What lies beneath Reversing the onset of type 2 diabetes for people with severe mental illness

Queenslanders diagnosed with severe mental illness, such as schizophrenia, face a tenfold greater risk of premature death from chronic physical disorders than suicide. Yet physical health receives far less attention. To better detect and offset the increasing incidence of type 2 diabetes in this group, Queensland Health is stepping up screening, detection and management of co-morbid physical health conditions across the state’s adult mental health services. Queensland Health’s Donna Carmichael reports why this is important for all health professionals to be across.

An historical perspective The relationship between diabetes and mental health is not new. In the early 1920s, some doctors studied and published their case notes of increased numbers of patients with schizophrenia (then called Dementia Praecox) who developed type 2 diabetes when compared to general community rates. In the 1950s, with the advent of the first range of medicines, antipsychotics radically changed mental health treatment and provided far better outcomes for people with psychosis, including schizophrenia. A downside, however, was further adding to the risk of developing type 2 diabetes. Sometimes type 2 diabetes was noted with very rapid onset of starting antipsychotic medication, while others developed the condition years into treatment. . .. risk of mortality from chronic physical disorders (including diabetes) is 10 times higher than suicide ...

It is estimated that as many as 20 to 30 per cent of people with schizophrenia will develop type 2 diabetes or pre-diabetes during the course of their mental health treatment. The reason behind this is multi-faceted, taking into account risks associated with the mental illness itself, genetics, poor diet, physical inactivity, smoking, social health determinants (for example limited income, accommodation and food security), and possible side effects of medications, such as weight gain. What’s clear, as noted in the National Mental Health Commission’s 2012 report card on mental health and suicide prevention, is that the risk of co-morbid physical health conditions, including type 2 diabetes, can be reduced – if not prevented – via healthy lifestyle choices: improved nutrition, increased exercise, and reduced drug/ alcohol consumption and smoking. In 2012, the Commission described the poor physical health and early deaths of people in Australia’s mental health community as a national disgrace. It also highlighted a 10 to 32 year mortality gap between the general population and those with severe mental illness. Of note, the risk of mortality from chronic physical disorders, including diabetes, cardiovascular disease, cancer

and chronic lung disease, is 10 times higher than that of suicide, yet receives far less attention. In Queensland, a separate project entitled “activate: mind & body” that ran from 2008 to 2012, with the objective of improving the physical and oral health of people with severe mental illness, collected similar data over a two-year period. Associate Professor David Crompton, Executive Director of Metro South Addiction and Mental Health Services, said it was concerning that mortality in Queenslanders with severe mental illness was approximately two-and- a-half times higher than the general population and above published rates elsewhere in Australia. The data also indicated that people with severe mental illness were less likely to be provided with treatment and rehabilitation for physical health conditions. Here, Associate Professor Crompton said the association between schizophrenia and diabetes had been recognised for well over a century (see fact box, right). “Diabetes (type 2) remains prevalent among people with schizophrenia, but for many it is left undiagnosed,” Associate Professor Crompton said.

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“They are also more likely to have limited income, transport and support, so health and community services need to be more supportive, coordinated and perhaps more creative in how treatment is provided.” Over the next two years, Queensland’s public mental health services will implement local solutions to improve the routine screening, detection and management of physical health concerns in people with serious mental health illness, initially focusing on those diagnosed with schizophrenia. The MHCC will support local services by providing regular feedback on progress that includes state-wide benchmarking and hosting six-monthly forums to showcase local innovation, review best practice and support open discussion around progress and challenges. Welcoming the initiative, Trish Roderick, who heads up Diabetes Queensland’s health team, said placing physical health, including heightened awareness of diabetes, at the forefront of mental health services was a positive step. “Diabetes Queensland has been working with Metro South Addiction and Mental Health Services to ensure mental health professionals have the best information available to them to help improve the quality of life of people with severe mental illness,” Ms Roderick said. “We are also currently exploring the possibility of providing targeted information days for mental health consumers with diabetes and their carers.” For more, visit http://www. activatemindandbody.com.au/ or contact

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In response, Queensland Health mental health clinicians have recently elected to target the screening, detection and management of co-morbid physical health conditions, including diabetes, for people with severe mental illness across adult mental health services. As part of a state-wide rollout, the Mental Health Clinical Collaborative (MHCC) initiative will bring clinicians from services across the state together to work on improving the routine physical health assessment of people with an enduring psychotic illness. This will involve metabolic monitoring as the starting point for routine physical health assessment, screenings of weight, height, waist circumference, BMI, blood glucose levels and cholesterol levels every six months MHCC Chair Dr Brett Emmerson said the decision to target physical health as a priority issue was timely, reflecting clear evidence that identified disproportionately adverse health outcomes among people with a serious mental illness when compared to the general population. Dr Emmerson added that prevention measures for type 2 diabetes and steps to improve wider physical and oral health of people in our mental health community is a shared responsibility of public mental health services and other providers, such as general practitioners. “We need to better inform consumers and their carers of our services about the issues surrounding their physical and oral health so they can be more proactive in their health and recovery, and start intervention early,” he said. “People with severe mental illness already have to deal with a range of mental health and possibly cognitive difficulties associated with their illness – take for example, poor memory, attention and motivation.

Donna.Carmichael@health.qld.gov.au n Donna Carmichael works with Queensland Health as Service Integration Co-ordinator with Metro South Addiction and Mental Health Services.

Teresa’s story My name’s Teresa. I’m 44 and recently found out that I have type 2 diabetes. I remember feeling unwell at home and called an ambulance. I was taken to hospital and found to have a blood glucose level (BGL) reading of 21. I spent a week in hospital. When I was discharged, I went to see my doctor who told me I had type 2 diabetes. I don’t recall having ever been screened for diabetes before this. I also had no idea that I could be at risk of developing diabetes and knew very little about the condition. My father had type 2 diabetes but he died some years ago. I don’t remember how he was treated apart from being on a special diet.

My doctor prescribed Diabex, which I take reasonably regularly, although my concentration is not always great and sometimes I forget. A nurse showed me how to test my BGLs, which I do every second day and I also saw a dietitian for a couple of sessions. It’s been more than 15 years since I was diagnosed with schizophrenia. I was working at the meatworks in Oxley and started feeling unwell and not thinking straight. I was hospitalised for a short time. I have been taking Risperdal (Risperidone) tablets since I was diagnosed and visit a mental health service from time to time. I receive good support from my doctor and case manager. I’ve lost 17kg over the past couple of years. I now weigh 88kg. I need to lose more. I try to

walk regularly, but experience fatigue and I sleep more than most people I know. Exercise can be a challenge. I’d like to receive more support when it comes to my physical health to help me lose the extra weight and to improve my overall fitness. n Teresa’s case manager reports that over the past two years Teresa has reported a variety of physical symptoms including dizziness, racing heart and generally feeling unwell. At times, her case manager says it has been difficult to work out if the symptoms stem from stress, anxiety or deterioration in her mental state. It is now apparent that Teresa has a number of underlying physical health issues – including diabetes-related complications.


Diabetes Network – Summer 2013/14


GPs air frustration over “a losing battle” with obesity

Exclusive Diabetes Queensland research reveals many of Queensland's GPs believe the obesity epidemic is being lost, with calls for attention to be focused on ensuring our children have a chance at a healthy future. Two thirds of Queensland doctors surveyed by Diabetes Queensland say they are spending almost half their time treating obesity-related conditions and illnesses including type 2 diabetes, heart disease and some cancers. Of concern, 100 per cent of GPs recently surveyed in Brisbane, Cairns and Toowoomba agreed there had been a marked increase in patients presenting with issues related to obesity over the past 10 to 15 years – estimating this to equate to a 25 per cent hike, with half of all cases involving children. As a result, seven out of 10 GPs said the obesity epidemic impacted on their work and capacity to treat other patients. Higher prevalence of obesity was also reported in families with a history of weight issues as well as people living in low-socio economic areas – echoing findings from the landmark Australian Diabetes Obesity and Lifestyle Study (AusDiab) that tracked 11,000 Australians over 12 years (see last issue of Diabetes Network ). Similar to calls for “radical action” arising from the AusDiab study, Queensland GPs supported a range of social policies that could help reduce the number of people who are overweight or obese. These included: – banning junk food advertising to children; – implementing workplace physical activity and healthy eating standards; – banning sugary drinks in locations

frequented by children; – offering free or government- sponsored community-based healthy living programs encompassing exercise and diet; and – taxing junk food, including energy dense foods and sugary drinks. Other issues discussed included: – subsidising allied health support from dietitians, nutritionists, exercise physiologists and counsellors; – implementing town planning laws prohibiting fast food outlets opening near schools; – creating compulsory nutrition classes in schools; and – banning sitting for longer than two hours at a time in schools and workplaces. Diabetes Queensland CEO Michelle Trute said it was time for all levels of government and the community to get serious about tackling the obesity epidemic. "Once upon a time it would have been unthinkable to walk into a smoke-free pub or nightclub, now we wouldn't expect anything else,” Ms Trute said. “We need to tackle obesity with the same commitment and vigour to avoid a public health catastrophe." Dr John Kastrissios, GP and Chairman of the Greater Metro South Brisbane Medicare Local, seconded the call for policy makers to heed warnings arising from Diabetes Queensland’s research, stressing that doctors were on the frontline in the war against obesity. "Up to half of the doctors surveyed found it difficult to talk to patients about their weight. There are a number of reasons for this, including doctors not wanting to offend patients and, more worryingly, patients not seeing their weight as a health problem,” Dr Kastrissios said. "Many people still don't see excess weight as a problem, despite the

fact that we know people in the overweight and obese categories are at a much higher risk of developing potentially fatal and debilitating chronic diseases like type 2 diabetes and heart disease." Diabetes Queensland, The Heart Foundation and Nutrition Australia Queensland are encouraging Queenslanders to eat healthier, smaller portions during the festive season. The Queensland partnership is also supported by the Australian Government's new obesity prevention initiative, Shape Up Australia. n Diabetes Queensland values the services that health professionals provide to people with diabetes. Our organisation aims to support you via access to up-to-date diabetes information services and programs, as listed under the heading “Health Professionals” on our website ( www.diabetesqld.org.au ). n Health professionals can also call Diabetes Queensland’s Infoline on 1300 136 588.


Diabetes Network – Summer 2013/14

under the spotlight Under the spotlight Photo of Natalie [Elizabeth - this does not have to be the standard headshot style photo for this Q&A, but see how it fits near the standfirst if possible?]

Natalie Wischer

Natalie Wischer, founder and executive director of Australian Diabetes Online Services, is not your average tech junkie. As a child, her engineer father banned computer games unless she wrote the programs; later, as the first “RAN” (Remote Area Nurse) at an outstation in Western Australia’s Gibson Desert, she had no option but to troubleshoot IT connection issues or lose contact with the rest of the world; and, more recently, turned to Apps to help shed 20kg. As a Diabetes Educator with more than 13 years experience, what Natalie loves most about technology, however, is its ability to both super-size and tailor services for clients, catering to diverse needs and spanning generation gaps, ultimately helping people with diabetes to better self-manage their condition, 24/7. She talks everything technology and why it’s important for health professionals to get up to speed.

How can use of innovative technology become a health professional’s best friend? For health professionals, there are never enough hours in a day to fully implement and follow up on lifestyle coaching and countless other elements required in diabetes education. The beauty of technology, of course, is that it allows us to do more for our clients in less time, also providing meaningful and innovative ways for us to engage with and motivate individuals to take a more active role in their own health care. “Patient engagement”, to cite a Twitter quote that recently went viral, is “the blockbuster drug of this century”. Technology – or more precisely, innovative use of technology, matched to our clients’ needs and interests – offers a powerful tool when it comes to effective patient engagement. While technology cannot replace the work of health professionals, it can be considered something of a best friend by the fact that it adds infinite value to the services we provide. Plus, it’s accessible 24/7 – something of vital importance to our clients. Indeed, anyone who has been acutely sick or had a sick child will understand how important it is to obtain relevant information or better still, someone to communicate with, in times of need – whatever the hour. I launched Australian Diabetes Online Services with this at the core. I realised that in my many years of practice, I had missed so many “teachable moments” with my clients for the simple fact that traditional face-to-face appointments did not always allow me to help them deal with burning issues at the time they occurred. Your own “eureka” moment, ultimately resulting in the formation of Australian Diabetes Online Services in 2011? For me personally, technology has provided an incredible educational tool, primarily via a variety of podcasts on the psychology of behaviour change and diet/exercise. [Standfirst] Natalie Wischer , founder and executive director of Australian Diabetes Online Services, is not your average tech junkie. As a child, her engineer father banned computer games unless she wrote the programs; later, as the first “RAN” (Remote Area Nurse) at an outstation i Western Australia’s Gibson Desert, she had no option but to troubleshoot IT connection issues or l se co tact with the rest of the world; and, more recently, turned to Apps to help shed 20kg, keeping the weight off for the past five years. However, as a Diabetes Educator of more than 13 years, what Natalie loves most about technology is its ability to both super-size and tailor her service for clients, catering to diverse needs and spanning generation gaps, ultimately helping people with diabetes to better self-manage their condition 24/7. She talks everything technology and why it’s important for health professionals to get up to speed. Q&A will go here TO COME TO COME TO COME [Breakout box] Natalie’s top diabetes-related Apps TO COME TO COME TO COME [Details to go at bottom of article] Natalie Wischer RN RM BN CDE GradDi Mg info@onlinediabetes.com.au www.onlinediabetes.com.au

My “eureka” moment came in the realisation that I learned far more through Apps and podcasts than any formal course or training. And so, I began to use Apps to help keep me motivated on dietary and exercise goals and these tools helped me to lose 20kg… and have assisted in keeping the weight off over the past five years. If technology could do this for me, I was confident it could help others. I understood that not all tools have the same value or impact on everyone, but with the plethora of resources available, technology can be called upon when pieces of the health jigsaw are either under-resourced or missing. I also wanted to provide my rural and remote clients with the most optimal diabetes education service available without them needing to leave home. Technology afforded me the leverage to offer this to a large population base without compromising on quality. When it comes to technology, what should health professionals be across – and comfortable using – as a bare minimum? Change is never comfortable or easy. Whether we like it or not, our professional/personal lives are becoming increasingly reliant on various forms of technology. If we don’t keep up, we’ll be left behind. We will become less relevant to younger generations and miss opportunities to enhance the work we already do with clients across all age groups. I know for a fact that many young people with type 1 diabetes disengage with health care professionals who either quietly or openly dismiss usefulness of technology that younger generations access as part of every-day life, including for diabetes self-management. I have heard some truly remarkable, perhaps even life-saving, stories from those who have joined online social media groups such as Diabetes Australia’s Twitter support group, OzDoc.

continued, page 5


Diabetes Network – Summer 2013/14

under the spotlight

Natalie’s top tech tips n Compile patient resources for local GPs (to be provided to people at time of diabetes diagnosis). This take-home package could include “old school” printed material, alongside trusted (well referenced) on-line educational resources and related Apps, helping to alleviate many of the burning questions that patients have post-diagnosis: “What can I now eat?”, “Do I have to test right away?”, “What do these numbers mean?”. n Stock your own waiting room with tablet computers loaded with educational videos about key diabetes topics such as pathophysiology, medications, exercise and diet. n Incorporate use of technology into conversations and explore what may work to help better engage

clients in meeting their health and diabetes goals. n Meters that download data or allow for levels to be emailed to health care providers have been an incredibly beneficial tool in facilitating meaningful and timely consultations in particular with type 1 clients during a time of medication or blood glucose fluctuations. In my experience, having access to the entirety of available data on a computer screen for thorough analysis and assistance with pattern recognition has enhanced the depth and timeliness of my clinical care. n Where appropriate for a client’s age and IT ability, blood glucose monitoring could be self-taught prior to the first consultation via carefully selected YouTube clips. This can save around 30 minutes during a consultation, enabling time to be spent checking technique and discussing the

meaning of results and what factors impact upon the blood glucose levels. n Remember, younger clients love to text questions, particularly after initial diagnosis when there is so much to understand and learn. This offers an effective way of reducing blood glucose fluctuations through timely management and improves engagement of this sometimes hard to reach cohort. It also provides them with a feeling of safety and support. Natalie’s favourite Diabetes Apps – RapidCalc – Diabetic Connect

– Glucose Buddy – Diabetes Buddy – OnTrack Diabetes – RealTime Health – dLife – Diabetes App – iBGStar

continued from page 4 Connecting with social networks of people living with the same condition can be normalising and empowering. As health professionals, the types of technology we use and how we use it will depend on our client base. An example of diverse ways that I have used technology is to show a non-English speaking, illiterate client a native-language YouTube clip that provided a step by step guide on use of a blood glucose meter. On this occasion, technology saved the day when a phone interpreter was unavailable. That said, the value and application of innovative technology in all its forms is too exhaustive to list in full.

Instead, I’ve listed some ideas to help navigate your journey (see my top tips, above). At the end of the day, my advice for anyone grappling with technology and its uses is to find out what resources are available, talk to colleagues and never look past a simple Google search such as “best exercise app”. Trust me, these three words will be rewarded with a wealth of information.

n Natalie Wischer RN RM BN CDE GradDipMgt info@onlinediabetes.com.au www.onlinediabetes.com.au

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Diabetes Network – Summer 2013/14


How Effective is Your Patient’s CPAP?

age cushions by playing with them and so have children, so your patient may want to keep their mask out of reach. Can your patient answer yes to any of the following questions? • Have the edges of your cushion or pillows become stiff or cracked? • Has your cushion changed to an opaque colour? • Are you experiencing discomfort, redness or skin irritation? • Does your filter show signs of wear, such as discolouration? If so, your filter may not be protecting you from everyday allergens. • Are you experiencing excessive leaks? You may be able to replace your mask or just your cushion or pillows for more comfortable therapy. • Has your tubing begun to change to an opaque colour? • Has your tubing developed tears? Small tears can occur between the coils, causing air to escape and reducing the effectiveness of therapy. • Has your headgear stretched? • Do you find you are over-tightening to avoid leaks? • Has the water chamber become discolored or cloudy? • Do you see any cracks or pitted areas? One of the most important steps in achieving comfortable and effective therapy is replacing the mask and accessories regularly. Even with proper care and cleaning, any mask can deteriorate over time and cause poor performance, leaving your patient uncomfortable and under-treated. Many insurance companies will assist them to cover the cost of replacing the mask, head-

It is important that your patients replace their CPAP mask and accessories on a regular basis to ensure they are receiving the most comfort- able, effective and hygienic therapy possible. Your dentist reminds you to replace your tooth- brush every 3-4 months to promote sound oral hygiene and your patients need to think of their CPAP mask and accessories in the same man- ner. The life of their mask is impacted by use, oils from their skin and cleaning. Even with regular care and maintenance, their mask and acces- sories become worn out over time. Their head- gear, cushion or pillows may stretch out or deteriorate, their tubing and humidifier water chamber may develop tears or cracks and their air filter may become old and worn. All of this means, that their CPAP therapy devices will not be performing at their best. It is always a good idea for your patient to inspect their mask routinely; poor care may adversely af- fect the fit of the cushion and thus performance. To get the longest life from a mask, they should wash their face each night before putting on the mask, and wash their mask after each use. Use only mild soap, nothing with perfumes, moistur- izers, antibacterial agents, bleaches, etc. Always dry the mask and cushion out of direct sunlight. Poor performance is often the first clue that the cushion may need replacement. Check for small tears or pinholes, anything that might cause a leak. Household pets have been known to dam-

gear, cushion, tubing, water chamber and air filters. Your patient should contact their health fund to find out what replacement options are available. AIR LIQUIDE Healthcare is the preferred CPAP treatment specialist of Diabetes Queensland AIR LIQUIDE Healthcare has over 20 years of ex- perience in helping people adjust to treatment. We will provide your patients with options to meet the needs of their prescription. We offer a serv- ice-driven solution, ensuring comfort and compli- ance with therapy over time. Our CPAP Therapy Consultants will work with your patients to ensure they are well educated on OSA, receive the products that they require and achieve successful treatment. They will support their ongoing needs and assess the effectiveness of their CPAP therapy to ensure they receive op- timal treatment.

Visit our website to find the CPAP clinic closest to you or phone us to make an appointment.

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Diabetes Network – Summer 2013/14

latest news

Keeping you in the loop

Bone complications Complications associated with

Brain holds diabetes clues The brain may play a key role in glucose metabolism and the development of type 2 diabetes, according to latest research, opening the door to new ways of prevention and treatment. Although the brain was originally thought to be involved in maintaining regular glucose metabolism, the focus of diabetes research/management since the 1922 discovery of insulin has centred on boosting insulin levels or increasing the body’s sensitivity to insulin. In a study published in Nature , a group of researchers suggests that glucose regulation depends on a partnership between the insulin-producing cells of the pancreas, the pancreatic islet cells, and neuronal circuits in the hypothalamus and other brain areas that are intimately involved in maintaining normal glucose levels. The theory runs that the development of type 2 diabetes requires a failure of both the pancreatic islet cell system

and this brain-centred system for regulating blood glucose levels. According to the researchers, the brain system is the one most likely to fail first. This puts pressure on the pancreatic islet cell system, which can compensate in the short term, but then also fails, causing further decline in the brain system. The end result: a vicious cycle of deterioration that leads to type 2 diabetes. Testing the light fantastic Self-monitoring of blood glucose levels (BGLs) could soon be blood (and pin-prick) free thanks to German researchers who have devised a non-invasive way of testing. The technology uses photoacoustic spectroscopy, involving painless application of an infrared laser light on top of the skin to measure glucose levels in fluid in and under skin cells to read BGLs – creating a measurable sound signal that researchers dub “the sweet melody of glucose”.

long-term hyperglycaemia are well known, including vascular and heart disease, eye problems, nerve damage and kidney disease. Now, a new study out of the Mayo Clinic has confirmed the suspicion that lower bone mineral density can be added to the list. Researchers performed bone mineral testing using a new tool (OsteoProbe) on 60 postmenopausal women – 30 of whom had type 2 diabetes – comparing them with a control group of women aged 50 to 80. The two groups presented no difference when it came to microarchitecture of the bone or bone density. However, the group with type 2 diabetes had significantly lower bone material strength and also experienced higher levels of hyperglycaemia over the previous 10 years, indicating potential detrimental effects of long-term glucose control outside of target range on bone quality.

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Diabetes Network – Summer 2013/14


Help is a phone call away An innovative telephone-based “buddy system” service, Connect2, has been launched by Diabetes Queensland, reaching out to people newly diagnosed with type 2 diabetes – and, importantly, also providing an invaluable means of secondary support for health professionals. As Diabetes Queensland’s Udani Abeypala explains, the initiative matches trained volunteers (peer supporters who have effectively managed type 2 diabetes for several years) with newly diagnosed participants. It aims to relieve anxiety, emotional isolation and improve self-management. “Fear of the unknown and a lack of understanding of the long-term consequences of type 2 diabetes is one of the biggest challenges facing people newly diagnosed with the condition – something that affects up to 60 Queenslanders every day,” Ms Abeypala said. “It’s important to understand that speaking with someone who has shared similar experiences and challenges is invaluable for people who may not instantly connect in the same way with health care professionals. “This is not a negative. The ‘buddy system’ approach works to break down fear of the unknown, with a positive off-shoot being that participants then feel more confident to engage with health care professionals and to improve self-management – a win-win for all.” Ms Abeypala said the trained peer supporters were not intended to replace the work of health professionals and, of note, would not provide medical advice. The Connect2 program, which goes live in December 2013, is the second telephone-based peer support service launched by Diabetes Queensland. The first, You2Connect, targets women newly diagnosed with Gestational Diabetes (GDM) – a condition estimated to affect between five and

What’s on in 2014 – Calendar Dates For health professionals

7 Mar

Understanding diabetes Diabetes education for support workers Diabetes Queensland, Milton 9.00am-12.00pm

For people living with diabetes

15 and 20 Jan

Know the score community presentation Centacare, Enogerra 11.30am-12.30pm

20 and 27 Feb

Diabetes – What now? Diabetes Queensland, Milton 5.30pm-7.30pm

Session 1 - 20 February Session 2 - 27 February

22 Feb

EXPOsing diabetes Kingaroy RSL 8.30am-3.30pm

*Dates and activities are correct at time of print and may be subject to change. We recommend that you check the website for details. n For more information about how Diabetes Queensland supports health professionals via a range of targeted services and programs, visit www.diabetesqld.org.au/health-professionals/ services-and-programs/ n For a full list of Diabetes Queensland activities

eight per cent of all pregnancies. If you think your patients with type 2 diabetes or GDM could benefit

from participating in Connect2 or You2Connect, respectively, please contact Udani Abeypala via

and services available in your local area – visit www.diabetesqld.org.au/get-involved

health@diabetesqld.org.au or call 1300 136 588 for more information.

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Diabetes Network – Summer 2013/14 Diab tes Queensland

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