December 9, 2019
T2DM: Diabetes and Indigenous Australians

T2DM: Diabetes and Indigenous Australians

Hi, I’m Warren Snowdon, Minister for Indigenous Health,
Rural and Regional Health and Regional Services Delivery. It’s my pleasure to introduce
this program, produced by the Rural Health
Education Foundation and which is funded
by the Australian Government Department of Health and Ageing. Five years ago, approximately
700,000 Australians had diabetes. Just three years later, the number had
jumped sharply to more than 818,000 or 4% of the population. The majority of those – 88% –
were cases of type 2 diabetes. Every day in Australia, about 275 adults
develop some type of diabetes. There are on average
10,600 deaths each year where diabetes is the underlying
and associated cause, which represents
about 8% of all deaths in Australia. In Indigenous populations,
the figures are far worse. The prevalence of type 2 diabetes amongst Aboriginal
and Torres Strait Islander people is at least three times higher
than for non-Indigenous Australians. And incredibly,
the rate of all types of diabetes amongst Indigenous Australians
in some remote communities is as much as ten times higher. Yet, type 2 diabetes is considered to be
largely a preventable disease. This program examines
evidence-based approaches to the management of diabetes, hypoglycaemic control and
diabetes-related complications amongst Indigenous Australians and is Part Four
in a series of type 2 diabetes and the new NHMRC endorsed Type 2
Diabetes Mellitus Clinical Guidelines. This program will assist GPs, Aboriginal
health workers, diabetes educators and all primary healthcare workers in
providing support and good care needed for Indigenous Australians
with type 2 Diabetes. I commend this broadcast as a key tool
in improving Australia’s performance on this important health issue. I strongly believe that a better
understanding of how to prevent, detect and diagnose diabetes
in Indigenous Australians will lead to improved health outcomes
and life expectancy for all Indigenous communities. Thank you, Minister. I’m Norman Swan. Welcome to this, the fourth program as
he said, on Type 2 Diabetes Guidelines and looking at diabetes
in Indigenous Australians. And on behalf of everyone, I’d like
to acknowledge that we are meeting on the land of the Wangal people. The Wangal people
are the traditional owners of this land and form part of the wider Aboriginal
nation commonly known as Eora. We also acknowledge
elders past and present and the descendants
of the Wangal people. Diabetes accounts for a significant
proportion of the gap in mortality rates between Indigenous
and non-Indigenous Australians. And as the Minister implied, this program focuses on a comprehensive
and culturally appropriate multidisciplinary approach
to prevention, detection, diagnosis and management
amongst Indigenous Australians. Now, if you’re watching
on your computer, you have the facility to type your
questions in directly to the studio, just type your question in the LiveTalk
text box below the slides. That also means of course
that we can ask questions of you and here’s one to get you going. Tell us where you are located – in metropolitan, regional,
rural or remote Australia. And we’ll come back to the answers
to that in a moment. As usual, there are a number of useful
resources available to you on the Rural Health Education
Foundation’s website – Now let’s meet our panel. Dr Pat Phillips is the Director of the
Diabetes Centre and Endocrinology at the Queen Elizabeth Hospital
in Adelaide and has been for many years
at the forefront of diabetes research and treatment and overseas,
the State Diabetes Outreach program. – Welcome, Pat.
– Thank you. What is the Diabetes Outreach program
in your state in South Australia? It’s really around building capacity
in rural and remote areas so it’s focusing
on the health professionals and trying to give them
a better capacity to deal with diabetes
in their communities. So it’s not parachuting in services, it’s getting the local services
to be able to do it better. The principle is that
if we can get the locals to do it, it’s a bit like teaching someone to fish
rather than giving them fish. NORMAN: Dr Rob Way
is a general practitioner at Katungul Aboriginal Medical Service
in Narooma, NSW. – Welcome, Rob.
– Thank you, Norman. You’d have a few people
in your community with diabetes? We have a few of our population, yes,
with diabetes and perhaps a few with diabetes to come. NORMAN: Sumaria Corpus
is an Aboriginal health worker and diabetes educator from Darwin. – Welcome, Sumaria.
– Hello. And we’re going to be talking about
your program in the Top End shortly, which is you’re quite actively going out
into communities looking for people
and helping people with diabetes. Yep. NORMAN: Bernadette Heenan
is a credentialed diabetes educator and registered nurse
from Far North Queensland Rural Division of General Practice
in Cairns. – So you’re actually providing services.
– That’s right. We parachute in. And doing that.
Right, can’t get away from it. Again, we will come back to both
your experiences and Sumaria’s later. So, Pat, do you have anything to add to
the statistics the Minister just gave? I think that was a very fair summary,
diabetes being very common and up to 50, 60, 70% in some Aboriginal
populations depending on their age. I think it was also a good point made
about the complications and the excess mortality
in Aboriginal people related to cardiovascular death and
renal disease, in particular those two. And I think the other comment
which was really important was that it’s a disease
that unfortunately is so common
amongst the Aboriginal population that you almost have to assume
that someone is going to get it and start looking for it
and treating it very, very early. Bernadette, is it different
amongst Indigenous people, Aboriginal and
Torres Strait Islander people, than in the general community? Um, yeah, I think we notice it,
certainly in the areas where I work. A lot of the clients that I,
well, all the clients, most of them I see have got diabetes and there’s certainly
a much greater proportion in each of the communities that I go to
that would have diabetes than you would see
in downtown Cairns, say, so… But how different is it
from non-Indigenous people? It’s hard to know to what degree
it’s a different disease in the sense that it’s much more serious
than in non-Indigenous people because the Indigenous people
have more risk factors so they have more hypertension,
a lot of dyslipidemia, a lot of central overweight. It’s also not clear also
whether it may just be something that they are genetically predisposed to and the third potential factor,
or at least a third one, is the prenatal environment so that their intra-uterine environment
is often breeding a tendency towards diabetes
metabolic syndrome renal disease even before they are born. And instances of kidney disease,
same with diabetes, is huge compared
to the non-Indigenous community. Very much so. So 30% of the population with
type 2 diabetes, non-Indigenous, may develop microalbuminuria
and potentially chronic kidney disease related to diabetes whereas it’s 70, 80, 90% of the
Aboriginal people with type 2 diabetes and is a major cause
of some of the other complications like cardiovascular disease. And that of course, Rob,
changes the way you look after people? That’s right, I think we are looking
at everybody as a work in progress and we’re just trying to make sure
that we minimise the risk factors as soon as we can
and actually, you know, I think I treat everybody
walking through my door with an Indigenous background
as pre-diabetic. Sumaria, what impact does
all of this have on communities? It has a great impact ’cause they’re not
functional at a higher level, a lot of people go to town for dialysis so it’s disrupting
the family everyday activities. And the support, there’s no support. Like, in the Territory,
they have to come, say, 800km to live in town and they can’t live
in their own communities so they’re taken away
from their homelands more or less. And how much awareness
do you think there is? There’s a lot of awareness but I think
we have to just do more promotion, health promotion,
and start in the schools. How young is the youngest person
with type 2 diabetes you’ve come across in your communities,
Sumaria? – The youngest is a ten-year-old.
NORMAN: Ten-year-old? Yes and that’s from
out in the remote area. And now she’s about 12 now and she’s on
oral hypoglycaemic medications and for that age, to have tablets
every day is really hard. Sure is. What’s the youngest
you’ve seen, Bernadette? Nine years of age this year and
she started on metformin straightaway. NORMAN: Rob?
ROB: Uh, 14. And that presentation was
with acanthosis nigricans so, yeah. So this is something
that not only happens more frequently, it happens at an earlier age? And it also means that the children
who develop their type 2 diabetes should they survive, they get the metabolic consequences
of having type 2 diabetes and the duration of having diabetes
that occurs in type 1 diabetes. So they get the complications
of type 1 diabetes and the complications of type 2 diabetes so they get a real,
a really bad set of problems. And we have the results
to our first poll question – where are you located? – and metropolitan – a third of you,
regional – a third, and rural – a third and, nobody’s admitting to,
well, a small percentage in fact are admitting to being in remote so it’s a pretty… 8.3% and the… So welcome to you all. I just wouldn’t mind just checking
your level, your self-perceived level of knowledge. Are you aware, do you think, of all
the risk factors for type 2 diabetes in Indigenous Australians? Yes, no, maybe a bit. And we’ll come back to the answers
to that in a moment. Let’s go to our first case study. Jim is a 30-year-old Indigenous man with a wife and three kids, living in a remote community, he’s unemployed, they share… The family shares a three-bedroom house with another family of four and all the four adults smoke. There is one store in the community. Jim enjoys playing cards, having a few drinks with his mates and occasionally goes hunting in the community Toyota. Jim’s mum was diagnosed with diabetes at the age of 50. What’s your assessment of Jim, Sumaria? Jim’s… With his mother being diabetic,
it’s a risk factor and being inactive
is another risk factor and not working
and alcohol, smoking they’re all risk factors so
yeah, it’s not too bright for Jim. So if he’s… Even before
you do a single test on him, the assumption is he’s pre-diabetic and he may already even be,
have diabetes? Yeah, most probably undiagnosed, yes. So if you don’t have experience
dealing with Aboriginal communities, looking after people in Aboriginal
or Torres Strait Islander communities, you might throw up your hands in horror
and say what could you possibly do? Well, I am going to ask you. What can you possibly do about someone
like Jim in your experience? Just talk to him, give, tell him
the truth and see what he wants to do, like, you build up your rapport
and inform him on his risk factors and what’s going to happen to him
and see what he wants to do about it. If he wants to start diet exercise, just small goals just to start with
would help. And what do you find motivates? Well, to motivate him,
employment would be a start. Getting the community involved,
community-driven activities. NORMAN: What does that mean, though? Not taking the Toyota
when you’re going out hunting or what? Well, they can go out hunting more often
using the community’s vehicle, doing community activities
with other families. NORMAN: Do they get much exercise
going out in the Toyota, though? Rather than sort of getting out
and walking? No, they don’t get much exercise but
what I am saying is going out to a spot and then go hunting from there, yeah. A lot of communities
are starting to do that now – taking people out
and just leaving them out there. How practical is looking for bush tucker and converting from
what might be a pretty unhealthy diet via the store to an expensive diet versus collecting your own bush tucker? There’s a lot of bush tucker
out in the Territory and it is, they can do it,
it’s just easier going to the shop. I promote going back to bush tucker,
hunting and gathering instead of just going to the shop
and buying meat where it’s much more healthier
to have to walk, to have to work for it and they have to chase it
so that’s natural. One of the traps I had was a guy,
one of my patients was telling me, ‘Oh, you only ate bush tucker,’ and this is in Tennant Creek
and what he meant by that was he ate a lot of kangaroo tail so he went down to the shop and
he got the kangaroo tail and ate that. That’s not bad, that’s lean meat,
isn’t it, or is that pretty fatty? That’s where
the kangaroo stores all its fat. Fat, oh, alright, so kangaroo tail
is not a good idea. And how would you monitor Jim, then? What sort of things
would you be looking for in terms of, or getting him to monitor himself? Would it be things like waist
circumference or you wouldn’t even…? Start with waist circumference. Ask him to see if he can start
30 minutes a day and weight loss, look at weight loss
and just set small goals and then he can grow on them. And make a change. NORMAN: Bernadette,
what would be your approach? Very similar, personalised to suit him. We’d give him a self-management folder and try and teach him a lot about
best blood pressure, what to aim for, we even encourage our clients
to self-blood-glucose monitor even if it’s only before and after
a meal once a week and we use lots of visual stuff so rather than having them
write it in diaries, we get them to download
their monitors to laptops so we use all the latest technology even if it’s out on someone’s verandah
or out somewhere. We just take our laptops with us
and so we do lots of pictures of, ‘This is when your blood sugars
weren’t so good and this is what’s happening now’ so there is always
before and after shots and always positive stories,
so positive role models. Sumaria, you’ve developed some materials
to actually help you or detect the symptoms of diabetes? Yes, we did this in Darwin
and it’s How Do You Feel? and these are signs and symptoms. We’ve done five chapters so we went to
What Now? I Have Diabetes, Taking Medications, Doing BGLs and just helps them understand
what they’re going through. And it’s a good tool
and it’s on the web. – So just show us a little bit of it.
SUMARIA: OK. The first steps is being lethargic,
sleepy, no energy and they can relate to that. And they say, ‘Oh, yeah,
that’s how I’ve been feeling.’ Some people are up all night
going to the toilet so the first thing you say is, ‘How many times do you actually
get up to go to the toilet?’ And then, you know,
that sends alarm bells. OK and then you can say, well, going to the toilet
if you get your blood sugars down, because your body is trying to get rid
of that excess sugar in your body and it’s making you get thirsty and the body is trying to get rid
of the excess sugar so they are urinating it out. And if people want to get a hold of some
of these materials, how do they do that? Contact your local diabetes office or look on the web
under Diabetes Australia. Let’s talk now about
your more active prevention, Pat. What other more active things
can be done? I mean, for example, is there any role
in Aboriginal communities for obesity surgery? I guess, that’s a question
I haven’t thought a lot about because I would imagine
it is very difficult to access and also very difficult
to support the person through some of the things that
are associated with bariatric surgery so if you’re going for
the malabsorptive surgery, for example, that really takes quite an investment
in terms of educational nutrition and if it’s lap banding,
it’s once again teaching people not to switch from solid to liquid food
which will just obviate the… So I’m not sure they would get
the sort of support after the surgery which is likely to make the surgery
successful. And is there any evidence that intervening in Aboriginal
and Indigenous Australians with their high risk of or
hypoglycaemic agents or insulin early actually helps to minimise the course? There have been some
not totally well-controlled but some intervention studies
and in particular relating to the kidney disease that I was talking about
a little while ago. And in Northern Australia,
in the Tiwi Islands, there’s a program which was organised by
a doctor, Wendy How, who… MAN: Hoy.
– Hoy, who – thank you – who actually basically gave everyone
an ACE inhibitor, an angiotensin-converting enzyme
inhibitor, because of the problems of
chronic kidney disease, hypertension and showed a progressive decrease
in both the total mortality and also the progression
of end-stage renal failure so it was, in that sense,
historical controls but it was a demonstration that
A – it was feasible to do this on a population-based scale
and B – it seemed to be effective. So what do the guidelines say? The guidelines suggest that an ACE
inhibitor is a preferred medication in type 2 diabetes
if the person has hypertension. There’s also been trials
in non-Indigenous people that an ACE inhibitor has benefits
in those who have type 2 diabetes and one other
cardiovascular risk factor. Of course, everyone’s got
one other cardiovascular risk factor so it’s virtually
everyone with type 2 diabetes. That was the HOPE study with… It has been repeated
with other ACE inhibitors. There have not really been
a lot of intervention studies which have been done in any sort
of trial basis in Aboriginal populations so the diabetes prevention program,
for example, was an American program and has been
repeated in lots of other countries using metformin,
other drugs have been used – the glitazones, acarbose,
several other drugs have been used. NORMAN: But not proven? Not in the Aboriginal population. In those populations they did reduce the
progression of pre-diabetes to diabetes. Let’s go to our first case study –
oh, sorry, our second case study. This is a film case study. It involves Greg,
a 37-year-old Indigenous man who presents to Western Sydney
Aboriginal Medical Service at Mt Druitt in New South Wales. He’s screen-diagnosed with diabetes
and engaged in an intervention. Let’s take a look. I think once you’ve seen
Indigenous patients who are very young having diabetes, having heart attacks,
having all sorts of vascular problems as we see in this setting, it really gets your radar working and you have to apply
the screening test at an earlier age than you would elsewhere. Greg. This morning, actually,
a patient of mine called Greg is coming back to see me. I saw him last week,
we were discussing diabetes ’cause he has a few family members
with the disease and we did some tests in fact
and today he’s coming back to have me tell him unfortunately
that he does have diabetes. Oh, I hope you got
some good news for me. Well, look, yeah, last week
we were discussing diabetes and… ‘Cause you were… Greg is getting on into his late 30s,
almost 40 now, quite a young man
for someone to be diagnosed with the mature onset type of diabetes. But being an Indigenous man, he has
an extra layer of risk, we might say. He’s not a big man, he’s not the shape
that makes doctors think, ‘Well, that person’s a suitor
for type 2 diabetes.’ But I guess it goes to show that
being Indigenous and even just being
a little bit overweight, they are risk factors enough
to actively look for diabetes. Can it go away
or is this going to be the answers? It’s something
that will be with you for life. Before we get too far ahead
of ourselves, I’d like to go back to sort of
explaining what diabetes is all about. It’s very important to actually make
sure the patient knows the consequences of having poorly managed diabetes and, you know, so we’re talking about
problems with the feet and problems with the eyes in particular but there are also problems as you know
with the heart and kidneys and brain… That’s a good starting base then to say,
‘Well, what can we do about it and how can we prevent those things
from happening?’ You know, if we are going to move
forward now and manage this effectively, we want to involve some key people
in helping you to manage it. It’s important simply to have
a very explicit, you know, listed plan of what’s going to happen next
and with whom so that everyone knows what is going on
and nothing is overlooked. In the first instance, I referred Greg
to the Aboriginal health worker whose specialty is diabetes and Louise has a very good understanding
of the disease and can talk to Greg about that
in a way that he’s, make it easier for him to understand that perhaps I wouldn’t be able
to do so well. So he’s in the waiting room now. So you want me to have
a little chat to him and… – If you could.
– What have you been through with him? A bit about… Apart from that,
obviously being Indigenous herself, she has that sort of innate
cultural awareness and ability to attend to perhaps
slightly different issues that would be different
from my perspective. Just a question, did you understand
what Dr Bill was talking about? Yeah, I did, yeah, but just he told me
there are ways of controlling it and so I just would like to talk about
what things to eat now and… OK, then, so… When a patient like Greg
or any of my patients come to me, I would normally talk to them
about diet changes, exercise and the complications
that diabetes can have in the long run if their diabetes is not managed. – Did he put you on any medication?
– Not as yet. No, so that’s good, so we’re just gonna
go on diet control at the moment. You got to try and focus
on the first thing. Like, Greg today, really,
about his diet changes ’cause it’s a big shock to their system,
like, they’re coming in newly diagnosed and you try and tell them
all these things, they’re just gonna forget about it
mostly ’cause they’re still
in a bit of a shock, you might just have to explain it
a bit more in simple terms. You know, your diet,
well, next time you go shopping, you might want to look at this and say, well, you know,
go at the back here and say, ‘Oh, on my shopping list
I might choose from this today.’ You know, on the shopping list
and your different choices… One thing too I do encourage
is that they do get a glucometer so they can measure their sugar levels so they can keep an eye on it
to see what’s going on but you know a lot of our patients
can’t afford it sometimes so… But they do come in here
and we can do it in here anyway if they don’t, if they can’t afford
to buy their own glucometer. So what have you eaten this morning,
Greg? Have you…? Oh, this morning
I had some vegemite on toast. 7.9 – that’s still a little bit high. So is that all you had,
vegemite on toast? Oh, and a meat pie. Well, once the patients
attend the service, you know, it’s usually a team approach. We do have a lot
of our visiting specialists come in like a podiatrist, a diabetes educator so that’s all done but as for the eyes,
we need to send them out. So you’ll book me in for a week’s time? I’ll book you in for a week’s time
with Heather. – So I’ll see you in a week.
– Yeah. We can only do so much
as health workers. Most of it we try and encourage it,
put it back onto the patients themselves like for self-management. By checking, buying a glucometer,
checking their sugars, having regular check-ups, making sure
they’re taking their medications. – I’ll see you next week.
– Thanks, Louise. Thanks a lot, have a good day. We still have a lot of our patients that
have gone down the track and, you know, ended up on dialysis. It would be so nice
to catch these patients early before it gets to that stage, I suppose. After all, I know things are not 100% but at least I am still going to be here
for as long as I can with the help of
the Aboriginal health workers here. Greg’s story from Mt Druitt
in New South Wales. – How typical is that, Rob?
ROB: It’s very typical. Mind you, Greg looks quite motivated and probably not too daunted
by his diagnosis whereas occasionally we find people
who are quite, quite upset, quite concerned about a diagnosis. And so I think with… I think Bernadette was talking about
emphasising the positive, the thing I would be making sure
that Greg knows is that it’s great that we picked it up
as early as we have. Hopefully it’s within a few months
of his blood sugar popping up so that we can start
all these preventions. The guidelines that we’re using here, this is a general practice
set of guidelines too, are they not? ROB: Yes and there’s – I don’t know
if we’ve got a slide of that coming up – but there’s some excellent
diabetes management guidelines that cover pretty much most of the
questions that we’re touching on today. Just going back
to the earlier point about screening, how regularly do you screen people
in an Aboriginal community? In an Indigenous practice,
I screen everybody every time they walk through the door
so it’s a set process they get. They get their weight,
we measure their waist regularly and we check their sugar
probably every, at least once a month if they’re popping in. NORMAN: What about you, Sumaria,
what’s your advice? We do waist-hip ratio, weight, BGL,
blood pressure. Do you use at risk tool with them or
do you just assume everybody is at risk? No, no. NORMAN: You just assume it’s everybody? It’s not designed, they never took it
into account for Aboriginal people ’cause they’ve got
the Aboriginal and Asians together and they’re totally different
body shapes and ethnic background so it doesn’t work. And, Bernadette, you try and personalise
the approach to somebody like this so that they’ve actually got
their own book. Yeah, we’ve got a self-management folder
that we use for people so we tend to take their photo and give them a whole book
that’s dedicated just to them. It’s full of lots of handouts and things
that are actually showing what their blood pressure is,
what their blood glucose levels are, what their HBA1C is
and there’s lots of handouts done by our doctors, dietitian,
podiatrist, etc., on how they can actually look
after things themselves so they’re… NORMAN: They even have
an appointments book in there? Yeah, there is an appointment book,
yeah, with a whole ten or so people, we call it ‘The mob
who help me look after my diabetes.’ ‘Cause what we haven’t said
but a lot of people watching know it, this is multidisciplinary team. Multidisciplinary team,
you can’t do it any other way, yeah. So that’s what this is about
and the idea is that it is something big so our clients, it’s harder to lose. The original patient held record, you
put it in your wallet and you lost it. This is so big
that it’s hard to lose at home. And hopefully, clients will bring it
with them to other appointments so we’ve even had people turn up
in Cairns to see their specialist and they’ve brought their folder
with them and the specialist has written a letter
back to the GP up in the Cape saying what happened on the day. And then you’re also empowering
the client so much because they’re in charge
of that communication between a specialist and another doctor so it’s very much tailored for them
and we invent things as we need them. Just before we go on, let’s take
the results to that poll question – are you aware of all the risk factors
for type 2 diabetes in Indigenous Australians? And half of you say yes and the vast majority of you have this
partial knowledge and no is 12.5%. Thank you for being so honest,
the 12.5% of you, and we’ll ask another poll question now
which is, ‘Does your service have a local
Indigenous diabetes education program to which it can make referrals?’ Yes, no
or it’s part of your own service. So let’s hear
what the answers are to that. What are the treatment options for Greg? I mean, the guidelines say
start with lifestyle but some people would argue
with Aboriginal people, given their high level of risk, you
might move a little bit more quickly. Well, actually, the Americans and the
Europeans have both sort of adopted that second approach,
that is, you’ve got type 2 diabetes, you counsel people on lifestyle
and start metformin at the same time. In Australia, we tend not to do that. We tend to use lifestyle first and then add in metformin
fairly shortly thereafter. It does have the advantage,
if you focus on lifestyle, is that you’re not taking their diabetes
away from them so that you’ve just been diagnosed
with type 2 diabetes and I give you a pill and say, ‘Take this pill and
that’s all you have to do about it’. Then the diabetes is now my problem – I’m prescribing the pills,
you just take the pills and that’s the end
of your responsibility. And if the pills don’t work,
that’s your problem, doctor. That’s right. But focusing in on the lifestyle
engagement in the lifestyle and engagement in understanding diabetes
and then using the medication, it might delay the medication, starting
the medication by a little while, but probably not much more
than weeks or a month or two. And in the context
of the type 2 diabetes, actually engaging the person
in their self-management is really very important. And what about this incredibly high risk
of kidney complications? I think there is a very strong case.
Now, I’m not a practitioner who deals a lot with rural and remote
populations of Aboriginal people but there’s a very strong case I think
of in much the same way considering starting an ACE inhibitor
pretty well straightaway too because you can be
very, very confident that that person if they don’t have
hypertension already, they will get it and if they haven’t got
kidney disease already, they will get that. And ACE inhibitors have been shown
to be good medications for hypertension and reduce the risk
of chronic kidney disease. And you don’t necessarily have
to have hypertension to have them? – No.
– Rob, what’s your practice? I’m also wondering…
I mean, yes, I think so. I think that we should be, there’s
evidence that both those medicines you know, delay
the onset of complications. The other question would be, should we
be starting a statin at the same time? Well, there is the…
There’ve been, as you are implying, there’ve been several studies using
statins in people with type 2 diabetes so there is the heart protection study
and there’s a card study and the a priori guess would be that that same benefit
reply to an Aboriginal population. Although stronger for antihypertensives. Sumaria, there’s an affordability
problem here. You have all these doctors
throwing around the scripts, people have actually got to pay
for the drugs. Um, in the Territory,
because they’re remote, we’re under the S100 so they get
Webster packs from the local clinic and then their medication is reviewed
every three months. So it’s… And, say, if they’ve moved –
that’s the difficulties – or they come to town,
they leave their medications at home and Indigenous people out bush
are always in and out of town so you just have to make sure
they understand why they’re taking the medications
and to take the medications with them. We give them a little esky to take
their insulin when they go fishing or they go bush so then
they can take their insulin with them. Just making things easy for them
to take it with them. How aggressive are you with insulin
in the remote communities? We’re quite aggressive with insulin because I look after
the gestationals as well and this is young girls
with gestational diabetes and the only treatment for that
is insulin. So we have to look after their baby
for the whole term so, yeah, we have to be there,
we have to… Like, a lot of people say,
‘Oh, it’s impossible to get them to do four, five blood sugars a day’ where,
if you educate them on the realistic what’s gonna happen to the baby
if they don’t, they’ll do it. And people say,
‘How can you have them on basal-bolus?’ That’s four injections a day
but they’re willing to do it so the right information and being consistent
in what messages you are giving them. I think that is really important. And what about non-gestational diabetes,
people with just regular type 2? Type 2, yeah, we do that
once they’re on maximum orals and then we’ll start them
on maybe a long-acting at night and it seems to work, yes. So less of a problem
than you might imagine? Yes, with the right information,
right support you can. Tell me a bit about your program
in Cape York for people like Greg although Greg’s
in metropolitan Sydney, really. Yeah, what we have up there is we’re part of an improved
primary healthcare initiative and there’s a group of us
who travel around together – GP, podiatrist, dietitian and a few other people – and these are the areas that we cover. So we cover a few of
the remote communities up Cape York and the Royal Flying Doctor Service
covers the other areas. And we try and cover the full spectrum of primary health care, comprehensive primary health care
across all the different… As well as just doing
the clinical areas, we go right through to trying
to educate and prevent and prevention in terms of
engaging with local shopkeepers, etc. So, um… Yeah, we try
and encourage the client to learn as much
about their condition as possible. That’s one of the large areas
that we’re involved in and the key person to our whole project is our community engagement coordinator. No matter what we do, we don’t go anywhere or engage in any activities, etc., without involving that person. And as you can see
from the slide up there at the moment, our CEC is the most important person. They’re always Indigenous so we have one in
each of the major areas we work – the Weipa Cluster, Cooktown Cluster and Mossman Gorge area. So if we were seeing someone like Greg, then it would be our CEC who would go
out there and make the initial contact if we were seeing him
out in the community and invite him to come in and see us
or we do home visits, whatever was appropriate. And we tend to be quite aggressive
with our management as well. NORMAN: And your booklet
provides the care plan? Yeah, it’s the care plan, the
communication document, the education and it’s all best practice, there’s no second best, second rate,
it’s all… yeah. Good. Let’s take some questions now
from you. Kirsty from
Charles Sturt University asks, ‘How do you explain to someone
with little formal education what diabetes is and the importance
of regularly taking their medication?’ Bernadette? When describing what diabetes is,
we would often draw things so we’d draw things
on a bit of scrap paper, maybe on a board, whatever’s available, and do a basic drawing
and show what happens. We use all sorts of things,
big drawings on pieces of material or the other day we started using a clear plastic container
with little balls, green balls for glucose
and red ones for red blood cells and you fill it up with 20 green balls to show how clogged things become
with glucose. We use lots of analogies
in our storytelling so whether it be Blu-Tack or
chewing gum on a keyhole on a door and how, you know, talk about
how the insulin won’t work with that so we use, so we draw pictures,
we also do blood… You know, when we’re drawing, putting
people’s blood pressure into their book, if they happen to come on a day
that they forgot, they haven’t taken their medication
this morning, you put that little note in there so the next time they come and
their blood pressure is in a good range, the person is learning straightaway
the relationship between taking your medications
or not taking them and what it’s having on their body
and they’re seeing it in a picture form so you don’t have to read
to use the books. Sorry, Rob? Can I just say, I think one thing that
doctors often really get worried about is that understanding initially
for a patient and I think that comes with time and sometimes, I don’t know,
I found when I was young and keen, I really wanted to tell the patient
all about diabetes up-front and I think and, really,
I think I put people off and I think, really, keeping the message
as simple as possible so that people feel more in command
of what’s happening is actually… And then go with the patient
as they want to understand more then, you know, you talk more
about their condition and go into… And, Sumaria, you’ve used those
materials you were showing us earlier. Yeah, I find more colour,
the more they understand and just keeping your messages simple
and just grow on that. Our next question comes from Natalie
in rural Victoria, who asks, ‘There’s been mention of a traffic light
in the food labelling program in remote communities
in Western Australia. Has this been applied
in other communities? Can you comment on
whether you think this would assist?’ Yeah that’s traffic light… It’s actually a British system,
isn’t it? It started in Britain. Mm, I don’t know,
I’d have to ask the dietitian that one. But I know that sometimes they use
green ticks and things like that in some other shops up the Cape and I know it’s still used
in some of the healthy food programs. A general practitioner from Melbourne
asks, ‘Should there be any difference
between treatment approaches between urban and remote
Indigenous people?’ Which we have kind of answered
but, Pat, do you…? I think there are practical differences
between the two populations and one of the practical differences
is the availability of S100 medications in South Australia
and some other states. I understand they’re not available
in every state but this is a Commonwealth program whereby the Aboriginal people
in rural and remote parts of Australia can actually get their medication
free of charge. NORMAN: But they don’t in the city.
– But they don’t in the city. And when people
from rural and remote come to the city, they no longer have access
to those medications. Rob was telling me earlier that the program doesn’t apply
in New South Wales so that would make a big difference to the rural and remote people
in New South Wales compared to those in South Australia,
for example, because New South Wales, they’re going to have to get
their medication some other way, South Australia, they can get it
through the S100 scheme. And is there any evidence that adherence
to medications is lower in the cities? I’m not sure that
there’s actually ever been done a trial but there’s lots… It’s really
a well-known phenomenon that people come to the city
and they don’t get their medication because they no longer have access
to the S100. The Aboriginal medical officers
in Adelaide are very, are continually lobbying
the Commonwealth to make the S100 drugs
available to city people and particularly to the rural and
remote people who come to the city. A nurse in Central Queensland asks, ‘Is there a simple way,
any simple way of assessing diabetes risk in Indigenous people?
Would we use the AusDrisk tool?’ I think you can certainly use
that tool and… NORMAN: But Sumaria reckons
it’s not much cop. (Laughs) That’s right. No, well, it’s not designed
for Indigenous. They’ve got a different body frame
to Asians so you can’t just throw everyone in
and say, you know, they’re all, we’ll just use this. As I said the best way
is waist-hip ratio. The jury may be out. Personally, the way I would use
the risk assessment tool is to say, is to show people that if you’re, say,
like many of my patients, Aboriginal, and you have a family history
of diabetes, you’ve already got five points
on your way to 15 points of being at the high risk. However the other points, the other
risk factors are actually things that you don’t necessarily have
to have – you don’t have to be a smoker, you don’t have to actually, you can eat vegetables and fruit
each day, you can do some exercise
so you can actually… So it points out a way of showing
how you can change your behaviour – as much as anything else.
ROB: That’s right. Jane from the North Coast
of New South Wales asks, ‘How early should we start screening
Aboriginal people for diabetes?’ Pat. The comment was made
by the earlier speakers that they’ve seen children
aged nine and ten and I think Rob has the practice
of starting screening aged ten and that seems like
a very reasonable thing. I think it’s also
just worth commenting here is that the teenage girls,
it’s particularly important to look out for early pregnancy because those girls
then get gestational diabetes and that has adverse outcomes for
their pregnancy but also for the child so I think that group in the younger
women is a really important group. Sumaria, what do you think? I think that’s a good point, yeah. We have to, um, screen them
at the age of ten and the younger women as well
and get them prepared for pregnancy instead of unplanned pregnancy. Those sorts of things have to be
addressed and reviewed as well, yes. Let’s get the results
of your last question – does your service have a local Indigenous diabetes education program to which it can make referrals? Answers – half of you, yes, half of you, no and a little bit of you say that it’s part of your service. So then the next question for you is: We’re not giving you
a little bit of option here so let’s see what your answers
are to that. Let’s go to our next film case study – the Aunty Jean’s Good Health Team
and it’s built around the idea that better results for
chronic disease management can be achieved
if the community works together with the elders leading the way. The program is a comprehensive approach to improved self-management
in Indigenous people. Let’s have a look. It’s named after Aunty Jean Morris who was a very much respected elder
in the Illawarra. She did a lot of volunteer work
for the community over her lifetime and she passed away. Permission from her family was sought
to use her photograph and her name as the Good Health Team. I first came here,
my sugar level was about 19. Now it’s dropped back down
to four or five, you know. So it’s good for me. Aboriginal people don’t go to the doctor
until they have to. It’s a last-minute thing
with the Aboriginal people. They won’t go to doctors
but coming up here, I know where I stand with my health. I think it’s the creation
of a culturally safe environment. Most of the people have chronic illness and we look beyond the clinic rather than the prescriptive which is normally clinical focus which is normally given
in other programs. We look at abilities, not disabilities, wellness rather than illness,
strengths and really engaging people and letting them build up
their confidence in self-managing and I think in that culturally
safe environment, it works really well. We’re gonna push down and out and then back down. We saw the need when
Caroline first came on to the program as the program manager. She’d done some background work
in talking to other service providers and organisations and asking about what they actually provided
for Aboriginal people with chronic care or chronic conditions and she found that there was
a great big gap in service provision. Some of the programs were either
too wordy and there was a lot of reading material and the other thing I guess
was isolation, they felt isolated
because they didn’t have other crew people
attending the program, etc. And some of them found it difficult
so those were some of the findings and we did some community consultations and asked the Aboriginal community
in the Illawarra and Shoalhaven and their carers
what they could identify as gaps in service provision to them
as well. We invited a group of elders in the
Illawarra to help us put the framework and the flesh, I guess,
of the program together. I’m one of the first and still attending and I was very down and very depressed. I used to hate to get up
and face the day. Coming here every week, I’ve enjoyed it.
It was something to get out of bed for. I’m not just sitting around
waiting to die now. I couldn’t move on Friday… I’m living a beautiful retirement. Much better than what my mum did. They didn’t have all this around them
but I have and I am very grateful for it. Went to the Wollongong specialist
for my kidneys and he said to me, ‘Well, I’m afraid I think
we’ll have to take your kidney out.’ I said, ‘You’re not taking parts
of my body, I’m not giving them away.’ And he said to me,
‘Well, get into exercises and so forth.’ I started doing weights here
Mondays and Tuesdays and then I went back
and saw the doctor six months later and he was so thrilled. He said whatever I’m doing there,
keep up the good work. He said he wished all his patients
would have been just as healthy, what I am now. Some people are actually staying
out of hospital because of the program. Those people with really chronic
and complex conditions come along and they’re, you know,
improving their flexibility and strength and learning to manage more. I do exercise
which I’ve never ever done. I get up on a morning
and I start walking. I’ve never ever done that, never. ‘Cause I used to sit home
and feel sorry for myself. But now I’ve got a life. I can walk further, I can swim better and I can annoy a lot of people
a lot better too now. I can touch my toes and do up my shoes
easy without puffing and blowing because since I’ve been doing this, I have also gone off
the asthma machine as well. I only use the puffers now because I was
an asthmatic when I first came here. WOMAN: You have to have good nutrients
so that means you got to be eating the right thing. For diabetic people, your blood sugars
must be under control… WOMAN: They help us, they talk to you
and explain everything to you, you know, with your diabetes
and things like that. My sugar level was just high, too. This means a lot to me. I wouldn’t stop coming here
’cause this is my family, my friends. So only for
Aunty Jean’s exercise classes, it’s really put me on top of the world. The Aunty Jean’s Good Health Program. – Rob, what do you think?
ROB: I think it’s fantastic. My only concern
with this type of program is that people go often enough to get that exercise regularly
throughout the week and my only concern was one
of the comments from one of the ladies is that she looks forward to
the Aunty Jean’s Program every week. I suppose, Sumaria,
if you look at it and you think, ‘What are they actually doing there?
They’re moving their feet up and down. Are they actually doing anything
significant?’ But in fact that’s actually
movement against a background, not just for Indigenous people
but for non-Indigenous people too where there’s obviously,
there’s probably not very much movement in their lives. No, that’s a good program. Out in the remote areas,
they don’t think about, like, exercising because they think,
‘Oh, we live a long way so we’re exercising walking around.’ NORMAN: We’re exercising
driving the Toyota. You know and stuff like that but, yeah. The communities
have to start being community-driven and start exercise programs
in the communities and a lot of the problems is dogs. You know, getting bitten by dogs
and stuff like that. And what we say is just take a group
of youse out and just go for a walk, you know, along the beach is beautiful and a lot of those areas
have spectacular views. And it’s just people supporting
and just prompting people, I think. And your program
is basically an outreach program going to those communities
and has links to specialists, etc.? Yes, we do, we promote self-management,
we give them the tools to make changes and ongoing education, support
and we do outreach from Port Keats over to Borroloola so we’ve got
the Top End, so, yeah, and… – So you’ve spent your life in a Toyota?
– No, aeroplane. – Too far to go.
– Yeah. And we do follow-ups with them
and stuff like that so we’re in contact with them. So, yeah, we’re slowly doing it,
we’re only a small team but… I think we’ve got the results
of your last question: And three quarters of you are saying
yes and a quarter of you, no. Let’s just talk quickly
about complications and the management of complications.
Rob? What’s the… What should be
the approach here? I think it’s prevention,
I think we, you know, from diagnosis, we brief the patient
that because they have a condition which can affect many parts of the body, we are going to have many parts,
many experts looking to prevent those problems occurring. And I think we make sure
they’re off to the ophthalmologist for an initial visit, off to
the podiatrist, the diabetes educator and other people as needed, perhaps the endocrinologist
if it’s a young or an unusual case. Pat, I mean, what about management
of complications and prevention? We spoke earlier about medications and I suppose we should really talk
about blood sugar control in this group and the medication regimes,
just remind people what the approach is. For non-Indigenous people, there’s a
tablet which is called the type 2 tablet which is recommended for all people
who have got type 2 diabetes and that’s got metformin, statin,
ACE inhibitor and aspirin in it. And in an ideal world, everyone who has type 2 diabetes
would take those medications which are pretty evidence-based
in terms of reducing the risk. Now, that would apply even more
probably to the Indigenous population but then you’ve got the problem
that you use four different medications, it’s six different
medication-taking occasions so it’s quite a burden. And I think in medication, one probably needs to say, ‘So what’s likely to give us
the best bang for our buck?’ And I think we can be
pretty confident with metformin, we can be pretty confident
with ACE inhibitors, pretty confident with insulin,
they are three good medications and blood glucose control is important because of the microvascular
complications. And if you don’t develop neuropathy,
you probably won’t get foot problems and if you don’t develop nephropathy,
your risk of cardiovascular disease is also very much less so glycaemic control and blood pressure
control are really important priorities because the blood pressure
also predisposed to the kidney disease. But the guidelines say no insulin until you’ve maxed out
of your oral hyperglycaemics. Well, that’s not entirely true either. The Americans and Europeans
have recently come out with a guideline that says you start with metformin, your
next medication could be a sulfonylurea, it could be insulin,
it could be a glitazone, it could be one of the other
less commonly used medications. So I think people are recognising
that insulin is very likely to be needed at some stage
and earlier may not be a bad idea. And, Sumaria, how well or badly
do people cope with hypoglycaemia particularly when you get on to
the sulfonylureas and insulin? We make sure they are self-monitoring,
we don’t put anyone on insulin unless they’re self-monitoring. They do manage, we have
blind people doing insulin injections and they count the clicks,
those sort of tools, you know, we try and work out what’s good for them and with the right information and
the right tools, people can do things. And in the Top End and in Cape York, what do you do about retinal screening,
foot care, that sort of thing? We have a podiatrist who travels with us and plus, most of the health workers
in any of the communities know how to do
simple assessment forms as well and there is an eye team
that comes up a couple of times a year up there as well. Plus, we link in with the… The endocrinologist does a visit
up there from the Cairns Diabetes Centre and we also link in
with the Cairns Diabetes Centre so if there is foot problems
or whatever, we telehealth in video conference
in to them as well. So we’re in constant contact
with specialist areas as well for that. It’s been fascinating,
thank you all very much indeed. What are your take-home messages from
people from the program? Bernadette? Educate people as much as you can, keep it simple
so that you can empower them. Yeah, ’cause if they can be
the boss of their diabetes, I think that’s where
we are going to see change is when the people feel
they are in control. Make it a positive story
and no growling. NORMAN: No growling.
– No growling. No bullying,
you’re not a bully, Sumaria. No, no, we don’t do bullying. I think it is just being consistent,
being supportive and being truthful and, you know, everyone has got holes
in their feet, they do muck up, they, you know, get off track, just have the patience
to help them back on track. Yeah. NORMAN: Rob? Treat the individual and, I think, be
positive about the story that they’ve… They’re actually the people
who can control most of their risk factors
in their diabetes. NORMAN: Pat? Assume all people
of Aboriginal descent are very likely to get diabetes. I think, screen Aboriginal people at
regular intervals, for example, yearly. Intervene actively
in so far as one can with metformin, ACE inhibitors in particular and monitor for complications
particularly for neuropathy because that is the way
you will prevent foot problems. Thank you all very much and
I hope you’ve enjoyed the program on type 2 diabetes
in Indigenous Australians and got a lot from it, I certainly have. This series will be available
of all four programs in December and that will be free on DVD. If you want to order,
you visit the Foundation’s website and if you’re interested
in obtaining more information about the issues raised tonight, there are a number of resources
available on the website at and that includes links to all the new
type 2 diabetes guidelines. Don’t forget to complete
and send in your evaluation forms and please register for CPD points
by completing your evaluation form. I’m Norman Swan
and I’ll see you next time. Captions by
Captioning & Subtitling International Funded by the Australian Government
Department of Families, Housing, Community Services
and Indigenous Affairs�

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