The Burden and Contributors to Cardiovascular Disease and Diabetes in Indigenous Australians

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The Burden and Contributors to Cardiovascular
Disease and Diabetes in Indigenous Australians

• Alex Brown
• Baker IDI

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Years of Life Lost (YLL) for the leading disease
and injury categories Indigenous persons 2003
CVD Diabetes
The Health and Welfare of Australias Aboriginal
and Torres Strait and Islander Peoples 2008 ABS
Catalogue No. 4704.0 AIHW Catalogue No. IHW 21
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Contributors to the Gap
B/w 1996-2000 NCD - 77 Gap in LE Grp I -
15-16 CVD 33 GUT 9 DM 9 Chronic Resp
- 9 Injury 8
16.7 years 1996-2000
19.0 years 1996-2000
Zhao and Dempsey, MJA 2006
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Driving Life Expectancy Differentials
Source AIHW Chronic Disease and Associated Risk
Factors in Australia, 2006.
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Risk factor prevalence in Australian populations
- glucose intolerance
Daniel M, Rowley KG, McDermott R, ODea K.
Diabetes and impaired glucose tolerance in
Aboriginal Australians prevalence and risk. Diab
Res Clin Pract 2002 57 23-33. Dunstan D et al.
Diabesity and associated disorders in Australia
2000. International Diabetes Institute,
Melbourne, 2000
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DIABETES MORTALITY -AUSTRALIA
Male Death Rates - Diabetes
Female Death Rates - Diabetes
The Health and Welfare of Australias Aboriginal
and Torres Strait and Islander Peoples 2008 ABS
Catalogue No. 4704.0 . AIHW Catalogue No. IHW 21
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Cardiovascular Consequences of DM

• Clustered risk factors MetS, dyslipidaemia,
  behavioural
• CHD - Diffuse /Multi-vessel Disease
• Silent Ischaemia
• Late diagnosis/recognition
• Complications of MI more frequent in DM
• CHF
• Diabetic Cardiomyopathy
• PVD
• CVA
• Absolute risk equivalent to PMHx of CHD

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Impact of DM on CHD Incidence INTERHEART I
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DM, CKD and CHD in Indigenous Australians
Wang and Hoy, Kidney Int 2005
Wang and Hoy. MJA 2005
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CAD and Diabetes in Aboriginal People
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Risk of Incident CVD in Aboriginal People
Central Australia (n739)
Rowley, Brown et al
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DM AND CVD IN CENTRAL AUSTRALIA
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Baseline Demographics and Clinical
Characteristics, CASPA Cohort 2001-2002.
Indigenous N214 Non-Indigenous N278 p-Value
Mean age ( SD) years 50.1 (12.5) 59.3 (12.5) lt0.001
Male () 57.0 69.8 0.003
History of CHD 39.3 45.5 0.166
Prior CABG 3.3 9.4 0.008
Hypertension 62.1 45.0 lt0.001
Smoker (current) 42.5 35.3 0.001
Dyslipidaemia 34.1 38.5 0.318
Diabetes Mellitus 55.6 30.2 lt0.001
CKD (GFR lt60) 39.3 24.7 0.001
End stage renal failure 16.4 1.8 lt0.001
ACS Risk Stratification NSTEACS - High Risk STEMI 65.9 22.9 49.3 20.5 lt0.001 0.402
ACS onset in rural location 112 (47.7) 23 (8.0) lt 0.001
Late Presentation gt12hrs 63 (28.5) 46 (17.1) 0.002
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ACS Co-Morbidity by Ethnicity
Indigenous (n235)
Non-Indigenous (n287)
68
149
74
63
64
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DM
DM and CKD
DM
DM and CKD
29
51
CKD
CKD
p0.0001
ACS and DM 59
ACS DM CKD 27
ACS CKD 12
ACS alone 29
ACS DM 30
ACS DM CKD 8
ACS CKD 18
ACS alone 52
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Age Adjusted Survival and MACE-Free Survival
ACS Males
Non-Indigenous
Indigenous
HR 3.762 2.15 - 6.58 p lt 0.001
HR 2.061 1.40 - 3.02 p lt 0.001
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CVD RISK PREDICTION AND DM
WANG, ROWLEY, BROWN ET AL 2009
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Potential Pathophysiological Pathways linking
Chronic Stress, Depression and Atherogenesis.
Adapted from Rozanski et al
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Depression in Aboriginal men -MHM
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INDEPENDANT CORRELATES OF OBESITY IN ABORIGINAL
MEN
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Diabetes and Heart Disease -The Rumsfeld Criteria

• There are known knowns there are things we
  know we know.
• We also know there are known unknowns that is
  to say there are some things we know we do not
  know.
• But there are also unknown unknowns- the ones
  we dont know we dont know
• Fmr US Sec Defence, Donald Rumsfeld

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The Known Known's CVD AND DM

• Extremely common
• DM is bad for your heart
• Independent contributor to CVD in men and women
• Independent predictor of adverse CVD outcomes
• Commonly co-morbid in Indigenous populations
• Accelerated atherogenesis the primary driver of
  excess death and morbidity in DM
• Same treatments are effective in DM
• We know what we have to do
• We know the system isnt doing its job

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Known Unknowns

• How to best deliver what needs to be done
• Community based interventions
• System level reforms
• Reducing the evidence-practice gaps
• Access
• Incorporating culture as a protective,
  preventative, management and palliative process
• SDIH
• Racism/Stress/Marginalisation biopsychosocial
  pathways to DM/CVD
• Burden of CHF/interplay of DM among Indigenous
  peoples
• How best to engage the family as the unit of
  intervention
• Disadvantage across the life-course