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Diabetes care at the centre of Australia: grassroots care and prevention A report on the 2010 symposium on Indigenous peoples’ health held in Alice Springs, Australia Elizabeth Barr, Alex Brown Baker, John Boffa, Paul Zimmet

The Baker IDI Heart and Diabetes (Baker IDI) Institute of Australia was established in 2008 following the merger of two eminent clinical academic bodies, the Baker Heart Research Institute and the International Diabetes Institute. Baker IDI is Australia’s first multidisciplinary organization tackling the deadly trio of obesity, diabetes and cardiovascular disease through research, education and care. In 2007, Baker IDI established a research group in Alice Springs in Central Australia under the leadership of Alex Brown, a leading Indigenous doctor/ researcher, to conduct cardiovascular and diabetes research focusing on improving health outcomes for Aboriginal and Torres Strait Islanders. One of the key objectives of the Alice Springs facility is to provide educational activities to health and community workers involved in the prevention and management of cardiovascular disease and diabetes among Indigenous people. The authors report on one of its several projects: a symposium held in 2010 on issues such as service delivery, prevention and management to reduce the disproportionate burden of diabetes experienced by Australian Indigenous people.

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The key presentations Primary prevention Paul Zimmet (Baker IDI) discussed the epidemiology and public-health impact of diabetes, highlighting the significance of the epidemic globally as well as locally. He showed that type 2 diabetes and prediabetes combined are estimated to affect between 3 and 4 million Australians. Diabetes alone is associated with an annual cost of AUD 8 billion. The impact of diabetes is magnified in Indigenous Australians, in whom it is associated with other chronic conditions, such as cardiovascular and renal disease, nonalcoholic steatosis of the liver and sleep apnoea. He pointed out that prevention strategies are of paramount importance and need to incorporate lifestyle, diet and exercise, but also improved child

June 2011 • Volume 56 • Special Issue 1


and maternal health. Under-nutrition in an unborn child, a factor affecting many Indigenous pregnancies, may increase its risk for diabetes in adult life. John Boffa, representing the Central Australian Aboriginal Congress, outlined the importance of comprehensive primary healthcare, encompassing several aspects of social care and healthcare, especially improving early childhood health and educational development. Gary Sinclair of the Northern Territory Department of Health emphasized the importance of a population approach to the primary prevention of diabetes and chronic disease in Central Australia based on New Zealand’s experiences. This implies a whole-community, wholelife-course and whole-family approach that is sustainable, has a focus on ethnicity and involves community partnerships. Christine Connors, also of the Northern Territory Department of Health, outlined the policy interventions that have already been undertaken in the Northern Territory to reduce risk factors for diabetes and cardiovascular disease. She explained that while the programmes for tobacco control were quite well developed, programmes for obesity required more attention. Nevertheless, several were in operation in the Northern Territory, including retail licensing and quality improvement, increasing the availability of fresh food, replacing soft drinks with diet versions, an ‘Eat Better Move More’ campaign and increasing the numbers of sport and recreational officers. Complications of diabetes Mark Cooper (Baker IDI) provided an overview of diabetic complications, not only the usual cardiovascular diseases, kidney disease, eye disease, foot ulceration and amputations, but also dental


disease, Alzheimer’s disease and cancer. He highlighted the high prevalence of rapidly progressive kidney disease in Indigenous Australians, stating that the mechanisms for rapid progression are largely unknown. Although controlling blood pressure and cholesterol are paramount to reducing the risk of renal and cardiovascular complications, there are still significant gaps in the literature on the efficacy and safety of treatments for kidney disease specifically in Indigenous Australians. David Goodman from St Vincent’s Hospital in Melbourne highlighted recent research showing that the burden of kidney disease may be increasing and is associated with low birth weight, which again emphasizes the importance of improving the status of maternal health. He discussed the significant medical, logistic and social difficulties in managing Indigenous people with end-stage kidney disease who require dialysis, suggesting that dialysis treatment should be made available closer to the person’s home. Tim Henderson from the Northern Territory Clinical School and Flinders

University discussed eye disease, noting that although the prevalence of diabetic retinopathy is similar in Indigenous people compared to their non-Indigenous counterparts, a significant number of Indigenous people with diabetes were not having their eyes checked. Jonathan Shaw (Baker IDI) emphasized the need to improve foot screening, quoting Australian research which shows that screening for foot complications was considerably worse for Indigenous Australians – and this despite clinical guidelines from Australia’s National Health and Medical Research Council, which recommends that Indigenous people with diabetes have their feet checked at every health visit. It is unlikely that financial constraints are to blame for this lack of cover: the equipment needed for a foot examination is far from expensive. Primary care systems – the role of care planning A subsequent session focused on systems currently being implemented in primary care to improve the prevention and management of chronic diseases in Indigenous communities. Flinders

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University‘s Malcolm Battersby discussed self-management programmes in diabetes: the Flinders Program has received AUD 5 million from the Federal Government’s ‘Closing the Gap’ campaign to train health professionals for implementation in Indigenous settings. Gaynor Garstone, a diabetes educator with the Northern Territory Department of Health, outlined a successful case-conferencing programme for the management of renal disease and diabetes that is being used in remote Northern Territory communities in conjunction with the Royal Darwin Hospital. The programme comprises case conferences in which the endocrinologist and diabetes educator in Darwin (who both have experience of community outreach) confer with the rural medical officer, nurse and/or Aboriginal health worker, with the patient’s consent. This has helped hospital staff to develop a better understanding of the issues affecting people who live remotely. Moreover, under this programme, people receive specialist care without having to travel. This begins to address a range of challenges, including the following: isolation h igh health-staff turnover v ariable understanding of diabetes, culture and society by health workers in the Northern Territory d ifficulty liaising with hospital staff providing care for people who do not want to travel to city medical facilities

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Joanna Smith and colleagues from the Santa Teresa Clinic then provided an inspiring case study on the successful implementation of multidisciplinary care at Santa Teresa in Central Australia to improve awareness and treatment of chronic diseases. Lifestyle change and the real world – making a difference What strategies can help people adopt healthy lifestyle behaviours? Kevin Rowley and colleagues from the University of Melbourne outlined an ‘ecological’ health promotion programme that was implemented by Indigenous communities in the State of Victoria to improve physical activity and nutrition using a wide variety of settings, targets and strategies. The programme’s successes were underpinned by community leadership and participation and the programme’s alignment with community values, local knowledge, social structures and organizations. David Dunstan (Baker IDI) discussed the health risks of sedentary behaviour, including prolonged TV viewing, which are associated with overweight and obesity, high blood glucose and cholesterol and an increased risk of heart disease and premature death. He explained that in addition to vigorous physical activity, being involved in light-intensity activities is beneficial to health both because of associated increased metabolic activity and by occupying time that would otherwise be taken up by sedentary activities! Michael Kyrios of the Swinburne University of Technology explained the influence of pre-historical, historical,


cultural, socioeconomic and political dimensions on Indigenous Australians’ health – influences not fully considered in conventional theories about barriers to behavioural change. Programmes for Indigenous people need to include individual health-related behavioural changes as well as multifaceted approaches that encompass these external influences. Maternal and child health Clair MacVicar, a paediatrician with the Central Australian Remote Health Service, revisited the importance of genetic and environmental influences on the risks of developing chronic diseases and explained that the risks increased when there was a mismatch between genetic make-up and environmental influences. Louise Maple-Brown of the Menzies School of Health Research and Royal Darwin Hospital reported that compared to non-Indigenous Australians, Indigenous Australians experience obesity and type 2 diabetes much younger, and that, given the paucity of evidence on the efficacy of medications in young people, their management was complex. Prevention strategies for young Indigenous Australians need further development.

Jeremy Oats, a senior obstetrician at the Royal Women’s Hospital in Melbourne and a member of the Victorian Consultative Council on Obstetric and Paediatric Mortality, discussed current recommendations for the diagnosis and management of gestational diabetes, summarizing the findings from the Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) study. This showed a continuous relationship between carbohydrate intolerance in pregnancy and adverse pregnancy outcomes that were independent of ethnicity. The new criteria for gestational diabetes are likely to identify more women and babies at risk in most populations; health services will need to plan for this increased demand. A high-risk initiative for the diabetes in pregnancy clinic at the Alice Springs Hospital was described by another obstetrician, Simon Kane from Canberra Hospital. The Diabetes Antenatal Care and Education Clinic (DANCE) is multidisciplinary and includes an obstetrician, midwife, diabetes educator and physician. Management takes place in the community to limit the need for women to travel large distances. The programme is audited to inform future changes in clinical practice and examines rates of

© Paul Zimmet

a lack of medical specialists in remote centres. The model is transferable and is being considered to improve diabetes management in pregnancy.

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© Paul Zimmet

gestational diabetes, the percentage of women presenting early in pregnancy, the percentage of women undergoing a 22-week ultrasound, and delivery and neonatal outcomes (such as birth weight). Glynis Dent, a diabetes educator at Alice Springs Hospital, later explained that DANCE facilitates a collaborative, holistic approach to care, using different antenatal care models, including hospital, general practitioner and midwife clinics. Barriers addressed particularly by allowing women to telephone clinic staff from their community setting have included dealing with mobile and remote clients, the lack of midwives working remotely, and the difficulty of encouraging people to monitor blood glucose and use insulin when living conditions were not supportive. Integrating primary and tertiary care The symposium ended with a session on the integration of primary and tertiary care in Indigenous health. Peter Fitzpatrick of the Borroloola Health Clinic outlined the challenging roles of the general practitioner, which incorporate both clinical and population health improvement and can change over time and across communities. Roles include

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leadership and encouraging Indigenous people to be leaders in their communities; involvement in infrastructure planning of housing and recreational facilities; advocacy on behalf of Indigenous people; improving integration between clinical services in communities and hospitals; conveying information on chronic diseases in an uncomplicated manner; and building relationships with community members. Challenges facing general practitioners include poor communication between remote clinic and hospital staff where staff turnover is high; inadequate linkage between electronic health records; poor engagement with Indigenous people; and breakdowns in well-coordinated primary care systems. Neale Cohen, an endocrinologist at Baker IDI, outlined the role of the specialists as important components of a multidisciplinary team. He emphasized that although the majority of people with diabetes can be managed in primary care, some develop more complex problems. People requiring a specialist referral include those with kidney or eye disease, neuropathy, people initiating insulin, using pumps or with psychological needs and pregnant women with diabetes.

Conclusions The overarching objective of the 2010 Alice Springs Symposium, to promote engagement between local healthcare providers, educators, researchers and policy makers in order to expand knowledge of evidenced-based care and thus reduce the ill health and mortality caused by the complications of diabetes, was successfully achieved. One aspect that we hope to improve on in future meetings is the level of attendance by Indigenous health professionals. Barriers to attendance could have related to the need for people to travel to Alice Springs, or leaving their community understaffed by health workers. The project will investigate the possibility of conducting some of the future Department of Health and Ageing educational symposia in remote communities in the Northern Territory.

Elizabeth Barr, Alex Brown Baker, John Boffa, Paul Zimmet Elizabeth Barr is an epidemiologist at the Baker IDI Heart and Diabetes Institute ([email protected]). Alex Brown Baker is Head of Indigenous Health Research at the IDI Heart and Diabetes Institute. John Boffa is Public Health Medical Officer with the Central Australian Aboriginal Congress. Paul Zimmet is Director Emeritus and Director of International Research at the Baker IDI Heart and Diabetes Institute.

Acknowledgment

The symposium was funded by the Australian Government Department of Health and Ageing.
