Guidelines and statements. Narrative reviews. Ethics and law. Medical education. Volume Issue 3. Emerging diabetes and metabolic conditions among Aboriginal and Torres Strait Islander young people. Med J Aust ; 3 : Topics Endocrine system diseases.
Pediatric medicine. Indigenous health. Anatomy and physiology. Health occupations. View this article on Wiley Online Library. Australian Institute of Health and Welfare. IHW Canberra: AIHW, Health and wellbeing of Indigenous adolescents in Australia: a systematic synthesis of population data. Lancet ; — Med J Aust ; Med J Aust ; — Diabetes in young people in the Top End of the Northern Territory. J Paed Child Health ; — Type 2 diabetes in youth is a disease of poverty. Lancet ; Prevalence of obesity and metabolic syndrome in Indigenous Australian youths.
Obes Rev ; — Australian Bureau of Statistics. Research has shown that Aboriginal people who live a Westernised lifestyle have high rates of obesity, impaired glucose tolerance, high blood pressure, high levels of triglycerides fats in the blood, and excessively high insulin levels in the blood. So, the combination of a genetic predisposition and an unhealthy lifestyle contributes to the high rates of type 2 diabetes in Indigenous Australians.
Treatment of type 2 diabetes involves lifestyle modification weight loss, dietary changes, increasing physical activity , monitoring blood glucose and, if necessary, medicines to help keep blood sugar under control oral hypoglycaemic medicines or, in some cases, insulin injections. Treatment also involves regular screening for complications of diabetes. Of course, the successful prevention and management of diabetes in Aboriginal and Torres Strait Islander communities encompasses a wider picture, in which economic and social factors and political intervention all play a part.
However, given that a Westernised lifestyle is a big contributor to the development of type 2 diabetes, evidence has shown that adopting the beneficial aspects of the traditional lifestyle can help improve the health of people with diabetes, and could help prevent the development of diabetes in those at risk.
Diabetes Australia Victoria. Aboriginal and Torres Strait Islander Program. Diabetes Australia. Diabetes in Australia updated 15 Oct Australian Indigenous Health InfoNet.
Diabetes background information. Review of diabetes among Indigenous peoples. Australian Institute of Health and Welfare. Populations of interest. Type 2 diabetes in young Indigenous Australians in rural and remote areas: diagnosis, screening, management and prevention. Med J Aust. Skip to content. Complications of diabetes include: kidney disease; eye disease; a higher risk of heart attack or stroke; erection problems; and nerve damage, which may result in traumatic injury and infection, possibly leading to limb amputation.
Why are Indigenous Australians at greater risk of diabetes? Author: myDr. Diabetes and Vision Loss — Dr. Norman Swan Diabetes July 30, ,. Diabetes Self-Care. One pilot study with a wait-list control group in Native Hawaiians showed that culturally adapted diabetes self-management education building on culturally relevant knowledge and activities i.
In a qualitative study in rural Australia, participants reported both negative influences i. Participants said that while they often felt overwhelmed and confused by the burden of chronic illness, they drew strength from being part of an Indigenous community, having regular and ongoing access to primary health care, and being well-connected to a supportive family network.
Within this context, elders played an important role in increasing people's awareness of the impact of chronic illness on people and communities Another qualitative study conducted with Canadian urban First Nations suggested they and their caregivers struggled with balancing two worlds, accessing care, and dealing with diabetes from cultural and emotional perspectives A recent study of health-care experiences among Indigenous people with type 2 diabetes highlights the perpetuation of inequalities in care from a sample drawn from 5 Indigenous communities in 3 Canadian provinces While service providers were identified as capable of mitigating potential for harm through engaging with patients' social worlds, a corresponding analysis of physician experiences of providing care to Indigenous peoples with type 2 diabetes highlights structural barriers undermining capacity to shift clinical relationships Finally, a recent systematic review found that multiple system-level approaches are required in the delivery of health-care for diabetic foot disease in Indigenous peoples While most diabetes education programs work most effectively when delivered by interprofessional teams, in Indigenous communities, where access to physicians and other critical allied health professionals is often limited, strategies to improve care should focus on building capacity of existing health-care providers e.
The study demonstrated a significant improvement in A1C levels and patient knowledge of reducing consumption of unhealthy foods Maori and Pacific Islander adults with type 2 diabetes and CKD received community care provided by local health-care assistants to manage hypertension and demonstrated a reduction in systolic blood pressure BP and in hour urine protein, and a greater number of prescribed antihypertensives; left ventricular mass and left atrial volume progressed in the usual care group, but not in the intervention group Regarding cost-effectiveness, a systematic review of primary care initiatives in Indigenous adult populations in Canada, Australia, New Zealand and the United States examined increased funding, system-level initiatives and single service components, concluding that the literature in this area was insufficient to make recommendations Of 2, publications, only 13 met the authors' inclusion criteria interventions aimed at improving the health system, clinic system or service level , and only 6 showed improvements in surrogate outcomes.
The review highlighted the general reliance on intermediate health outcomes and observational studies, and stressed the need for larger, more rigorous studies with more robust outcomes of interest i. Multifaceted clinical organizational and team-based interventions that have suggested benefit include: diabetes registries, recall systems, care plans and training for community health workers, and outreach services.
Despite the effectiveness of multifaceted interventions, key elements are unclear — and the economic effectiveness is undetermined Two newer Australian studies show that cycles of quality improvement that focus on organizational systems improve processes of care in pregnant women , as well as in-care processes and some surrogate outcomes in type 2 diabetes In Canada, provincial and federal government-led quality improvement projects have demonstrated improvements in type 2 diabetes outcomes in non-Indigenous settings — Indigenous-specific project funding is needed to examine the impact of community-driven quality improvement initiatives that are rooted in a cultural lens and prioritize community needs, resources and policies.
Finally, management of diabetes in women in the child-bearing years should focus on the identification and optimal treatment of pre-existing undiagnosed diabetes as it is commonly missed and has been associated with poor outcomes, including an increased risk for stillbirth 30, Dorothy is a year-old female from a reserve adjacent to your rural practice.
She has attended your clinic over the years for her general health needs and, most recently, for hypertension. She has booked to see you because she is concerned she has diabetes. Dorothy has a strong family history of diabetes and mentions that a close friend was recently quite ill and diagnosed as well. Dorothy has symptoms of diabetes, so you send her for bloodwork, confirming the diagnosis. You call her back to the clinic to inform Dorothy of this diagnosis and the need for her to begin self-monitoring of her blood glucose in order to determine appropriate treatment.
As expected, she is upset about the news but quickly settles, so you begin to provide your usual brief overview of diabetes, self-monitoring approach, and management tips.
You summarize by encouraging her to eat well and exercise. She agrees to your offer of a referral for more diabetes education. You provide a prescription for a glucose meter and ask her to book an appointment with you in a few weeks.
Nine months later, Dorothy returns for a refill of her antihypertensive medications and to re-engage about the diagnosis of diabetes. You realize she did not follow up from her last visit, which is quite similar to your other Indigenous patients. You inquire, and Dorothy reveals that she was so upset and overwhelmed with the delivery of the diabetes diagnosis and your subsequent approach during the last visit, that she went into denial.
You are surprised because you felt that the appointment went well and that your summary and plan were clear and concise. For moving forward at this critical moment within the clinical interaction, aspects of the care framework are highlighted:. Dorothy indicated that she was upset and overwhelmed by you during the last visit.
She hesitates but eventually explains that she feels as though you do not always care about her concerns, that you see her as taking up your precious time. She also adds that when you recommended she eat more vegetables, like carrots, it made her remember an experience in residential school, where a residential school worker once locked her in a cell in which all she had to eat for three days was a single carrot.
She says that when she had tried to speak up, she felt you spoke over her, so was unable to communicate her anxieties. The practice tips indicated above and E4E culture-based strategies in the table offer guidance for an enhanced health-care provider response.
Because you acknowledged your role causing Dorothy to withdraw from the interaction, Dorothy seems more at ease and states she is ready to focus on addressing her diabetes. The care framework suggests that health-care providers explore social contexts that may influence diabetes, and so you enquire about social resource limitations in her life and adverse life experiences that may be factors.
She asks why, and then explains that she is her grandchildren's primary caregiver, depended on by many people but without anyone to turn to for her own support. She also speaks about her fear of losing her job due to a hostile work environment in which even taking time off to visit the doctor is difficult. You share that those factors cause stress and are known in the research to diminish her resilience and often become barriers to health.
The care framework recommends that acknowledging the impacts of these social factors and identifying patient priorities are important steps at this phase. You do so, naming concepts of effort-reward imbalance and lateral violence These resonate with her, and she asks for tips to address these in her life, to work on together with her diabetes.
Much of the above literature indicates that the context of traditions, language and culture could play an important role in the care physicians provide, since usual approaches have had limited effect. Emerging evidence from an international research team, Educating for Equity , indicates that diabetes management should more directly focus on social and cultural aspects specific to Indigenous populations. The E4E framework guides physicians in addressing social and cultural domains in their clinical interactions with patients.
Core directives guide providers to: ensure reciprocal relationships, recognize the diversity of patients, provide care specific to each patient's needs, support them in developing capacity for addressing social determinants of health, and respect patient priorities.
These are embedded within a set of principles that recognize colonization as the predominant cause of health inequities for Indigenous peoples, health care equity as about providing appropriate resources according to need, and empowerment focused on building capacity with patients to address social drivers of disease. Within the framework, social factors e. The framework, therefore, provides a lens to understand, identify and apply opportunities for augmenting patient capacity for change.
As authors, we emphasize the relevance of this framework and, therefore, provide a synopsis and clinical vignette within this chapter in order to aid clinicians to explore its possibilities for clinical practice. Readers are invited to access E4E publications for more in-depth information around the evidence and consultation process supporting the framework Table 1.
Improving diabetes outcomes for Indigenous peoples with diabetes includes the need for organizational enhancements and team-based approaches, but is limited by the reality of health-care human resources in many Indigenous communities.
Health-care personnel gaps appear to be filled by expanding the roles of existing front-line staff. While prevention strategies must consider cultural elements and the influence of inequities on diabetes outcomes, so too must clinical service. The following section provides a description of an approach to care that integrates key aspects of the complex associations between cultural contexts and social inequities that frame diabetes within Indigenous populations. Material deprivation within the social environment directly impacts diabetes.
Relationships between resource limitations, socioeconomic status, and the social environment directly impact diabetes through material deprivation. Indirectly, psychosocial pathways, such as stress, depression, anxiety and loss of control, further undermine health outcomes.
This requires health-care providers to recognize socioeconomic disadvantage as a normalized state for many Indigenous peoples, limiting choices, increasing levels of stress, and diminishing capacity for self-care and lifestyle change.
Attention for limited resources among families is key to recognizing the contexts in which self-care occurs. Limited budgets for food and financial sharing result in the diversion of resources, making family an important source of support as well as a key stressor.
Persistent and recurring experiences of adversity accumulate, influencing wellness and health. These diminish resilience and capacity to cope with disease. Health-care providers should keep in mind that adversity and support are complex and often ambiguous. The impact of residential schools not only persists among traumatized individuals, but the system continues to adversely influence health behaviours that impact others.
Given the context of historical relationships, social exclusion and trauma experienced by Indigenous persons, clinical approaches that establish physician authority, expertise, status and professional distance can negatively impact physician-patient relationships.
Health-care providers should recognize unequal treatment as a reality in Canada's health system. This plays out for Indigenous peoples in heightened awareness and reaction when power and authority are expressed in the physician-patient relationship.
Viewing culture as a protective mechanism involves moving beyond envisioning Indigenous peoples' experience of health and illness from the patient's cultural lens alone, in order to understand and support a patient's own preferences and connections to cultural resources. As health is positively correlated with a sense of security in cultural identity, accessing cultural knowledge and traditions means that culture is protective for many Indigenous peoples.
While Indigenous peoples vary in how they connect with traditional worldviews, traditional medicine and ceremony are widely desired for accessing and re-connecting to culture in conjunction with Western medicine.
Many Indigenous people do not talk about traditional medicines or practices with health-care providers, possibly due to incongruence between these knowledge systems, as well as persistent mistrust and fear of reprisal from health-care providers. Cultural perspectives inform how patients experience diabetes and engage with health care. Patient resistance may reflect the need for health-care providers to focus on relationship-building strategies. Patients and health-care providers have a mutual interest in getting to know one another better.
Health-care providers who pay attention to issues of process and pace can help patients meet their desire to be treated with respect and without judgment; it can also allow health-care providers to move toward safer and more inviting environments that foster sharing.
An Indigenous person's experiences of diabetes and its care are also embedded in connectedness to others, particularly family dynamics and community supports and structures, of which patient-provider relationships and interprofessional health-care teams are a part. Through contextualization and exchange between health-care providers and patients, greater attention can be paid to reaching mutual understanding. Failing to elicit and address the patient's social and cultural contextual factors silences patient perspective and eliminates opportunity to ground clinical management approaches within a patient-centred approach, potentially exacerbating negative outcomes.
Limitations of diabetes and general health literacy stemming from inadequate access to education may hinder the Indigenous person's abilities to engage with health and diabetes management recommendations. Conversely, placing diabetes care knowledge within the cultural, social and political landscape of Indigenous peoples can facilitate patient engagement with accessing diabetes knowledge.
Effective communication for achieving knowledge exchange and patient education integrates intercultural communication strategies. It is not acceptable to presume that Indigenous people are uninterested in the physiology of diabetes when, in reality, they report wanting to understand what causes diabetes and how to manage the illness.
Health-care providers need to recognize stressors that adversely impact learning, draw on sources of health information actually available to patients in professional, popular and folk realms , mitigate resistance to health information due to health-care provider—patient relationship discord, and foster modes of knowledge transmission appropriate for the social and cultural context. Patient-centred care , cultural competency and cultural safety appear to be critical for quality care with Indigenous peoples, but are also broad concepts that require interpretation.
The E4E framework posits that improving health outcomes for Indigenous peoples involves addressing historical and contextual factors in which disease and illness occur, while healing distrust in the Canadian health-care system. This moves beyond merely defining cultural competency as a list of patient beliefs and behaviours for clinicians, toward structural competency that requires critical consciousness of social factors driving disease and wellness.
It also highlights the fundamental role of anti-racism in the equitable delivery of health care , On top of these are layered notions of authentic inclusion grounded in Indigenous cultural approaches, moving providers toward vital relational and culturally-informed aspects of care that enable the facilitation of improved diabetes outcomes. The E4E framework provides knowledge and recommendations for use as a motivational interviewing approach within the clinical interaction that unpacks the described complex concepts.
As described in the E4E vignette, patient engagement is facilitated by screening for resource limitations influencing diabetes onset, as well as exploring with patients their perspectives on adversities that undermine one's capacity to manage diabetes.
Notably, trauma informed relational work that seeks to address power imbalance, authoritarian approaches and a history of mistrust is the critical first step that enables patient engagement. First Nation, Inuit and Aboriginal Health. Accessed March 21, National Aboriginal Diabetes Association. PLoS Med 6 6 : e For more information, visit www. All content on guidelines.
For questions, contact communication diabetes. Next Previous. Key Messages Indigenous peoples living in Canada are among the highest-risk populations for diabetes and related complications.
Screening for diabetes should be carried out earlier and at more frequent intervals. Effective prevention strategies are essential and should be grounded in the specific social, cultural and health service contexts of the community.
Particular attention is needed for Indigenous women and girls of childbearing age, as the high incidence of hyperglycemia in pregnancy gestational and type 2 and maternal obesity increases the risk of childhood obesity and diabetes in the next generation.
Early identification of diabetes in pregnancy is important, and postpartum screening for diabetes in women with a history of gestational diabetes should be performed along with appropriate follow up.
Diabetes management targets in Indigenous peoples should be no different from the general population. A focus on building a therapeutic relationship with an Indigenous person with diabetes is important rather than a singular emphasis on achieving management targets.
The current poor success at achieving management targets highlights the limitations of health services when they are not relevant to the social and cultural contexts of Indigenous peoples. A purposeful process of learning and continuous self-reflection is required by the health-care worker to integrate Indigenous-specific contexts within the clinical approach to diabetes management.
If you are in a community with high rates of diabetes, see a health-care provider to learn about ways to be tested for and prevent diabetes. The causes of diabetes are complex. Learning about the medical, social and cultural contributions to diabetes is key to diabetes prevention.
In particular, seek to understand the relationships between the history of colonization and the current high rates of diabetes in Indigenous peoples.
Ask about community initiatives that promote healthy behaviours, such as diabetes walks, weight-loss groups, fitness classes, community kitchens and gardens, and school-based activities for children and teenagers. If you are planning a pregnancy or may get pregnant, get screened for diabetes.
If you are pregnant and have diabetes or have been diagnosed with gestational diabetes, visit your health-care providers more often, and find out about exercise, breastfeeding and other support groups for pregnant women and new mothers.
This legacy: Maintains socioeconomic disadvantage that limits healthy choices diet, physical activity, adherence to medication, etc. In clinical interactions, recognize, explore and acknowledge: Discord within the therapeutic relationship that may arise from heightened apprehension by the Indigenous person with diabetes as well as emotional reaction to prejudice, power and authority asserted by health-care providers; Interconnectedness between socioeconomic disadvantage, adverse life experiences and capacity for managing diabetes; One's own i.
Engage and connect broadly with the Indigenous community to: Implement prevention efforts and screening, with special attention to children and pre-gestational women, as well as the building of culturally safe interprofessional teams, diabetes registries and surveillance systems; Foster positive relationships at the individual, family and community levels that advocate for family and community resources for Indigenous peoples; Include traditional and cultural leadership to learn about local beliefs, practices and healing resources.
Introduction Improving health outcomes for Indigenous peoples with diabetes requires sufficient capacity and quality of health-care resources that are grounded in the person's specific social and cultural needs and contexts.
Management Similar to prevention strategies, management of diabetes with Indigenous peoples should incorporate the social and cultural contexts of the community from which the person originates, while also adhering to current clinical practice guidelines E4E Vignette: Dorothy is a year-old female from a reserve adjacent to your rural practice.
For moving forward at this critical moment within the clinical interaction, aspects of the care framework are highlighted: Dorothy indicated that she was upset and overwhelmed by you during the last visit. Educating for Equity E4E Care Framework Much of the above literature indicates that the context of traditions, language and culture could play an important role in the care physicians provide, since usual approaches have had limited effect.
Social and economic resource disparities Material deprivation within the social environment directly impacts diabetes. Accumulation of adverse life experiences Persistent and recurring experiences of adversity accumulate, influencing wellness and health. Colonization, inequity and health care Given the context of historical relationships, social exclusion and trauma experienced by Indigenous persons, clinical approaches that establish physician authority, expertise, status and professional distance can negatively impact physician-patient relationships.
Facilitating Outcomes Using a Cultural Approach Viewing culture as a protective mechanism involves moving beyond envisioning Indigenous peoples' experience of health and illness from the patient's cultural lens alone, in order to understand and support a patient's own preferences and connections to cultural resources.
Culture is therapeutic As health is positively correlated with a sense of security in cultural identity, accessing cultural knowledge and traditions means that culture is protective for many Indigenous peoples. Culture informs relationships Cultural perspectives inform how patients experience diabetes and engage with health care. Culture frames knowledge Through contextualization and exchange between health-care providers and patients, greater attention can be paid to reaching mutual understanding.
Key Concepts for Application of the E4E Care Framework Patient-centred care , cultural competency and cultural safety appear to be critical for quality care with Indigenous peoples, but are also broad concepts that require interpretation.
Recommendations Management of prediabetes and diabetes in Indigenous populations should follow the same clinical practice guidelines as those for the general population with respect for, and sensitivity to, particular social, historical, economic, cultural and geographic issues as they relate to diabetes care and education [Grade D, Consensus]. Starting in early childhood, Indigenous individuals should be evaluated for modifiable risk factors of diabetes e.
Screening for diabetes in Indigenous populations should follow guidelines for high-risk populations i. S16; Type 2 Diabetes in Children and Adolescents chapter, p. To promote access to screening for remote Indigenous populations, access to standard laboratory testing is recommended; in its absence, point of care testing for A1C may be considered where testing is associated with a quality control program; and interpretation and follow-up expertise is available [Grade D, Consensus]. Retinal photography screening programs may be used in Indigenous communities living in remote areas to promote access to screening [Grade B, Level 2 76 ] see Retinopathy chapter, p.
Attainment of a healthy body weight prior to conception should be promoted among Indigenous women to reduce their risk for GDM [Grade D, Consensus]. Nutrition counseling should be provided on healthy eating and prevention of excessive weight gain in early pregnancy, ideally before 15 weeks of gestation, to reduce the risk of GDM [Grade D, Consensus] see Diabetes and Pregnancy chapter, p.
If identified as having diabetes, receive preconception counseling that includes optimal diabetes management, including nutrition and physical activity advice, preferably in consultation with an interprofessional pregnancy team to optimize maternal and neonatal outcomes [Grade D, Consensus] see Diabetes and Pregnancy chapter, p.
Pregnant Indigenous women identified as being at risk for type 2 diabetes should: Be offered screening with an A1C test at the first antenatal visit, if not screened preconception [Grade D, Consensus] see Diabetes and Pregnancy chapter, p.
Pregnant Indigenous women with diabetes should: Receive management following the same clinical practice guidelines as those for the general population to improve pregnancy outcomes [Grade D, Consensus]. Postpartum: Indigenous women with pre-existing diabetes or GDM should be encouraged to breastfeed immediately to reduce the risk of neonatal hypoglycemia [Grade D, Consensus] see Diabetes and Pregnancy chapter, p.
The infant of a pregnant Indigenous woman with diabetes should receive close monitoring for neonatal hypoglycemia with capillary blood glucose monitoring for up to 36 hours [Grade D, Consensus]. S ] and regularly thereafter according to recommendations in Screening for Diabetes in Adults chapter, p.
S16 Reducing the Risk of Developing Diabetes, p. S20 Organization of Diabetes Care, p. S27 Monitoring Glycemic Control, p. S47 Weight Management in Diabetes, p. S Cardiovascular Protection in People with Diabetes, p. S Treatment of Hypertension, p. S Chronic Kidney Disease in Diabetes, p. S Retinopathy, p. S Foot Care, p. S Type 2 Diabetes in Children and Adolescents, p.
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