OmniaMed SB,
1–2 Hatfields, London
SE1 9PG, UK
All rights reserved. No part of this
journal may be reproduced or transmitted
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or mechanic, including photocopying,
recording or any information retrieval
system, without the publisher’s
permission.
ISSN 2397-2254
Diabetes & Primary Care Australia Vol 2 No 4 2017 127

Call for papers
Would you like to write an article
for Diabetes & Primary Care Australia?
The new journal from the Primary Care Diabetes Society of Australia
To submit an article or if you have any queries, please contact: rajna.ogrin@pcdsa.com.au.
Title page
Please include the article title, the full names of the authors
and their institutional affiliations, as well as full details of
each author’s current appointment. This page should also have
the name, address and contact telephone number(s) of the
corresponding author.
Article points and key words
Four or five sentences of 15–20 words that summarise the major
themes of the article. Please also provide four or five key words
that highlight the content of the article.
Abstract
Approximately 150 words briefly introducing your article,
outlining the discussion points and main conclusions.
Introduction
In 60–120 words, this should aim to draw the reader into the
article as well as broadly stating what the article is about.
Main body
Use sub-headings liberally and apply formatting to differentiate
between heading levels (you may have up to three heading levels).
The article must have a conclusion, which should be succinct and
logically ordered, ideally identifying gaps in present knowledge and
implications for practice, as well as suggesting future initiatives.
Tables and illustrations
Tables and figures – particularly photographs – are encouraged
wherever appropriate. Figures and tables should be numbered
consecutively in the order of their first citation in the text. Present
tables at the end of the articles; supply figures as logically labelled
separate files. If a figure or table has been published previously,
acknowledge the original source and submit written permission
from the copyright holder to reproduce the material.
References
In the text
Use the name and year (Harvard) system for references in the
text, as exemplified by the following:
● As Smith and Jones (2013) have shown …
● As already reported (Smith and Jones, 2013) …
For three or more authors, give the first author’s surname
followed by et al:
● As Robson et al (2015) have shown …
Simultaneous references should be ordered chronologically first,
and then alphabetically:
● (Smith and Jones, 2013; Young, 2013; Black, 2014).
Statements based on a personal communication should be
indicated as such, with the name of the person and the year.
In the reference list
The total number of references should not exceed 30 without prior
discussion with the Editor. Arrange references alphabetically first,
and then chronologically. Give the surnames and initials of all
authors for references with four or fewer authors; for five or more,
give the first three and add “et al”. Papers accepted but not yet
published may be included in the reference list as being “[In press]”.
Journal article example: Robson R, Seed J, Khan E et al (2015)
Diabetes in childhood. Diabetes Journal 9: 119–23
Whole book example: White F, Moore B (2014) Childhood
Diabetes. Academic Press, Melbourne
Book chapter example: Fisher M (2012) The role of age. In: Merson
A, Kriek U (eds). Diabetes in Children. 2nd edn. Academic Press,
Melbourne: 15–32
Document on website example: Department of Health (2009)
Australian type 2 diabetes risk assessment tool (AUSDRISK).
Australian Government, Canberra. Available at: http://www.
health.gov.au/preventionoftype2diabetes (accessed 22.07.15)
Article types
Articles may fall into the categories below. All articles should be
1700–2300 words in length and written with consideration of
the journal’s readership (general practitioners, practice nurses,
prescribing advisers and other healthcare professionals with an
interest in primary care diabetes).
Clinical reviews should present a balanced consideration of a
particular clinical area, covering the evidence that exists. The
relevance to practice should be highlighted where appropriate.
Original research articles should be presented with sections
for the background, aims, methods, results, discussion and
conclusion. The discussion should consider the implications
for practice.
Clinical guideline articles should appraise newly published
clinical guidelines and assess how they will sit alongside
existing guidelines and impact on the management of diabetes.
Organisational articles could provide information on newly
published organisational guidelines or explain how a particular
local service has been organised to benefit people with diabetes.
— Diabetes & Primary Care Australia —

Guest Editorial
The importance of values, beliefs and
intentions in diabetes management
As healthcare professionals we all strive
to be patient-centred in our care. While
evidence-based, step-wise intensification
of pharmacotherapy to help achieve glycaemic
targets is simple to describe, in reality – as GPs
and other primary care health professionals know
– it is extremely complex and an ongoing focus
of negotiation and discussion between the person
with type 2 diabetes and his or her health carers.
Insulin initiation and up-titration is a good
example of this complex work.
Psychological insulin resistance
In this edition, Elizabeth Holmes-Truscott and
Jane Speight explore the notion of psychological
insulin resistance in depth. This is clearly a critical
factor in the interactions between the clinician
and the person with type 2 diabetes in any
discussion about treatment changes that is focused
on starting or intensifying insulin therapy.
The authors show how the values, beliefs,
attitudes and intentions that people bring to this
interaction are critical in what happens to patients
over time. We need to avoid setting up negative
perceptions about insulin therapy, while being
realistic about addressing people’s concerns.
A dynamic and ongoing conversation
with the patient
What is important to understand is that these
attitudes and beliefs are dynamic and worthy of
ongoing conversations over time. Understanding
and responding to the ideas, concerns and
expectations of people with type 2 diabetes is a
key element of sustained patient-centred practice.
It will also help us make the most of important
opportunities and moments as they arise, to
optimise treatment and outcomes.
Ensuring timely treatment changes
Naturally, in order to make the most of these
conversations, as clinicians we need to be ready
to respond when the patient is ready. If the time
is right, if the clinical discussions go well and the
evidence suggests we should start insulin, the last
thing we need is a long delay while specialist care
off-site is arranged. We need to have the systems
and skills in place locally in the practice to make
those insulin starts safely and efficiently.
Practice nurses can play an important role in a
supportive practice system, working to the scope
of practice to support the transition to insulin
therapy, mentored by a credentialled diabetes
educator and in liaison with the GP (Furler et
al, 2017). This can be important in overcoming
some of the delays and avoiding the need for
referral out.
Building our own skills and confidence and
optimising the practice-based team is the critical
other side of the coin to addressing he patient’s
attitudes, beliefs and intentions about starting
insulin.
n
Furler J, O’Neal D, Speight Jet al (2017) Supporting insulin initiation
in type 2 diabetes in primary care: results of the Stepping
Up pragmatic cluster randomised controlled clinical trial.
BMJ 356: j783
John Furler
Associate Professor of General
Practice, University of Melbourne
Read more
online
The “NO TEARS” diabetes medication
review
Jane Diggle describes this tool to assess
individuals’ medicines.
Available at: https://is.gd/DPCADiggle
Premixed insulin analogues: A new
look at an established option
Ted Wu provides a new look with
practical guidance and advice for
considering initiative with, and using,
premixed insulin analogues.
Available at: https://is.gd/DPCAWu
Can obese adults with type 2 diabetes
lose weight while on insulin therapy?
Billy Law reviews the evidence relating
to weight outcomes in this group while
Gary Kilov provides an Australian
perspective.
Available at: https://is.gd/DPCALaw
Diabetes & Primary Care Australia Vol 2 No 4 2017 129

From the other side of the desk
From the other side of the desk:
Patient perspective
Why I adopted the low-carbohydrate
approach
Ron Raab
Citation: Raab R (2017) Why I
adopted the low-carbohydrate
approach. Diabetes & Primary Care
Australia 2: 130–2
About this series
The aim of the “From the other
side of the desk” series is to
provide a patient perspective and
a pause for thought to reflect on
the doctor–patient relationship.
I
was diagnosed with type 1 diabetes in
1957 when I was 6 years old. By the 1980s,
I had developed some complications: eye
damage (retinopathy) and nerve damage
(neuropathy), including delayed stomach
emptying (gastroparesis). Over the years, I
tried hard to keep good blood glucose levels
and applied the standard high-carbohydrate,
low-glycaemic advice. But I could not achieve
consistently near-normal blood glucose. As a
result, I was having severe hypoglycaemia, and
my diabetes complications were worsening. The
high-carbohydrate advice just did not work.
In 1998, I became aware of a novel approach
consisting of a low-carbohydrate food plan,
with a normal intake of protein and variable
consumption of fat, which results in reduced
insulin doses. I learnt about this approach
from various sources, including Dr Richard
Bernstein, an endocrinologist with type 1
diabetes, who has written extensively on this,
such as in his book Dr. Bernstein’s Diabetes
Solution. After much experimentation, I have
reduced my total daily intake of carbohydrate
from over 250 g to 80 g.
an appetite stimulant, and this regimen resulted
in much less insulin). I am more motivated, feel
less frustrated, and my subjective quality of life
and outlook have improved enormously.
I do not regard this food plan as “radical”
or a “fad”. It should not be confused with the
extreme nutritional plans, which are periodically
given publicity. This is not a “high-protein diet”;
protein content is chosen and adjusted in part
based on what gives a feeling of satiety.
Rationale
In Diabetes Voice in 2002, the Secretary-
General of the International Society for
Author
Ron Raab, President of Insulin for
Life Australia; Past Vice-President
of the International Diabetes
Federation, Caulfield North, Vic.
Seeing results
Since adopting the low-carbohydrate approach,
my insulin requirements have fallen by 50% to
25 units daily. My HbA 1c
has greatly improved.
Variations in my daily blood glucose levels
have reduced, and episodes of hypoglycaemia
are much less severe. As noted by my
ophthalmologist, my retinopathy has stabilised.
Importantly, hunger has decreased (insulin is
130 Diabetes & Primary Care Australia Vol 2 No 4 2017

From the other side of the desk
Paediatric and Adolescent Diabetes commented
that: “Nutritional management is commonly
described as one of the cornerstones of diabetes
care… unfortunately, it is the cornerstone
which may be least understood, most underresearched,
and to which there is the poorest
adherence.”
There remains enormous confusion and
misunderstanding about the optimal dietary
advice for people with diabetes. Why are
people with diabetes advised to eat so much
carbohydrate? Often this is 50% of calories for
carbohydrate, which effectively means 300 g
of carbohydrate daily. That is equivalent to
60 teaspoons of sugar daily! It should be borne
in mind that this is a food type that is the root
cause of blood glucose instability and which
increases the need for insulin – in turn creating
further problems.
Lowering daily carbohydrate intake makes
sense for many reasons. The greater the intake
of carbohydrate, the more unpredictable the
timing and size of the resultant increase in blood
glucose. This is exacerbated by the variability
of insulin absorption (the impact and timing
of the action of insulin in lowering blood
glucose). Moreover, this variability increases
as the quantity of injected insulin increases.
All of which means that a regimen consisting
of a high intake of carbohydrates, including
complex carbohydrates, results in erratic and
unpredictable blood glucose profiles, compared
to a low-carbohydrate, low-insulin regimen.
Gastroparesis
Gastroparesis, provoked by diabetes-related
nerve damage, further adds to variable and
unpredictable blood glucose levels. This
condition, which is very common in people with
long-standing diabetes, can be very unpleasant,
with symptoms ranging from mild discomfort
to acute pain. In people with gastroparesis,
large amounts of carbohydrate can remain in
the stomach for variable periods of time. Then,
unpredictably, and possibly very suddenly, these
carbohydrates are processed or emptied with
the resultant glucose entering the circulation
uncontrolled.
The large amounts of insulin that are
injected by people with gastroparesis on a highcarbohydrate
diet continue acting, contributing
to highly irregular blood glucose levels and the
possibility of major hypoglycaemia. The risk of
hyperglycaemia is increased as, at some point,
the carbohydrate is digested, resulting in a rapid
and drastic rise in blood glucose.
Understandably, recommendations to
consume high levels of carbohydrates are a
formula for very variable blood glucose levels and
hypoglycaemia. Indeed, this is the experience of
many people with diabetes. There are other
potential implications of high-carbohydrate
recommendations.
A possible relationship exists between high
insulin doses and the development of vascular
disease, including heart disease, independent of
any other factor. A growing body of evidence
describes the role of even brief increases in postmeal
blood glucose levels in the development
of disabling and potentially life-threatening
diabetes complications. It is speculated that
night-time hypoglycaemia – “dead-in-bed”
syndrome – may also be caused by the large
amounts of insulin taken by people trying
to match their high carbohydrate intake – in
many cases tragically resulting in a life-ending
hypoglycaemia.
What to eat
This is a simple and practical regimen; a wealth
of satisfying and tasty low-carbohydrate snacks
and meals are readily available or can be easily
prepared. Here is one example of a satisfying
meal that contains 10 g to 15 g of carbohydrate
and 120 g of protein:
l Soup made from stock.
l Garden salad with olive oil.
l A medium-sized serving of fish or vegetable
protein.
l Cooked vegetables (no potatoes or similar)
l Cheese (e.g Brie).
l Tea or coffee with a small amount of milk.
Such a meal requires very few units of insulin –
in my case 3 to 4. Compare this to the effects
of a meal with 100 g or more of carbohydrate:
more insulin is required in response, resulting
“Since adopting the
low-carbohydrate
approach, my insulin
requirements have
fallen by 50% to
25 units daily.”
Diabetes & Primary Care Australia Vol 2 No 4 2017 131

From the other side of the desk
“Standard dietary
advice, in effect,
obliges people with
diabetes to metabolise
the equivalent of three
glucose-tolerance-test
loads every day!”
in considerably greater variability and
unpredictability in blood glucose levels, and
worse outcomes.
Importantly, in a high-carbohydrate system
it becomes extremely difficult to estimate
accurately the intake of carbohydrates. Food
labelling provides only an approximation of
carbohydrate content. In a meal consisting
of 100 g of carbohydrates, a 20% error in
estimating translates into 20 g of carbohydrate
either overcompensated or undercompensated
(by the action of a dose of insulin). This
compounds unpredictability in blood glucose
levels. The degree of error described above
can be very significant; by comparison, the
treatment for hypoglycaemia is about 15–20 g
of glucose.
As an aside, the glucose tolerance test, which
is widely used in the diagnosis of diabetes,
uses 75 g or 100 g of carbohydrate to test
the body’s mechanism for regulating blood
glucose. “Standard” dietary advice, in effect,
obliges people with diabetes to metabolise the
equivalent (the type of carbohydrate might
differ, but the volume is the same) of three
glucose-tolerance-test loads every day! What is
the sense in recommending that a person who
has major problems metabolising carbohydrates
consume a huge carbohydrate load every day?
Why is so much carbohydrate
consumption recommended?
One of the historical reasons for the traditional
dietary recommendations for people with
diabetes – and indeed, the general population
– relates to heart disease and other vascular
disorders, which have been attributed to an
increased intake of fat. In order to reduce
the amount of fat consumed while meeting
the target intake of calories, a decision was
taken to recommend increasing the amount of
carbohydrate in people’s diet. However, this
was done without examining the contribution
of carbohydrate itself to heart disease and
obesity, the implications for people with
diabetes of higher carbohydrate intake in
terms of varying blood glucose levels, or the
negative effects from the large amounts of
insulin that are required to attempt to control
blood glucose.
We will see a reduction in the diabetes
epidemic when there is a major change
in dietary recommendations.
It is not difficult to live with a nutritional
regimen that is low in carbohydrates, higher
in fats (lower in saturated fat and higher in
the unsaturated fats) that help to provide the
required energy. Calories can be obtained from
healthy fats; for example, two tablespoons of
olive oil yield 360 calories – a significant
amount in terms of a person’s daily needs.
The premise that a high carbohydrate intake is
essential to meet caloric needs of people with
diabetes in order to reduce the risk of heart
disease is clearly unsound.
Conclusion
The current recommendations overlook
a fundamental reality: blood glucose levels
in people with diabetes vary with increasing
unpredictability as the consumption of
carbohydrate increases. A reduced intake of
carbohydrates requires smaller amounts of
insulin, resulting in increased predictability
and smaller variation in blood glucose levels.
The tools exist to maintain continuously nearnormal
blood glucose levels. Indeed, this
approach has improved my life enormously. Yet
only small numbers of people benefit from these
because high-carbohydrate recommendations
continue to be the standard advice. n
132 Diabetes & Primary Care Australia Vol 2 No 4 2017

Article
Low carbohydrate diets for people with
type 2 diabetes
Adele Mackie
Low carbohydrate diets were once the default method of treatment for diabetes before
the development of medications. They have once again emerged as a popular treatment,
although there is lack of long-term evidence to support their use. Short-term studies (less
than 2 years’ duration) have shown that both low carbohydrate and higher carbohydrate
diets can be very effective in managing type 2 diabetes and reducing cardiovascular
disease risk. Low carbohydrate diets may have some additional advantages over higher
carbohydrate/low fat diets, including a more significant reduction in glycaemic variability,
medication usage and triglycerides as well as a greater increase in HDL-cholesterol. Studies
comparing low carbohydrate to high carbohydrate diets lack a consistent definition, with
a range of carbohydrate prescriptions used for each diet arm. There are a range of dietary
patterns that can be selected to manage type 2 diabetes and this should be individualised
to meet the needs of the person living with diabetes.
The use of low carbohydrate diets to manage
type 2 diabetes is not a novel approach.
Before the discovery of insulin and oral
hypoglycaemic agents, extreme carbohydrate
restriction was the default treatment. Dietary
advice changed to a focus on reducing fat
following increased rates of cardiovascular disease
in this population group, and carbohydrate
intake was liberalised (Dyson, 2015).
Low carbohydrate diets have recently
re-emerged as a popular approach to managing
diabetes. However, there are very few large-scale,
well-controlled studies that examine the longterm
effects of this dietary pattern and there
are no studies longer than two years in duration
(Shai et al, 2008; Tay et al, 2015a; Dietitians
Association of Australia, 2016).
Nutrition therapy recommendations for
type 2 diabetes management
Australia currently lacks national evidence-based
nutrition guidelines for the management of type
2 diabetes, so diabetes health professionals refer
to major guidelines developed internationally.
It is generally well recognised that dietary
carbohydrate is the main nutrient influencing
glycaemic levels after eating (Accurso et al,
2008; Evert et al, 2013). Both the American
Diabetes Association (Evert et al, 2013) and
Diabetes UK (Diabetes UK, 2011) state that
there is insufficient evidence to recommend an
ideal amount of carbohydrate, and this should
be individualised in consultation with the person
who has diabetes.
In terms of preventing chronic disease, the
National Health and Medical Research Council
(2014) suggests that a carbohydrate intake of
45–65% of total energy consumption may
be protective. However, there are no specific
recommendations for management of chronic
conditions in this same document.
The Dietitians Association of Australia (2016)
recognise low carbohydrate diets as a possible
therapeutic option, stating that: “Low carbohydrate
diets may be an effective option in the non-acute
setting for weight loss and improvements in
glycaemic control and cardiovascular risk in the
short-term, for adults with type 2 diabetes under
individualised and ongoing care and assessment
by an accredited practising dietitian.”
Defining the low-carbohydrate diet
One problem that is encountered when reviewing
the evidence on low carbohydrate diets is the
Citation: Mackie A (2017) Low
carbohydrate diets for people with
type 2 diabetes. Diabetes & Primary
Care Australia 2: 133–8
Article points
1. There are currently no
Australian guidelines on
carbohydrate requirements for
managing type 2 diabetes.
2. Diabetes UK state that there
is insufficient evidence to
recommend an ideal amount
of carbohydrate and this
should be individualised
in consultation with the
person who has diabetes.
3. The National Health and
Medical Research Council
suggests that a carbohydrate
intake of 45–65% of total
energy consumption may help
prevent chronic disease.
Key words
– Higher carbohydrate diet
– Low carbohydrate diet
– Low fat diet
Authors
Adele Mackie is an Accredited
Practising Dietitian (APD) at
Diabetes Victoria, Melbourne, Vic
Diabetes & Primary Care Australia Vol 2 No 4 2017 133

Low carbohydrate diets for people with type 2 diabetes
Page points
1. Despite claims that low
carbohydrate diets are
superior for weight loss,
several systematic reviews
and meta-analyses of low
versus high carbohydrate diets
have reported there to be
no difference in weight loss
between the two diet arms
at either 3–6 months’ and/or
1–2 years’ follow-up.
2. A recent, well-designed study
supported previous findings that
low carbohydrate diets produce
much the same weight loss as
higher carbohydrate/low fat
diets at 1–2 years’ follow-up.
3. It can be concluded that low
carbohydrate diets are at least
as effective for weight loss as
low fat diets, but they are not
superior.
lack of a consistent definition. Many studies have
been published citing a range of carbohydrate
prescriptions for the low carbohydrate
intervention, from 20 g of carbohydrate per
day up to 45% of total energy intake from
carbohydrate (Feinman, 2008; Shai et al, 2008;
Hu et al, 2012; Ajala et al, 2013; Feinman, 2015).
A recent systematic review and meta-analysis
by Snorgaard et al (2017) found a wide variance
in reported carbohydrate intake between low
carbohydrate and high carbohydrate groups, with
low carbohydrate groups consuming 57–198 g
and the high carbohydrate groups consuming
133–205 g of carbohydrate daily. This obviously
makes it very difficult to compare results across
different studies. Table 1 lists the most common
definitions of carbohydrate intake cited in the
literature.
Evidence for low carbohydrate diets
Studies investigating low carbohydrate diets
replace some of the carbohydrate with a higher
intake of fat or protein or both. They are
compared to a control diet that is higher in
carbohydrate and lower in fat (Shai et al, 2008;
Elhayany et al, 2010; Ajala et al, 2013).
Outcomes measures of most studies have
focused on weight management, glycaemic
control and cardiovascular disease risk.
Weight management
Low carbohydrate advocates often make strong
claims about this particular dietary pattern being
superior for weight loss. Despite these claims,
several systematic reviews and meta-analyses of
low versus high carbohydrate diets have reported
there to be no difference in weight loss between
the two diet arms at either 3–6 months’ and/or
1–2 years’ follow-up (Hu et al, 2014; Naude et al,
2014; Dyson et al, 2015; Snorgaard et al, 2017).
These findings support the principle of energy
balance and a sustained energy deficit resulting
in weight loss, irrespective of macronutrient
composition (Naude et al, 2014).
The Commonwealth Scientific and Industrial
Research Organisation (CSIRO) have recently
completed one of the most well designed studies
looking at the effects of an isocaloric low
carbohydrate/high unsaturated fat diet compared
to a higher carbohydrate (low glycaemic index)/
low fat diet on 115 people with type 2 diabetes.
The findings from this larger scale study support
previous findings that low carbohydrate diets
produce much the same weight loss as higher
carbohydrate/low fat diets at 1–2 years’ followup,
with both groups achieving a mean weight
loss of 9.1% (Tay et al, 2015a).
Therefore, it can be concluded that low
carbohydrate diets are at least as effective for
weight loss as low fat diets, but they are not
superior (Feinman, 2008; Elhayany, 2010; Naude
et al, 2014; Tay et al, 2014; 2015a; Dyson, 2015;
Snorgaard et al, 2017).
Optimising glycaemic management
The effect of low carbohydrate diets on glycaemic
levels has been variable. Whilst the reviews by
Ajala et al (2013) and Snorgaard et al (2017) have
reported a slightly greater short-term reduction
in HbA 1c
(at 3–6 months) when following a low
Table 1. The most common definitions of carbohydrate intake (Feinman 2008; Shai et al, 2008;
Dyson, 2015; Noakes and Windt, 2016).
High carbohydrate
Moderate carbohydrate
Low carbohydrate
Very low carbohydrate, high fat (ketogenic)
Australian Nutrient Reference Values
(National Health and Medical Research Council, 2014)
NB These guidelines are for chronic disease
prevention, not for diabetes management.
>230 g of carbohydrate daily or >45% of energy.
130–230 g of carbohydrate daily or 26–45% of total energy.
50–130 g of carbohydrate daily or 10–26% of total energy.
20–50 g of carbohydrate daily or

Low carbohydrate diets for people with type 2 diabetes
carbohydrate diet, the evidence is not strong due
to heterogeneity between studies. The review
by Naude et al (2014) found no difference at
all. Dyson (2015) reported mixed results with
three studies showing a significant reduction in
HbA 1c
in the short-term (i.e. less than 1 year) and
four studies showing no significant difference.
Any reduction in HbA 1c
that is obtained at
3–6 months with the low carbohydrate diet
appears to be lost at 12 months or more, with
both low and high carbohydrate groups obtaining
a similar HbA 1c
at this time point (Dyson, 2015;
Snorgaard et al, 2017).
The data from Tay et al (2014; 2015a) support
these findings, as they showed that those
following the low carbohydrate diet achieved a
greater reduction in HbA 1c.
However, this only
occurred in people who had a baseline HbA 1c
of
>62 mmol/mol (>7.8%) and was not sustained
at 12 months. Both the low carbohydrate and
the high carbohydrate groups achieved a mean
reduction in HbA 1c
of 11 mmol/mol (1.0%).
Although there was no difference in HbA 1c
between the two diet arms of this study, glycaemic
variability was reduced in the low carbohydrate
group. Participants on the low carbohydrate
diet were 85% more likely to spend time in the
euglycaemic range, 56% less likely to spend
time in the hyperglycaemic range and 16% less
likely to spend time in the hypoglycaemic range
(Tay et al, 2014; 2015a). As glycaemic variability
is emerging as an independent risk factor for
diabetes related complications (Tay et al, 2015a;
2015b), this could be an important finding.
An additional consideration is that participants
following the low carbohydrate diet also
experienced a two-fold greater reduction in
their diabetes medications compared to those
following the higher carbohydrate, low fat diet
(Tay et al, 2014; 2015a).
Cardiovascular disease risk
Both low carbohydrate and higher carbohydrate
diets have been shown to effectively reduce
cardiovascular disease risk by lowering weight,
total cholesterol, LDL-cholesterol, blood pressure
and triglycerides, as well as increasing HDLcholesterol.
However, it appears from the literature
that low carbohydrate diets that are also high in
unsaturated fats (rather than saturated fats) have
an additional benefit, showing a more significant
reduction in triglycerides and increased HDLcholesterol
compared to higher carbohydrate,
lower fat diets (Shai et al, 2008; Elhayany et al,
2010; Hu et al, 2012; Tay et al 2014; 2015a).
It should be noted, however, that many of the
dietary interventions in this field implement
a low carbohydrate, higher saturated fat diet.
In these studies, participants have shown an
increase in LDL-cholesterol (Hu et al, 2012;
Noakes and Windt, 2016). Furthermore, there is
also evidence that saturated fats worsen insulin
resistance whilst mono-unsaturated and polyunsaturated
fats improve insulin sensitivity, lipid
profiles and blood pressure, independent of body
weight (Riccardi et al, 2004).
Comparison to other dietary
approaches
Ajala et al (2013) undertook a systematic review
and meta-analysis of 20 randomised controlled
trials looking at seven different diets followed
from 6 months to 4 years. They found that a
low carbohydrate, low glycaemic index (GI),
Mediterranean and high protein diet were all
effective at reducing HbA 1c
by 1.3–5.5 mmol/mol
(0.12–0.5%) compared with a low fat, higher
carbohydrate diet (50–60% energy intake from
carbohydrate). The Mediterranean diet produced
the greatest reduction.
Furthermore, the low carbohydrate, low GI
and Mediterranean diets all led to significant
improvements in lipid profiles with the low
carbohydrate diet showing a more significant
increase in HDL-cholesterol (Ajala et al, 2013).
Table 2 outlines the carbohydrate content of each
dietary intervention.
Following and maintaining a low
carbohydrate diet
Whilst low carbohydrate diets may be one viable
option to help manage diabetes, are people
actually able to sustain them? Tay et al (2015a)
found that after one year of their two-year
intervention, reported carbohydrate intake
increased from the prescribed 50 g per day to
about 70 g per day.
The review and meta-analysis by Snorgaard et
Page points
1. Results from studies on the
effect of low carbohydrate diets
on glycaemic levels have varied.
Glycaemic improvements seen
early on appear to be lost at
12 months or more.
2. Both low carbohydrate and
higher carbohydrate diets have
been shown to effectively
reduce cardiovascular disease
risk by lowering a number of
risk factors.
3. A systematic review of seven
different diets found that low
carbohydrate, low glycaemic
index, Mediterranean and
high protein diets were all
effective at reducing HbA 1c
compared with a low fat, higher
carbohydrate diet.
Diabetes & Primary Care Australia Vol 2 No 4 2017 135

Low carbohydrate diets for people with type 2 diabetes
Page points
1. Regular and ongoing support
from health professionals to
implement diet and lifestyle
change is important if study
results are to be replicated in
the “real world”.
1. A low carbohydrate diet is
clinically inappropriate for
certain groups of people.
Anyone wanting to follow a
low carbohydrate diet should
be properly assessed for
suitability by their diabetes
team, including an accredited
practising dietitian.
2. Hypoglycaemia may be an
immediate side effect of
low carbohydrate diets in
people with diabetes who are
using insulin or certain oral
hypoglycaemic agents.
4. For anyone contemplating a
reduction in their carbohydrate
intake, it is imperative that this
is done in conjunction with
input from their entire diabetes
team, and include a medication
review.
Table 2. Carbohydrate content of diet interventions (Ajala et al, 2013).
Dietary intervention
Low carbohydrate*
al (2017) found that carbohydrate intake among
low carbohydrate interventions increased from
an average prescription of 25% energy intake to
30% at 3–6 months and to 38% at one year with
further increases in studies lasting longer than
12 months.
Participants in the study conducted by Tay
et al (2014; 2015a) also received fortnightly
dietary counselling for the first 12 weeks and
then monthly thereafter. In addition, they
were supplied key foods from their dietary
intervention for the first 12 weeks and then either
key foods or an $50 food voucher on alternate
months thereafter. Furthermore, all participants
undertook free, supervised 60-minute exercise
classes three days per week for the duration of
the study.
The level of support provided to these
participants is a significant aspect of the
intervention, and it would be difficult to replicate
in the “real world”. It highlights the importance
and impact of regular and ongoing support from
health professionals to implement not just the
low carbohydrate diet, but any diet or lifestyle
change. The significant positive results achieved
by both the low and high carbohydrate arms
in this study further demonstrate that people
with diabetes should have access to ongoing
multidisciplinary care.
Are low carbohydrate diets appropriate
for everyone?
Low carbohydrate diets are simply one of many
dietary approaches that can be used to manage
diabetes. However, due to the restrictive nature
of this diet, there is a high risk of suboptimal
kilojoule (kJ) and nutrient intake if the diet is not
Average carbohydrate content
13–45%
20–60 g
Low glycaemic index 37–50%
Mediterranean diet 50%
High protein 40–45%
* Some studies listed as percentage of energy intake and other studies listed as total grams per day.
well planned (Calton, 2010; Gardner, 2010). This
makes the diet clinically inappropriate for certain
groups of people, such as:
l Somebody with an active or past history of
eating disorders/disordered eating.
l Somebody with active cancer.
l Somebody who is malnourished or in a state of
catabolism or renal failure.
l Anyone at risk of malnutrition, such as an
elderly person with type 2 diabetes.
l Children, due to the possible impact on growth.
People with diabetes who are keen to follow a low
carbohydrate diet should be properly assessed for
suitability by their diabetes team, including an
accredited practising dietitian.
Potential side effects and risks of a low
carbohydrate diet
Hypoglycaemia may be an immediate side
effect of low carbohydrate diets in people with
diabetes who are using insulin or certain oral
hypoglycaemic agents. For anyone contemplating
a reduction in their carbohydrate intake, it is
imperative that this is done in conjunction
with input from their entire diabetes team, and
include a medication review. Patients will need
to have their diabetes medications reduced or
ceased prior to changing their diet (Feinman et
al, 2008; Dyson, 2015; Feinman et al, 2015).
A low carbohydrate diet needs to be well
planned to ensure that it is nutritionally
adequate. Fibre is the main nutrient of concern
when considering the foods often significantly
reduced when adopting a low carbohydrate diet.
Studies looking at the nutrient intakes of popular
136 Diabetes & Primary Care Australia Vol 2 No 4 2017

Low carbohydrate diets for people with type 2 diabetes
diets, in particular the low carbohydrate/high
fat Atkins diet, have shown that it is often
deficient in a number of nutrients including
dietary fibre, vitamin C, folic acid, B-group
vitamins (thiamine, pantothenic acid and biotin),
vitamin E, potassium and calcium (Calton, 2010;
Gardner, 2010). Tay et al (2014; 2015a) showed
that a carefully planned low carbohydrate diet
can still meet the requirements for fibre, dairy
and micronutrients; however, it is known that
many popular low carbohydrate diets are not
as carefully planned and nutritionally balanced
(Calton, 2010; Gardner, 2010). Table 3 provides
an outline of a nutritionally balanced, low
carbohydrate diet.
Noakes and Windt (2016) have reported
that people may experience headache, fatigue
and muscle cramping during the initial stage
of implementing the low carbohydrate diet.
However, the symptoms are often transient and
subside when fat adaption occurs.
As there are no studies reported in the literature
extending beyond two years in duration, the longterm
risks and outcomes of a low carbohydrate
diet are not known (Dietitians Association of
Australia, 2016).
The state of Australia’s current diet
The latest National Nutrition Survey (NNS)
showed that Australians are currently consuming
about 45% of total energy from carbohydrate
(Australian Bureau of Statistics, 2015), which
is at the lower end of the guidelines for chronic
disease prevention. Alarmingly, the same survey
highlighted that 35% of total energy intake is
from discretionary foods such as cakes, muffins,
scones, desserts, cereal bars, sweet and savoury
biscuits and sweetened drinks – many of which are
significant sources of carbohydrate. Fewer than
7% of people are meeting the recommendations
for vegetables (Australian Bureau of Statistics,
2015). There is no reason to believe that people
with type 2 diabetes do not follow a similar
dietary pattern.
Given these statistics, it may be prudent to
encourage people with type 2 diabetes to reduce
their intake of discretionary foods and increase
their intake of vegetables before looking to
reduce the carbohydrate in their diet. Based on
average nutrient intake data recently obtained
from NNS, a daily reduction of approximately
70 g of carbohydrate can be achieved if people
>19 years of age were to reduce their intake of
discretionary foods to less than the recommended
600-kJ portion size (National Health and
Medical Research Council, 2013; Australian
Bureau of Statistics, 2015). Addressing the
overall quality of the diet, rather than focusing
on individual macronutrients may result in
greater health benefits than just improving blood
glucose levels.
Conclusion
Many dietary patterns have been shown to
effectively reduce weight, manage glycaemia and
reduce cardiovascular disease risk in people with
type 2 diabetes. A low carbohydrate diet is one
dietary option, and recent evidence indicates
that a well-planned low carbohydrate diet that is
also low in saturated fat/higher in unsaturated fat
may have some additional benefits for increasing
HDL-cholesterol and lowering triglycerides,
medication usage and glycaemic variability.
However, this dietary approach is not clinically or
socially appropriate for everyone. When choosing
a dietary approach to manage diabetes, it needs
Page points
1. A carefully planned low
carbohydrate diet can meet the
requirements for fibre, dairy
and micronutrients.
2. While Australians are currently
consuming about 45% of total
energy from carbohydrate,
35% of energy intake is
from discretionary foods.
Encouraging those with type 2
diabetes to reduce such foods
and to increase their intake of
vegetables may be prudent.
3. As well as reducing weight,
managing glycaemia and
reducing cardiovascular risk in
people with type 2 diabetes, a
well-planned low carbohydrate
diet that is low in saturated fat/
higher in unsaturated fat may
have some additional benefits.
Table 3. A balanced approach to low-carbohydrate eating (Tay et al, 2014; 2015).
This suggested meal plan provides approximately 70 g of carbohydrate.
Breakfast
Lunch
Dinner
Snacks
30 g high fibre, low glycaemic index cereal + 100 g reduced fat Greek yoghurt or milk
100 g baked salmon, 1–2 cups of salad vegetables, 40 g avocado, 1 tablespoon olive oil
with balsamic vinegar
150–200 g of lean red meat/chicken/fish + 100 g baked pumpkin + 100 g mixed lowstarch
vegetables (bok choy, broccoli, zucchini, etc) + 20 g parmesan cheese
40 g almonds + 200 g strawberries + 1 small coffee with reduced fat milk
Diabetes & Primary Care Australia Vol 2 No 4 2017 137

Low carbohydrate diets for people with type 2 diabetes
“Ongoing and intensive
multidisciplinary
support is crucial for
sustainable lifestyle
change, irrespective of
the dietary approach.”
to be decided on in conjunction with the person
with diabetes. It needs to be individualised and
suitable for them in terms of ease of adherence,
availability and affordability of foods, as well
as social and cultural acceptability. What is
clear from the evidence is that ongoing and
intensive multidisciplinary support is crucial for
sustainable lifestyle change, irrespective of the
dietary approach.
n
Feinman RD, Pogozelski WK, Astrup A et al (2015) Dietary
carbohydrate restriction as the first approach in diabetes
management: a critical review and evidence base. Nutrition
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Gardener CD, Soowon K, Bersamin A et al (2010) Micronutrient
quality of weight-loss diets that focus on macronutrients: results
from the A TO Z study. Am J Clin Nutr 92: 304–12
Hu T, Mills KT, Yao L, et al (2012) Effects of low-carbohydrate
diets versus low-fat diets on metabolic risk factors: a metaanalysis
of randomized controlled clinical trials. Am J Epidemiol
176: S44–54
Accurso A, Bernstein RK, Dahlqvist A et al (2008) Dietary
carbohydrate restriction in type 2 diabetes mellitus and
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(Lond) 5: 9
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Health - Australian Dietary Guidelines Summary. Available at:
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Ajala O, English P, Pinkney J (2013) Systematic review and metaanalysis
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type 2 diabetes. Am J Clin Nutr 97: 505–16
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recommendations to reduce chronic disease risk, Nutrient
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138 Diabetes & Primary Care Australia Vol 2 No 4 2017

CPD module
Psychological barriers to insulin use among
Australians with type 2 diabetes and
clinical strategies to reduce them
Elizabeth Holmes-Truscott and Jane Speight
Treatment intensification among adults with type 2 diabetes is commonly delayed beyond
the point at which clinical need is identified, particularly within primary care. Causes of
this delay are multifaceted. In addition to models of care to reduce systemic and healthcare
professional barriers to timely insulin prescription, strategies to reduce negative attitudes
towards insulin (known as “psychological insulin resistance”) among individuals with
type 2 diabetes are also needed. This module draws on recent evidence of the extent and
nature of the problem of psychological insulin resistance within Australia. The influence of
early clinical interactions and diabetes education on the development of illness perceptions
and medication beliefs among people with type 2 diabetes are discussed, as are strategies
to assist clinicians to identify and address concerns about insulin therapy.
Providing clinical management of
type 2 diabetes (T2D) within primary
care fosters continuity of care throughout
the person’s life with diabetes and within their
broader health and socioeconomic context.
Approximately half of adults with T2D in
Australian primary care have glucose levels
above recommended targets, suggesting that
treatment intensification may be required
(Swerissen et al, 2016). Insulin is an effective
yet complex treatment for T2D. Approximately
260 000 Australians with T2D (24% of the total)
currently use insulin therapy to manage their
diabetes, twice the number of Australians living
with type 1 diabetes (National Diabetes Services
Scheme, 2017).
Insulin therapy is often delayed beyond clinical
need within primary care (Shah et al, 2005;
Blak et al, 2012). The reasons for delayed insulin
initiation are multifaceted, with barriers reported
by both healthcare professionals and people with
T2D (Peyrot et al, 2005). To improve timely
treatment intensification, healthcare professionals
need be equipped with the knowledge and skills
to identify and address the psychological barriers
to insulin experienced by people with T2D.
Australian healthcare professionals report both
personal barriers (e.g. inadequate knowledge,
skills and confidence to initiate and titrate insulin
therapy) and systemic barriers (including time and
resource constraints) to insulin initiation (Furler
et al, 2011). Recent research has demonstrated
that insulin-specific training programs for health
professionals and multidisciplinary healthcare
team support can facilitate timely insulin
initiation within primary care (Dale et al, 2010;
Furler et al, 2017). Healthcare professionals
also report that people with T2D have negative
attitudes and emotional reactions to insulin
therapy that act as barriers to insulin initiation
(Peyrot et al, 2005; Phillips 2007). Indeed,
one-quarter of Australian adults with T2D for
whom insulin is clinically indicated are “not
at all willing” to commence insulin therapy if
recommended by their healthcare professional
(Holmes-Truscott et al, 2016a).
Citation: Holmes-Truscott E,
Speight J (2017) Psychological barriers
to insulin use among Australians
with type 2 diabetes and clinical
strategies to reduce them. Diabetes &
Primary Care Australia 2: 139–45
Learning objectives
After reading this article, the
participant should be able to:
1. Identify causes of psychological
insulin resistance.
2. Assess attitudes toward
insulin use among people
with type 2 diabetes.
3. Tailor conversations to
the individual’s concerns
and personal context,
acknowledging the benefits of
and barriers to insulin use.
Key words
– Attitudes
– Insulin therapy
– Psychological insulin resistance
– Type 2 diabetes
Authors
Elizabeth Holmes-Truscott,
Research Fellow, The Australian
Centre for Behavioural Research
in Diabetes, Diabetes Victoria,
School of Psychology, Deakin
University, Geelong, Vic;
Jane Speight, Foundation
Director, The Australian Centre
for Behavioural Research in
Diabetes, Diabetes Victoria; and
School of Psychology, Deakin
University, Geelong, Vic.
Diabetes & Primary Care Australia Vol 2 No 4 2017 139

CPD module – http://pcdsa.com.au/cpd
Page points
1. Psychological insulin resistance
is characterised by the negative
attitudes to, or beliefs about,
insulin therapy; it is not a
clinical diagnosis.
2. Attitudes towards insulin
change over time
3. Education may plan an
important role in the
development of illness
perceptions and, consequently,
medication beliefs and
receptiveness to treatment
progression.
4. Conversation is needed from
diagnosis about the progressive
nature of type 2 diabetes.
Psychological insulin resistance
Psychological insulin resistance (PIR) is
characterised by the negative attitudes to, or
beliefs about, insulin therapy held by people with
T2D that may lead to delayed insulin initiation,
intensification or omission of insulin therapy.
Adults with T2D who are unwilling to commence
insulin report significantly more negative insulin
appraisals than those who are receptive to initiation
(Holmes-Truscott et al, 2016a).
PIR is not a clinical diagnosis. Most people with
T2D facing the decision to use insulin will report
some concerns about treatment intensification,
and the presence of concerns about insulin
does not inevitably lead to refusal to use insulin
therapy. Furthermore, PIR is not static. Attitudes
toward insulin change over time (Hermanns
et al, 2010; Holmes-Truscott et al, 2017a) and,
with clinical support, those who initially refuse
insulin may go on to initiate treatment (Khan
et al, 2008). A minority of people with insulintreated
T2D, however, continue to report high
levels of negative insulin appraisals (Holmes‐
Truscott et al, 2015) and new barriers to optimal
insulin use may arise over time, e.g. in response
to changes in lifestyle or insulin regimen.
Beyond insulin initiation, PIR may impact on
self-care behaviours, such as insulin omission, and
willingness to intensify treatment (e.g. additional
injections per day). Thus, it is important to
consider the impact of negative attitudes toward,
and experiences of, insulin therapy at all stages
of clinical care, i.e. prior to and after insulin
initiation.
Concerns, or negative attitudes, about insulin
therapy typically surround:
l The necessity, effectiveness and side-effects of
insulin.
l Anxiety about injections and glucose
monitoring.
l Lack of practical skills and confidence in
undertaking injections.
l Fears about the progression of T2D.
l Impact upon identity, self-perceptions and
social consequences.
Religious, cultural and/or community norms
and values concerning health, the healthcare
system and medicines may also contribute to PIR
(e.g. Patel et al, 2012). The five most commonly
endorsed negative attitudes toward insulin among
Australian adults with T2D are given in Table 1
(Holmes-Truscott et al, 2014). The most salient
concerns about insulin, and their impact on
the decision to commence treatment, will differ
between individuals and needs to be assessed on
a case-by-case basis.
Early and ongoing care
Education received at the diagnosis of T2D and
reinforced thereafter may play an important
role in the development of illness perceptions
and, consequently, medication beliefs and
receptiveness to treatment progression. One of
the concerns most commonly reported by people
with T2D is the belief that, if insulin is needed,
it is because they have failed in terms of prior selfmanagement
efforts (see Table 1). This may be a
consequence of broader illness perceptions that
they themselves are to blame for their diagnosis
or their subsequent inability to maintain optimal
blood glucose levels (Browne et al, 2013).
Struggling to reach treatment goals can be
frustrating and promote feelings of failure and
self-blame. Such struggles can contribute to the
negative and emotional reactions when insulin
is recommended. In order to foster realistic
illness perceptions without recourse to selfblame,
proactive clinical conversation is needed
from diagnosis about the progressive nature
of T2D and the inevitable need for treatment
intensification over time (Meneghini et al, 2010).
Among people with non-insulin-treated T2D,
negative attitudes about insulin are positively
associated with concerns about current diabetes
medications, i.e. oral hypoglycaemic agents,
and diabetes-specific distress (Holmes-Truscott
et al, 2016b). Furthermore, both medication
beliefs and diabetes-specific distress have been
shown to be associated with medication-taking
behaviours (Aikens and Piette, 2009; Aikens,
2012). Proactively identifying and addressing
both thoughts and feelings from an early point in
the person’s journey with T2D is likely to improve
their current medication-taking behaviours, as
well as their receptiveness to further treatment
intensification. Open-ended questions can
be used to start a conversation and identify
140 Diabetes & Primary Care Australia Vol 2 No 4 2017

http://pcdsa.com.au/cpd – CPD module
Table 1. Top five negative attitudes towards insulin among Australians with non-insulin-treated
and insulin-treated type 2 diabetes (Holmes-Truscott et al, 2014).*
Rank
1
2
=3
Statement
Taking insulin means my
diabetes has become much
worse
Taking insulin makes life less
flexible
Taking insulin means I have
failed to manage my diabetes
with diet and tablets
Non-insulintreated
(n=499)
Rank
80% =1
Statement
Taking insulin means my
diabetes has become much
worse
Insulin-treated
(n=249)
51%
59% =1 Insulin causes weight gain 51%
58% 3
Taking insulin means I have
failed to manage my diabetes
with diet and tablets
39%
“Several questionnaire
tools to assess
attitudes towards
insulin therapy have
been developed. The
most widely used is
the Insulin Treatment
Appraisal Scale”
=3
Being on insulin causes
family and friends to be more
concerned about me
58% 4
Taking insulin increases the
risk of low blood glucose levels
(hypoglycaemia)
36%
5
I’m afraid of injecting myself
with a needle
48% =5
Being on insulin causes
family and friends to be more
concerned about me
34%
=5
Taking insulin makes me more
dependent on my doctor
34%
*Cited negative attitudes are selected statements from the Insulin Treatment Appraisal Scale (Snoek et al, 2007)
underlying concerns. For example: “What is the
most difficult part of living with diabetes for
you?”, “Tell me about your experiences using
your diabetes medication. How is it going?”
(Hendrieckx et al, 2016).
Identifying attitudes toward insulin
Several questionnaire tools to assess attitudes
towards insulin therapy have been developed
(and reviewed elsewhere; Holmes-Truscott et
al, 2017b). The most widely used is the Insulin
Treatment Appraisal Scale (ITAS; Snoek et al,
2007), which is suitable for use before and after
insulin initiation and has been validated for
use in Australia (English; Holmes-Truscott et
al, 2014). Neither the ITAS nor other existing
tools have been widely translated or culturally
validated to date. The ITAS, or a similar tool, can
be used clinically to tailor discussion of insulin
therapy to the individual’s concerns.
The use of any single questionnaire, however,
may limit discussion to the barriers included
in that specific measure. Furthermore, PIR
questionnaires do not quantify the strength of
the concern. For example, a preference to avoid
insulin injections and the associated pain is
endorsed by many, but a small minority may
be experiencing needle phobia. In addition,
PIR questionnaires do not qualify the concern
or negative attitude within the broader needs
and context of the individual with T2D. For
example, the perceived impact of the inflexibility
of insulin treatment may differ by life stage and
lifestyle. Indeed, adults with insulin-treated T2D
who are younger and employed report more
negative insulin appraisals (Holmes‐Truscott et
al, 2015), and greater insulin omission (O’Neil
et al, 2014; Browne et al, 2015), perhaps due to
the additional competing demands on their time.
We recommended that health professionals
ask open-ended questions to begin the
conversation, or to supplement the use of
validated questionnaires, in order to understand
the extent of an individual’s specific concerns,
misconceptions and expectations. Responses to
open-ended questions can be used to tailor
clinical discussion and intervention.
Insulin initiation: a clinical
conversation
Several commentaries on PIR and
recommendations to reduce negative attitudes
and guide the clinical conversation about insulin
therapy have been published (e.g. Polonsky and
Jackson, 2004; Meneghini et al, 2010). Most
recently, the National Diabetes Services Scheme
Diabetes & Primary Care Australia Vol 2 No 4 2017 141

CPD module – http://pcdsa.com.au/cpd
Page points
1. A balanced understanding of
insulin is needed to facilitate
informed decision making and
foster realistic expectations
about treatment.
2. Rather than focusing only
on the individual’s concerns
about insulin, begin with
discussing the advantages and
disadvantages of the current
treatment.
3. Targeted use of glucose
self-monitoring can improve
a person’s understanding of
hyperglycaemia.
published Diabetes and Emotional Health, an
evidence-based, clinically-informed, practical
handbook to support healthcare professionals in
meeting the emotional and mental health needs
of adults living with diabetes (Hendrieckx et al,
2016). A chapter is dedicated to psychological
barriers to insulin therapy, including a step-wise
practical approach to assessing and addressing this
within clinical care. A free copy of this handbook
can be accessed online (www.ndss.com.au),
alongside tools to support clinical care, including
the ITAS questionnaire and a brief factsheet
focused on psychological barriers to insulin to
give to the person with T2D.
Some techniques to identify negative insulin
appraisals and support the person with T2D
in the decision to initiate insulin therapy are
described below. Note that, while informed by
research and clinical experience, the effectiveness
of the proposed techniques in the specific context
of reducing PIR and increasing insulin uptake
is largely unknown. Indeed, few interventions
have been designed specifically to improve
attitudes toward insulin and none has been tested
empirically.
A balanced approach to information
provision
People with T2D who do not fill their first insulin
prescription are significantly more likely to report
misconceptions about insulin therapy and that
the risks and benefits of insulin therapy were not
well explained to them (Karter et al, 2010). To
facilitate informed decision making and foster
realistic expectations about treatment, a balanced
understanding of insulin therapy is needed,
highlighting potential benefits and disadvantages
of the treatment (both physical and psychological).
A “decisional balancing” approach can be used to
identify the individual’s beliefs and concerns,
and guide discussion of their treatment options.
In using this approach, the clinician invites the
person with T2D to list their top three perceived
disadvantages and advantages of continuing with
their current treatment and then to do the same
about initiating insulin therapy. Their responses
can be used as the basis for a conversation, to
guide further information provision and potential
strategies to overcome concerns.
Rather than starting with their concerns about
insulin, begin with the advantages of their current
treatment and then move onto the disadvantages.
The next step is to explore how insulin might
overcome these disadvantages, thereby eliciting
the advantages of insulin. Then, the disadvantages
of using insulin can be explored by asking
the person which disadvantage would be the
easiest for them to overcome. It is important to
appreciate that the “pros” and “cons” may differ
in their importance to the individual.
The “decisional balancing” approach is described
in full elsewhere (Hendrieckx et al, 2016).
Engagement with idea of type 2 diabetes as a
progressive condition
As shown in Table 2, most people with T2D
report a basic understanding of the benefits
of long-term insulin therapy (Holmes-
Truscott et al, 2014). However, knowledge
and personal salience are two different things.
Experience of hyperglycaemia (and diabetesrelated
complications) is a facilitator of insulin
receptiveness (Phillips, 2007; Jenkins et al, 2010).
While clinicians should definitely not wait for
complications to develop to convince the person
with T2D of the need to use insulin, targeted use
of glucose self-monitoring can improve a person’s
understanding of and appreciation that they
are experiencing persistent hyperglycaemia. The
Australian government has recently restricted
the use of glucose strips among people with noninsulin-treated
T2D, which may lead healthcare
professionals to believe that glucose monitoring is
unwarranted in this group (Speight et al, 2015).
Brief intervention with “structured” glucose
monitoring, however, provides an opportunity
for “experiential learning” and “discovery”.
Randomised trials have shown “structured”
monitoring to increase insulin uptake and reduce
HbA 1c
compared to usual glucose monitoring
(Polonsky et al, 2011).
The practical use of this approach has been
discussed elsewhere (Furler et al, 2016).
An insulin trial
Insulin uptake may be an effective intervention
to reduce PIR in and of itself. People with
T2D commonly, but not exclusively, report
142 Diabetes & Primary Care Australia Vol 2 No 4 2017

http://pcdsa.com.au/cpd – CPD module
Table 2. Perceived benefits of insulin use among Australians with non-insulin-treated and
insulin-treated type 2 diabetes (Holmes-Truscott et al, 2014).*
Statement
relief after injecting insulin for the first time
and longitudinal research suggests that negative
attitudes toward insulin reduce following insulin
initiation (Khan et al, 2008; Hermanns et al,
2010; Holmes-Truscott et al, 2017a). Thus, as
suggested by Polonsky and Jackson (2004), one
way to improve attitudes towards insulin therapy
may be an “insulin trial”. This involves the
individual trying an injection in the safety of the
clinic or using insulin at home for a predefined
short period of time. This approach is clearly
limited, however, by the fact that the person with
T2D must be willing to trial/use insulin therapy.
Conclusion
The phenomenon of PIR has been investigated
globally and, recently, in the Australian context
(Holmes-Truscott et al, 2014; 2015; 2016a;
2016b; 2017a). Many strategies have been
proposed to assist healthcare professionals in
identifying and addressing barriers to insulin
use among people with T2D and promote
timely insulin uptake. The National Diabetes
Services Scheme Diabetes and Emotional Health
handbook includes a chapter about identifying
and addressing psychological barriers to insulin
in clinical practice (Hendrieckx et al, 2016). A
key research gap is the need to empirically test
the effectiveness of these strategies for reducing
PIR and improving timely insulin uptake.
In addition to assessing and addressing PIR
at the time of insulin initiation, assessment of
concerns about diabetes and its treatment need to
be addressed throughout the progression of T2D
and may help improve receptiveness to future
treatment intensification, optimal medicationtaking
behaviours and adjustment to T2D. n
Non-insulin-treated
(n=499)
Insulin-treated
(n=249)
Taking insulin helps to prevent complications of diabetes 76% 77%
Taking insulin helps to improve my health 68% 76%
Taking insulin helps to maintain good control of my blood glucose 75% 79%
Taking insulin helps to improve my energy levels 31% 31%
*Cited benefits are selected statements from the Insulin Treatment Appraisal Scale (Snoek et al, 2007)
Acknowledgements
EHT is supported, in part, by funding from
Diabetes Australia for the National Diabetes
Services Scheme Starting Insulin in T2D
National Priority Area. JS is supported by The
Australian Centre for Behavioural Research
in Diabetes core funding provided by the
collaboration between Diabetes Victoria and
Deakin University.
Aikens JE (2012) Prospective associations between emotional
distress and poor outcomes in type 2 diabetes. Diabetes Care
35: 2472–8
Aikens JE, Piette JD (2009) Diabetic patients’ medication underuse,
illness outcomes, and beliefs about antihyperglycemic and
antihypertensive treatments. Diabetes Care 32: 19–24
Blak BT, Smith HT, Hards M et al (2012) A retrospective database
study of insulin initiation in patients with type 2 diabetes in UK
primary care. Diabet Med 29: e191–8
Browne JL, Ventura A, Mosely K, Speight J (2013) ‘I call it the
blame and shame disease’: a qualitative study about perceptions
of social stigma surrounding type 2 diabetes. BMJ Open 3:
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Browne JL, Nefs G, Pouwer F, Speight J (2015) Depression, anxiety
and self-care behaviours of young adults with type 2 diabetes:
results from the International Diabetes Management and Impact
for Long-term Empowerment and Success (MILES) Study. Diabet
Med 32: 133–40
Dale J, Martin S, Gadsby R (2010) Insulin initiation in primary care
for patients with type 2 diabetes: 3-year follow-up study. Prim
Care Diabetes 4: 85–9
Furler J, Browne JL, Speight J (2016) Blood glucose: to monitor
or not in type 2 diabetes? The practical implications of the
Choosing Wisely recommendation. Diabetes & Primary Care
Australia 1: 55–8
Furler J, Spitzer O, Young D, Best J (2011) Insulin in general
practice: Barriers and enablers for timely initiation. Aust Fam
Physician 40: 617–21
Furler J, O’Neal D, Speight J et al (2017) Supporting insulin
initiation in type 2 diabetes in primary care: results of the
Stepping Up pragmatic cluster randomised controlled clinical
trial. BMJ 356: j783
Hendrieckx C, Halliday JA, Beeney LJ, Speight J (2016) Diabetes
and Emotional Health: a Handbook for Health Professionals
Supporting Adults with Type 1 or Type 2 Diabetes.
National Diabetes Services Scheme, Canberra. Available at:
www.ndss.com.au (accessed 20.09.17)
“In addition
to assessing
and addressing
psychological insulin
resistance at the
time of insulin
initiation, assessment
of concerns about
diabetes and its
treatment need to be
addressed throughout
the progression of
type 2 diabetes.”
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CPD module – http://pcdsa.com.au/cpd
Hermanns N, Mahr M, Kulzer B et al (2010) Barriers
towards insulin therapy in type 2 diabetic patients:
results of an observational longitudinal study. Health
Qual Life Outcomes 8: 113
Holmes-Truscott E, Pouwer F, Speight J (2014) Further
investigation of the psychometric properties of the
insulin treatment appraisal scale among insulin-using
and non-insulin-using adults with type 2 diabetes:
results from diabetes MILES – Australia. Health Qual
Life Outcomes 12: 87
Holmes-Truscott E, Skinner TC, Pouwer F, Speight J (2015)
Negative appraisals of insulin therapy are common
among adults with type 2 diabetes using insulin: results
from Diabetes MILES –Australia cross-sectional survey.
Diabet Med 32: 1297–303
Holmes-Truscott E, Blackberry I, O’Neal DN et al (2016a)
Willingness to initiate insulin among adults with type 2
diabetes in Australian primary care: results from the
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126–35
Holmes-Truscott E, Skinner TC, Pouwer F, Speight J
(2016b) Explaining psychological insulin resistance
in adults with non-insulin-treated type 2 diabetes:
the roles of diabetes distress and current medication
concerns. Results from Diabetes MILES –Australia.
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Predictors of insulin uptake among adults with type 2
diabetes in the Stepping Up Study. Diabetes Res Clin
Pract (in press) doi:10.1016/j.diabres.2017.01.002
Holmes-Truscott E, Pouwer F, Speight J (2017b) Assessing
psychological insulin resistance in type 2 diabetes: a
critical comparison of measures. Curr Diab Rep 17: 46
Jenkins N, Hallowell N, Farmer AJ et al (2010) Initiating
insulin as part of the Treating to Target in Type 2
diabetes (4-T) Trial: an interview study of patients’ and
health professionals’ experiences. Diabetes Care 33:
2178–80
Karter AJ, Subramanian U, Saha C et al (2010) Barriers to
insulin initiation. Diabetes Care 33: 733–5
Khan H, Lasker SS, Chowdhury TA (2008) Prevalence
and reasons for insulin refusal in Bangladeshi patients
with poorly controlled type 2 diabetes in East London.
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Meneghini L, Artola S, Caputo S et al (2010) Practical
guidance to insulin management. Prim Care Diabetes
4: S43–S56
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Snapshot – Insulin Therapy (March 2017). Available at:
www.ndss.com.au/data-snapshots (accessed: 20.09.17)
O’Neil A, Williams ED, Browne JL et al (2014)
Associations between economic hardship and markers
of self-management in adults with type 2 diabetes:
results from Diabetes MILES – Australia. Aust N Z J
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and management in people with type 2 diabetes in an
ethnically diverse population: the healthcare provider
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DAWN Advisory Panel (2005) Resistance to insulin
therapy among patients and providers: results of the
cross-national Diabetes Attitudes, Wishes, and Needs
(DAWN) study. Diabetes Care 28: 2673–9
Phillips A (2007) Starting patients on insulin therapy:
diabetes nurse specialist views. Nurs Stand 21: 35–40
Polonsky WH, Jackson RA (2004) What’s so tough
about taking insulin? Addressing the problem of
psychological insulin resistance in type 2 diabetes.
Clinical Diabetes 22: 147–50
Polonsky WH, Fisher L, Schikman CH et al (2011)
Structured self-monitoring of blood glucose significantly
reduces A1C levels in poorly controlled, noninsulintreated
type 2 diabetes results from the Structured
Testing Program study. Diabetes Care 34: 262–7
Shah BJ, Hux JE, Laupacis A et al (2005) Clinical inertia
in response to inadequate glycemic control. Diabetes
Care 28: 600–6
Snoek FJ, Skovlund SE, Pouwer F (2007) Development
and validation of the insulin treatment appraisal scale
(ITAS) in patients with type 2 diabetes. Health Quality
Life Outcomes 5: 69
Speight J, Browne JL, Furler J (2015) Testing times!
Choosing Wisely when it comes to monitoring type 2
diabetes. Med J Aust 203: 354–6
Swerissen H, Duckett S, Wright J (2016) Chronic Failure in
Primary Care. Grattan Institute, Melbourne
Online CPD activity
Visit www.pcdsa.com.au/cpd to record your answers and gain a certificate of participation
Participants should read the preceding article before answering the multiple choice questions below. There is ONE correct answer to each question.
After submitting your answers online, you will be immediately notified of your score. A pass mark of 70% is required to obtain a certificate of
successful participation; however, it is possible to take the test a maximum of three times. A short explanation of the correct answer is provided.
Before accessing your certificate, you will be given the opportunity to evaluate the activity and reflect on the module, stating how you will use what
you have learnt in practice. The CPD centre keeps a record of your CPD activities and provides the option to add items to an action plan, which will
help you to collate evidence for your annual appraisal.
1. What proportion of Australians with type 2
diabetes (T2D), who would clinically
benefit from insulin initiation, report being
“not at all willing” to commence insulin
therapy?
Select ONE option only.
A. 1 in 10
B. 1 in 5
C. 1 in 4
D. 1 in 2
E. 2 in 3
2. Approximately how many Australians with
T2D are currently using insulin therapy to
manage their diabetes?
Select ONE option only.
A. 540 000
B. 260 000
C. 118 000
D. 37 400
E. 26 000
3. Which of the following statements about
psychological insulin resistance (PIR) is
FALSE? Select ONE option only.
A. PIR is characterised by the negative
attitudes to, or beliefs about, insulin
therapy.
B. PIR inevitably leads to refusal of insulin
therapy.
C. Attitudes to insulin therapy are
amenable to change.
D. PIR may lead to delayed insulin
initiation, intensification or omission of
insulin therapy.
E. PIR is a not a clinical diagnosis.
4. When do negative attitudes to, or beliefs
about, insulin develop?
Select ONE option only.
A. Before diabetes diagnosis.
B. Soon after diagnosis during initial
diabetes education.
C. At first clinical discussion of insulin
therapy.
D. After insulin initiation or change in
insulin dose regimen.
E. All of the above.
144 Diabetes & Primary Care Australia Vol 2 No 4 2017

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Online CPD activity
Visit www.pcdsa.com.au/cpd to record your answers and gain a certificate of participation
5. Which of the following statements
about existing questionnaires measuring
psychological insulin resistance is FALSE?
Select ONE option only.
A. They are widely translated and
culturally validated, allowing for broad
use in multicultural Australia.
B. They can be used to identify an
individual’s concerns and tailor the
clinical discussion accordingly.
C. Questionnaires do not qualify the
concern within the broader needs and
context of the individual with T2D.
D. Questionnaires do not quantify the
strength or salience of the concern to
the individual.
E. One questionnaire has been validated
for use among English-speaking
Australians with T2D.
6. Which of the following is the MOST
COMMON negative attitude or concern
about insulin reported by Australians with
non-insulin treated T2D?
Select ONE option only.
A. I’m afraid of injecting myself with a
needle.
B. Taking insulin means I have failed to
manage my diabetes with diet and
tablets.
C. Taking insulin increases the risk of low
blood glucose levels.
D. Insulin cases weight gain.
E. Injecting insulin is embarrassing.
7. A clinical conversation about commencing
insulin therapy should NOT (select ONE
option only):
A. Include discussion of the risks and sideeffects
of insulin therapy.
B. Focus on the benefits of insulin use and
downplay the risks or side-effects.
C. Involve open-ended questions to
identify an individual’s concerns,
misconceptions and expectations about
insulin.
D. Involve the use of a validated
questionnaire.
E. None of the above.
8. Some people with T2D who use insulin
therapy report (select ONE option only):
A. Feeling relief after injecting for the first
time.
B. Taking insulin helps to improve or
maintain their blood glucose levels.
C. That being on insulin causes family and
friends to be more concerned about
them.
D. That taking insulin makes them feel
like they have failed to manage their
diabetes.
E. All of the above.
9. Which of the following statements is
FALSE? Select ONE option only.
A. 76% of people with non-insulin-treated
T2D agree than insulin helps to prevent
complications of diabetes.
B. Adults with insulin-treated T2D who
are younger and employed report more
negative insulin appraisals.
C. 48% of people with non-insulin-treated
T2D have needle phobia.
D. Negative attitudes about insulin are
positively associated with concerns
about oral diabetes medications.
E. 77% of people with insulin-treated
T2D agree than insulin helps to prevent
complications of diabetes.
10. Which of the following is NOT a suitable
technique to increase timely insulin
initiation in primary care?
Select ONE option only.
A. Use the clinical conversation as
an opportunity to foster realistic
expectations about diabetes and
treatment progression.
B. Organise additional insulin-specific
training for yourself and your health
professional colleagues.
C. Encourage structured, meaningful,
blood glucose monitoring to help the
person with diabetes to recognise outof-target
blood glucose and the need
for insulin.
D. Propose an insulin trial involving an
insulin injection in the safety of the
clinic, or using insulin for a predefined
short period of time.
E. Avoid discussing insulin therapy until
absolutely necessary to avoid upsetting
the person with diabetes.
Diabetes & Primary Care Australia Vol 2 No 4 2017 145

The PCDSA is a multidisciplinary society with the aim
of supporting primary health care professionals to deliver
high quality, clinically effective care in order to improve
the lives of people with diabetes.
The PCDSA will
Share best practice in delivering quality diabetes care.
Provide high-quality education tailored to health professional needs.
Promote and participate in high quality research in diabetes.
Disseminate up-to-date, evidence-based information to health
professionals.
Form partnerships and collaborate with other diabetes related,
high level professional organisations committed to the care of
people with diabetes.
Promote co-ordinated and timely interdisciplinary care.
Membership of the PCDSA is free and members get access to a quarterly
online journal and continuing professional development activities. Our first
annual conference will feature internationally and nationally regarded experts
in the field of diabetes.
To register, visit our website:
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Article
Insulin pump therapy – a new language
Traci Lonergan
The use of insulin pumps by people with diabetes, in particular type 1 diabetes, to deliver
their insulin is becoming more prevalent. This article will support primary care providers
to become more familiar with insulin pump basics, and learn the new language around
insulin pump therapy.
The treatment regimen following a
diagnosis of type 1 diabetes requires that
insulin be administered subcutaneously,
with the aim of achieving euglycaemia. In
people with type 2 diabetes, insulin therapy
may also be required when oral medication is
insufficient for individuals to reach or maintain
optimal blood glucose levels (BGLs). Insulin
has historically been delivered via subcutaneous
injection consisting of a basal insulin either
once or twice per day and a rapid-acting insulin
with three main meals. Insulin can also be
delivered into the subcutaneous adipose tissue
via continuous subcutaneous insulin infusion
(CSII), through insulin pumps.
Insulin pumps have been available for some
time and, with the advances in technology
and improving ease of use, there are more
people with type 1 diabetes of varying ages
using an insulin pump to deliver insulin. Up
to 10% of Australians with type 1 diabetes are
currently using insulin pumps, and this figure is
increasing (Xu et al, 2015).
In Australia, the National Diabetes Services
Scheme currently only provides a subsidy to
people with type 1 diabetes for the consumable
products required for insulin pump therapy,
such as reservoirs and infusion sets. People with
type 2 diabetes cannot access this subsidy and,
due to the prohibitive costs, there are very few
people with type 2 using insulin pump therapy.
Multiple daily injections
Type 1 diabetes is a life-long and potentially
life-threatening condition that requires constant
management. The care of diabetes requires
adherence to a complex daily regimen that
balances nutritional intake with exercise and
insulin administration, traditionally given in
the form of multiple daily injections (MDI).
The dose of injected insulin often lacks
specificity and absorption can be unreliable due
to temperature or activity changes and using
different injection sites with different absorption
characteristics (Walsh and Roberts, 2012). A
depot of long-acting insulin is injected under
the skin either once or twice daily to cover the
body’s basal requirements. This basal insulin
is to be absorbed gradually over 24 hours and
there can be a variation in absorption by up
to 25% from one day to the next (Walsh and
Roberts, 2012).
The amount of lifestyle flexibility that can
be achieved with MDI is directly related
to the number of daily injections. This can
be inconvenient for some and, for younger
children, it can be inadvisable as MDI can
be difficult for the family to administer on a
daily basis. For the school-age child the midday
injection can be problematic as most schools
have policies where children are required to
receive their insulin in the school office. This
has children missing out on social time with
their friends as well as compounding the feeling
of appearing different (ISPAD, 2014). The result
is that children, and particularly adolescents,
will often omit this important dose of insulin,
resulting in sub-optimal glycaemic levels and
Citation: Lonergan T (2017) Insulin
pump therapy – a new language.
Diabetes & Primary Care Australia
2: 147–50
Article points
1. The advantages of insulin
pump therapy include
a more physiologically
precise delivery of insulin
and a greater likelihood of
achieving optimal glycaemic
levels without an increased
risk of hypoglycaemia.
2. As well as the evidence of
clinical advantages in the
use of insulin pump therapy,
improvements in quality of
life for the user and their
families has been recorded.
3. Insulin pump therapy is
challenging for the user, and
diabetes educators can assist
by setting realistic expectations.
It is not a suitable therapy for
everyone with type 1 diabetes.
Key words
– Injection
– Insulin
– Pump
– Type 1 diabetes
Authors
Traci Lonergan, Clinical Nurse
Specialist (Diabetes) at Launceston
General Hospital; Youth Program
Coordinator at Diabetes Tasmania,
Launceston, Tas.
Diabetes & Primary Care Australia Vol 2 No 4 2017 147

Insulin pump therapy – a new language
Page points
1. In contrast to multiple daily
injections (MDI), an insulin
pump can be programmed to
deliver basal insulin to mimic
the body’s circadian rhythm,
with the ability to change the
basal rate every 30 minutes
to match the changing
requirements for basal insulin.
2. The insulin absorption is more
consistent than MDI as only one
site is being used.
3. Continuous subcutaneous
insulin infusion via an insulin
pump is more precise, reducing
hypoglycaemia by as much as
four times when compared to
MDI.
increasing their risk for future long-term health
complications of diabetes (DCCT/EDIC Study
Research Group, 2016).
A regimen using long- and short-acting
insulins mixed together and given twice daily
has been used for younger children. The need
for fewer injections with this regimen is more
convenient, avoiding the need for administering
a lunchtime injection. However it does mean
that the effects of the different insulins are not
clearly defined. That is, if the child’s BGL is
high or low, it is difficult to determine with
any accuracy which insulin (the long- or shortacting)
was responsible.
Insulin pumps
An insulin pump is worn by the person and
delivers small doses of fast-acting analogue
insulin continuously via an infusion set which
has a small, soft cannula that is inserted just
under the skin. This infusion set is connected
to the pump via thin tubing through which
insulin travels, and is changed approximately
every two to three days. The pump is
programmed to deliver precise increments
of basal insulin throughout 24 hours, and
bolus insulin is given to cover meals and
correct high BGLs back to target. In contrast
to MDI, the pump can be programmed to
deliver basal insulin to mimic the body’s
circadian rhythm, with the ability to change
the basal rate every 30 minutes to match the
changing requirements for basal insulin. It
is common for up to five basal rates to be
entered into the pump settings (Walsh and
Roberts, 2012).
An insulin pump will deliver insulin in
increments as small as 0.025 units every
3 minutes, which enhances absorption, thereby
requiring less insulin administration overall
(Walsh and Roberts, 2012). The insulin
absorption is more consistent than MDI as only
one site is being used. Rapid-acting or “bolus”
insulin is injected up to three or more times
per day to cover meals and sometimes snacks.
As a result, CSII via an insulin pump is more
precise, reducing hypoglycaemia by as much as
four times when compared to MDI (Walsh and
Roberts, 2012).
Insulin pump therapy
Basal
Insulin is delivered over 24 hours in increments
as small as 0.025 units every 3 minutes. The
rates can be set to reflect the changing metabolic
requirements which affect BGLs throughout the
day and night. Basal insulin typically makes up
40–60% of total daily dose (TDD).
Bolus
Insulin is delivered rapidly as a meal bolus to
cover carbohydrate eaten or as a correction dose
in response to a high BGL.
Bolus calculator
This is insulin pump software that calculates
insulin doses using settings entered by the
individual to cover carbohydrates eaten and
correct BGLs back to their target. The bolus
calculator decreases the risk of insulin stacking
by tracking the amount of insulin still active
from the last bolus.
Insulin to carbohydrate ratio
This is the amount of carbohydrate in grams
that 1 unit of insulin will cover. Alternatively,
this can be set in exchanges, where an exchange
is equivalent to 15 grams of carbohydrate.
This setting is used to calculate a meal
bolus. An accurate insulin-to-carbohydrate
ratio will ensure that the BGL will return
to target within the time that the insulin is
active, which is approximately 4 hours after
a meal bolus is delivered. This is dependent
on the BGL being in target pre-meal, and
carbohydrate quantity in the meal being
accurately calculated.
Insulin sensitivity factor
This determines how much a BGL is expected to
drop after administering 1 unit of insulin. This
setting is used to calculate a correction bolus to
bring a high BGL back down to target.
Target range
An individualised BGL range can be set in the
bolus calculator and will be used to calculate
correction doses to keep the individual’s BGL
within this range.
148 Diabetes & Primary Care Australia Vol 2 No 4 2017

Insulin pump therapy – a new language
Active insulin time
This setting tells the pump how long a bolus
of rapid-acting insulin will actively lower BGL
after the bolus has been delivered. The insulin
action time of rapid-acting insulin is around
4.5 hours, although the active insulin time
setting in the pump can be set for a shorter
duration if required. This will allow the bolus
calculator to deliver another bolus once the
active insulin time that has been entered into
the pump settings has elapsed.
Insulin on board
The active insulin time is used by the bolus
calculator to calculate how much insulin is still
active in the body from the last bolus. This is the
amount of bolus insulin remaining from recent
meal and correction boluses that is still actively
lowering BGL within the active insulin time.
Insulin stacking
Once the first bolus of the day is given, insulin
stacking will occur when another bolus is given
within the time that the first bolus insulin dose
is active, causing them to overlap. The bolus
calculator in the pump will take into account
insulin still on board to suggest a dose which
will minimise the risk of insulin stacking and
the resulting hypoglycaemia.
Total daily dose (TDD)
This is the total amount of units of insulin a
person uses in a 24-hour period, including both
basal and bolus doses. The TDD is used to
calculate the basal rate, insulin-to-carbohydrate
ratio and insulin sensitivity factor.
Advanced features
Basal patterns
Several basal profiles or patterns can be saved for
use at different times when insulin requirements
vary, such as on school days versus weekend
days.
Temp basal
This feature allows the pump to deliver a
specified temporary reduction or increase in
basal rate for a set amount of time. It is
important to note that different pumps will
have different methods to set the temp basal,
so familiarity with the pump being used is
paramount when suggesting a change in basal
rate using the temp basal function.
Combination bolus
The user can specify how they want to deliver
a bolus. The whole bolus can be delivered over
a specified amount of time or the bolus can
be split with part of the bolus being delivered
immediately and part-delivered over time. The
user will specify the percentage split and time
to deliver. This is referred to as a combo bolus if
using an Animas pump, or a dual or square wave
bolus if using a Medtronic pump.
Advantages of insulin pump therapy
There are many advantages in using an insulin
pump. Due to the more physiologically precise
method of insulin delivery, it is easier to achieve
optimal glycaemic levels whilst retaining a
flexible lifestyle. The DCCT (Diabetes
Control and Complications Trial) showed that
a decrease in HbA 1c
was associated with an
increase in the risk of hypoglycaemia. Insulin
pump users, however, are more likely to have
a decrease in HbA 1c
without the increased risk
of hypoglycaemia (Coleman, 2008), a reduced
risk of diabetic ketoacidosis (DKA) and less
severe hypoglycaemia (Walsh and Roberts,
2012). Insulin absorption variability is reduced
from 25% with MDI to 3% on insulin pump
therapy due to the small increments of insulin
delivered, single site use and elimination of the
unpredictable absorption of long-acting insulins
(Walsh and Roberts, 2012).
Temporary basal rates can be used to
increase insulin delivery during illness
or decrease insulin delivery during or after
exercise to prevent hypoglycaemia. Temporary
basal rate adjustments can be made easily
and spontaneously. Using the insulin pump
bolus calculator, doses can be calculated to
match the carbohydrates eaten, and calculate
correction doses to bring down high BGLs
whilst minimising insulin stacking.
Use of CSII in paediatrics is useful, particularly
in children with fickle eating habits, common in
young children. While on injected insulin, the
Page points
1. There are many advantages in
using an insulin pump. Due to
the more physiologically precise
method of insulin delivery, it
is easier to achieve optimal
glycaemic levels whilst retaining
a flexible lifestyle.
2. Insulin pump users are more
likely to have a decrease in
HbA 1c
without the increased risk
of hypoglycaemia, reduction in
diabetic ketoacidosis and less
severe hypoglycaemia.
3. Insulin absorption variability
is reduced from 25% with
multiple daily injections to 3%
on insulin pump therapy due to
the small increments of insulin
delivered, single site use and
elimination of the unpredictable
absorption of long-acting
insulins.
Diabetes & Primary Care Australia Vol 2 No 4 2017 149

Insulin pump therapy – a new language
Page points
1. The need for regular selfblood
glucose monitoring is
paramount whilst on insulin
pump therapy and this must
be stressed to families and
children before continuous
subcutaneous insulin infusion
(CSII) is considered.
2. Healthcare providers must
also recognise that the primary
reason for the transition to CSII
for the person with diabetes
may not be optimisation of
blood glucose levels, but
improved lifestyle and quality of
life.
3. The increase in uptake of
insulin pumps to deliver insulin
has introduced a new language
for healthcare professionals to
become conversant with.
young person with diabetes is required to adhere
to a more rigid eating schedule dictated by the
insulin they have on board at any given time.
Conversely, a child on an insulin pump may eat
a greater variety of foods at whatever time and
in whatever quantities they please, matching
their boluses to the food, which eliminates a
stressor from the family dynamic.
As well as evidence of clinical advantages of
CSII, the improvements in quality of life for
insulin pump users and their families cannot
be denied. The person can sleep in without the
restriction of a regimen that can increase the
risk of hyperglycaemia or hypoglycaemia. They
can engage in activities more spontaneously and
still be able to adjust their insulin with shorter
notice than when on MDI, and without the
need to eat carbohydrates when they are not
hungry.
Injecting in public is no longer an issue and,
for children with diabetes, the lunchtime bolus
at school can either be administered by the
child if they are competent, or built into the
basal program for younger children (Walsh and
Roberts, 2012).
Implications for practice
Diabetes educators can assist families by
preparing them for the challenges of initial
insulin pump use and providing them with
realistic expectations. Initially, CSII requires
a process of re-education that can prove
challenging, especially the skill of accurate
carbohydrate counting if this has not already
become part of their diabetes management. The
need for regular self-blood glucose monitoring
is paramount whilst on insulin pump therapy,
and this must be stressed to families and
children before CSII is considered. Whilst the
clinical advantages are undeniably important,
healthcare providers must also recognise that
the primary reason for the transition to CSII
for the person with diabetes may not be
optimisation of BGLs, but improved lifestyle
and quality of life. This aspect is just as
important for a person with diabetes and
CSII should be accessible to all for whom it
is assessed as suitable therapy. Insulin pump
therapy is not for everyone, however, and a
discussion prior to considering CSII will assess
whether a person with diabetes has realistic
expectations and whether they possess the
level of commitment required to manage their
diabetes with CSII.
Conclusion
As the incidence of type 1 diabetes increases,
the likelihood of seeing clients in the
primary care setting who are using insulin
pumps increases. Whilst the management of
insulin pump therapy has been the domain
of diabetes educators, paediatricians and
endocrinologists, the need for specialist care
far outweighs the resources that are available
to service this growing demand. It is time to
become familiar with insulin pump basics
and learn the new language around insulin
pump therapy.
n
Coleman P (2008) Should I go on an insulin pump? Diabetes
Management Journal 22: 24
Diabetes Control and Complications Trial (DCCT)/Epidemiology
of Diabetes Interventions and Complications (EDIC) Study
Research Group (2016) Intensive diabetes treatment and
cardiovascular outcomes in type 1 diabetes: The DCCT/EDIC
Study 30-year follow-up. Diabetes Care 39: 686–93
ISPAD (International Society of Pediatric and Adolescent Diabetes)
(2014) ISPAD Clinical Practice Consensus Guidelines 2014.
ISPAD, Berlin, Germany. Available at: https://is.gd/XUdw7B
(accessed 20.08.17)
Walsh J, Roberts R (2012) Pumping Insulin: Everything You Need
for Success on an Insulin Pump (5 th edition). Torrey Pines Press,
San Diego, United States
Xu S, Alexander K, Bryant W et al (2015) Healthcare professional
requirements for the care of adult diabetes patients managed
with insulin pumps in Australia. Intern Med J 45: 86–93
150 Diabetes & Primary Care Australia Vol 2 No 4 2017

Article
Telehealth: making healthcare accessible for
people with diabetes living in remote areas
Natalie Wischer
For people with diabetes living in rural and remote areas, access to best practice care can be
challenging. Many people with diabetes need to travel long distances to seek care, and delays in
diagnosis and interventions are not uncommon, leading to poorer health outcomes. Telehealth,
which uses technology to remotely exchange data between a patient and their clinician, can
assist in bridging the divide of accessible healthcare for those living in rural and remote locations
across Australia. This article describes the benefits of telehealth consultations, and barriers and
enablers to implementation, as well as providing some practical information on what is needed
to initiate such a service. Telehealth can be a useful tool and, if it is well accepted by patients,
it could improve the care of people with diabetes living in rural and remote regions.
Living in rural areas is linked with reduced
access to healthcare and specialist services
which can increase the need to travel
long distances to seek care and result in an
increase in the time required to access health
care services. Such impacts add to the burden
on rural populations who statistically have lower
levels of income, education, transport and public
infrastructure (Australian Institute of Health
and Welfare, 2014).
Of note, rates of morbidity and mortality are all
significantly higher for those living in rural areas.
The prognosis for a person with diabetes living in
the country compared with their metropolitan
counterparts is significantly impacted.
With around 30% of Australia's population
living in regional and remote areas (Paul et al,
2016), there are certainly potential benefits in
the provision of telehealth in Australia’s rural
regions. Telehealth is defined as the “use of
telecommunication techniques for the purpose
of providing telemedicine, medical education,
and health education over a distance” (Australian
Government Department of Health, 2008).
The incidence of diabetes is not just higher
for people living in regional and remote areas
– the people in these areas have lower levels
of screening conducted, with 60% of rural
Australians not having regular HbA 1c
testing and,
of those above target, 77% failed to have followup
(Paul et al, 2016).
Technology can assist in bridging the divide of
accessible healthcare for those living in rural and
remote locations across Australia. Furthermore,
diabetes is a condition that lends itself well to
telehealth consultations, as a key component of
self-management is effective communication,
performed often and performed well, most of
which can be done via telehealth.
The benefits of telehealth consultations
Some of the benefits of telehealth in an Australian
setting include improved access to quality clinical
care and additional professional development
opportunities from specialists (Moffatt and Eley,
2010). Further benefits for the patient included
decreased time away from work, less travel,
reduced expense and higher levels of satisfaction
(Robinson et al, 2015).
Additional evidence of the benefits of telehealth
consultations are growing, with reported
improvements in adherence to recommendations
in areas of blood glucose level monitoring,
lifestyle changes and medication adherence
(Ciemins et al, 2011).
Clinicians also report the benefits of telehealth
to include more timely reviews, shared clinical
expertise, improved clinic attendance and clarity
on the specialists advice to the patient (Ciemins
et al, 2011).
Citation: Wischer N (2017)
Telehealth: making healthcare
accessible for people with diabetes
living in remote areas. Diabetes &
Primary Care Australia 2: 151–3
Article points
1. Around 30% of the
population live in regional
and remote areas.
2. Living in rural areas is linked
with reduced access to
health care and specialist
services, with lower levels
of screening conducted and
poor rates of follow up.
3. Benefits of telehealth in an
Australian setting includes
reduced expense, higher
levels of satisfaction for
patients, and improved access
to quality clinical care.
Key words
– Remote
– Rural
– Technology
– Telecommunication
– Telehealth
Author
Natalie Wisher, Executive
Director, Australia Diabetes
Online Services; CEO, National
Association of Diabetes Centres.
Diabetes & Primary Care Australia Vol 2 No 4 2017 151

Telehealth for diabetes
Page points
1. A significant challenge of
incorporating telehealth is the
technological capability.
2. There are a number of enablers
to implementing telehealth,
including working with existing
services that offer specialist
telehealth connections.
3. To gain the financial rewards
available for telehealth, it is
important that practice staff are
familiar with all the claimable
items numbers and set up
clinics in a way to maximise
clinical and financial benefits.
Barriers to telehealth
Further Australian research conducted in 2015
set out to improve access to specialist care using
technology. The project engaged rural general
practices and provided them with support to
connect patients via telehealth to specialist
services using bulk-billed video consultations.
The project also provided them with pathways for
upskilling staff in diabetes management. Whilst
benefits were noted, such as improved glycaemic
control for those above target HbA 1c
as well as
many cost and time benefits, some barriers were
also identified (Furler et al, 2017).
Of note, fee-for-service structures of the
Medicare rebate scheme in geographically eligible
areas do not fund the time needed to coordinate
and arrange consultations (Department of
Health and Ageing, 2011). Funding is available
for the general practitioner and endocrinologist
connection, but does not support credentialled
diabetes educator involvement in consultations.
It was suggested that innovative funding models
need to be developed to fully support multidisciplinary
care.
Technology capability was also noted as a
significant challenge. Issues included:
l Building IT infrastructure capability.
l Integration of telehealth consultations into
existing booking, billing and reporting
software.
l The capacity of the health professional team to
use and manage IT resources, and the training
that may be required.
l The availability of IT support for technical
difficulties.
l Uploading and sharing of blood glucose data
from the patient to the general practice and
again to the specialist.
Enablers
Experienced telehealth practitioners suggest that
problems can be avoided if some of the following
factors are considered (Furler et al, 2017):
l Administrative support.
l Face-to-face meetings between the specialist,
GP’s practice nurse and patients should be
scheduled regularly.
l Purpose-built telehealth medical units.
Further enablers include an understanding of
the community within the local context and
the establishment of trust and rapport. For this
reason, in-person consultations with new patients
are recommended to allow for the non-verbal
elements of communication and to build rapport.
To overcome some of these identified challenges,
practices may want to consider working with
existing services that offer specialist telehealth
connections. There is a growing choice of private
companies, such as myonlineclinic.com.au,
offering to install and manage the IT, training,
and set-up.
Other opportunities to work with established
telehealth specialist diabetes clinics can be sought
through various state and territory initiatives.
In Victoria, the Royal Flying Doctor
Service supports diabetes telehealth services
to eligible rural areas. Details are available at
https://is.gd/UGaLF5.
In Western Australia, Diabetes WA delivers a
telehealth services to those living with diabetes
in rural and remote regions connecting them
to specialists in Perth. Details are available at:
https://is.gd/jsFLDP.
Other models exist throughout Australia and,
whether private or publicly funded, utilising
existing expertise, resources and experience
can be of enormous value when launching a
telehealth service model.
Medicare Benefits Scheme
To gain the financial rewards available for
telehealth, it is important that practice staff are
familiar with all the claimable items numbers
and set up clinics in a way to maximise clinical
and financial benefits. Further details on
Medicare Benefits Scheme (MBS) item numbers
for telehealth can be found on the MBS website
at: https://is.gd/hnLT9b.
Getting it right from the start
Set-up costs can be as little as $70 for a camera
and $7 per month for Skype connection. The
type of technology used for consultations is
not restricted to expensive units, although
sophisticated cameras and screens with integrated
software can certainly improve the experience for
all concerned, allowing for better sound and
152 Diabetes & Primary Care Australia Vol 2 No 4 2017

Telehealth for diabetes
picture quality as well as fewer problems with
connectivity.
Also critical to the success of a telehealth service
model is the administration support required for
efficient scheduling and communication with
the specialist and patients, as well as to set up
the consultation and deal with any IT issues that
may arise.
Conclusion
Rural and regional communities will always
need extra care and support due to the social
and health inequalities that exist. Telehealth is
a platform that can offer significant benefits in
facilitating access to specialist care at the right
time, right place and at a potentially lower cost.
Telehealth is a useful tool that should be
considered by general practitioners for its
applicability not only for diabetes but other health
conditions. If it is well-accepted by patients, it
can be cost effective for practices and patients
and is likely to improve the care of people with
diabetes living in rural and remote regions. n
Further resources for telehealth
l The Royal Australian College of General
Practitioners, Telehealth: www.racgp.org.
au/telehealth
l Australian College of Rural & Remote
Medicine (ACRRM), Telehealth Provider
Directory: www.ehealth.acrrm.org.au/
provider-directory
l Australian College of Rural & Remote
Medicine, eHealth and telehealth: www.
acrrm.org.au/rural-and-remote-medicineresources/ehealth-and-telehealth
l Medicare Benefits Schedule Online,
Telehealth: Specialist video consultations
under Medicare: www.mbsonline.gov.au/
telehealth
“Telehealth is a
platform that can offer
significant benefits in
facilitating access to
specialist care at the
right time, right place
and at a potentially
lower cost.”
Australian Government Department of Health (2008) National
E-Health Strategy. Available at: https://is.gd/9L0MZ7 (accessed
14.08.17)
Australian Institute of Health and Welfare (2014) Australia’s
Health 2014. Understanding health and illness. Available at:
https://is.gd/GJBit8 (accessed 14.08.17)
Bergmann N, Gyntelberg F, Faber J (2014) The appraisal of chronic
stress and the development of the metabolic syndrome: a
systematic review of prospective cohort studies. Endocr
Connect 3: R55–80
Ciemins E, Coon P, Peck R et al (2011) Using telehealth to provide
diabetes care to patients in rural Montana: findings from the
promoting realistic individual self-management program.
Telemed J E Health 17: 596–602
Department of Health and Ageing (2011) Telehealth Business
Case, Advice and Options – Final Report. Available at:
https://is.gd/r6h48e (accessed 14.08.17)
Furler J, O'Neal D, Speight J et al (2017) Supporting insulin
initiation in type 2 diabetes in primary care: results of the
Stepping Up pragmatic cluster randomised controlled clinical
trial. BMJ 356: j783
Moffatt JJ, Eley DS (2010) The reported benefits of telehealth for
rural Australians. Aust Health Rev 34: 276–81
Paul CL, Piterman L, Shaw JE et al (2016) Patterns of type 2
diabetes monitoring in rural towns: How does frequency of
HbA1c and lipid testing compare with existing guidelines? Aust
J Rural Health 24: 371–7
Robinson, MD, Branham AR, Locklear A et al (2015) Measuring
satisfaction and usability of FaceTime for virtual visits in patients
with uncontrolled diabetes. Telemed J E Health Aug 21 [Epub
ahead of print]
Diabetes & Primary Care Australia Vol 2 No 4 2017 153

Meeting Report
American Diabetes Association 2017: a
primary care overview of scientific sessions
Mark Kennedy
Honorary Clinical Associate
Professor, University of Melbourne
and Chair, PCDS Australia
The American Diabetes Association (ADA)
77 th Annual Conference was held in San
Diego in June 2017. The highlight of the
scientific sessions was the release of the data from
the CANVAS (Canagliflozin Cardiovascular
Assessment Study) outcome study, which has
since been published (Neal et al, 2017). These
results are reviewed and interpreted in the broader
context of the sodium–glucose cotransporter 2
(SGLT2) inhibitor class here.
As always, there were many other sessions of
interest and relevance to primary care. A few
of the more interesting ones are also briefly
reviewed in this report.
CANVAS outcome study
The results of the CANVAS outcome study have
been eagerly anticipated since the publication of
the EMPA-REG OUTCOME (Empagliflozin
Cardiovascular Outcome Event Trial in
Type 2 Diabetes Mellitus Patients) trial data
almost 2 years ago. The EMPA-REG data showed
dramatic reductions in all-cause mortality and
cardiovascular (CV) mortality in patients with
type 2 diabetes at high CV risk who were treated
with empagliflozin (Zinman et al, 2015).
The CANVAS outcome study combined the
results of two outcome trials: CANVAS and
CANVAS-R (the renal endpoints trial). Although
they both had similar inclusion criteria, patient
populations and interventions, the trial durations
were different and there were differences in
the significance levels of some findings in the
different arms.
Cardiovascular benefits
The pooled data showed 14% lower rates in
the primary major adverse cardiac events
three-point outcome of CV death, non-fatal
myocardial infarction and non-fatal stroke in
the canagliflozin-treated patients compared to
placebo in patients with type 2 diabetes who
were known to have, or who were at high risk for,
CV disease (Neal et al, 2017). Despite showing a
trend towards a reduction in all-cause death, CV
death, myocardial infarction and stroke, none of
these showed statistical significance as individual
outcomes. The canagliflozin-treated patients also
had a 33% reduction in heart failure admissions
and a 27% reduction in the progression of
albuminuria compared to those in the placebo
arm.
During the average follow-up of 295.9 weeks
in CANVAS and 108.0 weeks in CANVAS-R,
the rate of the primary CV outcome per 1000
patient-years was 26.9 in the canagliflozin group
vs 31.5 in the placebo arm.
Amputations and fractures
Despite the CV benefits, the CANVAS outcomes
study also raised significant safety concerns.
There was a 97% increase in lower-limb
amputations and a 26% increase in fracture
rates. Individuals treated with canagliflozin had
an increased risk for amputation of toes, feet or
legs compared to placebo (6.3 vs 3.4 per 1000
patient-years, respectively; Neal et al, 2017). In
the pooled data, those treated with canagliflozin
had increased fractures, with rates of 15.4 vs
11.9 per 1000 patient-years in the canagliflozin
and placebo groups, respectively (Neal et al,
2017). Interestingly, this increase was statistically
significant in the longer CANVAS trial, but not
in the CANVAS-R trial.
Class effects
Since the EMPA-REG study, there has been
considerable debate about whether the CV
safety outcomes were too good to be true. The
CANVAS trials were, therefore, very important
in helping to establish whether the substantial
CV benefits would be replicated with other
agents in the same class.
CANVAS – along with the recently-presented
CVD-REAL (Comparative Effectiveness
of Cardiovascular Outcomes in New Users
154 Diabetes & Primary Care Australia Vol 2 No 4 2017

Meeting Report
of SGLT-2 Inhibitors) retrospective database
analysis (Kosiborod et al, 2017) – would
suggest that the CV benefits, reductions in
heart failure admissions and renal benefits seen
with empagliflozin are probably a class effect,
extending to canagliflozin and dapagliflozin.
CANVAS also expands the group of patients
likely to benefit from treatment with this class of
drugs because the patients in this study included
individuals at high risk for CV events rather than
just those who had established CV disease. This
would suggest that, as a class, SGLT2 inhibitors
do provide cardio-protection, at least for highrisk
patients.
The implications for clinical practice
I believe that we now have enough data from
EMPA-REG OUTCOMES, CANVAS and, to
a lesser extent, from CVD-REAL to consider
SGLT2 inhibitors as a class of medication with
additional benefits beyond glucose lowering for
people with type 2 diabetes and high CV risk.
For every 1000 patient-years of exposure in the
CANVAS study, treatment with canagliflozin
prevented 4.6 major adverse cardiac events at a
cost of 2.9 amputations and 3.5 fractures. The
increased amputations and fractures seen in
CANVAS, however, certainly adversely impact
the benefit-to-risk calculation for canagliflozin.
A history of amputation or peripheral artery
disease at baseline did not help to identify
those at higher risk for subsequent amputation,
making it difficult to recommend canagliflozin
be avoided just in specific higher-risk groups.
The fact that these problems have not been
identified with empagliflozin (Kohler et al, 2017)
makes it hard to imagine a situation where an
informed patient would choose canagliflozin as
his or her preferred SGLT2 inhibitor. Until we
see the CV safety study results for dapagliflozin
(the DECLARE-TIMI 58 trial [Multicenter
Trial to Evaluate the Effect of Dapagliflozin
on the Incidence of Cardiovascular Events],
which should be complete in late 2018 or early
2019) to establish the presence or absence of any
associated amputation or fracture risk with that
agent, it would seem that empagliflozin is the
safest option for providing this CV benefit to
high-risk patients without serious adverse risk.
SGLT2 inhibitors and CV outcomes: the
CVD-REAL study
The results of another study looking at SGLT2
inhibitors and CV outcomes (Kosiborod et al,
2017) were also presented at the ADA conference.
In this study, real-world data were collected from
databases in the UK, US, Norway, Denmark,
Sweden and Germany. CVD-REAL compared
the risk of hospitalisation, heart failure and/or
death in adults with type 2 diabetes who were
new users of SGLT2 inhibitors with those new to
other diabetes medications.
There were more than 150 000 patients in the
SGLT2 group and a matching number in the
control group of CVD-REAL. In the SGLT2
inhibitor group, 53% were using canagliflozin,
42% were using dapagliflozin and 5% were using
empagliflozin.
The data collected did vary a little between
databases. The follow-up period, however,
equated to in excess of 190 000 person-years of
treatment. Those using SGLT2 inhibitors had
39% lower rates of hospitalisation for heart
failure, a 51% reduction in death and 46% lower
rates of hospitalisation or death. There did not
appear to be significant heterogeneity in these
results between countries.
Implications of the results
Although this is not a randomised-controlled
study, the results do provide additional support
for SGLT2 inhibitors having a class effect when
it comes to CV outcome benefits. Interestingly, a
large proportion of the patients in this study were
at much lower CV risk than the patients in the
EMPA-REG OUTCOMES or CANVAS trials,
providing some hope that these benefits may
eventually extend to primary prevention as well
as secondary reduction of CV events.
Metabolic abnormalities in adolescence
linked to gestational diabetes
It is now well-known that increased diabetes risk
can begin early in life through a combination of
genetic, intrauterine and postnatal environmental
exposure. The intrauterine environment seems
to be particularly important to the early
development of type 2 diabetes.
EPOCH (Exploring Perinatal Outcomes in
“I believe we now
have enough data
to consider SGLT2
inhibitors as a class
of medication with
additional benefits
beyond glucose
lowering for people
with type 2 diabetes
and high cardiovascular
risk.”
Diabetes & Primary Care Australia Vol 2 No 4 2017 155

Meeting Report
“It may be possible
to reverse the
adverse metabolic
consequences of
childhood obesity.”
Children) has been following 437 children in
a historical prospective study for more than
15 years (Sauder et al, 2017). The authors
reported that intrauterine exposure to gestational
diabetes or obesity was associated with greater
insulin resistance in adolescence than in those
without such exposure. This finding adds further
support to the hypothesis that fetal overnutrition
results in metabolic abnormalities in childhood
and adolescence.
The study is ongoing and it is possible
that a clearer effect of diabetes exposure may
emerge as the cohort grows into adulthood.
In the meantime, as we know that early-onset
type 2 diabetes is associated with accelerated
development of complications and greater
morbidity and mortality than later-onset type 2
diabetes (Constantino et al, 2013), it would seem
appropriate for those managing children
and adolescents who were subjected to such
intrauterine exposure to keep in mind these risks
and monitor individuals as appropriate.
Teens who lose excess weight reduce
their risk of developing type 2 diabetes
A registry-based study by Bjerregaard et al (2017)
examined the effect of weight loss in young
adulthood in men who had been obese or
overweight in childhood. The records of more
than 60 000 men in Denmark who had weight
measurements taken at 7 years and then again
between 17 and 26 years of age were studied.
In this study, 5.4% of the men had been
overweight in childhood and 8.2% in young
adulthood. Those who were overweight
as children had an increased risk of having
type 2 diabetes at age 30, and those who were
overweight in young adulthood had an almost
three-fold higher risk of type 2 diabetes (hazard
ratio, 2.96) when compared to those who were
not overweight.
When the investigators looked at the 60% of
boys who were overweight at age 7 years but
who subsequently lost their excess weight in
adolescence, they found that the risk of type 2
diabetes at age 30 was no higher than in those
who had never been overweight. The risk of
type 2 diabetes at age 30 was almost three times
higher, however, for those who were overweight
at both measurement times or for those who
became overweight in young adulthood when
compared to those who had managed to lose
weight during adolescence.
The possibility of reversing metabolic
consequences of childhood obesity
While this is a registry-based study rather than
a prospective controlled trial, it does raise hope
that it may be possible to reverse the adverse
metabolic consequences of childhood obesity.
The results also provide support for the notion
that efforts to normalise weight in children
who are overweight are useful and should be
encouraged.
Treating major depression in type 2
diabetes with exercise or with cognitive
behavioural therapy
The Program ACTIVE II randomised-controlled
trial (de Groot et al, 2017) compared the use
of cognitive behavioural therapy (CBT) and
exercise in people with type 2 diabetes and major
depression on blood glucose levels and on their
depressive symptoms. The 140 subjects were
randomised into one of four arms:
l CBT: 10 individual sessions.
l Exercise: 12 weeks if a community-based
program and six classes run by a personal
trainer.
l CBT and exercise.
l Usual care.
All interventions led to significantly increased
rates of full remission of depression when
compared to usual care. The likelihood of full
remission was increased by 5.0 times in the
CBT group, 6.8 times in the exercise group and
5.9 times in the CBT plus exercise group.
When considering a combined endpoint of
full or partial remission of depression, only CBT
or exercise showed significant benefit, with the
rates of full or partial remission of depression
being 12.4 higher with CBT and 5.8 higher
with exercise. The CBT plus exercise arm did not
have any significant benefit over usual care. The
exercise arm also showed a reduction in HbA 1c
of
7.7 mmol/mol (0.7%) when compared to usual
care or CBT in those with a starting base-line
156 Diabetes & Primary Care Australia Vol 2 No 4 2017

Meeting Report
HbA 1c
of greater than 53 mmol/mol (>7.0%).
This study is ongoing and further follow-ups at
6 and 12 months are planned.
Although this is only a small study, the results
provide hope that exercise has additional benefits
for people with type 2 diabetes and depression,
not just in optimising individuals’ glycaemic
levels but also on the remission of full or partial
depression.
Nasal glucagon for hypoglycaemic
episodes in type 1 diabetes
An abstract presented at the ADA conference
showed that a glucagon nasal spray was effective
and efficient in managing moderate or severe
hypoglycaemic episodes in adults with type 1
diabetes. The spray was effective in more than
96% of participants using it for symptomatic
hypoglycaemia, with blood glucose levels
returning to normal within 30 minutes. The
nasal glucagon was associated with similar sideeffects
to injected glucagon, such as nausea and
vomiting, but was also associated with some
transient headache and nasal irritation.
A possible alternative to injectable glucagon
This new delivery form for glucagon may be a
useful alternative to injectable glucagon. If similar
results are found when it is tested in children and
adolescents, nasal glucagon may prove to be a
popular alternative for those who would prefer to
avoid giving or receiving an injection. It should be
noted that these data are yet to be published in a
peer-reviewed journal.
n
Bjerregaard LG, Jensen BW, Ängquist L et al (2017) Are adverse
effects of child overweight on risk of type 2 diabetes reversible
by remission to normal weight in young adulthood? American
Diabetes Association 77 th Scientific Sessions (abstract 11-OR).
San Diego, California, 9–13 June 2017
Constantino MI, Molyneaux L, Limacher-Gisler F et al (2013)
Long-term complications and mortality in young-onset diabetes:
type 2 diabetes is more hazardous and lethal than type 1
diabetes. Diabetes Care 36: 3863–9
de Groot MH, Guyton Hornsby WG, Pillay Y et al (2017) Program
ACTIVE II: a comparative effectiveness trial to treat major
depression in T2DM. American Diabetes Association 77 th
Scientific Sessions (abstract 376-OR). San Diego, California,
9–13 June 2017
Kohler S, Zeller C, Iliev H, Kaspers S (2017) Safety and tolerability
of empagliflozin in patients with type 2 diabetes: pooled
analysis of phase I–III clinical trials. Adv Ther 34: 1707–26
Kosiborod M, Cavender MA, Fu AZ et al; CVD-REAL Investigators
and Study Group (2017) Lower risk of heart failure and death in
patients initiated on sodium-glucose cotransporter-2 inhibitors
versus other glucose-lowering drugs: the CVD-REAL Study
(comparative effectiveness of cardiovascular outcomes in new
users of sodium-glucose cotransporter-2 inhibitors). Circulation
136: 249–59
Neal B, Perkovic V, Mahaffey KW et al; CANVAS Program
Collaborative Group (2017) Canagliflozin and Cardiovascular
and Renal Events in Type 2 Diabetes. N Engl J Med 377: 644–57
Sauder KA, Hockett CW, Ringham BM et al (2017) Fetal
overnutrition and offspring insulin resistance and ß-cell
function: the Exploring Perinatal Outcomes among Children
(EPOCH) study. Diabet Med 34: 1392–99
Zinman BC, Wanner C, Lachin JM et al; EMPA-REG OUTCOME
Investigators (2015) Empagliflozin, Cardiovascular Outcomes,
and Mortality in Type 2 Diabetes. N Engl J Med 373: 2117–28
“Results provide hope
that exercise has
additional benefits
for people with
type 2 diabetes and
depression.”
Diabetes & Primary Care Australia Vol 2 No 4 2017 157

The PCDSA is a multidisciplinary society with the aim
of supporting primary health care professionals to deliver
high quality, clinically effective care in order to improve
the lives of people with diabetes.
The PCDSA will
Share best practice in delivering quality diabetes care.
Provide high-quality education tailored to health professional needs.
Promote and participate in high quality research in diabetes.
Disseminate up-to-date, evidence-based information to health
professionals.
Form partnerships and collaborate with other diabetes related,
high level professional organisations committed to the care of
people with diabetes.
Promote co-ordinated and timely interdisciplinary care.
Membership of the PCDSA is free and members get access to a quarterly
online journal and continuing professional development activities. Our first
annual conference will feature internationally and nationally regarded experts
in the field of diabetes.
To register, visit our website:
www.pcdsa.com.au