Quantifying the excess risk for proteinuria, hypertension and diabetes in Australian Aborigines: comparison of profiles in three remote communities in the Northern Territory with those

2007 vol. 31 no. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 177© 2007 The Authors. Journal Compilation © 2007 Public Health Association of Australia

Quantifying the excess risk for proteinuria, hypertension

and diabetes in Australian Aborigines: comparison of

profiles in three remote communities in the Northern

Territory with those in the AusDiab study

Wendy E. Hoy, Srinivas Kondalsamy-Chennakesavan, Zhiqiang Wang

Centre for Chronic Disease, Discipline of Medicine, University of Queensland

Esther Briganti Department of Medicine, University of Melbourne, Victoria

Jonathan Shaw International Diabetes Institute, Victoria

Kevan Polkinghorne Monash Medical Centre, Victoria

Steven ChadbanRoyal Prince Alfred Hospital and University of Sydney, New South Wales

The AusDiab Study Group

Abstract

Objective: To estimate the magnitude

of excess risk for proteinuria, high blood

pressure and diabetes in Australian

Aboriginal adults in three remote

communities by comparing them with

nationwide Australian data.

Methods: Adult volunteers from three

remote communities in the Northern

Territory were screened for proteinuria,

high blood pressure, and diabetes between

2000 and mid 2003. Rates for people age

25 to 74 years were compared with those

from the AusDiab study conducted in 1999

and 2000.

Results: Compared with AusDiab, rates

of these conditions were elevated in all

Aboriginal communities, but differed

among them. With adjustment for age and

sex, rates of proteinuria were elevated 2.5-

to 5.3-fold, rates of high blood pressure

were elevated 3.1- to 8.1-fold and rates

of diabetes were elevated 5.4- to 10-fold

(p<0.001 for all). The risk of having any

condition ranged from 3.0- to 8.7-fold and

the risk of having two or more conditions

ranged from 5.8- to 14.2-fold.

Discussion: The data are compatible

with the excess morbidity and mortality

from cardiovascular disease, diabetes and

renal disease in these Aboriginal groups.

They reflect the multitude of risk factors

operating in these environments. They

dictate urgent and systematic intervention

to modify outcomes of established disease

and to prevent their development. However,

the resources required for effective

secondary intervention will differ among

communities according to the disease

burden.

Key words: Australian Aborigine,

proteinuria, hypertension, diabetes,

prevalence, health surveys.

(Aust N Z J Public Health. 2007; 31:177-83)

doi:10.1111/j.1753-6405.2007.00038.x

Non-communicable chronic diseases

(NCDs) represent one of the major

health issues of the 21st century.

Increasing rates of hypertension, type 2

diabetes and chronic kidney disease are

especially prominent in developing countries

and in minority populations undergoing

rapid epidemiologic and lifestyle transition.1

Australian Aborigines are experiencing

an accelerated and often brutal transition

and many are now living in deprived and

marginalised circumstances with poor access

to health services. Prior to the 1980s, almost

no NCDs were recognised, but they are now

rife, with average rates of cardiovascular

death more than three times those of non-

Aboriginal Australians, diabetes deaths

Correspondence to: Professor Wendy Hoy, Clinical Sciences Building, Royal Brisbane Hospital, Herston, Queensland 4029. Fax: (07) 4436 4812; e-mail: [email protected]

Submitted: October 2006 Revision requested: January 2007 Accepted: February 2007

increased eight-fold and renal failure about

10-fold.2,3 Rates are much higher in some

remote areas.4,5

Awareness and management of this

problem have improved in the past 10-

15 years. Screening programs have been

conducted in several regions.6-16 Systematic

management of affected people produces

good results. McDermott et al. showed

that structured diabetes care reduces

hospitalisations,17 and we showed that

systematic treatment for hypertension and

renal disease produces marked reductions in

non-renal and renal deaths,18 with dramatic

cost-savings in dialysis avoided. We also

showed that benefits are quickly lost when

treatment falters.19 Guidelines for chronic

Article Indigenous Health

178 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2007 vol. 31 no. 2© 2007 The Authors. Journal Compilation © 2007 Public Health Association of Australia

disease management have been incorporated into standard care

plans for Aboriginal adults in some regions.20 However, serious

deficiencies persist. The structures for Aboriginal primary health

care, in which chronic disease programs should be nested, are a

chaotic, inscrutable and ever-changing mix. They are inadequately

resourced, have a serious staffing shortage, and average per capita

spending is estimated at less than one-tenth of that for non-

Aboriginal Australians.21 In addition, there is a tacit assumption of

a uniform disease burden across Aboriginal Australia, suggesting

that one resourcing formula will suit all circumstances.

In this paper we describe the rates of proteinuria, high blood

pressure and diabetes in adults in three remote Aboriginal

communities in one region of Australia, and compare them with a

nationally representative survey of participants from the Australian

Diabetes, Obesity and Lifestyle Study (AusDiab). Our objective is

to define the magnitude of the problem, the degree of homogeneity

or variation, to speculate on causes and associations, and make the

case for systematic, needs-based health services planning.

MethodsThe Aboriginal study communities (named 1 through to 3), were

all situated in the Top End of the Northern Territory, Australia (see

Figure 1). They all represent aggregations of people from several

tribal groups in those regions. These communities have adult (25+

year) Aboriginal populations ranging from 135 to 512.22

Volunteers were tested in the context of programs to improve

the awareness and management of chronic diseases, conducted

between 2000 and 2003. Testing was generally done by Aboriginal

Health Workers who had been trained by nurse co-ordinators.

Results were recorded in hard copy and also entered in an

electronic database. Testing included a brief history, medication

review, anthropomorphic measurements, blood pressure, urine

dipstick for protein and assessment of the presence of diabetes.

The health profiles have been previously described.9,10,23

The AusDiab study was based on a stratified cluster sample of

Figure 1: Study communities in the ‘Top End’ of the Northern Territory, Australia.

11,247 consenting adults aged 25 and above who participated in

a nationwide survey in Australia conducted between 1999 and

2000.24 Only 1% of the study participants in AusDiab were of

Aboriginal or Torres Strait Islander origin.

Data on people age 25 to <75 years of age were used to

compare the Aboriginal and AusDiab findings. This lower limit

was set by the lower age limit in the AusDiab study, and the

upper limit was defined by the paucity of older people in the

Aboriginal group (among screened Aboriginal people age 25+

years, only 2.5% were aged 75+ years, compared with 7.2% for

the AusDiab group). Proteinuria was defined as protein •1+ (30

mg/dl) by urine dipstick. High blood pressure was defined at two

levels: as a blood pressure •140/90 mmHg and as an inclusive

definition of BP•140/90 and/or antihypertensive treatment for a

past diagnosis of hypertension. Diabetes was defined by history,

existing prescription of hypoglycaemic medication and/or by blood

glucose measurement on testing. Aboriginal people not already

known to be diabetic were screened by a fasting or random blood

glucose measurement; those with values of •7.0 mmol/l or •11.1

mmol/l respectively were deemed diabetic. These were confirmed

by repeat screening. AusDiab participants not already known to

be diabetic were screened with an oral glucose tolerance test

and deemed diabetic if the fasting value was •7.0 mmol/l or the

two-hour level •11.1 mmol/l. The prevalence of each of these

conditions was calculated. The prevalences of people with at

least one condition and with more than one condition were also

defined. Unadjusted proportions of people with these conditions

were compared, and the odds ratios (95% confidence intervals)

of the Aboriginal groups relative to the AusDiab population were

estimated using logistic regression, adjusted for age and sex.

Statistical analyses were performed using Stata, version 9.1.25 The Aboriginal data used for analyses in this report were

collected in projects approved by the ethics committees of the

Menzies School of Health Research, the Royal Darwin Hospital,

and the University of Queensland. Comparison with AusDiab data

was approved by the individual communities and by the ethics

committee of the University of Queensland, and publication of

the findings was approved by the individual communities. The

AusDiab study was approved by the ethics committee of the

International Diabetes Institute, and all participants gave written,

informed consent.

ResultsData were compared on 10,434 people in the AusDiab study and

814 Aboriginal people in the specified age range. The Aboriginal

participants represented approximately 71%, •100% and 64% of

the age-eligible populations in communities 1, 2 and 3 respectively.

(Participation in community 2 was greater than the Census

population of age-eligible adults.) Females constituted 55.1% of

the AusDiab group and 53.4% of the Aboriginal group (p=0.36).

Table 1 shows that the mean age of the Aboriginal participants

in each community was younger than the AusDiab population,

which was due to higher proportions of Aboriginal people in

Hoy et al. Article


the younger age group and lower proportions in the higher age

groups. However, age was well matched within each age stratum

(for age groups 25-<35, 35-<45, 45-<55 and 55-<75 respectively,

AusDiab ages (means) were 29.9, 39.8, 49.5 and 63.6 years, and

for Aboriginal were 29.7, 39.8, 49.0 and 63.0 years). Table 1 also

shows a marked gradation of body mass index (BMI) figures

among the Aboriginal communities, with only those in Community

3 exceeding those of AusDiab.

Figure 2A shows the aggregate unadjusted rates of proteinuria,

high blood pressure and diabetes. They were excessive in all the

Aboriginal communities relative to AusDiab, but differed among

them. The prevalence of proteinuria varied from 15% to 28%,

of high blood pressure from 34% to 54%, and of diabetes from

17% to 30%. With adjustment for age and sex, as shown in Figure

2B, these corresponded to odds ratios for proteinuria ranging

from 2.5 to 5.3, for high blood pressure from 3.1 to 8.1, and for

diabetes from 5.4 to 10.0. For all conditions the heterogeneity

among Aboriginal communities was significant, with p<0.0001.

As shown in Table 2, the proportions of Aboriginal people with

elevated blood pressure at examination, while still higher than the

AusDiab population, were relatively less elevated than the rates

of hypertension by the expanded definition, probably reflecting

some success in policies to control blood pressure in recent years

in the Aboriginal environments.

Figure 3A shows that between 43% and 68% of people in the

Table 1: Demographics of participants in this study.

Communities n Females % Age in years, mean (SD) BMI, kg/m2 mean (SD) Obese by BMI %AusDiab 10,434 55.1 49.4 (12.6) 27.0 (5.0) 22.9

Community 1 331 47.4 40.6 (12.0) 22.1 (4.7) 6.3

Community 2 157 56.7 41.9 (12.0) 25.7 (5.9) 23.4

Community 3 326 58.0 42.7 (13.2) 28.5 (6.2) 38.6

Figure 2A: Prevalences of proteinuria, hypertension and diabetes, by community.

DefinitionsProteinuria: Urine dipstick •1+.Hypertension: BP•140/90 and/or on antihypertensive medication.Diabetes: Fasting plasma glucose •7.0 or random or two-hour plasma glucose •11.1 mmol/or hypoglycaemic medication.

Figure 2B: Odds ratios for proteinuria, hypertension and diabetes relative to AusDiab, by community (adjusted for age and sex).

DefinitionsProteinuria: Urine dipstick •1+.Hypertension: BP •140/90 and or on antihypertensive medication.Diabetes: Fasting plasma glucose •7.0 or random or two-hour plasma glucose •11.1 mmol/or hypoglycaemic medication.

different Aboriginal communities had at least one of the three

conditions, and 17% to 34% had more than one condition. As

shown in Figure 3B, these correspond to odds ratios, adjusted for

age and sex, varying from 3.0 to 8.7 for any condition and from

5.8 to 14.2 for multiple conditions. In both instances, the apparent

heterogeneity among communities was significant (p<0.0001).

Figure 4A shows that the rates of these conditions were strongly

correlated with age in the Aboriginal communities. In the AusDiab

population, high blood pressure and diabetes also correlated

strongly with age, but proteinuria did not. Rates in Aboriginal

people were higher than those in the AusDiab population in every

age group. Figure 4B shows an elevated risk for proteinuria in all

age groups, but the risk accentuation was higher after age 35 years.

The figure shows that the risk accentuation for hypertension was

highest in younger Aboriginal adults. Finally, it shows a 19.5-fold

exacerbation of risk for diabetes among the youngest Aboriginal

adults and although the relative risk fell somewhat with age, it

remained very high throughout life.

Figure 5A shows that the probability of having at least one

condition rose with age in both populations, but was always greater

in the Aboriginal group. By age 35-44 years, 59% of Aboriginal

people had at least one condition and by age 55+ years, 79%

were affected. The probability of having multiple conditions was

strikingly higher at all ages among the Aboriginal people, and

reached 35% by middle age. Figure 5B shows that the adjusted

Indigenous Health Quantifying the excess risk for proteinuria


Figure 3A: Prevalences of any and of multiple conditions, by community.

Figure 4A: Prevalences of proteinuria, hypertension and diabetes, by age group and Aboriginal status.


Figure 4B: Odds ratios for proteinuria, hypertension and diabetes among Aborigines relative to AusDiab, by age group (adjusted for age and sex).


Figure 5A: Prevalences of any and of multiple conditions by age group and Aboriginal status.

Figure 5B: Odds ratios for any and for multiple conditions relative to AusDiab, by age group (adjusted for age and sex).

Figure 3B: Odds ratios for any and for multiple conditions relative to AusDiab, by community (adjusted for age and sex).

Hoy et al. Article


risk of having any condition was more than four times that of

AusDiab among the youngest adults, and peaked at 7.1-fold

increase among those age 35-44 years. The adjusted relative risk

for multiple conditions was greatest among the younger adults,

with an 18-fold increase.

DiscussionRates of proteinuria, high blood pressure and diabetes were

excessive in each of these Aboriginal communities relative to those

in the AusDiab study. The accentuations of risk in Community

1, with a 2.5-fold increase in proteinuria, a 3.1-fold increase

in hypertension and a 5.3-fold increase in diabetes, are serious

indeed; the 5.3-fold increase in proteinuria, 8.1-fold increase in

hypertension and a 10-fold increase in diabetes in Community 3

are truly striking. The risk of having any condition was increased

as much as nine-fold and the risk of having multiple conditions

was increased 14-fold and more.

Several factors limit the precision of our findings, although they

could not have caused a major distortion of the true relationships.

The groups were tested by different teams, measurements of blood

pressures might have varied with observers and, while reported

blood pressures were averaged from two or three readings in

AusDiab participants, they represent a single reading in the

Aboriginal people. The dipsticks for measuring proteinuria were

not necessarily the same brand, and urine protein concentration

could have been accentuated by the generally hot ambient

temperature in the Aboriginal settings. The accentuation of risk

for diabetes in Aboriginal people is probably understated, because

a glucose tolerance test was not routinely performed on those

without a known diagnosis of diabetes. Also, glucose screening

might have missed some people with unsuspected IGT/IFG/

diabetes by accepting ‘normal range’ fasting or random glucose

screening. This will result in understatement by estimates of the

risk exacerbation of the Aboriginal group compared with the

AusDiab data. The possible effect of differential participation by

age and gender among the communities is discussed below.

Striking as the risk accentuations are, the figures nonetheless

markedly understate the real burden of these conditions in the

Aboriginal communities. Participants in cross-sectional studies

are, by definition, survivors to that point: in the Aboriginal

context this means they have so far escaped the greatly excessive

risk for premature death carried by proteinuria, hypertension and

diabetes.26,27 According to nationwide estimates, about half the

males and only a marginally lower proportion of females have

already died before the age of 55 years, with the deaths heavily

segregated among those with the morbidities under study. This

must be contributing, at least in part, to the lower risk ratios in

older Aboriginal participants.

The data are compatible with the >20-fold increase in renal

failure and the three- to six-fold increase in premature deaths

in general, and cardiovascular deaths in particular, in these

regions, and with the nine-fold increase in deaths from ischaemic

heart disease and 28-fold increase in diabetes deaths in remote

Aboriginal Australia more generally.3,4,5,32 These are crisis-level

statistics.

It is challenging to consider the mix and balance of risks factors

that allows expression of disease at such levels. It is also important

to consider the implications for health services policy and needs-

based planning.

The very substantial overlap of conditions, described in more

detail elsewhere and demonstrated in the high rates of people

with more than one condition, suggests that they are, in part,

elements of a single vascular/renal/metabolic syndrome.9,10,14,28-30

Such integration suggests a shared base of risk factors. It also

supports integrated rather than disease-specific programs for

surveillance and containment and the need for multiple arms of

management. With almost 60% of Aboriginal people having at

least one morbidity by age 35-44 years, most people will need

medical treatment by middle age and many will need treatment

with multiple drugs. Treatment will need to be sustained for many

years if they are to aspire to a life span that approximates that of

non-Aboriginal Australians.

Some of the factors associated with these morbidities are

being defined.9-16,28,29,32-35 In addition to increasing age, they

include higher levels of body fat, which is particularly flagged

by higher waist measurements. A role for body fat is suggested

here by the fact that the differential rates of morbidities in the

Aboriginal groups follow the same pattern as their weights and

their BMIs.9 Alone, however, they do not account for most of the

excessive rates, for only in Community 3 are the BMIs greater

than in the AusDiab population. We have previously described

the body habitus profiles of these Aboriginal communities.9,10 The

associations of Aboriginal body size measurements with chronic

conditions and their comparisons with the AusDiab population

are subjects of proposed reports (Dr Kondalsamy-Chennakesavan,

University of Queensland). Other demonstrated risk factors

include birthweight (inversely), skin infections, noncutaneous

infections, inflammation, excessive alcohol use (for renal disease

at least), and grand multiparity, while high rates of smoking (up

to 80% in men and up to 50% of women) and psychosocial stress

are also probably instrumental.9-12,14,36-40 All the conditions are

Table 2: Proportion of participants with high blood pressure using two definitions, and odds ratios relative to AusDiab, adjusted for age and sex.

BP•140/90 OR (95% CI) BP•140/90 and/or on medication OR (95% CI)AusDiab 23.0% Referent 29.0% Referent

Community 1 24.6% 2.3 (1.7-3.1) 33.7% 3.1 (2.4-4.1)

Community 2 32.7% 3.6 (2.5-5.2) 47.1% 6.0 (4.2-8.5)

Community 3 35.4% 3.7 (2.8-4.8) 54.4% 8.1 (6.2-10.6)



probably multi-determinant, with the simultaneous or sequential

operation of more than one risk factor amplifying effects of the

others.11,41 We have already defined this in relationship to renal

disease in an Aboriginal setting,10,33 and an important precedent

exists internationally in the polyfactorial model for ischaemic

heart disease.42 Such models help explain the massively higher

rates of disease in environments with a high density of risk factors.

We have also emphasised that the emergence of this epidemic is

a consequence, in part, of prior health triumphs. The recent vast

reduction in infant mortality since the 1950s, as a result of better

hospital management of sick babies, has allowed cohorts of low

birthweight babies to survive to adult life where, as proposed by

Barker and becoming manifest in the Aboriginal setting, they are

at increased risk for chronic disease.33-35 In addition, reduction in

competing mortality, particularly due to fewer infectious deaths,

has increased adult longevity and thus the opportunity for chronic

disease expression.

The uniformly excessive rates support clinical impressions that

all remote communities are afflicted by this epidemic of chronic

disease. The variation in rates, however, shows that the magnitude

of the situation cannot be generalised at any one particular time.

Plausible reasons for the differences include obvious variations

in body habitus, differences in diet, alcohol use and rates of

smoking, differences in timing of the improved infant survival

phenomenon, in the duration and intensity of lifestyle changes,

in palpably different degrees of disadvantage at this point in

time and, potentially, differences in genetic predisposition. Men

constituted a somewhat larger proportion of the total screened

population in Community 1 than in the other sites (see Table 1),

and they tended to be somewhat younger. These phenomena were

driven by an all-male screening team and a paucity of males aged

45+ years in this community due to premature deaths, in large

part associated with substance abuse and violence. However, the

differences in rates of morbidities by community, and particularly

the lowest rates in Community 1, are very real. They applied for

all the three conditions, except arguably for proteinuria, for any

morbidity and for multiple morbidities in both sexes, and for all

age groups below 55 years, after which small numbers sometimes

became limiting.

The situation constitutes an emergency by any standards.

With the clinical benefits and cost savings of effective treatment

demonstrated, there can be no rational argument against early

screening and intervention programs.18,44-46 There are also

plenty of avenues for primary prevention, targeting exercise,

nutrition, hygiene, smoking and infections, which can be

implemented or strengthened even while working to understand

the pathophysiology more precisely. A problem of equal magnitude

among non-Indigenous Australians, adequately exposed, would

excite a vigorous and systematic response.

The variation in rates by community, however, dictates needs-

based health services planning.9 Primary prevention strategies

might vary little across communities, but the level of resourcing

for programs of screening and treatment will depend on the disease

burden. Disease burden might influence the optimal frequency

of regular testing throughout life, but will certainly influence the

requirements of personnel, reagents, facilities, medicines, tests

and documentation needed for proper treatment and intensified

surveillance of people with morbidities. The capacity for a high

treatment burden to overwhelm poorly resourced chronic disease

intervention programs has already been demonstrated in such

settings.19,23

The governments of the Northern Territory and most other States

have endorsed the need for good chronic disease surveillance and

management, and protocols have been incorporated into standard

care guidelines for Aboriginal people.20 Our observations in these

outreach communities, in an ongoing relationship with the Tiwi

community, and in the radically different environments of two

large and empowered Aboriginal Medical Services in Western

Australia, combined with much anecdotal information more

broadly, indicate that systematic application of these principles is

constrained by limited resources.19,47 Ironically, hospital services

and renal replacement therapy offered to Aboriginal people are of

good quality and essentially uncapped, with the latter now posing

a fiscal crisis for health care budgets.44 The problem requires a

rethinking of Aboriginal health services, adequate resourcing,

strategies to combat the obstacles and hardships associated with

remote locations and placements, and accountability at every

level of the system.

AcknowledgementsWe thank all the remote Aboriginal communities and their

councils who participated in this study, and all the community

liaison people, health workers, nurses and doctors working in

these communities. We also thank the project teams working

with the Menzies School of Health Research in the 1990s,

and more recently with the Chronic Disease Outreach Team,

including Rebecca Davey, Gaye Gokel, Kiernan McKendry,

Suresh Sharma, Joanne Smith and Phillip Hoy. The data on

which the analyses in Aboriginal communities were done were

derived from studies supported by Kidney Health Australia (then

the Australian Kidney Foundation), the Office of Aboriginal and

Torres Strait Islander Health, Rio Tinto, Janssen-Cilag, Helen

Hayes, the Colonial Foundation and the National Health and

Medical Research Council of Australia. The AusDiab study was

supported by the Commonwealth Department of Health and

Aged Care, Abbott Australasia Pty Ltd, Alphapharm Pty Ltd,

Aventis Pharmaceutical, AstraZeneca, Bristol-Myers Squibb

Pharmaceuticals, Eli Lilly (Aust) Pty Ltd, GlaxoSmithKline,

Janssen-Cilag (Aust) Pty Ltd, Merck Lipha s.a., Merck Sharp &

Dohme (Aust), Novartis Pharmaceutical (Aust) Pty Ltd, Novo

Nordisk Pharmaceutical Pty Ltd, Pharmacia and Upjohn Pty Ltd,

Pfizer Pty Ltd, Roche Diagnostics, Sanofi Synthelabo (Aust) Pty

Ltd, Servier Laboratories (Aust) Pty Ltd, BioRad Laboratories

Pty Ltd, HITECH Pathology Pty Ltd, the Australian Kidney

Foundation, Diabetes Australia, Diabetes Australia (Northern

Territory), Queensland Health, South Australian Department of

Human Services, Tasmanian Department of Health and Human

Hoy et al. Article


Services, Territory Health Services, Victorian Department of

Human Services, and Health Department of Western Australia.

Also, for their invaluable contribution to the set-up and field

activities of AusDiab, we are enormously grateful to A. Allman,

B. Atkins, S. Bennett, S. Colagiuri, M. de Courten, M. Dalton, M.

D’Embden, D. Dunstan, T. Dwyer, D. Jolley, I. Kemp, P. Magnus,

J. Mathews, D. McCarty, A. Meehan, K. O’Dea, P. Phillips, P.

Popplewell, C. Reid, A. Stewart, R. Tapp, H. Taylor, T. Welborn,

F. Wilson and P Zimmet.

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Documents

Quantifying the excess risk for proteinuria, hypertension and diabetes in Australian Aborigines: comparison of profiles in three remote communities in the Northern Territory with those