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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 - rhef.com.au.
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 *** 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 rhef.com.au
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�