Aboriginal and Torres Strait Islander Male Health Module for Aboriginal Health Workers. Unit 10. Chronic disease and male-specific health issues

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1 Aboriginal and Torres Strait Islander Male Health Module for Aboriginal Health Workers Unit 10. Chronic disease and male-specific health issues

2 Content from: Unit 10. Chronic disease and male-specific health issues For the purposes of this guide, the term Aboriginal Health Worker (AHW) is used to describe Aboriginal and Torres Strait Islander allied health professionals that proide clinical and primary health care for indiiduals, families, and community groups. It is recognised that there are different registration requirements for the AHW workforce in different States and jurisdictions. Acknowledgement Andrology Australia would like to thank the Aboriginal and Torres Strait Islander Male Health Reference Group for their guidance and input into the deelopment of this report. Prerequisite learning Students are required to hae undergone prior training in aspects of heart health, diabetes, respiratory disease and depression. There are many health promotion and clinical programs now aailable to educate and help preent and manage a range of different health conditions. These can often be accessed from major professional organisations to ensure that eidence-based practice is adopted: Diabetes Australia Heart Foundation Australian Lung Foundation SANE Australia Mental Health Council of Australia beyondblue: the national depression initiatie Australian Drug Foundation Andrology Australia 2015

3 1 SHARED RISK FACTORS AND ASSOCIATED CONDITIONS The management of health (and disease) needs to be considered as a whole-of-body approach because of the inter-connectedness of the bodily system. For example, if a man experiences a specific problem such as diabetes, the disease, or medicines, can hae an impact on other areas of his health, for example foot problems. Most clinical practice for chronic disease recognises that other health problems also co-exist. Similarly, some lifestyle risk factors, such as smoking and obesity, increase the chance of a range of chronic conditions. Adopting a multidisciplinary and holistic approach to the management of the chronic disease is essential to improe the quality of life and care of the patient. Howeer, for males, chronic disease can often be associated with more sensitie health issues, such as mental health and sexual and reproductie health problems. These issues can often be oerlooked and not openly discussed with a health professional. Sometimes, males experience sexual health problems before they deelop a life-threatening condition, such as heart disease, suggesting that sexual health problems may also be an early warning sign of chronic disease (Holden, et al., 2010a). The strong association between erectile dysfunction and cardioascular disease and diabetes suggests that common mechanisms exist between reproductie problems and chronic diseases. Erectile dysfunction may present as a sentinel eent for cardioascular disease, making it important for males to discuss any erectile problems with a health professional irrespectie of age or sexual desire. Similarly, strong associations between lower urinary tract symptoms and cardioascular disease and treatment of hypertension hae been demonstrated (Klein, et al., 1999). Studies hae also demonstrated associations between reproductie health disorders and depression highlighting the effect of reproductie health problems on quality of life, as potentially manifest by psychosocial factors. These associations again highlight that reproductie health problems co-exist with, or may be considered as clinical markers of, other co-morbid diseases (Holden, et al., 2010a). The associations between chronic disease and sexual and reproductie health may bring potential windows of opportunity for preention and health promotion strategies. Due to the oerlap of risk factors between reproductie health and chronic disease, management of disease may be improed when reproductie health is also considered. METABOLIC SYNDROME Risk factors between reproductie health and chronic disease appear to oerlap with suggestions that management of disease may be improed when reproductie health is also considered. A growing area of interest is now emerging in light of the obesity epidemic, which considers a possible link between testosterone and the metabolic syndrome. The components of the metabolic syndrome include abdominal obesity plus two of the following: hypertension; high serum triglycerides; low HDL cholesterol leels in the blood; and high fasting blood glucose (or diagnosed diabetes). The metabolic syndrome is associated with increasing age, lack of physical exercise, smoking and a diet that is high in fats and sugars. It is estimated that approximately 29% of Australian adults oer 25 years and about 40% of Australians oer 40 years of age suffer from the metabolic syndrome. Of all Australian males, Copyright Andrology Australia

4 26% are obese (Australian Institute of Health and Welfare (AIHW), 2011) and middle-aged males hae the highest incidence of metabolic syndrome. People with obesity hae a three times greater chance of suffering type 2 diabetes and about double the chance of cardioascular conditions including heart disease, high blood pressure and stroke. Testosterone leels are frequently low in males with type 2 diabetes and/or those with obesity. Many of these males hae symptoms suggestie of, but not diagnostic of androgen deficiency. The widespread use of testosterone therapy in such males is controersial, howeer when testosterone is gien to those with established deficiency, improement is seen in insulin sensitiity, glucose homeostasis and body composition (specifically a reduction in isceral adiposity) and symptoms (Kapoor, et al., 2006). It is clear that testosterone appears to preferentially target the isceral fat in obese middleaged males (Marin, et al., 1992). This type of fat accumulation is widely regarded as carrying the most aderse cardioascular risk. PSYCHOSOCIAL FACTORS Psychosocial factors Lifestyle factors Figure: The oerlap and associations between reproductie health and chronic disease Many studies are now beginning to suggest that common mechanisms between general and reproductie health exist, as eidenced by oerlapping risk factors. Lifestyle modifications are known to reduce the risk of chronic disease and maintain general health and may confer additional benefits for reproductie health; this concept warrants further direct study (Holden, et al., 2010b). Physical actiity appears to confer benefits in sexual function among older males, with physically actie older people reporting higher rates of sexual actiity and sexual satisfaction than their less actie counterparts (Bortz & Wallace, 1999). Similarly, studies suggest that physically actie older adults report lower rates of depressie illness (Strawbridge, et al., 2002). The metabolic syndrome is a group of factors that can potentially contribute to the deelopment of cardioascular disease, type 2 diabetes, kidney disease, lier disease and stroke. There are also oerlapping risk factors with reproductie health. With current health promotion failing to curb the increasing burden of chronic disease, innoatie strategies are needed to more fully engage males about their health by focusing on male-specific issues to which they can identify, an approach that warrants further testing. Copyright Andrology Australia

5 2 CHRONIC DISEASES AND REPRODUCTIVE HEALTH PROBLEMS CARDIOVASCULAR DISEASE AND SEXUAL AND REPRODUCTIVE HEALTH Recent studies suggest that the degree of risk for a cardioascular eent after deeloping erectile dysfunction is similar to the risk of being a current smoker or haing a family history of heart attack. The failure of males to seek adice about erectile dysfunction, means that they are missing a ital predictor of impending cardioascular disease, as within a year of the first significant episode of erectile dysfunction 2% of males will hae a major stroke or heart attack and within 5 years, this rises to 11% (Holden, et al., 2010a). Consequently, it has been suggested that assessment of erectile function in middle-aged and older males may proide a useful indicator to detect, and potentially preent other life-threatening conditions. DIABETES AND SEXUAL AND REPRODUCTIVE HEALTH Sexual problems as a result of haing diabetes can affect both males and females. Males with diabetes are at increased risk of: erectile problems; testosterone (or androgen) deficiency; lack of libido (sexual desire); retrograde ejaculation (semen flows back into the bladder); and balanitis (inflammation of the head of the penis). Erectile problems Estimates suggest that up to four in eery fie males with diabetes will experience erectile problems, and they are twice as likely to hae erectile problems as males without diabetes (Holden, et al., 2010a). Age also increases the risk of getting both diabetes and erectile dysfunction. Often erectile problems deelop after a man has had diabetes for seeral years. Diabetes can cause erectile problems by: reducing blood flow to the penis or by affecting the function of blood essels in the penis, making it more difficult for a man to get and/or keep an erection this is more common in males with high blood pressure and high cholesterol, conditions both linked with diabetes; damaging the neres in the penis, which are essential for erections; and lower leels of testosterone (the male sex hormone). Some males with diabetes can hae erectile problems as a result of psychological issues, including performance anxiety, and not as a direct result of the diabetes. Erectile problems are more likely to happen when blood glucose leels are poorly controlled. Keeping blood glucose and blood lipids (cholesterol and triglycerides) in the normal range is important to preent nere and blood essel damage to the penis. Not smoking and limiting alcohol intake may also help make erectile problems less likely. It is important to manage the diabetes and any other associated conditions, such as high blood pressure, first. When diabetes is properly controlled, most doctors start treatment for erectile problems with oral medicines (PDE5 inhibitors) such as Viagra, Cialis or Leitra. The tablets work in about half of males with diabetes. If oral medicines do not work well, other treatments can be gien and include acuum deices, penile injections and surgery. Copyright Andrology Australia

6 Testosterone deficiency Testosterone deficiency is common in males with diabetes and about one in three males with type 2 diabetes hae low serum testosterone leels (Holden, et al., 2010a). Males with type 2 diabetes are more likely to hae low testosterone leels if they are also obese. Modifying lifestyle to control blood glucose leels by maintaining a healthy weight and regular exercise may improe testosterone leels. Males with diabetes and testosterone deficiency should get treatment for the diabetes and other illnesses first as hormone leels may return to normal and testosterone therapy may neer be needed. They should be adised to lose weight if they are oerweight or obese. Howeer, for males with diabetes and low testosterone leels caused by genetic disorders or other conditions, testosterone therapy can be gien to return testosterone leels in the blood to normal. The aailable forms of treatment are testosterone injections, implants, oral capsules, skin patches, creams and gels. Lack of libido Low testosterone leels can cause lack of libido (lack of interest in sexual actiity or low sex drie), therefore some males with diabetes and low testosterone leels may hae a lower libido. Psychological problems are also a common cause of lack of libido. In males with diabetes and erectile problems, the psychological impact of sexual dysfunction may also lower their interest in sexual actiity. Managing and controlling diabetes should be the first treatment option for males with diabetes and low libido to help improe feelings of sexual desire. Males who hae lack of libido due to testosterone deficiency diagnosed by a doctor may need testosterone replacement. In addition, it is important that a doctor checks for any other possible underlying physical or psychological causes. Often, lack of libido in males with diabetes can hide a desire for more non-sexual intimacy and sharing. Indiidual or couple counselling can be helpful in identifying and addressing any issues to improe sexual desire. Retrograde ejaculation Retrograde ejaculation in males with diabetes may be caused by nere damage to the muscle (external sphincter muscle) that opens and closes the bladder neck. High leels of blood glucose can damage the nere and muscles of the sphincter, and the sphincter muscle may not close completely to stop semen from going back into the bladder. Controlling blood glucose leels and making lifestyle changes may improe retrograde ejaculation when it is a result of diabetes. Most males who hae retrograde ejaculation do not need treatment. Howeer, if trying to conceie, couples may need to seek assisted reproductie technologies. Balanitis In males with diabetes, some urine may become trapped under the foreskin after urinating. The combination of a moist area and glucose in the urine can lead to bacteria growing and then infection (balanitis). If a man has diabetes and balanitis, he can take antibiotics or antifungal medicine to help clear up the infection, and wash under the foreskin with soap and warm water. He should also speak to his doctor about controlling blood glucose leels. Education of health professionals to consider reproductie health disorders as part of oerall health assessments may allow early detection of other more serious disease. Copyright Andrology Australia

7 3 PROMOTING UNDERSTANDING OF THE LINKS BETWEEN SEXUAL HEALTH AND CHRONIC DISEASE Aboriginal and Torres Strait Islander males are also less likely to seek help for sexual and reproductie health problems (Adams, 2007; Adams, et al., 2013). Poorer help-seeking behaiours for personal and sensitie health issues are not unique to Aboriginal and Torres Strait Islander males but are further amplified by a lack of community understanding and awareness of male reproductie health issues, and confounded by cultural and social issues (for example, the presence of a female attending doctor (Adams, et al., 2013). Aboriginal and Torres Strait Islander males generally experience poorer health compared to the oerall population (Australian Institute of Health and Welfare (AIHW), 2012) and while many modulating factors contribute to the poorer health status of Aboriginal and Torres Strait Islander males, anecdotal eidence suggests that health serice access by Aboriginal and Torres Strait Islander males is improed when a male-friendly health serice and deliery approach is adopted, particularly with the presence of an attending male AHW or allied health professional. Further, it has been suggested that the failure of Aboriginal and Torres Strait Islander males with erectile dysfunction to be able to discuss these matters could lead to frustration, depression and substance abuse, potentially resulting in domestic iolence. Such matters hae been explored further as part of the doctoral thesis undertaken by an Aboriginal and Torres Strait Islander researcher (Adams, 2007). Barriers exist that highlight that it is imperatie to normalise reproductie health problems through both mainstream and dierse communities to encourage all males and health professionals to engage in open dialogue about reproductie health. It is hoped that if males are gien opportunities to discuss their health they may more readily discuss those issues of a personal and sensitie nature that may also impact on their general health and relationships. Deeloping culturally appropriate education and supportie enironments for both males and health professionals is fundamental to improing the health status of Aboriginal and Torres Strait Islander males more broadly (Adams, 2007; Adams, et al., 2013). By improing the health of the Aboriginal and Torres Strait Islander male population, it is enisaged that the health of the Aboriginal and Torres Strait Islander community will also benefit more broadly. With the current spotlight on the health of Aboriginal communities in Australia, it is essential that the health of Aboriginal and Torres Strait Islander males is incorporated into any longterm strategy. Failing to discuss sensitie and personal health concerns in doctor consultations is a cumulatie factor in male health behaiours. Compared to females, males demonstrate poorer lifestyle behaiours, such as diet, smoking and higher alcohol consumption and underlying social, cultural and enironmental determinants, for example delayed helpseeking, symptom reporting. A significant body of eidence suggests that males are less likely than females to seek help that in part explains the gender differences in mortality and morbidity. Howeer gender comparisons regarding help-seeking behaiours proide little insight into the factors underlying the obsered behaioural differences (Galdas, et al., 2005). There are still many gaps in our understanding, particularly for programs that are culturally appropriate for Aboriginal and Torres Strait Islander peoples. As our understanding improes, better programs will be deeloped and rolled out, to help improe the health status and quality of life of many Aboriginal and Torres Strait Islander liing with chronic disease. Raising community awareness of the associations between chronic disease and reproductie health disorders is imperatie to encourage males to speak to their doctor early. Copyright Andrology Australia

8 REFERENCES Adams, M. (2007). Sexual and reproductice health problems among Aboriginal and Torres Strait Islander males. Unpublished PhD, Queensland Uniersity of Technology. Aailabe at Adams, M. J., Collins, V. R., Dunne, M. P., de Kretser, D. M., & Holden, C. A. (2013). Male reproductie health disorders among Aboriginal and Torres Strait Islander men: a hidden problem? Med J Aust, 198(1), Australian Institute of Health and Welfare (AIHW). (2011). The health of Australia s males Cat. no. PHE 141. Canberra: AIHW. Australian Institute of Health and Welfare (AIHW). (2012). The health of Australia s males: a focus on fie population groups. Cat. no. PHE 160. Canberra: AIHW. Bortz, W. M., 2nd, & Wallace, D. H. (1999). Physical fitness, aging, and sexuality. West J Med, 170(3), Galdas, P. M., Cheater, F., & Marshall, P. (2005). Men and health help-seeking behaiour: literature reiew. J Ad Nurs, 49(6), Holden, C. A., Allan, C. A., & McLachlan, R. I. (2010a). Windows of opportunity: a holistic approach to men's health. Med J Aust, 192(12), Holden, C. A., McLachlan, R. I., Pitts, M., Cumming, R., Wittert, G., Ehsani, J. P., et al. (2010b). Determinants of male reproductie health disorders: the Men in Australia Telephone Surey (MATeS). BMC Public Health, 10(1), 96. Kapoor, D., Goodwin, E., Channer, K. S., & Jones, T. H. (2006). Testosterone replacement therapy improes insulin resistance, glycaemic control, isceral adiposity and hypercholesterolaemia in hypogonadal men with type 2 diabetes. Eur J Endocrinol 154(6), Klein, B. E., Klein, R., Lee, K. E., & Bruskewitz, R. C. (1999). Correlates of urinary symptom scores in men. Am J Public Health, 89(11), Marin, P., Holmang, S., Jonsson, L., Sjostrom, L., Kist, H., Holm, G., et al. (1992). The effects of testosterone treatment on body composition and metabolism in middle-aged obese men. Int J Obes Relat Metab Disord, 16(12), Strawbridge, W. J., Deleger, S., Roberts, R. E., & Kaplan, G. A. (2002). Physical actiity reduces the risk of subsequent depression for older adults. Am J Epidemiol, 156(4), Copyright Andrology Australia

9 BACKGROUND READING AND RESOURCES The Aboriginal Health Workers Heart Health Manual: a resource tool designed specifically to train AHWs in cardioascular health to assist them in reducing the high prealence of heart disease among Aboriginal people. Aailable from: The Heart Foundation, tel: (local call cost) Diabetes Australia: Visit the website for more general information about diabetes and its treatment. See: Flipcharts for health care professionals working with Indigenous communities. Aailable from: Diabetes Australia, tel: (local call cost) or online at: Learning about Lung Health. Educational material aailable from The Australian Lung Foundation. Aailable from: Mental health resources aailable from: a) SANE Australia: b) beyondblue: the national depression initiatie: Copyright Andrology Australia