“Aboriginal and Torres Strait Islander community controlled primary health care services play a major role in delivering essential primary health care services to Aboriginal and Torres Strait Islander people in a culturally secure manner [125].

Health services run by Aboriginal and Torres Strait Islander communities provide holistic care that is relevant to the local community and addresses the physical, social, spiritual and emotional health of the clients [13].

Such services can deliver effective prevention and management programs that enable lifestyle changes that are maintained and supported by the community. 

The review found that after age-adjustment, Aboriginal and Torres Strait Islander people are: more than three times as likely as non-Indigenous people to have diabetes; four times as likely to be hospitalised for diabetes as non-Indigenous people; and that diabetes is the second leading underlying cause of death among Aboriginal and Torres Strait Islander people.

In addition the evidence shows that competent, culturally appropriate primary health care services can be effective in improving diabetes care and outcomes for Aboriginal and Torres Strait Islander people.”

 Media Release – latest review confirms high rates of diabetes among Aboriginal and Torres Strait Islander people

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Edith Cowan University’s Australian Indigenous HealthInfoNet has released a new review titled Review of diabetes among Aboriginal and Torres Strait Islander people.

The review is part of a series of translational research products produced by the HealthInfoNet to provide up to date information about health conditions affecting Aboriginal and Torres Strait Islander people.

HealthInfoNet Director, Professor Neil Drew said ‘Our important work in the area of translational research means that we synthesise current evidence and information into one document and make it freely available on our web resource. This saves busy health professionals and policy maker’s considerable time and provides them with an up to date and comprehensive review of a health topic’.

The review found that after age-adjustment, Aboriginal and Torres Strait Islander people are: more than three times as likely as non-Indigenous people to have diabetes; four times as likely to be hospitalised for diabetes as non-Indigenous people; and that diabetes is the second leading underlying cause of death among Aboriginal and Torres Strait Islander people.

The review identified that short-term healthy lifestyle programs designed to prevent type 2 diabetes among Aboriginal and Torres Strait Islander people can have positive health effects for up to two years, and are more likely to be effective if they are initiated by the community.

In addition the evidence shows that competent, culturally appropriate primary health care services can be effective in improving diabetes care and outcomes for Aboriginal and Torres Strait Islander people.

The Diabetes Australia Action plan (2013) and the new Australian national diabetes strategy 2016-2020 highlight the need for a coordinated national approach to the development of holistic diabetes programs that integrate cultural values and address the health of Aboriginal and Torres Strait Islander people across their lifespan.

Key facts

The context of Aboriginal and Torres Strait Islander health and diabetes

• The factors contributing to diabetes among Aboriginal and Torres Strait Islander people reflect a combination of broad historical, social and cultural factors as well as proximal health risk factors.
• In 2012-2013, after age-adjustment, Aboriginal and Torres Strait Islander people were more likely than non-Indigenous people to: be overweight or obese (1.2 times); have high blood pressure (1.2 times); have abnormal high density lipoprotein cholesterol (1.8 times) and triglycerides (1.9 times); and to smoke (2.6 times). Aboriginal and Torres Strait Islander people were less likely to meet the guidelines for daily fruit intake (0.9 times) or daily vegetable intake (0.8 times) than non-Indigenous people.
• In 2012-2013, obese Aboriginal and Torres Strait Islander people were nearly five times as likely to have diabetes than those who were of normal weight or underweight (19% compared with 4%).
• In 2012-2013, Aboriginal and Torres Strait Islander people with high blood pressure were nearly three times as likely as those without high blood pressure to have diabetes(24% compared with 9%).

The extent of diabetes among Aboriginal and Torres Strait Islander people

• Individual studies provide varying estimates of the prevalence of diabetes in specific Aboriginal and Torres Strait Islander communities—some as low as 4%, others as high as 33%.
• In 2012-2013, national estimates of the prevalence of diabetes (type 1, type 2 or high sugar levels) among Aboriginal and Torres Strait Islander people ranged from 9% (based on self-reported data) to 11% (based on biomedical data). After age-adjustment, Aboriginal and Torres Strait Islander people were more than 3 times as likely as non-Indigenous people to have diabetes.
• Between 2006 and 2011, the age-specific incidence rates of type 2 diabetes for young Aboriginal and Torres Strait Islander people were more than eight times higher than those for non-Indigenous 10-14 year olds, and almost four times higher than those for non-Indigenous 15-19 year olds.
• Between 2005 and 2007, 1.5% of Aboriginal and Torres Strait Islander women who gave birth had pre-existing diabetes and 5.1% had gestational diabetes mellitus (GDM). Aboriginal and Torres Strait Islander women who gave birth were more than three times as likely to have pre-existing diabetes and almost two times as likely to have GDM as their non-Indigenous counterparts.
• In 2012-13, after age-adjustment, Aboriginal and Torres Strait Islander people were four times more likely to be hospitalised for diabetes than non-Indigenous people. They were nearly two times more likely to be hospitalised for type 1 diabetes and GDM, and four times more likely to be hospitalised for type 2 diabetes, than their non-Indigenous counterparts.
• In 2013, diabetes (excluding GDM) was the second leading underlying cause of death among Aboriginal and Torres Strait Islander people, with an age-adjusted death rate six times higher than that for non-Indigenous people.

Complications and comorbidities associated with diabetes

• In 2012-13, age-standardised hospitalisation rates for complications of type 2 diabetes (as a principal diagnosis) were almost six times higher for Aboriginal and Torres Strait Islander people living in all jurisdictions, than those for non-Indigenous people.
• In 2012-13, hospitalisation rates for renal complications of type 2 diabetes were 10 times higher among Aboriginal and Torres Strait Islander people than those among non-Indigenous people.
• In 2012-13, Aboriginal and Torres Strait Islander people with diabetes, cardiovascular disease and chronic kidney disease (i.e. all three conditions at the same time) were seven times more likely to be hospitalised than their non-Indigenous counterparts.
• In 2005-2007, Aboriginal and Torres Strait Islander mothers who had diabetes during pregnancy were more likely than their non-Indigenous counterparts to have complications, including: pre-term delivery, pre-term induction, and a long hospital stay. Their babies were more likely than non-Indigenous babies to have a low Apgar score, high level resuscitation, and a long hospital stay.

Prevention and management of diabetes

• Evidence suggests that short-term healthy lifestyle programs designed to prevent type 2 diabetes among Aboriginal and Torres Strait Islander people, can have positive health effects for up to two years, and are more likely to be effective if they are initiated by the community.
• Evidence suggests that structured management strategies used in primary care settings can lead to sustained improvements in diabetes care and health outcomes for Aboriginal and Torres Strait Islander people.

Diabetes programs and services

• Evidence suggests that competent, culturally appropriate primary health care services can be effective in improving diabetes care and outcomes for Aboriginal and Torres Strait Islander people.
• Evidence suggests that primary health care services that apply continuous quality improvement (CQI), can experience improvements in both service delivery rates and clinical outcome measures in Aboriginal and Torres Strait Islander patients with diabetes.

Diabetes policies and strategies

• In 2013, Diabetes Australia developed the Aboriginal and Torres Strait Islanders and diabetes action plan. It provided to government a proposed national plan, the first of its kind, to guide future approaches in Aboriginal and Torres Strait Islander diabetes policy and program development.
• At the end of 2015, the Federal Government released the Australian national diabetes strategy 2016-2020. This strategy includes a specific goal to reduce the impact of diabetes among Aboriginal and Torres Strait Islander people. Many of the potential areas for action identified in the strategy are consistent with recommendations in the Diabetes Australia Action plan.
• The Diabetes Australia Action plan and the new National diabetes strategy highlight the need for a coordinated national approach to guide the development of holistic diabetes programs that integrate cultural values and address the health of Aboriginal and Torres Strait Islander people across their lifespan.

The context of Aboriginal and Torres Strait Islander health and diabetes

The risk of developing diabetes is influenced not only by an individual’s behavior, but also by: historical, social, cultural, geographical, economic and community factors; and government health policies and services [16]. Diabetes exists alongside a broad range of historical, social and cultural determinants that influence the health of Aboriginal and Torres Strait Islander people [13, 15].

The broad health disadvantages experienced by Aboriginal and Torres Strait Islander people can be considered historical in origin [17], but they have been perpetuated by the contemporary social and cultural determinants of health that contribute to current Aboriginal and Torres Strait Islander health inequalities [18, 19]. To understand the impact of diabetes on Aboriginal and Torres Strait Islander people it is necessary to understand the historical, social and cultural context of Aboriginal and Torres Strait Islander health.

The historical, social and cultural context

Aboriginal and Torres Strait Islander people maintained a hunter-gatherer lifestyle up until the late 18th century, but the arrival of Europeans in 1788 led to major changes in lifestyle [20, 21]. Traditional activities associated with finding renewable food and resources, maintaining familial and cultural practices, and sustaining the spiritual connection to country changed over time [17, 20-23].

Adverse changes in physical activity and nutrition (key risk factors for diabetes) played an important role in the development of diabetes in Aboriginal and Torres Strait Islander people, particularly in the second half of the 20th century [20, 23]. The first case of diabetes among Aboriginal and Torres Strait Islander people was recorded in Adelaide in 1923 [24]. Records prior to this time showed that Aboriginal and Torres Strait Islander people were fit and lean, and did not suffer from the metabolic conditions characteristic of European populations [25 cited in 26]. The earliest detailed studies investigating the development of diabetes in Aboriginal and Torres Strait Islander populations were not undertaken until the early 1960s [26]. These and subsequent studies found a significant correlation between the development of a ‘westernised’ lifestyle and the levels of diabetes in the Aboriginal and Torres Strait Islander population [26, 27].

In contemporary society, economic opportunity, physical infrastructure and social conditions influence the health of individuals and communities [18, 28, 29]. These factors are apparent in measures of education, employment, income, housing, access to services, connection with land, racism, and incarceration. On all these measures, Aboriginal and Torres Strait Islander people suffer substantial disadvantage in comparison with their non-Indigenous counterparts.

The factors contributing to diabetes among Aboriginal and Torres Strait Islander people reflect a combination of broad historical influences, and social and cultural determinants, as well as proximal health risk factors. It is beyond the scope of this review to discuss the underlying social and cultural determinants that influence the development of diabetes; or emerging evidence regarding the role of epigenetic factors³, the intrauterine environment and other early life factors [2]; but the main health risk factors are discussed below.

Factors contributing to diabetes among Aboriginal and Torres Strait Islander people

Several behavioural and biomedical factors are known to increase the risk of developing diabetes, particularly type 2 diabetes [31]; conversely improvements in these factors can reduce the risk of diabetes and become protective in nature.

Protective factors

Beneficial changes in lifestyle, such as a reduction in obesity, increases in physical activity and improvements in diet, are critical to reducing the risk of type 2 diabetes [16, 31]. There is also evidence that breastfeeding can reduce the risk of maternal type 2 diabetes in later life [32]. An Australian study published in 2010, found an excess risk of diabetes among childbearing women who did not breastfeed, compared with women who did not have children. This risk was substantially reduced by breastfeeding, and the benefit increased with the duration of breastfeeding. Breastfeeding also reduces the risk of babies becoming overweight [13], and reduces the risk of early onset obesity and diabetes in babies born to mothers who have diabetes in pregnancy [15]. According to the 2004-2005 National Aboriginal and Torres Strait Islander health survey, 84% of Aboriginal and Torres Strait Islander mothers aged 18-64 years reported having breastfed their children [33]. In the 2008 National Aboriginal and Torres Strait Islander social survey, 76% of Aboriginal and Torres Strait children aged 0-3 years were reported to have been breastfed [34].

Risk factors

Behavioural and biomedical risk factors known to increase the risk of developing diabetes, particularly type 2 diabetes, include high blood pressure, high blood cholesterol, tobacco smoking, low levels of physical activity, poor diet, and being overweight or obese [31]. Aboriginal and Torres Strait Islander people are more likely to have these risk factors for diabetes than non-Indigenous Australians [5], and many who already have diabetes have multiple risk factors and other related health problems [35-37].

Primary health care services

At a local level, most mainstream and community controlled primary health care services in Australia play a critical role in the delivery of diabetes care [93]. To meet the needs of Aboriginal and Torres Strait Islander people, primary health care services need to deliver both competent and culturally appropriate chronic disease care [120].

Culturally appropriate primary health care services

Culture and identity are central to Aboriginal and Torres Strait Islander perceptions of health, which encompass both the physical wellbeing of the individual, and the social, emotional and cultural wellbeing of the community [120]. It is important that services that deliver primary health care to Aboriginal and Torres Strait Islander people are culturally appropriate and recognise the importance of community values such as connection to culture, family and land, and opportunities for self-determination [107].

Culturally appropriate chronic disease services are typically characterised by [120]:

• a high level of Aboriginal and Torres Strait Islander community engagement and effective communication at all levels
• local knowledge about what works and what is acceptable
• strong Aboriginal and Torres Strait Islander leadership
• partnerships and community engagement that foster shared responsibilities
• sufficient sustainable resources and effective financial and project management
• integrated data and information systems to monitor the impacts of the intervention.

The involvement of Aboriginal and Torres Strait Islander Health Workers has been identified by health professionals and patients as an important factor in the delivery of good diabetes care to Aboriginal and Torres Strait Islander people [93, 121]. Aboriginal and Torres Strait Islander Health Workers have been shown to help patients feel comfortable, help break down communication and cultural barriers that may exist between patients and non-Indigenous health staff [93], and provide culturally appropriate self-management support [121].

A cluster randomised controlled trial, conducted between 2011 and 2013, found that an Indigenous Health Worker led case management approach to diabetes care (supported by an Indigenous clinical outreach team) was effective in improving diabetes care and control among Aboriginal and Torres Strait Islander adults in remote FNQ communities [121]. The health workers helped patients make and keep appointments, understand their medications, and learn about nutrition and the effects of smoking. Where appropriate, they also helped families to support the patient in self-management. Home visits and out of clinic care were provided, according to the patients’ preferences.

However, there can be barriers to the involvement of Aboriginal and Torres Strait Islander Health Workers in diabetes care such as: inadequate training; lack of clear role divisions among health care professionals; lack of stable relationships with non-Indigenous staff; and high demands for acute care [122]. Workforce initiatives that have been implemented to address some of the training needs of Aboriginal and Torres Strait Islander Health Workers include: the development of the diabetes education tool ‘Feltman’ (a life-sized felt body showing relevant organs and body parts) [123]; and the delivery of accredited postgraduate diabetes educator courses [124]. However, primary health care services need more Aboriginal and Torres Strait Islander Health Workers (including males) [122] and more diabetes-trained Aboriginal and Torres Strait Islander staff at all levels (health and allied health professionals, and support workers) [13]. This will require greater access to training and mentoring [13], clarification and support for the role of the Health Worker [122], and the identification and promotion of structured career pathways in Aboriginal and Torres Strait Islander chronic disease management [13].

Aboriginal and Torres Strait Islander community controlled primary health care services

Aboriginal and Torres Strait Islander community controlled primary health care services play a major role in delivering essential primary health care services to Aboriginal and Torres Strait Islander people in a culturally secure manner [125]. Health services run by Aboriginal and Torres Strait Islander communities provide holistic care that is relevant to the local community and addresses the physical, social, spiritual and emotional health of the clients [13]. Such services can deliver effective prevention and management programs that enable lifestyle changes that are maintained and supported by the community. In 2011-12, 80% of Aboriginal and Torres Strait Islander primary health care services that received funding from the Federal Government provided early detection activities for diabetes [126].