Nrth West Adelaide Health Study Summarised findings and implicatins 2000-2008 March 2009
Acknwledgements This reprt frms part f the Nrth West Adelaide Health Study (NWAHS), a cllabrative prject f SA Health, the University f Suth Australia, The University f Adelaide, the Institute f Medical and Veterinary Science, The Queen Elizabeth Hspital and the Lyell McEwin Hspital. It is an initiative f the Ppulatin Research & Outcme Studies, SA Health, and was prduced by Andrew Vickers, the SA Health 2008 Public Health Graduate trainee. It is a cmpilatin f a range f jurnal publicatins, reprts and cnference presentatins frm the Nrth West Adelaide Study Team, including Prf Richard Ruffin, Assc Prf Anne Taylr, Prf David Wilsn, Dr Pat Phillips, Assc Prf Rbert Adams, Dr Kay Price, Catherine Chittlebrugh, Dr Tiffany Gill, Elenra Dal Grande, Janet Grant, Sarah Appletn, Katherine Baldck and Alicia Mntgmerie. The study team are mst grateful fr the genersity f the chrt participants in the giving f their time and effrt t participate in the study. The study team is als very appreciative f the wrk f the study management, clinic, recruiting and research supprt staff fr their substantial cntributin t the success f the study. The Queen Elizabeth Hspital Natinal Library f Australia Catalguing-in-Publicatin entry: Authr: Suth Australia. Ppulatin Research and Outcme Studies Unit. Title: Nrth West Adelaide Health Study : summarised findings and implicatins 2000-2008 / Suth Australia Dept. f Health, Ppulatin Research & Outcme Studies Unit. ISBN: Ntes: Subjects: 9780730898627 (pbk.) Bibligraphy. Health surveys--suth Australia--Adelaide. Health behavir--suth Australia--Adelaide. Chrnic diseases--suth Australia--Adelaide. Adelaide (S. Aust.)--Statistics, Medical. Other Authrs/Cntributrs: Suth Australia. Dept. f Health. Dewey Number: 614.4294231
Table f Cntents CHAPTER 1: Intrductin... 5 1.1 Purpse f this reprt... 6 1.2 Backgrund... 6 1.3 Study methdlgy... 7 1.4 Ethics... 8 1.5 Prevalence and incidence... 8 1.6 Health-related quality f life... 8 1.7 Frmat f this reprt... 8 CHAPTER 2: Chrnic Cnditins... 9 2.1 Asthma... 10 2.1.2 Undiagnsed asthma... 11 2.1.3 Asthma in lder peple... 12 2.1.4 Asthma perceptins, utcmes and management... 12 2.2 Chrnic bstructive pulmnary disease (COPD)... 14 2.2.1 Prevalence and incidence... 14 2.2.2 Undiagnsed COPD... 15 2.2.3 COPD and smking... 15 2.2.4 COPD assciatin with physical activity... 16 2.3 Diabetes... 17 2.3.1 Prevalence and incidence... 17 2.3.2 Undiagnsed diabetes... 18 2.3.3 Pre-diabetes (impaired fasting glucse) and the metablic syndrme... 19 2.3.4 Quality f life alng the diabetes cntinuum... 20 2.3.5 Achieving diabetes management targets... 21 2.3.6 Prevalence and management f diabetes-related cmplicatins... 22 2.3.7 Crnary heart disease risk in peple with diabetes... 23 2.3.8 Educatin and infrmatin issues amng peple with diabetes... 23 2.3.9 Perceptins and csts f diabetes risk factrs... 24 2.4 Arthritis and musculskeletal pain and stiffness... 26 2.4.1 Arthritis... 26 2.4.2 Musculskeletal pain and stiffness... 26 2.5 Osteprsis... 30 2.5.1 Prevalence... 30 2.6 Kidney disease... 32 2.6.1 Prevalence... 32 2.7 Cardivascular disease... 33 2.7.1 Prevalence... 33 2.8 Chrnic cnditins verall... 34 2.8.1 The burden f chrnic cnditins n health-related quality f life... 34 2.8.2 Experiences and perceptins f peple with a chrnic cnditin... 34 2.8.3 Health service csts assciated with chrnic cnditins... 35 3
CHAPTER 3: Risk Factrs... 37 3.1 Alchl cnsumptin... 38 3.2 Chlesterl... 39 3.3 High bld pressure (hypertensin)... 40 3.4 Obesity... 41 3.4.1 Obesity and verweight accrding t Bdy Mass Index (BMI)... 41 3.4.2 Hw valid are self-reprted height and weight?... 42 3.4.3 Obesity and verweight accrding t central adipsity... 43 3.4.4 Severe besity accrding t Bdy Mass Index (BMI)... 44 3.4.5 Which is the best measure t classify besity?... 45 3.4.6 Sci-ecnmic status and besity prevalence... 46 3.4.7 Investigating besity-asthma assciatins... 47 3.4.8 Gender differences in asthma assciated with besity... 48 3.4.9 Self-perceptin f bdy weight... 48 3.4.10 Beliefs abut fast-fd cnsumptin... 49 3.5 Physical activity... 51 3.6 Smking... 52 3.7 Risk factrs verall... 53 3.7.1 The burden f risk factrs n health-related quality f life... 53 3.7.2 MBS and PBS use and csts assciated with chrnic disease risk factrs... 54 3.7.3 Distributin f risk factrs acrss the life curse... 54 Appendices... 57 Appendix 1 - Publicatins... 58 Appendix 2 Published Reprts... 61 Appendix 3 Cnference presentatins... 63 References... 71 4
CHAPTER 1: Intrductin 5
Intrductin 1.1 Purpse f this reprt Results frm the Nrth West Adelaide Health Study (NWAHS) have been published in a wide variety f reprts, peer-reviewed jurnal articles, cnference presentatins and psters, and health prfessinal newsletters and magazines. The aim f this reprt is t summarise these findings in rder t prvide health care prviders, plicy makers and cnsumers with an verview f what the study has examined abut chrnic cnditins and risk factrs thus far, as well as sme f the plicy implicatins. The full details f the publicatins frm where the infrmatin in this reprt was surced, are included in the reference sectin at the end f this reprt. Cpies f these publicatins are available upn request thrugh the Study C-rdinatr, Janet Grant n (tel) 8226 6054 r email via janet.grant@health.sa.gv.au. The verall aim f this reprt is t stimulate further changes t plicy and practice t imprve the health f the cmmunity. 1.2 Backgrund The NWAHS is a cllabrative prject between the Suth Australian Department f Health (SA Health), The University f Adelaide, the University f Suth Australia, The Queen Elizabeth Hspital and Lyell McEwin Hspital campuses f the Central Nrthern Adelaide Health Service, and the Institute f Medical and Veterinary Science. The primary purpse f the study is t investigate the stability, prgressin r regressin f study participants alng a ptential disease cntinuum using bth self-reprted and bimedical data. These data will allw future interventins t be targeted at thse wh will benefit mst in terms f better health utcmes and mst efficient use f resurces. The better thse with specific health prblems, diseases, r risk factrs are described, the mre precisely they can be targeted fr plicies and interventins that are based n a range f apprpriate evidence-based characteristics. Further infrmatin abut the NWAHS can be dwnladed via the SA Health website (<www.health.sa.gv.au/prs>) and NWAHS website (<http://www.nwadelaidehealthstudy.rg/>). The chrnic diseases included in the study explain a great deal f the verall burden f chrnic disease and sme rank high as natinal pririties. 1,2,3 Mst are als diseases where cnsiderable prgress can be made thrugh primary and secndary preventin strategies, especially if these are crdinated as part f a public health respnse t the cnditins. Each f the chrnic cnditins has stages f develpment when patients have different preventin, management and treatment needs. This chrnic disease cntinuum is shwn in Figure 1.1. 4 Figure 1.1: The chrnic disease cntinuum 6
Intrductin 1.3 Study methdlgy The participants in the NWAHS are a representative sample aged 18 years and ver (at the time f initial recruitment) f the nrth west regin f Adelaide, randmly selected frm the Electrnic White Pages (EWP). The nrth west regin f Adelaide stretches gegraphically frm Glenelg t Gawler. Bimedical infrmatin was btained frm participants at clinic appintments and self-reprted data were cllected via telephne interviews and self-cmpleted questinnaires. 5,6 The Stage 1 sample fr the study (n=4060) was recruited in tw phases. Phase 1A (n=2523) was recruited between Nvember 1999 and December 2000, and Phase 1B (n=1537) was recruited between August 2002 and July 2003. Each randmly selected respndent within the husehld was asked a number f health-related and demgraphic questins via a telephne interview, and invited t attend a clinic fr a 45 minute appintment at either The Queen Elizabeth Hspital r the Lyell McEwin Hspital. Study participants were sent an infrmatin pack abut the study, including a self-reprt questinnaire abut a number f chrnic cnditins and health-related risk factrs. During the clinic visit, height, weight, waist and hip circumference, and bld pressure were measured. Lung functin and allergy skin prick tests were cnducted, and a fasting bld sample was taken t measure glucse, triglycerides, ttal chlesterl, high density lipprtein (HDL), lw density lipprtein (LDL), and glycated haemglbin (HbA 1c ). Cnsent was btained frm participants t link t their Medicare Australia data. In Stage 1 there were 4060 participants wh attended the clinic. 7 The main bjective f Stage 1 f the chrt was t establish representative self-reprted and bimedically measured infrmatin n diabetes, asthma and chrnic bstructive pulmnary disease (COPD), and health-related risk factrs in terms f thse wh were at risk f these cnditins, thse wh had these cnditins but had nt been diagnsed, and thse wh had previusly been diagnsed. One f the strengths f NWAHS is the ability t determine the undiagnsed rates f cmmn chrnic diseases in the cmmunity. Participants were invited t attend the clinic fr Stage 2 via a telephne interview that als btained demgraphic and health-related infrmatin. Of the riginal living chrt, 3564 (90.1%) participants prvided sme Stage 2 infrmatin, and 3206 (81.0%) attended the clinic between 2004 and 2006 fr their secnd visit. In additin t the measurements taken at Stage 1 (except skin prick tests), musculskeletal tests were cnducted including hand grip strength, hand phtgraphs, shulder range f mvement and ft pain. A urine sample was als supplied by the participant, which was tested fr albumin and creatinine as ne measure f kidney functin. Participants aged 50 years and ver were ffered a dual-energy x-ray absrptimetry (DEXA) scan t measure their bne density, and fat and lean bdy mass. The lngitudinal nature f the chrt study means that fllwing Stage 2, valuable infrmatin was btained abut the number f peple in the chrt wh had develped chrnic cnditins ver time, and the factrs that may have increased their risk f develping chrnic disease. Fr the first time in Suth Australia (SA), annual incidence figures fr these majr chrnic diseases was determined. The data were weighted by regin (western and nrthern health regins), age grup, gender, and prbability f selectin in the husehld, t the Australian Bureau f Statistics 1999 Estimated Residential Ppulatin and the 2001 Census. Prbability f selectin f the adult in the husehld was calculated frm the number f adults in the husehld, and the number f telephne listings in the EWP that reach the husehld. Weighting was used t crrect fr the disprprtinality f the sample with respect t the ppulatin f interest. The weights reflect unequal sample inclusin prbabilities and cmpensate fr differential nn-respnse. The data were weighted using the ABS data s that the health estimates calculated wuld be representative f the adult ppulatins f the nrth west area f Adelaide. Each stage f the study is weighted separately with the initial ppulatin as the fundatin figure. Stage 3 f the study has nw started in with all respndents again being asked t attend the clinic fr assessment. Results in this reprt are limited t Stages 1 and 2. 7
Intrductin 1.4 Ethics Ethics apprval fr the each stage f the NWAHS was granted by the Ethics f Human Research Cmmittee f The Queen Elizabeth and Lyell McEwin Hspitals. 1.5 Prevalence and incidence Stage 1 data prvided the prevalence f chrnic cnditins, risk and preventive factrs, and health utcmes. In this reprt, prevalence is a measure f the number, r prprtin, f peple with a certain chrnic cnditin in the ppulatin. Other prevalence estimates relate t lifetime prevalence, which is the prprtin f peple wh have ever had a chrnic cnditin. Incidence is the number f new cases f a certain cnditin in a ppulatin within a perid f time. Annual Incidence was calculated after the cmpletin f Stage 2. 1.6 Health-related quality f life Health-related quality f life is discussed thrughut this reprt. The mean scres fr each dimensin f health-related quality f life were calculated frm a set f questins asked in the self reprt questinnaire. This set f questins makes up the Shrt Frm 36 (SF-36), which prvides a generic indicatr f health status, and assesses the impact f varius health cnditins in the ppulatin. There are eight dimensins f the SF-36, including Physical Functining (PF), Rle Physical (RP), Bdily Pain (BP), General Health (GH), Vitality (VT), Scial Functining (SF), Rle Emtinal (RE) and Mental Health (MH). 8,9 Brief descriptins f the meanings f the eight dimensins are listed in Table 1.1. Table 1.1: Brief descriptins f SF-36 health-related quality f life dimensins Dimensin Descriptin PF Physical functining Limitatins in physical activities because f health prblems RP Rle physical Limitatins in nrmal rle activities because f physical health prblems BP Bdily pain Intensity f bdily pain r discmfrt GH General health General health perceptins VT Vitality Energy and fatigue SF Scial functining Limitatins in scial activities due t physical r emtinal prblems RE Rle emtinal Limitatins in usual rle activities because f emtinal prblems MH Mental health Psychlgical distress and well-being 1.7 Frmat f this reprt The main bdy f the reprt is divided int tw chapters. Chapter Tw includes sectins relating t the chrnic cnditins investigated by the NWAHS, particularly asthma, chrnic bstructive pulmnary disease (COPD), and diabetes. Chapter Three cntains infrmatin relating t a range f chrnic disease risk factrs. A discussin f why each issue is imprtant is fllwed by findings and prpsed implicatins. There are strng links between varius chrnic diseases, utcmes and risk factrs cvered within NWAHS. As such, sme f the tpics discussed in this reprt wuld be apprpriately lcated in mre than ne sectin. In instances where this is the case, readers are referred t the lcatin f related tpics in ther sectins f this reprt. Again, readers are reminded that NWAHS has prduced many methdlgical, epidemilgical and scientific reprts. If mre detail is required n any aspect cvered in this summary dcument, the reader is encuraged t reference these additinal reprts. 8
CHAPTER 2: Chrnic Cnditins 9
Chrnic Cnditins 2.1 Asthma Related sectins: 3.4.7 Undiagnsed asthma 3.4.8 Gender differences in asthma assciated with besity 2.1.1.1 Why is it imprtant? Asthma is identified as a Natinal Health Pririty Area 2 because f the significant burden that it places n the cmmunity in terms f health, scial, ecnmic and emtinal csts. Over tw millin Australians have asthma, and it is a leading cause f hspitalisatin. 10 Asthma affects peple f all age grups, and indirectly, all thse wh care fr peple with asthma. 11 Effective treatment is available, but successful health utcmes are generally dependent n patient self-management, using a written asthma management plan. 4 Asthma is a cmplex respiratry disrder characterised by chrnic inflammatin f the airways, recurrent episdes f wheezing, breathlessness, tightness f the chest, and reversible airways bstructin. Asthma causes many emergency department visits and hspitalisatins. The ppulatin prevalence f asthma has increased in recent decades. The reasns fr this are nt clear and culd be explained by lifestyle, envirnment, diet, genetics, r cmbinatins f these. The diagnsis f asthma is based n measurement f reversibility f airflw bstructin, in additin t an apprpriate clinical histry. Dctr awareness f asthma and change in diagnstic criteria ver time can affect prevalence. In sme patients, particularly the elderly, it can be difficult t discriminate between asthma and chrnic bstructive pulmnary disease (COPD). The reversible airway bstructin cmpnent in these patients may be difficult t diagnse. 2.1.1.2 Investigatin and findings The NWAHS results indicated that 12.5% (ne in eight) f study participants had asthma, representing apprximately 142,700 adults in SA. 5,7 The annual incidence f develping asthma was 24.6 incident cases per 1000 in the adult ppulatin. Of thse wh did nt have asthma at Stage 1, 5.7% develped asthma by stage 2 (3.2% diagnsed, 2.5% undiagnsed). The incidence f develping asthma was highest amng peple wh were 75 years and ver, physically inactive r n a lw annual husehld incme ( $20,000). 12 The prevalence f asthma was higher in females, peple undertaking hme duties, retired peple and students, and lwer in peple with an educatinal level f bachelr degree r higher, r an annual grss husehld incme higher than $40,000 per annum. 5 The assciatin f sci-ecnmic factrs such as educatin and emplyment status with asthma varied by gender. 13 Thse with current asthma scred wrse than thse withut asthma n the quality f life dimensins f Physical Functining, Rle-Physical, Bdily Pain, General Health, Vitality and Scial Functining. Peple with asthma were mre likely t have used general practitiner, day surgery, hspital accident and emergency department, hspital clinic, pdiatrist, and eye specialist/phthalmlgist health services than peple withut asthma in the last 12 mnths in Suth Australia. 2.1.1.3 Implicatins The quality f life f peple with diagnsed asthma was impaired in terms f their general health. This highlights the need fr imprved management strategies fr asthma t imprve quality f life. The identified demgraphic and sci-ecnmic subgrups where the prevalence and/r incidence f asthma were fund t be higher shuld be targeted by health prfessinals fr urgently needed interventin prgrams and strategies. 10
Chrnic Cnditins 2.1.2 Undiagnsed asthma Related sectins: 2.2.2 Undiagnsed asthma 2.3.2 Undiagnsed diabetes 2.1.2.1 Why is it imprtant? The gals f the Natinal Asthma Strategy 14 include delaying the prgressin f asthma, imprving quality f life, reducing hspitalisatin and cmplicatins, reducing the scial and ecnmic impact f the cnditin n the cmmunity, and ptimising asthma management. In rder t achieve these gals it is crucial that all individuals in Australia with asthma are identified, diagnsed and prvided with the apprpriate treatment, assistance and advice. 15 2.1.2.2 Investigatin and findings The NWAHS results indicated that the prevalence f previusly undiagnsed asthma was 2.9% (ne in 34) f the participants. Of the peple with current asthma, 23.7% did nt knw they had asthma prir t participating in the study. Fr apprximately every three peple previusly diagnsed with asthma, ne persn had current asthma but did nt knw it, representing apprximately 34,700 peple with undiagnsed asthma in Suth Australia. 5,7 The prevalence f previusly undiagnsed asthma was higher amng peple aged ver 50 years, brn utside f Australia, widwed, retired r undertaking hme duties, and lwer amng peple in the nrthern regin, thse with an annual grss husehld incme abve $40,000 and peple wh had never been married. Undiagnsed asthma was mre cmmn in males 50 years and lder (48%) and females 50 years and ver (34%). 16 Peple with undiagnsed asthma were less likely than peple with diagnsed asthma t have used general practitiner, hspital accident and emergency department, chirpractr, alternative therapist and ther health services. Thse with previusly undiagnsed asthma scred better than thse with previusly diagnsed asthma n the quality f life dimensins f Physical Functining and General Health. Cmpared t thse withut asthma, thse with undiagnsed asthma scred lwer n the Physical Functining and Rle Physical health-related quality f life dimensins. 17 2.1.2.3 Implicatins Peple with previusly undiagnsed asthma represent ver ne-fifth f the asthma ppulatin. Detectin and diagnsis f this grup remains a pririty s that peple with undiagnsed asthma can be in a psitin t cntrl and manage their cnditin, and reduce their risk f hspitalisatin and health service use. 18 Spirmetric screening in primary care shuld be cnsidered fr all smkers and ex-smkers and anyne with chest symptms. 19 There is a need t put in place research strategies t understand reasns fr lack f asthma diagnsis and impaired quality f life in diagnsed asthmatics. This means explring: patients perceptins f symptms; access t medical care and drug availability; patients attitudes twards medicines; and medical practitiners awareness f issues in diagnsing asthma. A significantly lwer prprtin f peple with undiagnsed than diagnsed current asthma saw a general practitiner in the last 12 mnths, which may partly explain why they remain undiagnsed. This supprts the need t prmte annual health checks and screen fr asthma in annual health checks. As undiagnsed asthma was fund t be mre prevalent in the lder age grups (particularly men), this is an imprtant target ppulatin grup fr general practitiners. If the prgress and impact f asthma educatin and plicies are t be measured and evaluated, it is imprtant t imprve asthma detectin and diagnsis rates. 11
Chrnic Cnditins 2.1.3 Asthma in lder peple 2.1.3.1 Why is it imprtant? It has been recgnised that there is a higher prevalence f asthma in lder peple, and that lder peple with asthma have higher death rates than their peers. It is als knwn that asthma in sme lder peple is undiagnsed, meaning that it is nt treated, resulting in prer than necessary health and wellbeing utcmes (refer sectin 2.1.2). 2.1.3.2 Investigatin and findings Data were analysed t determine the rates f diagnsed and undiagnsed asthma in lder peple ( 55 years), cmpared t thse yunger than 55 years. 20 Sme f the findings f the study included: Asthma prevalence was 14.7% in peple aged 55 years and ver cmpared t 13.6% in thse less than 55 years f age. Of thse with asthma, it was undiagnsed in 46% f lder men, cmpared t 33% f lder wmen, 30% f yunger men and 29% f yunger wmen. Of the lder peple with asthma, bth the diagnsed and undiagnsed grups visited their general practitiner an equal mean number f times per year (8.5). There was a higher prprtin f current and ex-smkers in the diagnsed grup. 2.1.3.3 Implicatins The higher rates f undiagnsed asthma in lder peple (particularly men) suggested that imprved screening practices need t be devised and implemented fr general practice. This is particularly evident when cnsidering that the undiagnsed grup visited their general practitiner as frequently as the diagnsed grup. A particular target grup fr such screening wuld be men aged 55 years and ver, and mre specifically thse wh have never smked. The ptential fr undiagnsed asthma in lder peple needs t be highlighted t the GP prfessin and prmted t the target audience using health prmtin techniques. In additin, prmtin f the use f spirmetry based n agreed guidelines fr the diagnsis f asthma in general practice wuld be likely t reduce the prevalence f undiagnsed asthma in all age grups, in turn delivering imprved ppulatin health utcmes. 2.1.4 Asthma perceptins, utcmes and management Related sectin: 2.1.4.1 Why is it imprtant? 2.8.2 Experiences and perceptins f peple with a chrnic cnditin It has been demnstrated that self-management, written actin plans and regular medical review are effective in imprving health utcmes and reducing hspital admissins fr peple with asthma. Therefre, it is imprtant t understand the perceptins f peple with asthma regarding their cnditin, and t quantify the prprtin f peple with asthma that have current asthma management plans. 2.1.4.2 Investigatin and findings Fllwing the Stage 1 clinic, a fllw up interview was cnducted f NWAHS participants with current asthma t determine their perceptins f the severity f their cnditin, their asthma management, and any specified negative utcmes arising frm their cnditin in the previus 12 mnths. 21 Sme f the findings f the study included: Of the participants interviewed, 48% thught their asthma was nt a prblem, 32% thught is was mild, 15% said it was mderate and 5% perceived their asthma t be severe. 12
Chrnic Cnditins Thse wh thught their asthma was mderate r severe were mre likely t have been wken frm sleep in the last mnth, lst days frm usual activities in the last year and been admitted t hspital in the last 12 mnths as a result f their asthma. Hwever, f thse that thught their asthma was mild r nt a prblem, 6% had been wken by their asthma, 4% had been admitted t hspital and 11% had lst days frm usual activities. Of thse that had been admitted t hspital as a result f asthma, 44% cnsidered their asthma t be mild r nt a prblem. Only 24% f peple with self-perceived mderate t severe asthma and 21% f peple wh thught that their asthma was mild r nt a prblem had a written actin plan. Of thse wh believed that their asthma was mderate r severe, 25% had seen mre than ne GP fr their asthma in the past year. 2.1.4.3 Implicatins Sme peple with asthma, wh have detrimental utcmes including hspital admissin, cnsider their asthma t be mild r nt a prblem. This suggests that awareness prgrams shuld highlight the seriusness f the cnditin and the imprtance f crdinated management. Despite the prven benefit f written actin plans, ver three quarters f thse with asthma (including thse with self-perceived severe asthma) did nt have ne. This is an area that needs t be urgently addressed by health prfessinals and awareness prgrams. It is a cncern that ne quarter f thse with self-reprted mderate t severe asthma are nt receiving cntinuity f care as indicated by the fact that they used mre than ne GP in a year. This has implicatins fr the successful lng term management f their cnditin and the reductin f adverse cmplicatins. 13
Chrnic Cnditins 2.2 Chrnic bstructive pulmnary disease (COPD) 2.2.1 Prevalence and incidence 2.2.1.1 Why is it imprtant? COPD (including emphysema, chrnic brnchitis and chrnic bstructive brnchitis) is a serius health prblem in Australia, being the furth leading cause f death and accunting fr 5.0% f ttal deaths. 22 COPD and asthma are the third and ninth leading causes f verall disease burden in Australia, accunting fr 6.3% f the ttal burden in terms f disability-adjusted life years (DALYs). 3 Chrnic lung disease (COPD and asthma) accunts fr the majrity f the burden f chrnic respiratry diseases, being respnsible fr 88% f chrnic respiratry disease DALYs. COPD is characterised by a single physilgical feature: the limitatin f expiratry airflw. It is, hwever, a cnstellatin f diseases embracing emphysema and brnchitis. Cigarette smking is the main cause f COPD, resulting in an 80 90% risk f the disease develping at sme level. 23 Other factrs that increase the risk f COPD include expsure t ccupatinal dust, envirnmental air pllutin r tbacc smke. Clinical manifestatins f COPD include ne r mre f dyspnea (shrtness f breath), wheeze, cughing and sputum (mucus frm the respiratry tract) prductin. These symptms are less cmmn and less severe in the early stages f the disease. As the disease prgresses it prduces extremely disabling effects n physical and mental health. 24 COPD pses a significant and increasing cst t sciety and the health system as a result f assciated direct and indirect csts. 25 2.2.1.2 Investigatin and findings The NWAHS results indicated that 3.9% (ne in 26) f study participants had COPD, representing apprximately 41,500 adults in Suth Australia. 5,7 The annual incidence f develping COPD was 6.1 incident cases per 1000 in the adult ppulatin. The prevalence f COPD was higher amng thse aged 50 years r ver, brn in the UK r Ireland, widwed, r undertaking hme duties r retired, and lwer amng thse wh had undertaken pstsecndary educatin, had an annual grss husehld incme f mre than $20,000 per annum, r wh had never been married. The prevalence f COPD was higher amng peple wh were smkers, exsmkers, r had high bld pressure, and lwer amng thse wh were physically active and peple wh were bese. The prevalence f COPD was higher amng peple with cardivascular disease (heart attack, strke, and angina). Thse peple with COPD scred statistically significantly lwer n the Physical Functining, Rle Physical, General Health and Vitality quality f life dimensins. Peple with COPD were mre likely than peple withut COPD t have had day surgery, visited a hspital clinic, r seen an eye specialist r phthalmlgist, and less likely than peple withut COPD t have seen a physitherapist r chirpractr in the last 12 mnths. 2.2.1.3 Implicatins The prevalence f COPD was higher fr smkers and ex-smkers (als refer t sectin 2.2.3). This knwledge prvides specific targeting infrmatin and highlights the imprtance f cntinuing antismking and quit smking campaigns t reduce the prevalence f smking, as well as the develpment f campaigns that specifically target the smking/copd relatinship. COPD specific prgrams shuld target thse demgraphic grups where smking is mre prevalent. In additin, because smking is mre prevalent in lwer incme grups, nictine replacement therapy shuld be cnsidered fr additin t the Pharmaceutical Benefits Scheme (PBS). Additinal research is needed t explre prgressin alng the cntinuum f COPD and the factrs assciated with peple prgressing frm mild t mderate r severe COPD, and the impact this will have n health services. 14
Chrnic Cnditins 2.2.2 Undiagnsed COPD Related sectins: 2.1.2 Undiagnsed asthma 2.3.2 Undiagnsed diabetes 2.2.2.1 Why is it imprtant? Many peple at an early stage f COPD are unaware f their cnditin and fail t cnsult their dctr fr respiratry symptms. Cnsequently, they d nt receive apprpriate cunselling and treatment which wuld prevent r slw their transitin alng the disease cntinuum. The airflw bstructin in COPD is generally prgressive ver a perid f years and is largely irreversible. Hwever, quality f life can be imprved by physical fitness and pulmnary rehabilitatin prgrams. Early identificatin and treatment f COPD can lead t substantial declines in mrtality and mrbidity and imprvements in quality f life. 2.2.2.2 Investigatin and findings The NWAHS results indicated that the prevalence f previusly undiagnsed COPD was 2.8% (ne in 36) f participants. Of the peple wh had COPD, 80% did nt knw they had it prir t participating in the study. Fr every persn previusly diagnsed with COPD, apprximately fur peple had COPD but did nt knw it, representing apprximately 32,900 adults with undiagnsed COPD in Suth Australia. 5,7 The prevalence f previusly undiagnsed COPD was higher amng thse with an incme between $20,001 and $40,000 per annum, and lwer amng thse aged 60 years and ver. The prevalence f previusly undiagnsed COPD was lwer amng peple with a mental health illness (anxiety, depressin, stress related disrder, r ther). As a grup, peple with previusly undiagnsed COPD scred higher than thse with diagnsed COPD n the Physical Functining, Rle Physical, General Health, and Vitality quality f life dimensins. 2.2.2.3 Implicatins Almst 3% f the Nrth West Adelaide adult ppulatin has COPD but has nt been diagnsed. Early detectin f COPD is imprtant, and guidelines are required fr primary care t identify thse with early symptms and thse at risk. The largest prprtin f undiagnsed COPD patients suffered mild COPD, but this is the grup wh wuld benefit mst frm early detectin and interventin. It is pssible t stp further deteriratin by gd management at an early stage f COPD. Peple with undiagnsed COPD were hardly impaired in terms f quality f life, cmpared t peple with diagnsed COPD. The develpment f COPD is ne f prgressive airflw deteriratin. Simple spirmetric measures shuld ccur in all peple at risk (smkers and thers at ccupatinal risk) t detect early stage COPD and t act t prevent further deteriratin and cmplicatins. 2.2.3 COPD and smking Related sectins: 3.6 Smking 2.2.3.1 Why is it imprtant? Smking is the main causal risk factr fr COPD, and smking cessatin campaigns are the dminant public health strategy used t prevent COPD r reduce further lss f lung functin in thse already diagnsed. While it has been demnstrated that a large prprtin f smkers develp COPD, it is uncertain t what extent envirnmental and genetic factrs are invlved in the burden f COPD. T further cmplicate the issue, there are at least five different sets f respiratry guideline criteria used t diagnse COPD, resulting in different prevalence rates depending n the criterin used. This means that depending n the guideline values used, many individuals may nt be diagnsed and therefre treated. 15
Chrnic Cnditins 2.2.3.2 Investigatin and findings Data frm the NWAHS were analysed t determine the ppulatin burden f COPD due t smking, based n the varius diagnstic criteria. The aims were t determine the fractin f the ppulatin that are nt targeted by the current quit smking campaigns, and t investigate pssible strategies fr earlier case finding. 26 Sme f the findings f the study included: There was substantial disagreement in the prevalence f COPD between the different criteria; hwever, the Eurpean Respiratry Sciety (ERS) ne residual standard deviatin (1RSD) criterin captured mst f the cases identified by all f the ther criteria guidelines. Using the ERS 1RSD values, an estimated 78% f the COPD burden was attributable t current r previus smking histry (current 40% and ex-smkers 38%). ERS 1RSD criterin suggested that 22% f the COPD needs t be explained by ther genetic and envirnmental risk factrs; hwever this figure was as high as 40% using ther diagnstic methds. 2.2.3.3 Implicatins The high prprtin f COPD burden attributable t ex-smking and the bserved inclusiveness f cases identified by the ERS 1RSD guidelines suggested that general practice shuld adpt an apprach f asking abut smking histry fllwed by spirmetric screening accrding t ERS 1RSD criterin. Such practice wuld be likely t capture the majrity f COPD cases in the ppulatin, enabling the instigatin f treatment t reduce prgressin f COPD in the large prprtin f COPD sufferers wh currently remain undiagnsed. Specific health prmtin campaigns that target smkers and ex-smkers shuld be established t increase awareness and screening, in rder t reduce the lng term burden f COPD. Further research is required t identify the ther ptentially preventable risk factrs that are invlved in the develpment f a substantial prprtin (20-40%) f COPD (including passive smking, diet, respiratry infectins and ccupatinal and envirnmental expsures). 2.2.4 COPD assciatin with physical activity Related sectins: 3.5 Undiagnsed asthma 2.2.4.1 Why is it imprtant? It is recgnised that peple diagnsed with COPD are limited in their exercise capacity, yet physical activity is imprtant in the management f chrnic disease and cmplicatins t maintain functin. As such it is imprtant t understand the physical activity behaviur f peple acrss the COPD cntinuum. 27 2.2.4.2 Investigatin and findings Data frm the NWAHS were analysed t determine the exercise behaviur f participants classified as nt having COPD, having undiagnsed COPD and thse with diagnsed COPD. Sme f the findings f the analysis included: Participants classified as having COPD (diagnsed r undiagnsed) were mre likely t be sedentary than thse withut COPD. Participants with undiagnsed COPD were less likely t have walked in the last tw weeks and mre likely t be sedentary than thse with diagnsed COPD. 2.2.4.3 Implicatins COPD has a significant impact n exercise behaviur, with thse with COPD mre likely t be inactive. Hwever, peple with undiagnsed COPD are mst likely t be sedentary, perhaps due t their reduced exercise capacity resulting frm their unmanaged cnditin. Early identificatin and diagnsis f thse with COPD will enable actin and treatment t be taken t increase their capacity t exercise, which in turn may assist in delaying r halting disease prgressin and imprving health-related quality f life. Prmtin f physical fitness is an imprtant cmmunity activity. 16
Chrnic Cnditins 2.3 Diabetes Related sectins: 3.4.3 Undiagnsed asthma 2.3.1 Prevalence and incidence 2.3.1.1 Why is it imprtant? Diabetes is recgnised as a State and Natinal Health Pririty Area because f the significant burden that it places n the cmmunity in terms f health, scial, ecnmic and emtinal csts. 1 The Natinal Diabetes Strategy 28 and the Strategic Plan fr Diabetes in Suth Australia 29 identify the need t prevent r delay the prgressin f diabetes and related cmplicatins, imprve the quality f life f peple with diabetes, and reduce the scial and ecnmic impact f diabetes n the cmmunity. 2.3.1.2 Investigatin and findings The NWAHS results indicated that 6.6% (ne in 15) f study participants had diabetes, representing apprximately 79,700 adults in Suth Australia. 5,7 The annual incidence f develping diabetes was 6.8 incident cases per 1000 in the adult ppulatin, meaning that apprximately 7,500 Suth Australian adults develp diabetes each year. The prevalence f diabetes was higher amng peple wh were 50 years r ver, had an annual grss husehld incme lwer than $20,000, were brn utside f Australia, widwed, retired r undertaking hme duties, and lwer amng thse wh had never been married, r had an educatin level f bachelr degree r higher. Further investigatin f the assciatin between incme and diabetes prevalence indicated that even when cntrlling fr the effects f age, the prevalence f diabetes is higher amng thse with lwer incme. 30 When adjusted fr age and sex, lw annual grss husehld incme (<$20,000) remained assciated with diabetes amng thse aged 65 years and lder, but nt in the yunger age grups. 31 The prevalence f diabetes was higher amng peple wh were ex-smkers, verweight r bese r had a high waist-hip rati, high bld pressure, a family histry f diabetes, r a high haemglbin (HbA 1c ) level, and lwer amng thse wh were lw risk alchl drinkers r physically active. Glycsylated haemglbin (HbA 1c ) is a measure f the amunt f glucse-bund haemglbin, and prvides infrmatin n lng-term glucse cntrl. Men with diabetes were mre likely t be an exsmker and less likely t have high chlesterl. Wmen with diabetes were mre likely t have a high waist-hip rati, high bld pressure, and a histry f mental r cardivascular illness. 32 Thse with diabetes scred wrse than thse withut diabetes in all f the health-related quality f life subscales f the SF-36. Peple with diabetes scred lwer n the Physical Functining, General Health and Rle emtinal quality f life dimensins than thse with asthma, and lwer n all quality f life dimensins than thse with COPD. 33 The prevalence f diabetes was higher amng peple with cardivascular disease (including heart attack, strke r angina) r mental health illness (including anxiety, depressin, and stress related prblem r any ther mental health prblem). NWAHS data have als indicated that lung functin is increasingly impaired alng the diabetes cntinuum (refer sectin 2.3.4). 34 This has raised suggestins f sme as yet unexplained assciatin between diabetes and sme cases f COPD. 2.3.1.3 Implicatins The quality f life f peple with diabetes is severely affected, and many peple with diabetes have multiple risk factrs fr cmplicatins, indicating that diabetes is nt being managed as well as it culd be. T address this and prevent r delay the develpment and prgressin f cmplicatins wuld invlve: imprved prgrams fr tracking peple with diabetes in the primary health care system (eg. diabetes centres, GPs), and prviding them with regular care. Links between GPs and ther health services will need t be prmted; and 17
Chrnic Cnditins imprved use f required health services by peple with diabetes and imprved client-related data cllectin and analyses t imprve health utcmes. It is als evident that a number f factrs assciated with diabetes differ between men and wmen, a fact which shuld be cnsidered when develping targeted health prmtin, preventin and management prgrams and plicies. The bserved inverse incme gradient effect in the prevalence f diabetes suggests that preventin and management strategies fr diabetes must include a fcus n incme inequalities. This is particularly evident in lder peple, and preventin and management strategies fr diabetes amng lder peple shuld include a fcus n incme inequalities. These recmmendatins will have implicatins fr the diabetes health services wrkfrce. Audits have shwn that the health services wrkfrce is already under-resurced fr the functins that it is required t perfrm. Successful implementatin f any plicy recmmendatins will require ptimal wrking relatinships between health funders, prviders and the cmmunity, as well as increased health system resurces and supprt. 2.3.2 Undiagnsed diabetes Related sectins: 2.1.2 Undiagnsed asthma 2.3.2 Undiagnsed diabetes 2.3.2.1 Why is it imprtant? In rder t achieve the gals f the Natinal Diabetes Strategy 28 and the Strategic Plan fr Diabetes in Suth Australia, 29 it is crucial that all individuals in Australia with diabetes are identified, diagnsed and prvided with the apprpriate treatment, assistance and advice. It is pssible t stp further deteriratin by gd management at an early stage f diabetes, especially if the undiagnsed have nt yet develped cmplicatins. Peple wh are unaware that they have diabetes may already be prgressing twards cmplicatins. 35 2.3.2.2 Investigatin and findings The NWAHS results indicated that the prevalence f previusly undiagnsed diabetes was 1% f participants. This means that fr apprximately every five r six peple with diagnsed diabetes, there was ne persn with undiagnsed diabetes, representing apprximately 11,600 adults with undiagnsed diabetes in Suth Australia. 5,7 This finding differed frm previus natinal data, which estimated that there was ne undiagnsed case fr every diagnsed case f diabetes in Australia. 36 Explanatins fr this difference may include variatins in glucse measurement, sampling strategies, and respnse rates acrss the studies. Peple with undiagnsed diabetes were mre likely t be aged 50 years r ver than thse withut diabets, reflecting the increased prevalence f diabetes in lder age grups. When cmpared t peple with diagnsed diabetes, thse with undiagnsed diabetes were mre likely t have an incme greater than $60,000, an educatin level f trade, apprenticeship, certificate r diplma, r be a current smker r lw risk alchl drinker, and less likely t be aged 60 years r ver, r emplyed part-time. Thse with diagnsed diabetes scred wrse than thse with previusly undiagnsed diabetes n the General Health quality f life dimensin. There were n ther significant differences in quality f life between thse diagnsed with diabetes cmpared t thse with undiagnsed diabetes. 2.3.2.3 Implicatins The large number f peple with undiagnsed diabetes can be identified as an imprtant target grup fr detectin and care, and a grup wh are likely t affect future health system csts. Identificatin f these 18
Chrnic Cnditins peple is a high pririty, as in the absence f diagnsis they are unlikely t be taking steps t reduce their risk f develping cmplicatins. A mre aggressive apprach t case finding wuld invlve: public educatin prgrams n the imprtance f early detectin and thse wh are at risk; imprved educatin f health prfessinals n the imprtance f early detectin and management; nging mnitring f the study chrt t identify mre clearly the ppulatin with undiagnsed diabetes and hw they may be effectively targeted fr health plicy initiatives; and imprved health prmtin and service prgrams dealing with diabetes assciated risk factrs. 2.3.3 Pre-diabetes (impaired fasting glucse) and the metablic syndrme Related sectins: 2.6 Kidney disease 2.7 Cardivascular disease 2.3.3.1 Why is it imprtant? Impaired fasting glucse (IFG) and the metablic syndrme are recgnised as significant risk factrs fr diabetes and cardivascular disease. Impaired fasting glucse is a particularly significant pre-cursr in the develpment f diabetes. Peple with IFG were defined as thse wh had a fasting plasma glucse (FPG) level f 6.1 mml/l and <7.0 mml/l. 37 Metablic syndrme was defined as having central besity accrding t waist circumference plus any tw f the fllwing: triglyceride >1.7mml/L, HDL (gd) chlesterl <0.9mml/L, high bld pressure and fasting plasma glucse 5.6mml/L. 38,39 It is imprtant t understand the prevalence and distributin f pre-diabetes and metablic syndrme t enable the effective targeting f health prmtins and interventins twards thse at greatest risk f develping diabetes. 2.3.3.2 Investigatin and findings The NWAHS data indicated that the prevalence f IFG was 4.3% f participants, representing apprximately 52,300 adults in Suth Australia. 5 Hwever, using the lwered diagnstic criteria (FPG 5.6 mml/l and <7.0 mml/l) suggested by the American Diabetes Assciatin, the prevalence f IFG was 13.8%. 40 The prevalence f IFG was higher amng ex-smkers, males, peple aged 50 years r ver, peple living in the nrthern suburbs, thse brn in the United Kingdm r Ireland, widwed, retired r undertaking hme duties, and lwer amng lw risk alchl drinkers, thse with an incme ver $40,000 per annum, peple wh had never been married, peple wh were physically active and thse part time r casually emplyed. Peple with IFG were mre likely than peple withut IFG t be verweight r bese, r t have a high waist hip rati, high bld pressure r high chlesterl. Males and females with IFG had similar demgraphic and risk factr prfiles. Hwever, high bld pressure and high chlesterl were assciated with IFG amng males but nt females. Als, in males besity accrding t BMI was assciated with IFG, whereas in females IFG was assciated with a high waist hip rati. 41 The prevalence f IFG was higher amng peple with cardivascular disease (including heart attack, strke r angina). With regards t quality f life, thse with IFG scred wrse than thse with nrmal glucse levels n the Physical Functining, General Health and Bdily Pain health-related quality f life dimensins, but higher than thse with diabetes n the Physical Functining, General Health, Vitality, Scial Functining and Rle Emtinal dimensins. 42 Thse with metablic syndrme scred wrse than thse withut metablic 43, 44 syndrme n all quality f life dimensins except fr Rle Emtinal and Mental Health. Analysis f NWAHS data indicated that the incidence f diabetes was almst 10 times greater amng thse with IFG than thse with nrmal glucse. 45 19
Chrnic Cnditins In additin, it was fund that peple with IFG are mre likely t have impaired kidney functin than thse with nrmal bld glucse as indicated by prtein cncentratins in urine (micralbuminuria). 46 The prevalence f metablic syndrme was 22.9%, but was als higher amng men (26.4%) than wmen (19.5%). In men, metablic syndrme was mre likely in thse with secndary educatin r less. In females, metablic syndrme was mre likely in thse with an annual grss husehld incme under $60,000 and in thse with a wrk status f unemplyed, retired, hme duties r student. 47 2.3.3.3 Implicatins Pre-diabetes and metablic syndrme have a significant impact n quality f life even befre the develpment f diabetes (refer sectin 2.3.4), and as such, interventins t imprve glucse metablism and metablic syndrme risk factrs will have benefits beynd the preventin f diabetes. The different risk factr prfiles fr IFG that were bserved between males and females prvide general practice with infrmatin regarding thse individuals where investigatin f pre-diabetes is imprtant. That peple with IFG were ten times mre likely t develp diabetes, indicates that screening thse at risk f IFG fllwed by effective management f thse identified with IFG has the ptential t reduce the incidence and burden f diabetes in the ppulatin. That kidney damage was fund t be mre likely in thse with IFG suggest that micralbuminuria screening and/r preventin therapies shuld be cnsidered fr all peple fund t have IFG. Based n the increased prevalence f pre-diabetes amng men, it may be wrth designing and implementing health prmtins and interventins that specifically target men in high risk grups. The sci-ecnmic factrs assciated with metablic syndrme vary by gender, with educatin level significant fr males, and husehld incme and emplyment status significant fr females. This shuld be taken int cnsideratin frm a plicy perspective, particularly when aiming t minimise and reduce health inequalities. 2.3.4 Quality f life alng the diabetes cntinuum Related sectins: 2.8.1 Undiagnsed asthma 2.3.4.1 Why is it imprtant? Diabetes has a substantial effect n functining, premature mrtality and health service use, and requires day t day management in rder t maintain gd metablic cntrl. Pr management f diabetes can result in impaired health-related quality f life. Hwever, there is limited research n quality f life impairment at varius stages alng the diabetes cntinuum (n diabetes > impaired fasting glucse > undiagnsed diabetes > diagnsed diabetes with gd metablic cntrl > diagnsed diabetes with pr metablic cntrl). Increasing understanding f the stages f diabetes where quality f life is diminished will enable the priritisatin f interventins t imprve health utcmes and reduce related health service csts. 2.3.4.2 Investigatin and findings NWAHS data were analysed in several studies t describe the health-related quality f life at varius stages f the diabetes cntinuum. 48,49,50,51,52 Sme f the findings f the studies included: Peple with impaired fasting glucse scred significantly lwer than thse with nrmal glucse with regards t Bdily Pain, Physical Functining and General Health perceptins. Peple with undiagnsed diabetes were further impaired in Physical Functining than thse with IFG. Peple with diagnsed diabetes scred less than thse with nrmal glucse in all quality f life dimensins (physical, scial, and vitality) with the exceptin f mental health. Of the peple with diabetes, 41% had pr glycaemic cntrl. 20
Chrnic Cnditins Thse with diabetes with pr metablic cntrl scred lwer than peple with diabetes under gd metablic cntrl in all quality f life dimensins except Rle Emtinal. Pr glycaemic cntrl in thse with diabetes had a mderate impact n Physical Functining and a large effect n General Health perceptins. Females with diabetes scred lwer than males with diabetes in all quality f life dimensins except General Health perceptins and Vitality. 2.3.4.3 Implicatins Diabetes has a significant effect n health-related quality f life which increases as peple prgress alng the cntinuum. This prvides supprt fr interventins that imprve glycaemic cntrl t delay r prevent the prgressin f diabetes and imprve quality f life. That quality f life reduces after diagnsis, suggests that management f newly diagnsed diabetes shuld cnsider quality f life. The results als indicate the imprtance f cnsidering gender in diabetes management, given that diabetes has a greater effect n the health-related quality f life f females cmpared t males. 2.3.5 Achieving diabetes management targets 2.3.5.1 Why is it imprtant? Assessing hw successfully peple with diabetes manage their cnditin against clinical management targets prvides valuable infrmatin abut their diabetes-related health status and their risk fr future diabetes-related cmplicatins. By quantifying the demgraphic grups and specific target gals where imprvements can be made gives health prfessinals the pprtunity t direct targeted interventins that have the ptential t deliver imprved health utcmes fr peple with diabetes. 2.3.5.2 Investigatin and findings Data frm the NWAHS were analysed t determine the achievement f diabetes management targets by peple with diagnsed diabetes using the clinical management guidelines fr type 2 diabetes develped by the Suth Australian Divisins f General Practice and the Suth Australian Department f Health. 53 The nine targets investigated were: glycsylated haemglbin (HbA 1c ) level, fasting plasma glucse, plasma triglycerides, ttal, HDL (gd) and LDL (bad) chlesterl, bld pressure, waist circumference and bdy mass index. 54 Sme f the findings f the investigatin included: The prprtin f participants achieving the target levels ranged frm a maximum f 64.6% wh had HDL levels f >1.0mml/L, t a minimum f 12.8% wh had a BMI in the nrmal range (see Table 2.1). N sci-demgraphic differences were nted between peple wh achieved few (0-2) targets and thse wh achieved three r mre targets. Over 50% f participants achieved nly 2-4 targets. Apprximately 19% f participants achieved 0-1 targets. Apprximately 13% f participants achieved 5 targets. Apprximately 12% f participants achieved 6-7 targets. Only 1% f participants achieved 8 targets. N participants achieved all 9 targets. 21