Indigenous diabetes has now reached crisis point

INDIGENOUS Australians are three times more likely to have diabetes mellitus type 2 than non-Indigenous Australians.

According to the Australian Bureau of Statistics, diabetes is the underlying cause of death in 8% of all deaths in the Indigenous population.

There are a number of factors contributing to this epidemic. Among them are social disadvantage, dietary changes, genetics and epigenetics. There are also great challenges in the management of diabetes in remote settings, particularly in the context of limited medical services, poor housing and education.

Compliance with complex treatment regimes including tablets, insulin injections, blood glucose testing and diet is extremely difficult and, as a result, control of diabetes is often very poor. 

Indigenous patients have some of the highest complication rates in the world with renal failure and lower limb amputations rates being the most notable. 

When compared to non-Indigenous Australians, the Indigenous population has a 2.5 to 5.2-fold higher risk of proteinuria and 3.1 to 8.1-fold higher risk of hypertension.

While Indigenous people make up only 2.5% of the total population, they account for 16.7% of new cases of renal failure requiring dialysis or kidney transplantation caused by diabetes. 

Furthermore, dialysis centres are rarely located in remote communities and require travel and social dislocation. The largest dialysis unit in the Southern Hemisphere is located at the Alice Springs Hospital, and this is perhaps the most frightening statistic for this growing problem in the Northern Territory. 

In older patients, diabetes results in cardiovascular disease, foot ulcers and retinal disease, although only 2–6% of Indigenous Australians are aged over 65 given the gap in life expectancy  with non-Indigenous Australians.

Some of these longer term complications are being seen less frequently given the early mortality and relatively younger age of Indigenous patients with diabetes. Conversely, we are seeing an alarming increase in Indigenous children and adolescents developing type 2 diabetes.

In a recent visit to a remote community, we were confronted with a newly diagnosed boy with type 2 diabetes, aged 15 with overt proteinuria. Sadly, this type of story is becoming increasingly common. 

There are no easy answers. We need to address diabetes from a number of different angles – from housing and education through to health promotion and better access to healthy food choices. 

We need to do more to reduce the early onset of diabetes in children. In particular, we need to improve the detection and management of diabetes during pregnancy in order to reduce the risk of obesity and later diabetes, among offspring. We must also improve the post-pregnancy follow up and care of these women who are at higher risk of diabetes.

One of the biggest issues at a clinical level is continuity of care and a lack of resources. Understandably, when resources are stretched, an asymptomatic chronic illness may not get the full attention of healthcare workers. 

Furthermore, treatment regimes such as multiple daily insulin injections are often complex and not practical in remote settings. 

It is critical that we develop improved systems of care for diabetes more suitable for remote communities, with a dedicated diabetes task-management workforce, including diabetes educators, clinicians, podiatrists and renal specialists.

New technologies and therapies will also play a role, with new medications such as once-weekly GLP-1 agonists and new long-acting insulin analogues which may assist with treatment compliance in remote communities.

Improved communication through telemedicine and remote glucose meter downloads is already being used to provide more integrated multidisciplinary care.

For the past two decades, research has demonstrated diabetes and its complications in Indigenous communities is a growing health problem.

We have now reached crisis stage in terms of the devastating effects of this insidious chronic disease on Indigenous health, and urgent action is needed. An emphatic response is needed to turn the tide of what is rapidly becoming a national disaster. 

Increased funding for resources, improved integration of multidisciplinary services and a rethink on the delivery of chronic disease management to remote communities are key. 

Professor Sandra Eades

Head, Indigenous Maternal & Child Health Research, Baker IDI Heart and Diabetes Institute

Associate Professor Neale Cohen

General Manager, Diabetes Services, Baker IDI Heart and Diabetes Institute