“Early onset of type 2 diabetes is very common in Aboriginal communities following Westernisation, so I agree with the recommendations of NACCHO and the RACGP, which recommended early screening.

Whether you do it annually or every 3 years is a less important question to me, and very patient-dependent.

Only 18% of Indigenous adults were tested for diabetes annually, as per the more intensive guidelines by the National Aboriginal Community Controlled Health Organisation (NACCHO), leading the authors to claim that the RACGP/DA guidelines were more practicable “

Professor Kerin O’Dea, Professor Emeritus at the University of South Australia and Honorary Professor at the University of Melbourne, said that the NHMRC recommendations “really need to be updated”.

Originally published MJA

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MORE can be done to increase diabetes screening rates among Indigenous Australians and enable earlier intervention, say experts who are calling for a greater focus on young adults.

A study published in the MJA found enormous variation in diabetes screening rates between different Aboriginal Community Controlled Health Services (ACCHSs).

The proportion of Indigenous adults screened for diabetes at least once in 3 years – as per the Royal Australian College of General Practitioners and Diabetes Australia (RACGP/DA) guidelines – ranged from 16% to 90% between different services.

Overall, 74% of Indigenous adults received a screening test for diabetes at least once between 2010 and 2013, the study found, based on de-identified data on 20 978 patients from 18 ACCHSs.

Only 18% of Indigenous adults were tested for diabetes annually, as per the more intensive guidelines by the National Aboriginal Community Controlled Health Organisation (NACCHO), leading the authors to claim that the RACGP/DA guidelines were more practicable.

Extract Overview provided by NACCHO

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http://www.racgp.org.au/download/documents/AHU/2ndednationalguide.pdf

Type 2 diabetes is most commonly found in obese adults who develop increasing insulin resistance over months or years. For these patients there is a substantial ‘prediabetic’ window period of opportunity to offer preventive interventions. Screening for diabetes is safe, accurate and cost effective, and detects a substantial proportion of people who may not otherwise have received early intervention.¹ This chapter discusses type 2 diabetes in adults who are not pregnant.

The prevalence of type 2 diabetes in Aboriginal and Torres Strait Islander populations is 3–4 times higher at any age than the general population, with an earlier age of onset.² The precise prevalence is hard to pinpoint; a 2011 systematic review of 24 studies showed prevalence estimates ranged from 3.5–31%, with most lying between 10% and 20%. Diabetes prevalence in remote populations is approximately twice that of urban populations and is higher among Aboriginal and Torres Strait Islander people.³

Aboriginal and Torres Strait Islander men and women die from diabetes at 23 and 37 times the rate of non-Indigenous Australian men and women respectively, in the 35–54 years age group.⁴ Large scale clinical trials have demonstrated that appropriate management of diabetes can prevent the development or delay the progression of complications such as myocardial infarction, eye disease and renal failure.⁵

Obesity is a very strong predictor for diabetes; a body mass index (BMI) ≥30 kg/m² increases the absolute risk of type 2 diabetes by 1.8–19-fold, depending on the population studied. A cohort study of non-diabetic Aboriginal adults aged 15–77 years in central Australia found that those with a BMI of ≥25 kg/m² had 3.3 times the risk of developing diabetes over 8 years of follow up compared to those with a BMI <25 kg/m².¹ The AusDiab study found that three measures of obesity: BMI, waist circumference and waist-to-hip ratio, all had similar correlations with diabetes and CVD risk.⁶ Waist circumference performed slightly better than BMI at predicting diabetes in a remote Aboriginal community

The study defined screening tests to include glycated haemoglobin (HbA_1c) testing as well as the oral glucose tolerance test and venous glucose level testing.

Barriers to screening included being aged under 50 years, being transient rather than a current patient and attending the service less frequently, the study found. The authors concluded that particular attention should be given to increasing the screening rate in these groups.

The finding that young people were less likely to be tested was “intuitively reasonable”, the authors said, given that the risk of developing diabetes rises with age. However, they suggested that it was still best practice to test Indigenous adults from the age of 18 years, as it provided a “substantial opportunity for limiting the impact of type 2 diabetes”.

Indigenous Australians aged 25–34 years are five times more likely to have diabetes or high blood sugar levels than non-Indigenous Australians of the same age, they noted.

Despite this difference between Indigenous and non-Indigenous people, the National Health and Medical Research Council (NHMRC) only recommends screening Indigenous people for diabetes once they are aged over 35 years, and doing it every 3 years.

Professor Kerin O’Dea, Professor Emeritus at the University of South Australia and Honorary Professor at the University of Melbourne, said that the NHMRC recommendations “really need to be updated”.

“Early onset of type 2 diabetes is very common in Aboriginal communities following Westernisation, so I agree with the recommendations of NACCHO and the RACGP, which recommended early screening,” she told MJA InSight.

“Whether you do it annually or every 3 years is a less important question to me, and very patient-dependent,” she said.

Professor O’Dea said that more widespread use of HbA_1c testing could increase the screening rate in Aboriginal communities, particularly among younger people and those who were more transient.

“If screening for diabetes was just a simple opportunistic HbA_1c test, you wouldn’t have so many problems getting people to have it done,” she said. “HbA^1c testing will give you a good idea of the mean glucose level, and unlike the glucose tolerance test, you don’t have to ask the patient to return in the fasting state.

“If it does turn out that the patient has borderline diabetes, then you can ask if they are prepared to do a glucose tolerance test,” she added.

Study co-author, Associate Professor Christine Paul, said that there was significant variation in the use of HBA_1c testing across sites and across time in the study.

“I think it is possible that increasing the use of HbA_1c as a screening test may help [to increase screening rates]; however, I don’t think it’s the main answer,” she said. “Clearly some health services need support to get systems in place, regardless of which test they use.”