ANMJ Featured Story

DIABETES: A ticking time bomb

Wednesday 26th April, 2017

Diabetes is fast becoming one of the biggest epidemics in the world. Nowhere is this more apparent than in Australia where approximately 1 million Australians have been diagnosed with the disease. Natalie Dragon investigates why Diabetes has become so prevalent and what is being done about it. 

Diabetes Nurse Practitioner (NP) Giuliana Murfet remembers doing bladder catheterisation for preventing UTI in diabetes patients with autonomic neuropathy. “We were accustomed to those things we don’t see anymore. When I first started every third person had an amputation, many children had severe hypos and fitting with coma.”

The growth in diabetes, along with progress in care has been phenomenal, says Giuliana who works in rural Tasmania.

“A lot of that growth is in primary care in general practice looking at early diagnosis and management – certainly we are doing a lot better there.”

One of the first four NPs in Tasmania, Giuliana was endorsed in 2010. With almost 10 years’ experience she runs multiple clinics – Type 1, pregnancy, insulin pumps, and a new obesity clinic, which includes referral for bariatric surgery. The NP role in diabetes is about improving patient flow and has enabled increased access to vulnerable populations. 

“In Tasmania, the diabetes NPs target those with mental health issues, pregnancy complicated by diabetes, those with cancer and those in high risk foot clinics. We definitely have seen a reduction in the number of amputations.”

Giuliana has been Director of the Board of the Australian Diabetes Educators Association (ADEA) and a member of the government’s Tasmanian Lead Clinicians Group.  “Whether it’s paediatrics, pregnancy, high risk foot, obesity, I keep trying to find ways of improving care in the region for people with diabetes. 

“How can I develop a model of care that is evidence based, multidisciplinary, based on national guidelines and incorporate those people so they are getting the same care as that in the finest urban, metropolitan diabetes centre?”

Sheer scale

Diabetes Australia CEO Adjunct Professor Greg Johnson says the global impact of diabetes is staggering. “We have a long way to go to have any effect nationally on what is arguably the biggest health epidemic to affect the world.”

There are nearly 1.3 million Australians who have voluntarily registered as having diabetes and there is an unknown undiagnosed and silent Type 2 diabetes population estimated at 250,000-400,000.

“When we put these together the current number of Australians with diabetes is around 1.7 million people right now,” says Professor Johnson. “In just over 12 months, there were over 105,000 new cases of diabetes – that’s 280 people every day diagnosed with diabetes – and it’s continuing to grow.”

One size doesn’t fit all

“What we are seeing in Australia is being seen in other countries which is a massive change in lifestyle and the risk profile,” says Professor Johnson. However there is not ‘one thing’ for all diabetes, he says. 

“It’s often over-simplified. Type 2 diabetes is due to obesity which is a disservice to the complexity of this serious epidemic – that people with Type 2 diabetes are people who eat too much and are largely overweight, this simplifies a complex epidemic that affects all groups of Australians.

There are many more people in their 20s getting Type 2 diabetes, says Professor Johnson. “Many in adolescence and childhood getting Type 2 diabetes that was unheard of 15 years ago. It is much more complex.

“Yes, vast numbers of Australians buy takeaway as the norm because it’s cheap and available but this notion of choice – some people do not have choice on the true economies of scale. 

“For the poor and more socially disadvantaged they are more likely to have Type 2 diabetes. The price of a 2 litre bottle of sugary drink is cheaper and gets to rural areas before an apple or banana. There are a lot of social drivers where people do not have a choice in terms of supply and genetics – there is a huge population with high risk Type 2 diabetes independent of other factors.”

National Diabetes Strategy

The federal government released a National Diabetes Strategy in November 2015, which sets out key goals and potential areas for action to address the outcomes for people with diabetes. Yet response has been slow and frustrating, says Professor Johnson. 

“In some areas there have been some specific decisions but we haven’t seen serious implementation of the national strategy. 

“If we step back and assess the size and scale of the issue, the response at a federal, state and territory and community response is not big enough and almost certainly diabetes will get bigger and worse and more suffering and cost as a community will ensue.”

A comprehensive response by government – federal and state and territory – to all sign up to invest more to prevent diabetes is urgently needed, Professor Johnson says. “We need more states and territories to partner with the Commonwealth to deliver comprehensive diabetes-prevention initiatives that link with a national framework and stronger national public health policies.

“We need to prevent more people with Type 2 diabetes with a range of things more public health initiatives such as the unhealthy food supply, a levy on sugary drinks, and targeted diabetes programs across the country to make a difference.”

Cost

As the numbers of people with diabetes increases, so do the healthcare costs.

Research published in BMJ Journals estimates the indirect economic cost of rising numbers measured in ‘lost productive life years’ is set to hit $2.9 billion a year by 2030, up from $2.1 billion in 2015. The research was based on population growth and disease trend data of those aged 45-64 years by 2030. It projected costs of lost income, tax revenue, GDP, ‘productive life years’ and rising welfare costs. 

“People can glaze over the costs but to put it more meaningfully one of the things that staggers people is to break it down. In Australia diabetes impacts in serious ways – there are 4,000 amputations a year due to diabetes and the vast majority are preventable – 85% are preventable,” says Professor Johnson.

Prevention

Worldwide there is good evidence to prevent up to 60% of Type 2 diabetes.

Nurse and diabetes educator at Diabetes SA Daniela Nash says prevention is key.

“We work with people with pre-diabetes to prevent them getting a diagnosis. We get people to ‘check out the numbers’ – of what their cholesterol is, what their blood pressure is. Ask the doctor what the numbers actually are. Are they better, stable or worse?”  

Daniela sees the role of those who work in diabetes as empowering each person to knowledge and self-management. 

Dieticians and nutritionists at Diabetes SA take small groups of up to eight clients with diabetes on supermarket tours. 

“It’s looking at the content on the labels empowering people to make healthier choices for themselves,” Daniela says. “Looking for low salt and fat content – a fibre content of 5g or sodium less than 200g or 200-400g.”

Daniela presents in a three-week Living Well with Diabetes series for people with Type 2 diabetes. “I see people in week three of the series come from knowing very little to feeling like they know much more about their condition and are better equipped with that knowledge. 

“They often then book in for a one to one for more individual care planning on their BSL monitoring, more detail about their medications and general management of their health.”

“My mantra is to equip them to control their diabetes rather than the diabetes taking control of them.” 

Nurse led intervention

A nurse-led education program in Queensland is helping women with Type 2 diabetes manage their condition.

Women aged 45-65 with Type 2 diabetes undertake an evidence based e-health 12 week lifestyle intervention. Nurses provide advice on sleep, diet, exercise, alcohol intake and stress levels.

“The fact that it is nurse led makes a difference; it gives the program a lot of credibility and we have seen the results – women have found it empowering and it’s given them control,” Griffith University’s Janine Porter-Steele says. 

The prime focus is on nutrition, Janine says. “With Type 2 diabetes we want to decrease the risk of chronic disease and look at waist circumference of less than 88cm which puts these women at increased risk of other disease such as heart disease, cancer of the bowel
and breast.” 

However the program is much broader than addressing a physical ailment, says Janine. “We get them to goal set. What we are trying to do is to promote self-efficacy to make changes. If we can increase their self-efficacy to exercise and keep exercising it helps improve their resources and motivation.”

The women in the program have a Facebook group in which they stay connected, says Janine.  “They are still getting targeted peer support.”

Globesity

A comprehensive report: Globesity: tackling the world’s obesity pandemic shows obesity rates have more than doubled since 1980, with 13% of adults worldwide classified as obese and nearly 40% as overweight. 

Current figures show around two thirds of Australian adults have a body mass index (BMI) greater than 25. Obesity is predicted to reach 35% by 2025 – up from the current 28%. 

Of even more concern is the prevalence of severe obesity. By 2025, 13% or one in eight adults will have a BMI of over 35 – up from 5% in 1995 and 9% in 2014/15.

It is estimated more than 27% of Australian children are overweight or obese. In 1995, around one in 10 young adults were obese, but in 2014 it was closer to one in five.

The World Health Organization’s (WHO) targets to maintain 2010 levels of overweight and obese people will not be met in Australia, according to joint modelling.

High risk

Statistics show Type 2 diabetes has a greater impact on the disadvantaged. Those in lower socioeconomic areas, people in rural and remote areas and Aboriginal and Torres Strait Islanders are all more likely to develop Type 2 diabetes and more likely to develop serious complications.

Indigenous

The incidence of diabetes in Indigenous Australians is high with rates as high as 26% - six times higher than the general Australian population.

cohealth Community Health Nurse in the Aboriginal and Torres Strait Islander Health team in Melbourne’s west, Sally Berger, says her clients have complex needs with multiple chronic diseases. cohealth runs a bulk-billed endocrinology service in Braybrook which was set up in 2011. “Research showed there was very little in endocrinology services in the west yet the stats showed a really high prevalence of diabetes,” Sally says. 

The cohealth Aboriginal and Torres Strait Islander Health team have a Foodshare program which supplies free nutritious food every Thursday to the community. “Mapping in the west showed access to nutritious food was poor. There were a lot of takeaway shops and so there is an emphasis on fresh food and growing vegetables.”

Educational events and expert talkers tap into Foodshare and other event days to promote key healthy lifestyle and prevention messages.

Sally and an endocrinologist run a monthly Diabetes clinic for Aboriginal and Torres Strait Islander clients and much of Sally’s work is care coordination including linking community members to dietetic, podiatry, optometry and specialist services. “It’s very specific to Aboriginal and Torres Strait Islander clients’ needs. Those with complex needs such as with housing, Centrelink, disability support often need assistance, support and follow up.”  In-depth education and support of clients with pre-existing diabetes to self-manage complications is important and targeting prevention of diabetes through community engagement is a major part of the role.

Advocacy is key says Sally. “Ensuring that clients have access to a culturally responsive service system is essential to improve health outcomes.”

Children

Researchers have found that rates of gestational diabetes in some regional and remote areas in Western Australia are two to three times higher than other areas of the state.

Clinical co-lead of WA’s Diabetes and Endocrine Health Network Mark Shah says the huge increase in gestational diabetes seen across the country is of concern on several levels.

“Children are being exposed to high levels of glucose in the womb, leading to increased risk of congenital malformation, risks to the mother in pregnancy and later on risks to mother developing Type 2 diabetes and child developing diabetes themselves.”

The gestational diabetes rate across Australia was up by 16% in 2016, says Mark. “Obstetric services and diabetes services are struggling to cope with the number of women with gestational diabetes.”

Mark is a diabetes nurse practitioner at the Princess Margaret Hospital which is WA’s only paediatric tertiary centre. This provides WA with data on almost 100% of children with Type 1 diabetes and about 92% of children with Type 2 diabetes. 

“We do have a state-wide model of care with established health networks on policy and guidelines for children with diabetes.

“In some respects with childhood diabetes it’s easier as we have good data and we know how many children in WA have diabetes. That’s not the case with adult diabetes and it’s something services are working on with health networks to develop better data and it is something for all states and the Commonwealth to ensure we have data to improve care.”

Young adults

Nurse and CDE Margie Vitanza specialises in care for young adults aged 16-25 years who are transitioning from paediatric to adult services. The dedicated nurse transition clinic was established only 12 months ago at the Mater Young Adult Health Centre in Brisbane. 

“The big concerns with this age group is that they are lost to follow up – they are comfortable with paediatric services and there is the uncertainty with adult care and it can be quite daunting,” Margie says 

The nurse transition clinic shows young adults what adult care looks like and helps with the adjustment. 

“We cannot underestimate the impact it has on a person - even the most sound person has to manage this disease which can require three to six injections a day and it’s a challenge and we are conscious of that,” Margie says.

There is a focus on young adult self-management. “Literature suggests establishing rapport with young children and then handing over the reins gently to them for self-managed own care as they transition into adulthood,” says Margie.

“I see when the penny drops for them. Some are flippant, others are driven and know exactly what they want. You have to be really flexible and non-judgemental; it is a transient point in their life. They go from immaturity to maturity and you are helping guide them.”

Way forward

ADEA CEO Joanne Ramadge says there will need to be better use of the resources used in a much more strategic way.

Better use of existing and new infrastructure, increased use of technology, and working with people with diabetes to focus on self-management.

“Having good systems in place is really key for management of all chronic disease, not just diabetes. Diabetes is a really important chronic disease and overlaps with other chronic diseases, not in isolation – it’s really important health professionals working in their areas have collaboration.”

Dr Ramadge wants to see increased standard knowledge base of diabetes for all health professionals. “All health professionals have a role in providing and working with people with diabetes, who may be at risk of diabetes and who may have pre-diabetes. All health professionals need to have an understanding about diabetes.”

To read more articles from ANMJ, view the full journal online at https://issuu.com/australiannursingfederation/docs/anmj_may_17_issuu