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Diabetes

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Diabetes

Diabetes is a group of disorders marked by high levels of glucose in the blood [1]and caused by either or both of the following:

There are several types of diabetes, of which the most frequently occurring are type 1, type 2 and gestational diabetes mellitus (GDM) [1][3]. Type 1 diabetes is relatively uncommon in the Aboriginal and Torres Strait Islander population [4]. Type 2 diabetes, however, represents a serious health problem for many Aboriginal and Torres Strait Islander people, who tend to develop it at earlier ages than other Australians, and often die from it at younger ages. GDM develops in some women during pregnancy [5] and is more common among Aboriginal and Torres Strait Islander women than among non-Indigenous women [6].

Diabetes can lead to life-threatening health complications, some of which may develop within months of diagnosis while others may take years to develop [7]. Complications of diabetes include diseases of the large blood vessels (macrovascular disease), which can lead to heart disease and stroke, and diseases of the small blood vessels (microvascular disease), which can lead to kidney failure, limb amputations, eye disease and blindness [7][8]. For many Aboriginal and Torres Strait Islander people diabetes is not diagnosed until after complications have developed [9].

Diabetes is known to have adverse effects on pregnant women and their babies [6]. Outcomes that may occur for the mother include: pre-term birth; pre-term induced labour; caesarean section; hypertension; and increased length of stay in hospital. Outcomes that may occur for the infant include: higher rates of stillbirth, pre-term birth; high birthweight; low Apgar score; high-level resuscitation; admission to special care unit; and increased length of stay in hospital.

Diabetes statistics for Aboriginal and Torres Strait Islander people are often underestimated for several reasons, including under-identification of Indigenous status.1 Self-reported diabetes data may underestimate the prevalence of diabetes by up to 50% [10].

Extent of diabetes among Aboriginal and Torres Strait Islander people
Incidence and prevalence

Around 8.6% of Aboriginal and Torres Strait Islander people (8.8% of Aboriginal people and 7.0% of Torres Strait Islander people) aged 2 years and over reported in the 2012-2013 AATSIHS that they had type 1 or type 2 diabetes and/or high sugar levels in their blood or urine [11][12]. After age-adjustment, rates of diabetes and/or high sugar levels were more than three times higher among Aboriginal and Torres Strait Islander people than among non-Indigenous people [13]. Diabetes and/or high sugar levels were reported by a higher proportion of Aboriginal and Torres Strait Islander females (9.6%) than Aboriginal and Torres Strait Islander males (7.7%) [14].

The prevalence of diabetes and/or high sugar levels increased with age, for example 5.3% for Aboriginal and Torres Strait Islander people aged 25-34 years2 to 40% for those aged 55 years and over (Figure 3)[13]. The age-specific levels from 25 years onwards were between three and five times higher than those for non-Indigenous people.

Figure 3. Proportions (%) of people reporting diabetes/high sugar levels as a long-term health condition, by Indigenous status, and age-group, Australia, 2012-2013

Note: Proportions are expressed as percentages

Source: ABS, 2014 [13]

The prevalence of diabetes/high sugar levels was lower among Aboriginal and Torres Strait Islander people living in non-remote areas (7.5%) than among those living in remote areas (13%) [15]. After age-adjustment, the disparity in diabetes prevalence between Aboriginal and Torres Strait Islander adults (18 years and over) and non-Indigenous adults was greater in remote areas (six times greater) than in non-remote areas (three times greater) [16].

The self-reported results obtained from the AATSIHS were broadly consistent with biomedical results obtained for a subset of Aboriginal and Torres Strait Islander adults (18 years and over) who provided blood and urine samples [17]. In 2012-2013, results for fasting plasma glucose levels revealed that:

National estimates of the prevalence of type 1 diabetes among Aboriginal and Torres Strait Islander adults have not been identified, but Aboriginal and Torres Strait Islander children have the lowest prevalence of type 1 diabetes among children aged 0-14 [23]. At the end of 2013, 6,091 children in Australia had type 1 diabetes (139 cases per 100,000 children), of these, only 167 were Aboriginal and Torres Strait Islander children (69 cases per 100,000 Indigenous children).

The most recent national estimates of the prevalence of GDM are for 2005-2007 when almost 7% of Aboriginal and Torres Strait Islander women who gave birth in NSW, Vic, Qld, WA, SA and the NT3 had diabetes during pregnancy: 1.5% had pre-existing diabetes and 5.1% had GDM [6]. Aboriginal and Torres Strait Islander women who gave birth were three times more likely than their non-Indigenous counterparts to have pre-existing diabetes and almost twice as likely to have GDM.

National incidence data for diabetes are based on estimates for insulin-treated diabetes and obtained from the National (insulin-treated) diabetes register (NDR) [24]. Of the new cases of type 1 diabetes in 2013, 70 (3%) were among Aboriginal and Torres Strait Islander people [25]. Between 2005 and 2013, 489 Aboriginal and Torres Strait Islander people were diagnosed with type 1 diabetes. The incidence rate for Aboriginal and Torres Strait Islander people in this period was lower than the rate for non-Indigenous people (7 per 100,000 population compared with 10 per 100,000 population).

In 2011, Aboriginal and Torres Strait Islander people accounted for 2.6% of new cases of type 1 diabetes, 1.8% of new cases of type 2 diabetes, and 1.9% of new cases of GDM (among women aged 15-49) [24]. For 2006-2011, after age and sex adjustment, incidence rates for type 1 diabetes were lower for Aboriginal and Torres Strait Islander people (7 per 100,000) than for non-Indigenous people (10 per 100,000); they were almost 4 times higher for type 2 diabetes (134 per 100,000 for Aboriginal and Torres Strait Islander people compared with 36 per 100,000 for non-Indigenous people); and were similar for GDM (60 per 100,000 for Aboriginal and Torres Strait Islander women compared with 59 per 100,000 for non-Indigenous women).

There is growing concern regarding the emergence of type 2 diabetes in Aboriginal and Torres Strait Islander children and adolescents, although data are limited [26]. Between 2006 and 2011, 252 new cases of diabetes were reported among Aboriginal and Torres Strait Islander youth aged 10-19 years at diagnosis4 [27]. Of these, 55% were type 2 and 43% were type 1 diabetes. The age-specific rates of type 2 diabetes for young Aboriginal and Torres Strait Islander people were much higher than for their non-Indigenous counterparts (8.3 times as high among 10-14 year olds and 3.6 times as high for 15-19 year olds).

General practice attendances and hospitalisation

General practitioners (GPs) are usually the initial point of contact for people with diabetes and often play a key role in coordinating the other specialised services and health professionals who are needed to manage the condition [28]. In the period April 2008 to March 2013, diabetes was managed in 5% of encounters (82 per 1,000 encounters) between Aboriginal and Torres Strait Islander patients and GPs [29]. After age-adjustment, diabetes was managed 2.8 times more frequently among Aboriginal and Torres Strait Islander patients than among other patients. This was due mainly to type 2 diabetes (77 per 1,000 encounters) and after age-adjustment, this was almost three times the rate for other patients. For type 1 diabetes, GP encounters occurred much less frequently (4.2 per 1,000 encounters) than for non-Indigenous patients (rate ratio 1.8 after age-adjustment). GP encounters with Aboriginal and Torres Strait Islander women for GDM also occurred much less frequently (1.1 per 1,000 encounters) than for non-Indigenous patients (rate ratio 2.7 after age-adjustment).

Hospital services are typically required to treat the advanced stages of complications of diabetes or acute episodes of poor glycaemic control [30]. There were 6,391 hospital separations for ICD ‘Endocrine, nutritional and metabolic diseases’ (which includes diabetes) among Aboriginal and Torres Strait Islander people in Australia in 2013-14, accounting for 1.6% of separations identified as Indigenous [31].

In 2012-13 there were 2,749 hospital separations for diabetes (excluding GDM) for Aboriginal and Torres Strait Islander people in Australia5 [32]. After age-adjustment, Aboriginal and Torres Strait Islander people were four times more likely to be hospitalised for diabetes than non-Indigenous people. There were similar numbers of hospitalisations for Aboriginal and Torres Strait Islander males and females (1,379 and 1,370 respectively). However, the disparity in hospitalisation rates between Aboriginal and Torres Strait Islander males and females and their non-Indigenous counterparts was greater for females (4.7 times higher) than males (3.5 times higher). Hospitalisation rates for Aboriginal and Torres Strait Islander people with diabetes increased with increasing remoteness. Aboriginal and Torres Strait Islander people were 5.3 times more likely to be hospitalised for diabetes in remote and very remote areas, 3.4 times more likely to be hospitalised in inner and outer regional areas, and 2.8 times more likely to be hospitalised in major cities, than their non-Indigenous counterparts.

In 2012-13, Aboriginal and Torres Strait Islander people were more likely to be hospitalised for type 1 and type 2 diabetes (as the principal and/or an additional diagnosis) than non-Indigenous people (two and four times more likely respectively) [30]. Aboriginal and Torres Strait Islander females were 1.9 times more likely to be hospitalised with a principal or additional diagnosis of GDM than non-Indigenous females. Aboriginal and Torres Strait Islander males and females were more likely to be hospitalised for each type of diabetes than their non-Indigenous counterparts. The disparity was greatest for Aboriginal and Torres Strait Islander females with a principal diagnosis of type 2 diabetes, who were eight times more likely to be hospitalised than non-Indigenous females.

From 2011-12 to 2012-13, the majority of hospitalisations of Aboriginal and Torres Strait Islander people with a principal diagnosis of diabetes mellitus were for type 2 diabetes (61%), followed by GDM (21%) and type 1 diabetes (17%) [29]. In this period, age-specific hospitalisation rates for diabetes (all types excluding GDM) generally increased with age for both Aboriginal and Torres Strait Islander people and non-Indigenous people, but Aboriginal and Torres Strait Islander males and females had higher hospitalisation rates for diabetes than their non-Indigenous counterparts in all age-groups from 15-24 years onwards. The disparity between Aboriginal and Torres Strait Islander and non-Indigenous hospitalisation rates was greatest for males in the 45-54 year age-group; and greatest for females in the 55-64 year age-group (six and eleven times higher respectively).

Hospitalisations for various chronic conditions, including complications of diabetes, are considered potentially preventable [32]. In 2012-13, diabetes complications accounted for the largest proportion (67%) of potentially preventable hospitalisations for Aboriginal and Torres Strait Islander people, resulting in an age-adjusted rate that was six times greater than the rate for non-Indigenous people.

In 2012-13, hospitalisation rates for complications of type 2 diabetes among Aboriginal and Torres Strait Islander people in Australia were consistently higher than for non-Indigenous people: ten times higher for renal complications; almost three times higher for circulatory and ophthalmic complications; and almost seven times higher for multiple complications of diabetes [32].

Mortality

In 2013, diabetes6 was the second leading underlying cause of death7 among Aboriginal and Torres Strait Islander people, with an age-adjusted death rate six times higher than that for non-Indigenous people [33][34]. Diabetes was responsible for 7.6% of deaths (202 deaths) among Aboriginal and Torres Strait Islander people living in NSW, Qld, SA, WA and the NT [33][34]. There were more deaths from diabetes among Aboriginal and Torres Strait Islander females (121 deaths) than among males (81 deaths) [34]. After age-adjustment, Aboriginal and Torres Strait Islander females and males were both more likely to die from diabetes than their non-Indigenous counterparts (eight and four times respectively).

From 2010-2012, diabetes was the underlying cause of death for 564 Aboriginal and Torres Strait Islander people (8% of all Indigenous deaths) in NSW, Qld, SA, WA and the NT [16]. Of these deaths, the underlying cause of death was recorded as: type 1 diabetes (5.0% of deaths); type 2 diabetes (46% of deaths); or the type of diabetes was unspecified (49% of deaths). In this period, diabetes was the underlying or associated cause of death for 1,474 Aboriginal and Torres Strait Islander people (21% of all Indigenous deaths).

Between 2009 and 2013, the greatest disparity in Indigenous:non-Indigenous age-specific death rates occurred in the 45-54 year age-group [34]. In this age-group Aboriginal and Torres Strait Islander people were 17 times more likely to die from diabetes than their non-Indigenous counterparts (rate ratios were 26.5 for females and 12.9 for males). Between 2008 and 2012, diabetes (excluding GDM) accounted for the largest proportion of the Indigenous:non-Indigenous mortality gap for females (21%) and the second largest for males (17%) [35]. Despite some annual variation, there was little change in the gap in death rates for diabetes as an underlying or associated cause of death between Aboriginal and Torres Strait lslander people and non-Indigenous people for 1998 to 2012 [16].

References

  1. Lalor E, Cass A, Chew D, Craig M, Davis W, Grenfell R, Hoy W, McGlynn L, Mathew T, Parker D, Shaw J, Tonkin A, Towler B (2014) Cardiovascular disease, diabetes and chronic kidney disease: Australian facts - mortality. Canberra: Australian Institute of Health and Welfare
  2. Diabetes Australia (2011) What is diabetes?. Retrieved September 2011 from http://www.diabetesaustralia.com.au/Understanding-Diabetes/What-is-Diabetes/
  3. Diabetes Australia (2013) Diabetes in Australia. Retrieved 2013 from http://www.diabetesaustralia.com.au/Understanding-Diabetes/Diabetes-in-Australia/
  4. Australian Institute of Health and Welfare (2010) Australia's health 2010: the twelfth biennial report of the Australian Institute of Health and Welfare. Canberra: Australian Institute of Health and Welfare
  5. Australian Institute of Health and Welfare (2009) Insulin-treated diabetes in Australia 2000–2007. Canberra: Australian Institute of Health and Welfare
  6. Australian Institute of Health and Welfare (2010) Diabetes in pregnancy: its impact on Australian women and their babies. Canberra: Australian Institute of Health and Welfare
  7. Australian Institute of Health and Welfare (2011) Prevalence of Type 1 diabetes in Australian children, 2008. Canberra: Australian Institute of Health and Welfare
  8. Royal Australian College of General Practitioners (2014) General practice management of type 2 diabetes: 2014-2015. Melbourne: Royal Australian College of General Practitioners
  9. National Aboriginal Community Controlled Health Organisation (2005) Evidence base to a preventive health assessment in Aboriginal and Torres Strait Islander peoples. Melbourne: The Royal Australian College of General Practitioners
  10. Australian Institute of Health and Welfare (2011) Key indicators of progress for chronic disease and associated determinants: data report. Canberra: Australian Institute of Health and Welfare
  11. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: updated results, 2012–13. Canberra: Australian Bureau of Statistics
  12. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: updated results, 2012-13 - Australia: table 21.3 [data cube]. Retrieved 6 June 2014 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&472705500621.xls&4727.0.55.006&Data%20Cubes&166861F2585F8D85CA257CEE0010DAE7&0&2012%9613&06.06.2014&Latest
  13. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: updated results, 2012-13 - Australia: table 6.3 [data cube]. Retrieved 6 June 2014 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&472705500606.xls&4727.0.55.006&Data%20Cubes&7F2DBD07A515E7A2CA257CEE0010D7BF&0&2012%9613&06.06.2014&Latest
  14. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: updated results, 2012-13 - Australia: table 5.3 [data cube]. Retrieved 6 June 2014 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&472705500605.xls&4727.0.55.006&Data%20Cubes&A95A701E3429A625CA257CEE0010D780&0&2012%9613&06.06.2014&Latest
  15. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: updated results, 2012-13 - Australia: table 2.3 [data cube]. Retrieved 6 June 2014 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&472705500602.xls&4727.0.55.006&Data%20Cubes&A0A5C6AE5F15C5DECA257CEE0010D6DC&0&2012%9613&06.06.2014&Latest
  16. Australian Institute of Health and Welfare (2015) Cardiovascular disease, diabetes and chronic kidney disease - Australian facts: Aboriginal and Torres Strait Islander people. Canberra: Australian Institute of Health and Welfare
  17. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: biomedical results, 2012-13. Canberra: Australian Bureau of Statistics
  18. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: biomedical results, 2012-13 - Australia: table 1.3 [data cube]. Retrieved 10 September 2014 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&4727.0.55.003_1.xls&4727.0.55.003&Data%20Cubes&92FBF63F35F71948CA257D4E001700FC&0&2012-13&10.09.2014&Latest
  19. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: biomedical results, 2012-13 - Australia: table 3.3 [data cube]. Retrieved 10 September 2014 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&4727.0.55.003_3.xls&4727.0.55.003&Data%20Cubes&FE28D6D39E8ED1FACA257D4E0017027A&0&2012-13&10.09.2014&Latest
  20. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: biomedical results, 2012-13 - Australia: table 4.3 [data cube]. Retrieved 10 September 2014 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&4727.0.55.003_4.xls&4727.0.55.003&Data%20Cubes&B80B0E57A2672E00CA257D4E001702AE&0&2012-13&10.09.2014&Latest
  21. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: biomedical results, 2012-13 - Australia: table 5.3 [data cube]. Retrieved 10 September 2014 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&4727.0.55.003_5.xls&4727.0.55.003&Data%20Cubes&76FB2FC429853BA3CA257D4E001702E1&0&2012-13&10.09.2014&Latest
  22. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: biomedical results, 2012-13 - Australia: table 6.3 [data cube]. Retrieved 10 September 2014 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&4727.0.55.003_6.xls&4727.0.55.003&Data%20Cubes&F653985C855EA253CA257D4E00170316&0&2012-13&10.09.2014&Latest
  23. Australian Institute of Health and Welfare (2015) Prevalence of type 1 diabetes among children aged 0–14 in Australia 2013. Canberra: Australian Institute of Health and Welfare
  24. Australian Institute of Health and Welfare (2014) Incidence of insulin-treated diabetes in Australia 2000-2011. Canberra: Australian Institute of Health and Welfare
  25. Australian Institute of Health and Welfare (2015) Incidence of type 1 diabetes in Australia 2000-2013. Canberra: Australian Institute of Health and Welfare
  26. Zimmet PZ, Magliano DJ, Herman WH, Shaw JE (2014) Diabetes: a 21st century challenge. The Lancet Diabetes & Endocrinology; 2(1): 56 - 64
  27. Australian Institute of Health and Welfare (2014) Type 2 diabetes in Australia’s children and young people: a working paper. Canberra: Australian Institute of Health and Welfare
  28. Australian Institute of Health and Welfare (2008) Diabetes: Australian facts 2008. Canberra: Australian Institute of Health and Welfare
  29. Australian Institute of Health and Welfare (2015) Aboriginal and Torres Strait Islander health performance framework 2014 report: detailed analyses. Canberra: Australian Institute of Health and Welfare
  30. Australian Institute of Health and Welfare (2014) Cardiovascular disease, diabetes and chronic kidney disease: Australian facts: morbidity - hospital care. Canberra: Australian Institute of Health and Welfare
  31. Australian Institute of Health and Welfare (2015) Admitted patient care 2013–14: Australian hospital statistics. Canberra: Australian Institute of Health and Welfare
  32. Steering Committee for the Review of Government Service Provision (2014) Overcoming Indigenous disadvantage: key indicators 2014. Canberra: Productivity Commission
  33. Australian Bureau of Statistics (2015) Causes of death, Australia, 2013. Canberra: Australian Bureau of Statistics
  34. Australian Bureau of Statistics (2015) Causes of death, Australia, 2013: Deaths of Aboriginal and Torres Strait Islander Australians [data cube]. Retrieved 31 March 2015 from http://www.abs.gov.au/ausstats/subscriber.nsf/log?openagent&3303_12%20%20deaths%20of%20aboriginal%20and%20torres%20strait%20islander%20australians.xls&3303.0&Data%20Cubes&4D9A9ADDB3C2F0ACCA257E18000F913C&0&2013&31.03.2015&Latest
  35. Australian Institute of Health and Welfare (2014) Mortality and life expectancy of Indigenous Australians 2008 to 2012. Canberra: Australian Institute of Health and Welfare
  36. International Diabetes Federation (2013) IDF diabetes atlas. 6th ed. Brussels, Belgium: International Diabetes Federation

Endnotes

1. For further details see ’Limitations of the sources of Aboriginal and Torres Strait Islander information’.

2. The prevalence for Indigenous people in the 2-14 years and 15-24 years age-groups were also reported (0.5% and 1.4% respectively), but data for non-Indigenous people in these age groups was not provided [13].

3. Data from the NT are for public hospitals only [6].

4. Based on combined data from the National diabetes services scheme (NDSS) and the Australasian Paediatric Endocrine Group (APEG) [27].

5. Data are for public and private hospitals in all jurisdictions [32].

6. Based on the ICD-10-AM sixth edition codes E10-E14 (this excludes GDM) [34].

7. It should be noted that death data on diabetes are probably an underestimate as the condition tends to be under-reported on death certificates or is not recorded as the underlying cause of death [5][36].

8. The ICD chapter ‘Mental and behavioural disorders’, used for the classification of both hospitalisation and mortality, is very broad. As well as mental illness and mental health problems, it includes mental retardation and a broad sub-category for disorders relating to the use of psychoactive substances (including alcohol, tobacco, other drugs and volatile substances). The chapter doesn’t include, however, the results of intentional self-harm, which are classified within the ICD chapter ‘External causes of morbidity and mortality’.

9. Under the ICD, intentional self-harm is classified under ‘External causes of morbidity and mortality’ (codes X60-X84); details are provided separately.

 
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