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There are several types of diabetes, of which the most frequently occurring are type 1, type 2 and gestational diabetes mellitus (GDM) . Type 1 diabetes is relatively uncommon in the Indigenous population . Type 2 diabetes, however, represents a serious health problem for many Indigenous people, who tend to develop it at earlier ages than do other Australians, and often die from it at younger ages. GDM, which can occur during pregnancy, is more common among Indigenous women than among non-Indigenous women .
Statistics on diabetes incidence, prevalence, hospitalisation, and mortality among Indigenous people are often underestimated for several reasons, including under-identification of Indigenous status, and information only being collected routinely for types of diabetes that require insulin treatment ; self-reported diabetes data may underestimate the prevalence of diabetes by up to 50% .
Diabetes can lead to life-threatening health complications, some of which may develop within months of diagnosis while others may take years to develop . Complications of diabetes include disease of the large blood vessels (macrovascular disease), which can cause heart disease and stroke, and disease of the small blood vessels (microvascular disease), which can cause eye disease and peripheral nerve disease. For many Indigenous people diabetes is not diagnosed until after complications have developed .
Diabetes is known to have adverse effects on pregnant women and their babies . 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; higher birthweight; low Apgar score; high level of resuscitation; admission to special care unit; and increased length of stay in hospital.
Around 8.2% of Indigenous people reported in the 2012-2013 AATSIHS that they had diabetes and/or high sugar levels in their blood or urine . After age-adjustment, the level of diabetes and/or high sugar levels among Indigenous people was 3.3 times higher among Indigenous people than that among non-Indigenous people. Diabetes and/or high sugar was reported by a higher proportion of Indigenous females (10%) than Indigenous males (7%).
The prevalence of diabetes and/or high sugar levels increased with age for all age-groups over 25 years . The prevalence ranged from 5% for Indigenous people aged 25-34 years to 39% for those aged over 55 years (Figure 1). The age-specific levels were between three and five times higher than those for non-Indigenous people.
Figure 1. 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 percentagesSource: ABS 2013 
The prevalence of diabetes/high sugar levels was lower for Indigenous people living in non-remote areas (7.3%) than among those living in remote areas (11.2%) .
The most recent analysis of diabetes incidence in Australia was undertaken by the AIHW in 2009 using data from Australia’s National Diabetes Register (NDR), which is for all Australians who have commenced using insulin for diabetes since 1999 . In 2005-2007, Indigenous people aged 15 years or older accounted for 1.9% of new cases of type 1 diabetes, 2.6% of new cases of type 2 diabetes, and 2.2% of new cases of GDM.
In the period 2005-06 to 2007-08, almost 7% of Indigenous mothers in NSW, Vic, Qld, WA, SA and the NT had diabetes during pregnancy: 0.1% had pre-existing type 1 diabetes; 1.5% had pre-existing type 2 diabetes; and 5.0% had GDM . Indigenous women who gave birth were 3.2 times more likely than their non-Indigenous counterparts to have pre-existing diabetes and 1.6 times more likely to have GDM.
Hospitalisation rates are not an accurate reflection of the burden of diabetes in the community because, as is the case for most chronic health conditions, the treatment of diabetes is well supported by primary health care from doctors, nurses, and allied health professionals. In the period 2006-07 to 2010-11, diabetes problems were managed at a rate of 76 per 1,000 general practitioner (GP) encounters for Indigenous people, about three times the rate for non-Indigenous people; this was mainly due to the higher management rate of type 2 diabetes . GP encounters for gestational diabetes for Indigenous females were managed at 1.5 times the rate of encounters for other females.
There were 5,269 hospital separations for ICD ‘Endocrine, nutritional and metabolic diseases’ (which includes diabetes) among Indigenous people in 2011-12, accounting for 2.6% of separations identified as Indigenous (excluding dialysis) .
For the two year period July 2008 to June 2010, diabetes accounted for almost 8,000 episodes of hospitalisation, and was the principal diagnosis for 1.4% of all hospital separations for Indigenous people living in NSW, Vic, Qld, WA, SA and the NT . Around 84% of diabetes-related hospitalisations among Indigenous people were for type 2 diabetes. After age-adjustment, rates of hospitalisation with a principal diagnosis of type 2 diabetes were 3.9 and 5.7 times higher for Indigenous males and females, respectively, than those for their non-Indigenous counterparts . The rate of hospitalisation for type 1 diabetes was around twice as high for Indigenous people as that for non-Indigenous people. Hospitalisation rates increased with age, particularly for Indigenous people. The Indigenous:non-Indigenous rate ratios were around 9 for males in the 35-44 years and 45-54 years age-groups, and more than 9 for all age-groups of females between 35 and 64 years.
For Indigenous people living in NSW, Vic, Qld, WA, SA and the NT in the period July 2008 to June 2010, diabetes hospitalisation rates were highest for remote areas (21.5 per 1,000), very remote (19.3 per 1,000), and outer regional areas (17.1 per 1,000) . The lowest rates were for the major cities (8.8 per 1,000) and inner regional areas (11.4 per 1,000).
Complications from diabetes, particularly renal complications but also circulatory and ophthalmic conditions, were the cause of high rates of hospitalisations. Hospitalisation rates for renal complications of diabetes were 11.2 times higher for Indigenous people living in NSW, Vic, Qld, WA, SA and the NT in 2008-09 than those for non-Indigenous people . The hospitalisation rate for multiple complications of diabetes was 6.5 times higher for Indigenous people than that for other Australians in 2008-09 (3.1 compared with 0.5 per 1,000).
Diabetes was responsible for one-in-twelve deaths (201 deaths) of Indigenous people living in NSW, Qld, SA, WA and the NT in 2012 . Diabetes was the second leading specific cause of death for Indigenous people, with an overall death rate 7.0 times higher than that for non-Indigenous people. (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 .)