Youth-onset type 2 diabetes among First Nations young people in northern Australia: a retrospective, cross-sectional study
2021; Elsevier BV; Volume: 10; Issue: 1 Linguagem: Inglês
10.1016/s2213-8587(21)00286-2
ISSN2213-8595
AutoresAngela Titmuss, Elizabeth A. Davis, Vicki O’Donnell, Mark Wenitong, Louise Maple‐Brown, Aveni Haynes, Angela Titmuss, Elizabeth A. Davis, Vicki O’Donnell, Mark Wenitong, Elizabeth Barr, John Boffa, Alex Brown, Christine Connors, Sumaria Corpus, James Dowler, Sian Graham, Emma Griffiths, Renae Kirkham, Christopher Lee, Elizabeth Moore, Glenn Pearson, Jonathan E. Shaw, Sally Singleton, Ashim Sinha, Gwyneth White, Paul Zimmet, Louise Maple‐Brown, Aveni Haynes,
Tópico(s)Diabetes and associated disorders
ResumoThe prevalence of youth-onset type 2 diabetes, defined as that diagnosed before the age of 25 years, is increasing worldwide,1Viner R White B Christie D Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden.Lancet. 2017; 389: 2252-2260Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar particularly in marginalised, socioeconomically vulnerable, and First Nations communities.2McGavock J Wicklow B Dart AB Type 2 diabetes in youth is a disease of poverty.Lancet. 2017; 3901829Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 3Pettitt DJ Talton J Dabelea D et al.Prevalence of diabetes in U.S. youth in 2009: the SEARCH for diabetes in youth study.Diabetes Care. 2014; 37: 402-408Crossref PubMed Scopus (288) Google Scholar The pathophysiology, phenotype, comorbidities, complications, treatment response, and prognosis of youth-onset type 2 diabetes are markedly higher risk than for later-onset diabetes, raising serious concerns for the future health of affected young people.1Viner R White B Christie D Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden.Lancet. 2017; 389: 2252-2260Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar Despite this global concern, and very high rates of type 2 diabetes and other cardiometabolic conditions within Australian Aboriginal and Torres Strait Islander communities4Australian Institute of Health and WelfareAustralia's Health 2018. Australian Institute of Health and Welfare, Canberra2018https://www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/table-of-contentsDate accessed: July 10, 2022Google Scholar (referred to here as First Nations), data regarding type 2 diabetes prevalence among Australian young people are scarce. The prevalence of type 2 diabetes has increased among all Australian young people over the past 20 years,5Haynes A Kalic R Cooper M Hewitt JK Davis EA Increasing incidence of type 2 diabetes in Indigenous and non-Indigenous children in Western Australia, 1990–2012.Med J Aust. 2016; 204: 303Crossref PubMed Scopus (18) Google Scholar, 6Australian Institute of Health and WelfareType 2 diabetes in Australia's children and young people: a working paper. Australian Institute of Health and Welfare, Canberra2014https://www.aihw.gov.au/reports/diabetes/type-2-diabetes-in-australia-s-children-and-young/contents/table-of-contentsDate accessed: February 20, 2022Google Scholar with a steeper trajectory in incidence among First Nations young people.5Haynes A Kalic R Cooper M Hewitt JK Davis EA Increasing incidence of type 2 diabetes in Indigenous and non-Indigenous children in Western Australia, 1990–2012.Med J Aust. 2016; 204: 303Crossref PubMed Scopus (18) Google Scholar Worldwide, most existing prevalence data rely primarily on administrative billing and hospital data. This means that these data probably underestimate the true prevalence,3Pettitt DJ Talton J Dabelea D et al.Prevalence of diabetes in U.S. youth in 2009: the SEARCH for diabetes in youth study.Diabetes Care. 2014; 37: 402-408Crossref PubMed Scopus (288) Google Scholar, 7Amed S Islam N Sutherland J Reimer K Incidence and prevalence trends of youth-onset type 2 diabetes in a cohort of Canadian youth: 2002–2013.Pediatr Diabetes. 2018; 19: 630-636Crossref PubMed Scopus (15) Google Scholar as many young people with type 2 diabetes are managed by primary health-care services or community based services using different funding models.1Viner R White B Christie D Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden.Lancet. 2017; 389: 2252-2260Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar To our knowledge, the burden of youth-onset type 2 diabetes in the very high-risk population of First Nations people across northern Australia has not previously been evaluated. Northern Australia is made up of four regions, the Top End, Central Australia, Kimberley, and Far North Queensland (appendix p 2). Its population is more remote, younger, substantially more socioeconomically disadvantaged, and has a higher proportion of First Nations people than other areas of Australia.4Australian Institute of Health and WelfareAustralia's Health 2018. Australian Institute of Health and Welfare, Canberra2018https://www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/table-of-contentsDate accessed: July 10, 2022Google Scholar We aimed to determine the prevalence of youth-onset type 2 diabetes in First Nations people across northern Australia, using cross-sectional data from primary health-care services (appendix pp 2–6), including both government and Aboriginal Community Controlled Health Services, and to determine the characteristics of these young people. Young people attended participating health services at least once between Jan 1, 2016, and Dec 31, 2017. 381 people aged 24 years or younger with type 2 diabetes were identified from an estimated resident population of 56 882 young First Nations people (appendix p 7). The majority were female (n=258 [68%]) and the youngest reported age at diagnosis was 4·4 years. The crude prevalence was 6·7 per 1000 people aged 24 years or younger (95% CI 6·0–7·4; figure; appendix p 7). In all four regions of northern Australia, prevalence was higher among females than among males, and was higher in those aged 15–24 years than among those younger than 15 years (appendix p 7). Of the four regions, the estimated prevalence was highest in Central Australia (14·4 cases per 1000 young First Nations people [95% CI 12·2–17·0]; appendix p 7). Within Central Australia, the estimated prevalence among females was 23·0 cases per 1000 (95% CI 18·4–28·3) and among people aged 15–24 years was 31·1 cases per 1000 (25·4–37·7; appendix p 7). Of the 381 young people, 289 (76%) had at least one HbA1c result recorded between Jan 1, 2016, and Dec 31, 2017 (appendix p 9). Median HbA1c was high in all regions at 9·7% (IQR 7·1–12·5; 83 mmol/mol [IQR 53–113]), and only 41 (14%) of these individuals met glycaemic targets of HbA1c less than 6·5% (48 mmol/mol; appendix p 9).1Viner R White B Christie D Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden.Lancet. 2017; 389: 2252-2260Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar 226 (69%) of 328 young people (excluding Kimberley) were prescribed at least one medication (appendix p 12), and 148 (45%) had both medication and HbA1c data (figure). Individuals aged 15–24 years were more likely to have obesity (defined by adult equivalent BMI of 30 kg/m2), than younger participants (p<0·0001; appendix p 9), with no sex differences in BMI. Of the 258 women, 43 (17%) had gravida reported, and 44 (17%) had parity, with discrepancy between gravida and parity in 32 (74%) women. It was unclear whether they were currently pregnant, or had had a previous miscarriage, stillbirth, or termination. Of those with gravida reported, 23 (54%) had gravida of more than one (maximum five), and of those with parity recorded, seven (16%) had parity of more than one (appendix p 11). We report a very high prevalence of type 2 diabetes among First Nations youth in northern Australia, arguably the highest reported prevalence in any population of youth internationally within the past 25 years. To our knowledge, this study is the first report of youth-onset type 2 diabetes prevalence in northern Australia, and suggests that prevalence is substantially greater than previously reported prevalence estimates in Australia, of 0·5 cases per 1000 First Nations Australians younger than 25 years,8Stone M Baker A Maple Brown L Diabetes in young people in the Top End of the Northern Territory.J Paediatr Child Health. 2013; 49: 976-979Crossref PubMed Scopus (6) Google Scholar 0·1 cases per 1000 Australian 10–14 year olds, and 0·9 cases per 1000 Australian 20–24 year olds.6Australian Institute of Health and WelfareType 2 diabetes in Australia's children and young people: a working paper. Australian Institute of Health and Welfare, Canberra2014https://www.aihw.gov.au/reports/diabetes/type-2-diabetes-in-australia-s-children-and-young/contents/table-of-contentsDate accessed: February 20, 2022Google Scholar A key strength of our study is its unique inclusion of primary health-care data, with eligible youth ascertained from both government and Aboriginal Community Controlled health services across northern Australia, as previously published data have mostly relied on hospital data, probably resulting in under-ascertainment.6Australian Institute of Health and WelfareType 2 diabetes in Australia's children and young people: a working paper. Australian Institute of Health and Welfare, Canberra2014https://www.aihw.gov.au/reports/diabetes/type-2-diabetes-in-australia-s-children-and-young/contents/table-of-contentsDate accessed: February 20, 2022Google Scholar, 8Stone M Baker A Maple Brown L Diabetes in young people in the Top End of the Northern Territory.J Paediatr Child Health. 2013; 49: 976-979Crossref PubMed Scopus (6) Google Scholar Internationally, we note the very high prevalence of type 2 diabetes reported in one Native American Pima community (38 cases per 1000 males aged 15–19 years and 53 cases per 1000 females aged 15–19 years) between 1987–1996,9Dabelea D Hanson RL Bennett PH Roumain J Knowler WC Pettitt DJ Increasing prevalence of type II diabetes in American Indian children.Diabetologia. 1998; 41: 904-910Crossref PubMed Scopus (333) Google Scholar although more recent prevalence is unknown. Of concern, our reported prevalence of 31 cases per 1000 Central Australian females aged 15–24 years approaches these levels.9Dabelea D Hanson RL Bennett PH Roumain J Knowler WC Pettitt DJ Increasing prevalence of type II diabetes in American Indian children.Diabetologia. 1998; 41: 904-910Crossref PubMed Scopus (333) Google Scholar We report a much higher prevalence of type 2 diabetes than seen in recent years in First Nations youth internationally, with reported prevalence ranging between 0·6 cases per 1000 young people3Pettitt DJ Talton J Dabelea D et al.Prevalence of diabetes in U.S. youth in 2009: the SEARCH for diabetes in youth study.Diabetes Care. 2014; 37: 402-408Crossref PubMed Scopus (288) Google Scholar and 2·7 cases per 1000 young people.7Amed S Islam N Sutherland J Reimer K Incidence and prevalence trends of youth-onset type 2 diabetes in a cohort of Canadian youth: 2002–2013.Pediatr Diabetes. 2018; 19: 630-636Crossref PubMed Scopus (15) Google Scholar The risk of youth-onset type 2 diabetes is increased by in-utero exposures such as maternal hyperglycaemia and obesity,1Viner R White B Christie D Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden.Lancet. 2017; 389: 2252-2260Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar and therefore a new diagnosis also represents many potentially affected future offspring. Offspring of young people diagnosed with type 2 diabetes before, or during, their reproductive years are likely to develop cardiometabolic conditions at an even younger age. This is of relevance to First Nations Australian young people and the very high prevalence of type 2 diabetes among their families,4Australian Institute of Health and WelfareAustralia's Health 2018. Australian Institute of Health and Welfare, Canberra2018https://www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/table-of-contentsDate accessed: July 10, 2022Google Scholar as well as 31 (12%) young women in our study reporting at least one pregnancy. The high proportion of young people with overweight or obesity further supports the need for early primary prevention and reduction of cardiometabolic risk. Only 41 (14%) First Nations young people with type 2 diabetes had glycaemia within recommended targets,1Viner R White B Christie D Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden.Lancet. 2017; 389: 2252-2260Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar consistent with the scarce data available globally. In addition, only 289 (76%) young people had HbA1c measured within the 2 year study period, suggesting that many have limited access to, or engagement with, health services. This is consistent with international data indicating that young people with type 2 diabetes are highly socioeconomically vulnerable2McGavock J Wicklow B Dart AB Type 2 diabetes in youth is a disease of poverty.Lancet. 2017; 3901829Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar and the crucial importance of continuity of care with culturally appropriate, trusted, and youth-friendly health services.2McGavock J Wicklow B Dart AB Type 2 diabetes in youth is a disease of poverty.Lancet. 2017; 3901829Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar Median HbA1c was high at 9·7% (83 mmol/mol), at a median of 2·4 years (IQR 0·9–4·3) post-diagnosis. Medication prescribing did not appear to reflect current guidelines for the management of type 2 diabetes in the paediatric population.1Viner R White B Christie D Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden.Lancet. 2017; 389: 2252-2260Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar The reasons for this are unclear but suboptimal glycaemic control has substantial implications for future health, particularly considering the more aggressive phenotype seen in youth-onset type 2 diabetes.1Viner R White B Christie D Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden.Lancet. 2017; 389: 2252-2260Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 10Bjornstad P Drews KL Caprio S et al.Long-term complications in youth-onset type 2 diabetes.N Engl J Med. 2021; 385: 416-426Crossref PubMed Scopus (27) Google Scholar 59 (18%) young people required antihypertensive medication and 28 (9%) required an HMG-CoA reductase inhibitor (appendix p 12), suggesting a high prevalence of cardiovascular comorbidities soon after diagnosis. The findings of this study need to be interpreted after considering the following limitations. First, some sites could not be included, and this might have led to underestimation of diabetes prevalence. Second, ethnicity reporting has been shown to have some inaccuracies.4Australian Institute of Health and WelfareAustralia's Health 2018. Australian Institute of Health and Welfare, Canberra2018https://www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/table-of-contentsDate accessed: July 10, 2022Google Scholar Third, many young people with type 2 diabetes are asymptomatic, and this is associated with delayed diagnosis,1Viner R White B Christie D Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden.Lancet. 2017; 389: 2252-2260Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar which might have led to underestimation of diabetes prevalence in this audit. Fourth, although considerable efforts were undertaken to verify diabetes type with participating health services, classification was based on clinical diagnosis and medical records, with some records having incomplete information to assist in verification, such as phenotype and autoantibody results. Hence misclassification of diabetes type, and overestimation of type 2 diabetes, might have occurred, particularly among younger people. Finally, the sample size was likely to have been underpowered to detect differences between subgroups. Despite this, our study provides the first estimate of diagnosed type 2 diabetes in First Nations young people across northern Australia, with a higher prevalence than that reported internationally in recent years. The majority of young people had unacceptably high HbA1c values, suggesting a concerning trajectory ahead without intervention. Although participants represented diverse young First Nations people from across a vast Australian area, our findings might not be generalisable to other First Nations peoples globally. However, there are many commonalities of historical experience and socioeconomic inequities. New approaches to preventing and managing type 2 diabetes in young First Nations people are urgently required. These include culturally, age, and linguistically appropriate engagement of young people and communities, advocacy to eliminate underlying socioeconomic inequities, interventions in pregnancy and early childhood, adequate resourcing, education of health professionals, and openness to reconsidering current models of care. We need to hear the voices of First Nations young people and communities behind these high prevalence rates, working together to reduce risk and improve the health of future generations. We declare no competing interests. We thank other members of the Hot North Diabetes in Youth collaboration (Northern Australia Tropical Disease Collaborative Research Program, NHMRC project grant 1131932) and others who have contributed to the study (appendix p 13). Members of the Hot North Diabetes in Youth Collaboration group are listed in appendix p 13 and author contributions are listed in appendix p 14. LJM-B and AH contributed equally. Download .pdf (.95 MB) Help with pdf files Supplementary appendix
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