The State of Play of Diabetes Indicators

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1 The State of Play of Diabetes Indicators South Australian and National Information Catherine Chittleborough Janet Grant Anne Taylor April 2003 Diabetes Clearing House Population Research and Outcome Studies Unit (formerly Centre for Population Studies in Epidemiology) SOUTH AUSTRALIAN DEPARTMENT OF HUMAN SERVICES

2 This work is copyright. It may be reproduced and the Population Research and Outcome Studies Unit (PROS) (formerly the Centre for Population Studies in Epidemiology (CPSE)) welcomes requests for permission to reproduce in the whole or in part for work, study or training purposes subject to the inclusion of an acknowledgment of the source and not commercial use or sale. PROS will only accept responsibility for data analysis conducted by PROS staff or under PROS supervision. Published April 2003 by the South Australian Department of Human Services Diabetes Clearing House, Population Research and Outcome Studies Unit, Strategic Planning and Research Branch PO Box 287 Rundle Mall 5000 South Australia, Australia National Library of Australia Cataloguing-in-Publication: State of play of diabetes indicators : South Australian and national information. ISBN Diabetes - South Australia - Statistics. 2. Diabetes - Australia - Statistics. 3. Diabetes - South Australia - Prevention. 4. Diabetes - Australia - Prevention. 5. Health status indicators - South Australia. 6. Health status indicators - Australia. I. South Australia. Dept. of Human Services

3 TABLE OF CONTENTS EXECUTIVE SUMMARY 5 CHAPTER 1: INTRODUCTION ION Introduction Why do we need indicators? Indicator development Overview of document 13 CHAPTER 2: SUMMARY OF O NATIONAL HEALTH PRIORITYP AREA DIABETES INDICATORS 15 Diabetes prevalence and incidence 16 Risk factors for diabetes and associated complications 16 Diabetes complications 16 Hospital separations for diabetes complications 17 Mortality 17 Health status 17 Screening and management 17 CHAPTER 3: CURRENT C INFORMATION ON O NHPA DIABETES INDICATORS 19 Indicator 1.1 ~ Prevalence of Type 1 and Type 2 diabetes 20 Indicator 1.2 ~ Incidence for Type 1 and Type 2 diabetes 22 Indicator 1.3 ~ Gestational diabetes 23 RECOMMENDATIONS Diabetes Prevalence and Incidence (Indicators 1.1 to 1.3) 25 Indicator 2.1 ~ Obesity 26 Indicator 2.2 ~ Exercise 28 Indicator 2.3 ~ High blood pressure 30 Indicator 2.4 ~ Cholesterol 32 Indicator 2.5 ~ Triglycerides 34 RECOMMENDATIONS Diabetes Risk Factors (Indicators 2.1 to 2.5) 35 Indicator 3.1 ~ End-stage renal disease 37 Indicator 3.2 ~ Eye disease 38 Indicator 3.3 ~ Foot problems 39 Indicator 3.4 ~ Coronary heart disease and stroke 41 RECOMMENDATIONS Diabetes Complications (Indicators 3.1 to 3.4) 42 Indicator 4.1 ~ Hospital separations for end-stage renal disease 43 Indicator 4.2 ~ Hospital separations for coronary heart disease or stroke 44 Indicator 4.3 ~ Hospital separations for other conditions 46 RECOMMENDATIONS Diabetes-related Hospital Separations (Indicators 4.1 to 4.3) 48 Indicator 5.1 ~ Mortality for diabetes 49 Indicator 5.2 ~ Mortality rate for coronary disease and stroke among people with diabetes 51 RECOMMENDATIONS Diabetes-related Mortality (Indicators 5.1 to 5.2) 52 Indicator 6.1 ~ Self-assessed health status 53 RECOMMENDATIONS Self-assessed health status (Indicator 6.1) 54 Indicator 7.1 ~ Glycosylated haemoglobin 55 Indicator 7.2 ~ Screening for gestational diabetes 56 RECOMMENDATIONS Screening and management (Indicators 7.1 to 7.2) 57 CHAPTER 4: OTHER INDICATORS ICATORS 59 Diabetes Indicators used in the United States 60 Other indicators for consideration 61 APPENDIX 1: DATA SOURCES 63 REFERENCES 65 3

4 EXECUTIVE SUMMARY 5

5 Executive Summary EXECUTIVE SUMMARY The National Health Priority Area (NHPA) indicators for diabetes, published in 1998, were designed to provide a baseline for assessing progress towards the overall goal of reducing diabetes and its impact on the population. These indicators addressed the following areas:! Prevalence and incidence of Type 1, Type 2 and gestational diabetes;! Risk factors;! Complications;! Hospital separations;! Mortality;! Self-assessed health status, and;! Screening and management. This document details the current national and South Australian data available on the NHPA indicators. It also outlines recommendations for future use of the indicators in the surveillance of diabetes in South Australia. Systematic collection and analyses of surveillance data allows diabetes-related outcomes to be monitored over time. Monitoring and surveillance allows recognition of the public health burden of diabetes, identification of highrisk groups, development of strategies to reduce the burden, formulation of policies, and evaluation of progress in diabetes prevention and control. Prevalence and incidence The prevalence of diabetes among South Australians aged 15 years and over was 5.1% in This prevalence has increased over time and will continue to be monitored among all age groups by the Diabetes Clearing House, DHS. The National Diabetes Register aims to report on the incidence rate of insulin-treated diabetes, although incidence of self-reported diabetes will continue to be monitored in South Australia. Monitoring the prevalence of gestational diabetes among women of all ages is possible using Pregnancy Outcome Unit data. Risk factors Among South Australian adults, the prevalence of obesity is higher among people with Type 2 diabetes than the general population. Overweight and obesity will continue to be monitored through self-report and biomedical measurements. Monitoring physical activity, an important element of management for people with diabetes, requires a clear definition of what constitutes regular, sustained, moderate aerobic exercise that can be used consistently over time. It is recommended that the indicator for high blood pressure not be divided by age groups given that although the risk of complications increases with age, the definition of hypertension remains the same regardless of age. South Australian estimates of the prevalence of high blood pressure among people with diabetes are similar for self-reported measures (54.6% in ) and biomedical measurements (58.7% in 1998 and 59.6% in 2000). 6

6 Executive Summary The definitions of high total cholesterol and hypertriglyceridaemia in the indicators for lipids should be changed to reflect the most recent Lipid Management Guidelines. Complications Hospital morbidity collections and mortality statistics may be best for monitoring the prevalence of diabetes-related complications, including renal, eye, foot and cardiovascular problems, over time. The South Australian Diabetes Study 1998 examined several diabetesrelated complications and found that, among people with diabetes, the prevalence of retinopathy was 19%, neuropathy was 48%, ischaemic heart disease was 34%, and peripheral vascular disease was 32%. Mortality Mortality rates form an important part of a diabetes surveillance system, providing information about the end of the diabetes continuum that is not available from cross-sectional population surveys. For the period , diabetes was listed as either a principal or contributing cause of death for 7.7% of all South Australian deaths. This proportion was statistically significantly higher for indigenous diabetes-related deaths (19.7%). Self-assessed health status Measures of self-assessed general health status need to continue to be monitored as they provide important information about how chronic conditions impact on the lives of people with such conditions. South Australian Health Omnibus Survey data showed that people with diabetes were significantly less likely than people without diabetes to report that their health was good, very good or excellent. Screening and management There is currently little population information on the proportion of people with diabetes who have their glycosylated haemoglobin tested every six months. Similarly, the proportion of pregnant women tested for gestational diabetes is not currently monitored in South Australia. It may also be useful to measure the proportion of people with diabetes who see a health professional about their diabetes. Other indicators There are other indicators not included in the NHPA indicators that should be considered in providing a more complete picture of diabetes in South Australia. The NHPA indicators lack focus on education and health service use to determine if people with diabetes are obtaining the information, management skills, and care that they require. Indicators to monitor risk factors such as smoking and alcohol use are also important, as these are risk factors for developing diabetes-related complications. 7

7 CHAPTER 1: INTRODUCTION 9

8 Introduction 1.1 INTRODUCTION This document provides a summary of the national and South Australian data currently available that directly address the National Health Priority Area (NHPA) diabetes indicators. In using indicators, a surveillance approach is adopted and stable criteria are accepted against which progress can be assessed. The basis of surveillance over time is that good quality data can be collected for longitudinal analyses to monitor outcomes for the population. This document provides some discussion on the current NHPA and other diabetes indicators that should continue to be monitored in South Australia. 1.2 WHY DO WE NEED INDICATORS? Collection and monitoring of data that describes diabetes and its associated risk factors and complications over time are critical to the increased recognition of the public health burden of diabetes, identification of high risk groups, development of strategies to reduce the burden, formulation of health care policy, and evaluation of progress in disease prevention and control 1,2. A core function of the Diabetes Clearing House, Department of Human Services (DHS), is to provide information on the status of diabetes in the South Australian population, thus enabling progress towards State diabetes goals and targets to be monitored as stated in the Strategic Plan for Diabetes 3. In reality, it is not feasible to collect data on everything that relates to diabetes. Like many chronic conditions, the web of causation of diabetes is complex and there are many related risk factors, complications and outcomes that could be measured. Indicators are used to reduce the number of possible measurements to a few that are necessary and sufficient for a given purpose 4. They incorporate knowledge about what is important and provide a way of dealing with what is often a large amount of information. Indicators are also used to monitor the diabetes-related health status of a population or to make comparisons with a different population or the same population at a different point in time 5, and can therefore be used for assessing progress towards goals 6. It is important to define priorities for collection and monitoring of diabetes population data, but flexibility and capacity to detect and address emerging and unexpected issues must also be retained. Relevant and differentiated indicators are imperative for a diabetes information system capable of supporting the development of policy objectives. Indicators used for monitoring purposes should have all or some of the following qualities 7. They should be:! worth measuring, that is, they should represent an important, salient aspect of the public s health;! understood by people who need to act, and be of such a nature that action can be taken;! relevant to policy and practice, with the potential for action that can lead to improvement when applied;! measurable over time to reflect results of actions;! feasible to collect and report. It is recognised that not all indicators can address these criteria all of the time. In some instances, currently available South Australian information may not exactly match an indicator as it is defined, although it is hoped that over time, such discrepancies will be minimised. It is considered that some indicators have been designed and defined on the availability of national data, and comments (where appropriate) have been included in the recommendations section at the end of each major indicator group. 10

9 Introduction 1.3 INDICATOR DEVELOPMENT Health-related indicators are at different stages of development some are well developed, while others are less tried and tested. In Australia, the best health-related indicators agreed on to date are listed in the National Health Data Dictionary 8. The National Health Data Dictionary, under the National Health Information Agreement, is the authoritative source of health data definitions used in Australia where national consistency is required 8. It was designed to improve the comparability of data across the health field, and to ensure that information collected is appropriate to its purpose. An objective of the National Health Data Dictionary is to establish a core set of uniform definitions relating to the full range of health services and a range of population parameters. It promotes data uniformity, availability, reliability, validity, consistency and completeness. Use of the dictionary helps ensure uniform collection of data elements throughout Australia. While the data dictionary already includes several parameters relevant to diabetes, such as height, weight, body mass index, tobacco smoking and demographic characteristics, diabetes-specific definitions are not yet developed. Indicators specifically related to diabetes have, however, been further developed under the NHPA initiative 6. The NHPA initiative was established after shortcomings of the National Health Goals and Targets process were recognised, namely that there were too many indicators, and that there was a lack of emphasis on treatment and ongoing management. NHPA indicators for diabetes were designed to provide a baseline for assessing progress towards the overall goal of reducing diabetes and its impact on the population 6. These indicators provide a basis for assessing the gaps in diabetes population surveillance and the inadequacies of indicators and datasets currently used. Gaps in existing data sources Australia-wide have already been identified in that they fail to provide sufficient information for assessing the impact of diabetes on the Australian community and for comprehensive nation-wide diabetes surveillance 6. Specific deficiencies identified have included:! no national data on screening for diabetes, incidence, diabetes care, or long-term outcomes of care;! information not available by type of diabetes;! lack of national trend information about diabetes, complications and costs;! incidence and prevalence based on self-reported information alone and not supported by laboratory-based diagnostic criteria, therefore magnitude of problem cannot be reliably assessed (eg. extent of undiagnosed problem unknown);! little information has been collected on biomedical aspects of risk factors for diabetes and its complications;! few data collections are nationally representative, have sufficient numbers from priority populations, use nationally agreed instruments, undertake routine validation of self reports or include biological measurements;! no linking of records to generate profiles of diabetes management. Sources of data for monitoring diabetes are wide and varied. Within the Population Research and Outcome Studies Unit (PROSU, formerly the Centre for Population Studies in Epidemiology), representative population surveys, including the South Australian Health Omnibus Survey, Social and Environmental Risk Context Information System (SERCIS) and Health Monitor, collect data on diabetes-related indicators. These survey vehicles, together with a new initiative of PROSU the South Australian Monitoring and Surveillance System 11

10 Introduction (SAMSS) will systematically monitor trends of health conditions, including diabetes, risk factors and other human services issues over time. Where appropriate, biomedical examination and survey information has also been used from the North West Adelaide Health Study, conducted in 2000, of a representative population of 2523 adults in the north-west regions of Adelaide. In addition, the Diabetes Clearing House can draw on information from other sources such as ABS mortality data, hospital separations data, and perinatal statistics. Information from these diabetes-related surveillance systems is used to 5 :! track diabetes and risk factor trends over time and place, and across population subgroups;! quantify the burden of diabetes to assist in the reasonable allocation of resources for public health programs;! establish broad program priority areas and goals;! plan, implement, and evaluate specific public health policies, programs, and services. The health outcomes framework used to design the NHPA indicators was developed by the National Health Information Management Group Working Party on Health Outcomes Activities and Priorities 9. This framework, when applied to diabetes, addresses the continuum of diabetes care from prevention through to management and maintenance (Figure 1.1). Primary outcome indicators, include prevalence, incidence, mortality and quality of life, together with risk indicators that characterise individuals as more likely to develop diabetes or related complications, and process and quality indicators, which refer to the performance of interventions aimed at preventing people from progressing along the continuum. Priority areas for development of information on diabetes health outcomes have emerged through the application of the indicators framework to existing national information in the NHPA report 6 and to South Australian information in this document. Current limitations and future recommendations for surveillance of diabetes and related issues are discussed for each NHPA indicator in this document. Figure 1.1 The Diabetes Continuum Stage Not at risk At risk Previously undiagnosed Previously diagnosed without complications Previously diagnosed with complications Death Risk factors for progression along continuum Family history Age Obesity Physical inactivity Previous gestational diabetes Pre-diabetic state / IFG / IGT Smoking Obesity Non-adherence to medications HbA1c (>7%) Hypertension High cholesterol Physical inactivity PREVENTION DELAY / EARLY DETECTION PREVENTION / DELAY / EARLY DETECTION / CARE 12

11 Introduction 1.4 OVERVIEW OF DOCUMENT This document provides a summary of how South Australia is collecting data related to diabetes indicators. It is based on the NHPA indicators for diabetes, as these are the most comprehensive indicators currently available and agreed upon for this condition. Chapter 2 summarizes the NHPA indicators for diabetes. Chapter 3 provides detail on the data sources nationally and in South Australia that are currently used to measure each NHPA indicator. Indicators need to be assessed, where possible, by valid and reliable question modules, which are also currently being developed. This section also provides current available evidence on these indicators from recent survey results both nationally and in South Australia an integral part of the function of the Diabetes Clearing House is the ongoing surveillance of these indicators, and others to be developed in South Australia. This chapter also includes recommendations for future surveillance of each group of indicators. Chapter 4 outlines indicators considered priorities under the United States Centers for Disease Control and Prevention s Healthy People 2010 that are not included as part of the NHPA indicators. Appendix 1 provides information on the methodology of data sources used in this document. 13

12 CHAPTER 2: SUMMARY OF NATIONAL HEALTH PRIORITY AREA DIABETES INDICATORS 15

13 NHPA Indicators - Summary DIABETES PREVALENCE AND INCIDENCE National Health Priority Area Indicator 1.1 Prevalence rates for Type 1 and Type 2 diabetes in: (a) general population; (b) Indigenous population; and (c) among persons from culturally and linguistically diverse backgrounds. National Health Priority Area Indicator 1.2 Incidence rates for Type 1 and Type 2 diabetes in: (a) general population; (b) Indigenous population; and (c) among persons from culturally and linguistically diverse backgrounds. National Health Priority Area Indicator 1.3 Gestational diabetes among women aged years, by parity. RISK FACTORS FOR DIABETES AND ASSOCIATED COMPLICATIONS National Health Priority Area Indicator 2.1 Prevalence rates for obesity and being overweight (as measured by BMI) among persons (over 30 years of age) in: (a) general population; and (b) among persons with Type 2 diabetes. National Health Priority Area Indicator 2.2 Rates for non-participation in regular, sustained, moderate aerobic exercise in: (a) general population; and (b) among persons with Type 2 diabetes. National Health Priority Area Indicator 2.3 Prevalence rates for high blood pressure among persons with Type 2 diabetes: (a) 140 mmhg systolic and/or 90 mmhg diastolic and aged < 60 years; (b) 160 mmhg systolic and/or 90 mmhg diastolic and aged 60 years; and/or (c) those on medication for blood pressure. National Health Priority Area Indicator 2.4 Prevalence rates for high levels of lipoproteins among persons with Type 1 and Type 2 diabetes: (a) total cholesterol above 5.5 mmol/l; and (b) high density lipoproteins below 1.0 mmol/l. National Health Priority Area Indicator 2.5 Prevalence rates for fasting hypertriglyceridaemia among persons with Type 1 and Type 2 diabetes. DIABETES COMPLICATIONS National Health Priority Area Indicator 3.1 Proportion of persons with end-stage renal disease with diabetic nephropathy as a causal factor. National Health Priority Area Indicator 3.2 Incidence rate for eye disease among clinically diagnosed persons with diabetes. National Health Priority Area Indicator 3.3 Prevalence rate for foot problems among clinically diagnosed persons with diabetes. National Health Priority Area Indicator 3.4 Incidence rate for coronary heart disease and stroke in: (a) general population; and (b) among clinically diagnosed persons with diabetes. 16

14 NHPA Indicators - Summary HOSPITAL SEPARATIONS FOR DIABETES COMPLICATIONS National Health Priority Area Indicator 4.1 Hospital separation rate for end-stage renal disease with diabetes as an additional diagnosis. National Health Priority Area Indicator 4.2 Hospital separation rates for coronary heart disease or stroke with diabetes as an additional diagnosis. National Health Priority Area Indicator 4.3 Hospital separation rates for conditions other than end-stage renal disease and coronary heart disease/stroke among: (a) persons for whom diabetes was reported as the principal diagnosis or an additional diagnosis; and (b) people without diabetes as a reported diagnosis. MORTALITY National Health Priority Area Indicator 5.1 Death rates for diabetes in: (a) general population; (b) Indigenous population; and (c) among people from culturally and linguistically diverse backgrounds. National Health Priority Area Indicator 5.2 Death rates for coronary heart disease and stroke among persons with diabetes in: (a) general population; (b) Indigenous population; and (c) among people from culturally and linguistically diverse backgrounds. HEALTH STATUS National Health Priority Area Indicator 6.1 Self-assessed health status of persons with and without diabetes. SCREENING AND MANAGEMENT National Health Priority Area Indicator 7.1 Proportion of persons with diabetes tested for glycosylated haemoglobin level at least every six months. National Health Priority Area Indicator 7.2 Proportion of pregnant women being tested for gestational diabetes. 17

15 CHAPTER 3: CURRENT INFORMATION ON NATIONAL HEALTH PRIORITY AREA DIABETES INDICATORS 19

16 DIABETES PREVALENCE AND INCIDENCE Indicator 1.1 ~ Prevalence of Type 1 and Type 2 diabetes Prevalence rates for Type 1 and Type 2 diabetes in (a) general population; (b) Indigenous population; and (c) among people from culturally and linguistically diverse backgrounds. Rationale for Indicator Prevalence of diabetes varies considerably between different population groups 6. Surveillance of this indicator is necessary to monitor the increasing prevalence of diabetes over time. RECENT AUSTRALIAN RESULTS The prevalence of diabetes in Australia according to the National Health Survey 1995 is shown in Table 3.1. Table 3.1: : Prevalence of diabetes (age-standardised) among Australians aged 15 years and over, National Health Survey 1995 Type 1 % Type 2 % All Diabetes % General population n/a Indigenous population n/a n/a 8.8 Culturally and linguistically diverse backgrounds n/a The AusDiab Study 2000 (adults aged 25 years and over) found the prevalence of diabetes to be 7.5%, with 3.8% known and 3.8% newly diagnosed. The National Health Survey 2001 found that an estimated 554,200 persons (2.9% of the population) had been diagnosed with diabetes mellitus and considered themselves to still have the condition. The majority of people with diabetes reported they had Type 2 (adult onset) diabetes (78%), 17% reported Type 1 (sometimes referred to as insulin dependent diabetes) while 5% reported diabetes but did not know which type. A further 61,000 people (0.3%) reported they currently had high sugar levels in the blood or urine, but had not been diagnosed with diabetes. RECENT SOUTH AUSTRALIAN RESULTS The prevalence of self-reported diabetes among South Australian adults by type is shown in Table 3.2. * Further details on the surveys and data sources used in this report can be found in Appendix 1. 20

17 Table 3.2: Prevalence of diabetes among South Australian adults aged 18 years and over, SERCIS Health Priority Area Surveys Type 1 % Type 2 % All Diabetes* % General population Indigenous population Culturally and linguistically diverse backgrounds** * Does not include gestational diabetes ** Born overseas The more recent SERCIS South Australian Health and Well Being Survey 2000 showed the overall self-reported prevalence of diabetes to be 6.2% among adults aged 18 years and over. The prevalence of self-reported diabetes among South Australians aged 15 years and over from 1991 to 2002 is shown in Figure 3.1. Figure 3.1 Age-sex standardised self-reported prevalence of diabetes among South Australians aged 15 years and over, Health Omnibus Survey Diabetes prevalence (%) Year The overall prevalence of diabetes among people aged 18 years and over in the North West Adelaide Health Study 2000 was 6.7%, with 5.4% diagnosed and 1.2% previously undiagnosed. 21

18 DIABETES PREVALENCE AND INCIDENCE Indicator 1.2 ~ Incidence for Type 1 and Type 2 diabetes Incidence rates for Type 1 and Type 2 diabetes in: (a) general population; (b) Indigenous population; and (c) among persons from culturally and linguistically diverse backgrounds. Rationale for Indicator Surveillance of this indicator is necessary to monitor the changing incidence of diabetes over time and to detect any variations in trends that can be mapped to interventions. RECENT AUSTRALIAN RESULTS One of the primary objectives of the National Diabetes Register is to report on incidence rates of insulin-treated diabetes, which includes Type 1 and Type 2 diabetes, in Australia 10. The Register reports that the incidence rate for diabetes is approximately 19 per 100,000 population. This estimate, however, is only provided for children aged 0 to 14 years, as this is the only population group on the Register where coverage is considered to be close to 100%. RECENT SOUTH AUSTRALIAN RESULTS According to the SERCIS Health Priority Area Surveys , 0.8% of respondents aged 18 years and over had been diagnosed with Type 1 or Type 2 diabetes in the last year (Table 3.3). Table 3.3: : Incidence of diabetes among South Australian adults aged 18 years and over, SERCIS Health Priority Area Surveys n % General population Indigenous population Culturally and linguistically diverse backgrounds

19 DIABETES PREVALENCE AND INCIDENCE Indicator 1.3 ~ Gestational diabetes Gestational diabetes among women aged years, by parity*. * total number of previous pregnancies resulting in live births or stillbirths Rationale for Indicator It is estimated that fifty percent of Australian women who have gestational diabetes mellitus (GDM) will develop Type 2 diabetes within ten years of delivery 28. Early screening and ongoing surveillance of this high-risk group will lead to earlier detection, and better management and control of the condition and its complications. RECENT AUSTRALIAN RESULTS Hoffman et al 11 report that most Australian centres report a GDM incidence of 5.5% to 8.8%. The prevalence of GDM is not reported in the NHPA Diabetes Mellitus Report RECENT SOUTH AUSTRALIAN RESULTS The proportion of all women who had gestational diabetes, recorded by midwives and neonatal nurses as an obstetric complication as opposed to a pre-existing condition on the DHS Pregnancy Outcome Unit Supplementary Birth Record from 1981 to 2001 are shown in Figure 3.2. The prevalence of gestational diabetes in women aged years from 1981 to 1999 and of all ages from 2000 onwards is shown in Table 3.4. The increasing number of women recorded as having GDM is likely to be due to both a true increase in prevalence and improvements in screening. In an analysis of parity and gestational diabetes from data supplied by the Pregnancy Outcome Unit, from 1995 to 1997, there was a trend for gestational diabetes to increase with the number of prior pregnancies and to be significantly higher than expected with women with three or more pregnancies and live births. However, when controlled for age, the relationship between parity and gestational diabetes was not statistically significant 1. Figure 3.2: : Prevalence of gestational diabetes per annum in South Australian women (all ages), 1981 to 2001, Pregnancy Outcome Unit, DHS % GDM Year 23

20 Table 3.4: : Prevalence of gestational diabetes in South Australian women, aged years, all ages, Pregnancy Outcomes Unit, DHS Year No of confinements Aged years n % 1981* 18, , , ,036 n/a n/a , , ** 19, , , , , , , , , , Gestational diabetes ,394 Impaired glucose tolerance Gestational diabetes ,421 Impaired glucose tolerance Gestational diabetes ,233 Impaired glucose tolerance ALL AGES Gestational diabetes ,577 Impaired glucose tolerance (Provisional) Gestational diabetes ,380 Impaired glucose tolerance * From 1981 to 1996, glucose intolerance was included in the gestational diabetes data ** Improvements in screening initiated, therefore detecting more cases 24

21 RECOMMENDATIONS Diabetes Prevalence and Incidence (Indicators 1.1 to 1.3) The prevalence of diabetes is currently the most comprehensively monitored indicator nationally and in South Australia. The prevalence of diabetes in South Australia is increasing over time and will continue to be monitored by the Diabetes Clearing House through existing population surveys, together with the regular monthly survey (SAMSS) conducted by CPSE from July SAMSS will provide the opportunity to systematically monitor diabetes prevalence among South Australians of all ages. Monitoring the prevalence of diabetes by type will enable determination of whether increases in prevalence over time, and among various age groups, are due to increases in Type 1, Type 2, or gestational diabetes. Determination of the prevalence of diabetes through monitoring of self-report data provides an estimate of the number of people with diagnosed diabetes. Biomedical measurement such as the North West Adelaide Health Study 2000 is required to monitor the extent of the undiagnosed diabetes problem. In determining the prevalence of diabetes through biomedical measurement, care must be taken with comparisons across studies because of the various diagnostic criteria that are used nationally and internationally 16. To provide a complete picture, the prevalence of gestational diabetes will continue to be monitored by the Pregnancy Outcome Unit DHS for pregnant women of all ages, rather than only those aged years. For comparisons with national estimates based on Indicator 1.3, analyses will be performed using only women aged years. 25

22 RISK FACTORS FOR DIABETES AND ASSOCIATED COMPLICATIONS Indicator 2.1 ~ Obesity Prevalence rates for obesity and being overweight among persons (over 30 years of age) in: (a) general population and (b) among persons with Type 2 diabetes. Rationale for Indicator Overweight and obesity increase the risk of developing Type 2 diabetes and its complications 6. Surveillance is required to monitor the currently increasing prevalence of overweight and obesity. Definitions used Overweight Obesity Body Mass Index (BMI) National Health Survey & AusDiab Survey 25 and < 30 kg/m 2 30 kg/m 2 SERCIS Health Priority Area Surveys, SA Diabetes Study, & North West Adelaide Health Study > 25 and 30 kg/m 2 > 30 kg/m 2 Waist circumference AusDiab Survey North West Adelaide Health Study Males 94 & < 102 cm Females 80 & < 88 cm Males 95 & < 100 cm Females 80 & < 90 cm Males 102 cm Females 88 cm Males 100 cm Females 90 cm RECENT AUSTRALIAN RESULTS The prevalence rates of overweight and obesity among persons with Type 2 diabetes and the general Australian population are shown in Table 3.5. Table 3.5: : Self-reported prevalence of overweight and obesity among Australians aged 15 years and over, National Health Survey 1995 Persons with Type 2 diabetes Males Females General population Males Females Crude rates % Age standardised rates % Overweight Obese Overweight Obese The National Health Survey 2001 found that 58% of males and 42% of females were overweight or obese. Table 3.6 shows the prevalence of overweight and obesity as measured by BMI and waist circumference in the AusDiab study. 26

23 Table 3.6: : Measured prevalence of overweight and obesity among Australian adults aged 25 years and over, AusDiab 2000 Overweight % Obese % BMI Waist circumference RECENT SOUTH AUSTRALIAN RESULTS The self-reported prevalence of overweight and obesity is shown in Table 3.7. Table 3.7: : Self-reported prevalence of overweight and obesity among South Australian adults aged 18 and over, SERCIS Health Priority Area Surveys BMI status Overweight Obese % % Persons with Type 2 diabetes (n=364) General population (n=11,299) The SA Diabetes Study 1998 found that 83.4% of people with diabetes were overweight or obese when measured. The measured prevalence of overweight and obesity from the North West Adelaide Health Study is shown in Table 3.8 for BMI and Table 3.9 for waist circumference. Table 3.8: : Measured prevalence of overweight and obesity (BMI) among South Australian adults aged 18 and over, North West Adelaide Health Study 2000 BMI status Overweight Obese % % Persons with Type 2 diabetes (n=168) General population (n=2523) Table 3.9: : Measured prevalence of overweight and obesity (waist circumference) among South Australian adults aged 18 and over, North West Adelaide Health Study 2000 Waist circumference Overweight Obese % % Persons with Type 2 diabetes (n=168) General population (n=2523)

24 RISK FACTORS FOR DIABETES AND ASSOCIATED COMPLICATIONS Indicator 2.2 ~ Exercise Rates for non-participation in regular, sustained, moderate aerobic exercise in: (a) general population; and (b) among persons with Type 2 diabetes. Rationale for Indicator Physical activity protects against the development of diabetes 16 and also improves insulin and glucose homeostasis. It is also important in maintaining a healthy body weight, which is central to the management of diabetes 6. The adoption of regular physical activity may have the greatest benefit to those who are most sedentary 16. Definitions used National Health Survey Number of times and total amount of time performed walking, moderate exercise other than walking, and vigorous exercise in previous two weeks. Intensity = 3.5 for walking, 5.0 for moderate exercise and 9.0 for vigorous exercise. Exercise level = (number of times activity undertaken) x (average time per session) x (intensity). Low level exercise: 100 to < 1600 Sedentary level exercise: < 100 AusDiab Survey Physical activity time calculated as the sum of time spent walking, performing moderate activity plus double the time spent in vigorous activity (to reflect its greater intensity), in the previous week. Sufficient: At least 150 minutes physical activity per week. Insufficient: Less than 150 minutes physical activity per week Sedentary: No participation in physical activity per week North West Adelaide Health Study DEFINITION 1: Physical activity time calculated as the sum of time spent walking, performing moderate activity plus double the time spent in vigorous activity (to reflect its greater intensity), in the previous two weeks. Sufficient: At least 150 minutes physical activity per week. Insufficient: Less than 150 minutes physical activity per week Sedentary: No participation in physical activity per week. DEFINITION 2: Activity in previous two weeks includes weighting of vigorous activity by a factor of two. Must be accrued in at least five separate sessions. Sufficient: At least 150 minutes of activity per week Insufficient: Less than 150 minutes of activity per week. SERCIS Health Priority Area Surveys Walked for exercise in previous two weeks: (ie for sport, recreation or fitness) No exercise in previous two weeks: Did not walk for sport, recreation or fitness. RECENT AUSTRALIAN RESULTS Table 3.10 shows participation in low level and sedentary exercise of people with diabetes and the general population. 28

25 Table : : Participation in low level and sedentary exercise among Australians aged 30 years and over, National Health Survey 1995 Persons with Type 2 diabetes Males Females General population Males Females Unadjusted rate % Age standardised rate % Low Sedentary Low Sedentary The AusDiab 2000 study found that 15.6% of Australians aged 25 years and over did not take part in physical activity in the previous week. Sufficient physical activity was undertaken by 49.8%, and insufficient physical activity was undertaken by 34.5% of Australians. RECENT SOUTH AUSTRALIAN RESULTS Table 3.11 shows the prevalence of physical activity for the general population and those with diabetes from the SERCIS Health Priority Area Surveys Table : : Prevalence of physical activity among South Australian adults aged 18 years and over, SERCIS Health Priority Area Surveys Walked for exercise No exercise % % Persons with Type 2 diabetes (n=389) General population (n=11,299) Table 3.12 shows the prevalence of physical activity for the general population and those with diabetes from the North West Adelaide Health Study Table : : Prevalence of physical activity among South Australian adults aged 18 years and over, North West Adelaide Health Study 2000 Sufficient activity None/insufficient activity % % DEFINITION 1 Persons with diabetes (n=168) * General population (n=2350) DEFINITION 2 Persons with diabetes (n=168) * General population (n=2350) * Note: Diabetes defined as clinical (fasting plasma glucose 7.0 mmol/l) or self-reported diabetes 29

26 RISK FACTORS FOR DIABETES AND ASSOCIATED COMPLICATIONS Indicator 2.3 ~ High blood pressure Prevalence rates for high blood pressure among persons with Type 2 diabetes: (a) 140mmHg systolic and/or 90mmHg diastolic and aged < 60 years; (b) 160mmHg systolic and/or 90mmHg diastolic and aged 60 years; and/or (c) those on medication for high blood pressure. Rationale for Indicator High blood pressure is a known risk factor for cardiovascular disease and puts people with diabetes at risk for a cardiovascular event. High blood pressure also contributes to microvascular complications such as lower extremity amputations, end-stage renal disease, and retinopathy. Tight control of blood pressure has been shown to reduce morbidity and mortality from macrovascular and microvascular complications 12,13. Since high blood pressure is associated with age, this indicator is based on two separate age groups 6. Definitions used National Health Survey AusDiab Survey SERCIS Health Priority Area Surveys SA Diabetes Study North West Adelaide Health Study 140/90 mmhg for ages < 60 years, 160/90mmHg for ages 60 years, or on medication for high blood pressure 140/90 mmhg or on medication for high blood pressure Self reported high blood pressure or on medication for high blood pressure > 160/95 mmhg and > 140/90 mmhg 140/90 mmhg RECENT AUSTRALIAN RESULTS The National Association of Diabetes Centres Survey 1998 found 32.8% of people with diabetes younger than 60 years of age, and 35.5% of people with diabetes aged 60 years or over to have high blood pressure according to the indicator definition. The AusDiab Study 2000 found 28.8% of Australians aged 25 years and over had high blood pressure, and less than half of these (46.5%) were on medication for high blood pressure. 30

27 RECENT SOUTH AUSTRALIAN RESULTS Prevalence of self-reported high blood pressure and use of blood pressure medication is shown in Table Table : : Prevalence of self-reported eported high blood pressure and use of high blood pressure medication among South Australian adults aged 18 years and over, SERCIS Health Priority Area Surveys High blood pressure % On high blood pressure medication % Persons with Type 2 diabetes (n=389) General population (n=11,511) Biomedical measurement in the SA Diabetes Study 1998 showed that 58.7% of people with diabetes had blood pressure greater than 140/90mmHg and 33.4% had blood pressure greater than 160/95mmHg. Of people with diabetes aged 18 years and over in the North West Adelaide Health Study 2000, 59.6% had high blood pressure. 31

28 RISK FACTORS FOR DIABETES AND ASSOCIATED COMPLICATIONS Indicator 2.4 ~ Cholesterol Prevalence rates for high levels of lipoproteins among persons with Type 1 and Type 2 diabetes: (a) total cholesterol above 5.5 mmol/l; and (b) high density lipoproteins (HDL) below 1.0 mmol/l. Rationale for Indicator There is some evidence that high levels of lipoproteins, or dyslipidaemia, may precede abnormal glucose tolerance. People with diabetes are at a higher risk of hyperlipidaemia than the general population, putting them at high risk of developing heart disease and circulation problems 6. Definitions ns used National Health Survey AusDiab Survey & North West Adelaide Health Study SERCIS Health Priority Area Surveys SA Diabetes Study Total cholesterol > 5.5 mmol/l, HDL cholesterol < 1.0 mmol/l Total cholesterol 5.5 mmol/l, HDL cholesterol 1.0 mmol/l Self reported high cholesterol Total cholesterol > 6.5 mmol/l, HDL cholesterol 0.9 mmol/l RECENT AUSTRALIAN RESULTS The National Association of Diabetes Centres Survey 1998 found the rates of high total cholesterol among people with Type 1 and Type 2 diabetes to be 24.2% and 36.6%, respectively. The AusDiab Study 2000 found that 51.2% of Australians aged 25 years and over had high total cholesterol and 11.9% had low HDL. RECENT SOUTH AUSTRALIAN RESULTS Table 3.14 shows the proportion of people with either Type 1 or Type 2 diabetes (n=453) reporting ever being told by a doctor that they have high cholesterol and reporting a high cholesterol level when last tested. Table : : Prevalence of self-reported high cholesterol among persons aged 18 years and over with Type 1 and Type 2 diabetes, SERCIS Health Priority Area Surveys Ever been told they have high cholesterol % Type 1 (n=64) 11.2 Type 2 (n=389) 34.2 High cholesterol when last tested % Type 1 (n=58) 2.2 Type 2 (n=361)

29 The proportion of people with diabetes with high total cholesterol was found to be 52.4%. The proportion of people with diabetes in the SA Diabetes Study 1998 with low HDL was found to be 45.9%. Of people with diabetes aged 18 years and over in the North West Adelaide Health Study 2000, 35.7% had high total cholesterol and 21.3% had low HDL. 33

30 RISK FACTORS FOR DIABETES AND ASSOCIATED COMPLICATIONS Indicator 2.5 ~ Triglycerides Prevalence rates for fasting hypertriglyceridaemia among persons with Type 1 and Type 2 diabetes. Rationale for Indicator Elevated triglyceride levels have been consistently associated with Type 2 diabetes, impaired glucose tolerance and Syndrome X. Hypertriglyceridaemia is also an independent risk factor for cardiovascular disease 6. Definitions used National Health Survey AusDiab Survey & North West Adelaide Health Study SERCIS Health Priority Area Surveys SA Diabetes Study > 4.0 mmol/l 2.0 mmol/l Self reported high triglycerides 4.0 mmol/l RECENT AUSTRALIAN RESULTS The National Association of Diabetes Centres Survey 1998 found the prevalence of fasting hypertriglyceridaemia to be 24.2% among people with Type 1 diabetes and 36.6% among people with Type 2 diabetes. The AusDiab Study 2000 found 20.5% of Australians aged 25 years and over had fasting hypertriglyceridaemia. RECENT SOUTH AUSTRALIAN RESULTS The self-reported prevalence of high triglycerides among people with diabetes is reported in Table Table : : Prevalence of self-reported high triglycerides among South Australian people aged 15 years and over with diabetes, Health Omnibus Surveys Year High triglyceride levels % 1995 (n=114) (n=114) (n=113) (n=122) 19.5 Biomedical measurement in the SA Diabetes Study 1998 showed 15.6% of adults aged 18 years and over with diabetes had high triglycerides and 32.2% had intermediate triglycerides (2.1 to 3.9 mmol/l). Of people with diabetes aged 18 years and over in the North West Adelaide Health Study 2000, 40.4% had fasting hypertriglyceridaemia. 34

31 RECOMMENDATIONS Diabetes Risk Factors (Indicators 2.1 to 2.5) Obesity and overweight Given that the prevalence rates of both obesity and diabetes are increasing among younger people 14,15, it is recommended that the indicator reflect at least the whole adult population, and ideally include all ages, and not be limited to persons over 30 years of age. The BMI cutoffs used should be those recommended in the National Health Data Dictionary 8 and by the World Health Organization 17. A BMI 25kg/m 2 is classified as overweight, and a BMI 30kg/m 2 as obese. Biomedical measurement of obesity would also allow measurement of waist hip ratio and/or waist circumference in addition to BMI. Whereas BMI is a summary of overall height and weight, or total adiposity, waist hip ratio and waist circumference provide measures of fat distribution. An android or centralised pattern of fat distribution, where excess body fat is distributed in the abdominal region rather than on the hips and thighs, plays an important role in determining risk of cardiovascular disease and diabetes, particularly in men 16,17. Physical activity Monitoring and making comparisons of physical activity among people with diabetes and the general population requires a clear definition of what constitutes regular, sustained, moderate aerobic exercise. The definitions used in the National Physical Activity Survey could be used. In this, sufficient physical activity was defined as at least 150 minutes per week of walking, moderate activity or vigorous activity 18. Blood pressure The co-existence of diabetes mellitus and hypertension is important, as they are multiplicative risk factors for macrovascular and microvascular disease, resulting in increased risks of cardiac death, coronary heart disease, congestive heart failure, cerebrovascular disease and peripheral vascular disease 19. The rationale for dividing the NHPA high blood pressure indicator by age is not clear. According to the WHO guidelines for hypertension, there is no distinction of different definitions according to age 19. Hypertension is defined as a systolic blood pressure of 140 mmhg or greater and/or a diastolic blood pressure of 90 mmhg or greater in subjects who are not taking antihypertensive medication 17,20. It is acknowledged that the risk of cardiovascular complications increases for men aged over 55 years and women aged over 65 years, but the definition of hypertension remains the same, regardless of age. It is therefore recommended that the indicator for biomedical measurement should be the prevalence rates of high blood pressure (defined as a systolic blood pressure of 140 mmhg or greater and/or a diastolic blood pressure of 90 mmhg or greater) among people with diabetes and the general population. 35

32 Lipids It is recommended that the indicator for total cholesterol be changed to greater than or equal to 4.0 mmol/l, instead of over 5.5 mmol/l, to reflect recent changes in the Lipid Management Guidelines 21. These guidelines also define fasting hypertriglyceridaemia as greater than or equal to 2.0 mmol/l. The Lipid Management Guidelines 21 recommend that people at increased risk of coronary heart disease (CHD) events, including those who have diabetes, heart disease, renal failure, family history of high cholesterol, or who are Aboriginal or Torres Strait Islander, should have their cholesterol levels measured at least annually. Individuals who are not at high risk should have their lipid levels tested regularly (at least five-yearly) from the age of 45 years onwards. Selfreported information on cholesterol levels and screening in a chronic disease surveillance system should reflect these guidelines. Overall Risk factors for diabetes and related complications are well monitored in South Australia with self-report data. Opportunities for biomedical measurement of these risk factors in clinical representative population studies should be explored. The benefits and costs of clinical studies versus self-report population surveys then require consideration. It may be more beneficial to ascertain, for example, the prevalence of self-reported high blood pressure, or height and weight, than to clinically measure blood pressure or waist and hip circumference. Further investigation is being performed on the correlation between self-reported and clinical measures in the North West Adelaide Health Study. Risk factors for diabetes and related complications are common to many chronic conditions. The National Public Health Partnership (NPHP) is taking a cluster approach to modifiable risk and protective factors and preventable conditions 22. Many conditions are related to, for example, the metabolic syndrome, characterised by insulin resistance, hypertension, low HDL levels, high LDL levels, and high triglyceride levels, and associated with obesity and physical inactivity. SAMSS will have the capacity to utilise this cluster approach, and risk factor indicators relevant to diabetes and other chronic diseases could be monitored through this system. 36

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