Self-Reported Diabetes and Health Behaviors in - Diabetes Care

Self-Reported Diabetes and Health Behaviors in - Diabetes Care

Epidemiology/Health Services/Psychosocial Research O R I G I N A L A R T I C L E Self-Reported Diabetes and Health Behaviors in Remote Indigenous Co...

91KB Sizes 0 Downloads 10 Views

Recommend Documents

Posttransplantation Diabetes - Diabetes Care
Vesco et al. (10,11). Analysis of a transplant registry. (AZA-Pred, ..... O'Brien, and Robert A. Rizza for their thought

Focal Entrapment Neuropathies in Diabetes - Diabetes Care
MONONEURITIS AND. ENTRAPMENT SYNDROMES —. Peripheral neuropathies in diabetes are a diverse group of syndromes, not al

Obstetric Management in Gestational Diabetes - Diabetes Care
there are comorbid conditions, such as preeclampsia. ... 2007 by the American Diabetes Association. O R I G I N A L. A R

Type 2 Diabetes in Children and Adolescents - Diabetes Care
type 2 diabetes in children and adolescents. If the incidence and prevalence of type 2 diabetes in children are increasi

Screening for Type 2 Diabetes - Diabetes Care - American Diabetes
Screening for Type 2 Diabetes. AMERICAN DIABETES ASSOCIATION. Diabetes mellitus is a group of meta- bolic diseases chara

Supplementary Data - Diabetes Care - American Diabetes Association
Russell, Ms Teresa Anderlic, Angel Bouvier, Ms Audrrey Bhairo, Ms Christine Chan, Ms Dawn-. Lee Mclaughlin, Ms Lindsay N

observations - Diabetes Care - American Diabetes Association
Binge eating episodes were reported by 49.7% of ..... Alphabetical hemoglobin variant list (Ed- itorial). ..... School o

diabetes care in rwanda: AGAINST ALL ODDS - International Diabetes
in rwanda: AGAINST ALL ODDS. Crispin Gishoma. While Rwandan institutions were over- whelmed by multiple emergencies, the

Epidemiology/Health Services/Psychosocial Research O R I G I N A L

A R T I C L E

Self-Reported Diabetes and Health Behaviors in Remote Indigenous Communities in Northern Queensland, Australia BRAD MCCULLOCH, BSC, GDIPCOMPSCI1,2 ROBYN MCDERMOTT, MB, BS, MPH1,2 GEOFF MILLER, BSC1,2

DYMPNA LEONARD, MPH1 MICHELLE ELWELL, GDIPDIABED1 REINHOLD MULLER, PHD2

OBJECTIVE — This study examines associations between self-reported diabetes and selfreported smoking, alcohol consumption, fruit consumption, and participation in adequate exercise in remote indigenous communities, using data from the Well Persons’ Health Check (WPHC). RESEARCH DESIGN AND METHODS — The WPHC was a cross-sectional survey of 2,862 indigenous individuals (1,602 Aborigines, 1,074 Torres Strait Islanders, and 186 persons of joint descent) aged ⱖ15 years. The study was conducted in 26 remote communities in northern Queensland, Australia, between March 1998 and October 2000. RESULTS — A total of 32% of individuals with self-reported diabetes and 25% of other individuals reported eating enough fruit, according to National Health and Medical Research Council criteria: odds ratio (OR) 1.407 (95% CI 1.108 –1.786), P ⫽ 0.006. After adjustment for age, sex, and ethnicity, no significant difference could be observed: adjusted OR 1.22 (0.944 – 1.574), P ⫽ 0.128. A total of 58% of participants who reported diabetes and 51% of others reported adequate exercise: OR 0.761 (0.609 – 0.952), P ⫽ 0.018. This difference was not significant after adjustment for age, sex, and ethnicity: adjusted OR 0.896 (0.705–1.14), P ⫽ 0.370. A total of 43% of individuals who reported diabetes and 72% of others reported consuming alcohol: OR 0.295 (0.235– 0.369), P ⬍ 0.001. After adjustment for age, sex, and ethnicity, this difference was still significant: adjusted OR 0.550 (0.428 – 0.709), P ⬍ 0.001. Diabetic drinkers consumed alcohol at harmful levels similar to those of nondiabetic drinkers (P ⫽ 0.691). A total of 40% of individuals who reported diabetes and 63% of other persons were tobacco smokers: OR 0.403 (0.322– 0.505), P ⬍ 0.001. Although this crude difference was attenuated by adjustment for age, sex, and ethnicity, persons with self-reported diabetes were still significantly less likely to smoke tobacco than other participants: adjusted OR 0.666 (0.521– 0.852), P ⫽ 0.001. Smoking prevalence among the diabetic indigenous participants was more than double that in nondiabetic nonindigenous Australians. CONCLUSIONS — This study suggests that indigenous individuals with diabetes living in rural and remote communities are not adopting lifestyle changes required for optimal selfmanagement of the disease. This contributes to the large excess of mortality and morbidity experienced by this population. Diabetes Care 26:397– 403, 2003

D

iabetes has long been recognized as an important health issue in many indigenous populations, particu-

larly the Australian indigenous population (1–3). Cohort studies have shown that tobacco smoking (4) as well as obe-

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● 1

From the Tropical Public Health Unit Network, Queensland Health, Cairns, Queensland, Australia; and the 2 School of Public Health and Tropical Medicine, James Cook University, Queensland, Australia. Address correspondence and reprint requests to Brad McCulloch, Tropical Public Health Unit Network, Queensland Health, P.O. Box 1103, Cairns Queensland 4870, Australia. E-mail: [email protected] health.qld.gov.au. Received for publication 27 May 2002 and accepted in revised form 24 October 2002. Abbreviations: AusDiab, Australian Diabetes, Obesity, and Lifestyle Study; OR, odds ratio; NHS, National Health Survey; STI, sexually transmissible infection; WPHC, Well Persons’ Health Check. A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion factors for many substances.

DIABETES CARE, VOLUME 26, NUMBER 2, FEBRUARY 2003

sity and other features of the metabolic syndrome (5–9) are independent predictors of incidence of diabetes. In addition, tobacco smoking has been found to be a significant contributor to the incidence of complications of diabetes such as neuropathy, nephropathy, retinopathy, erectile dysfunction, and ischemia (4). Avoidance of tobacco is an important component in the management of diabetes (4,10). It is known that smoking recruitment and nicotine addiction rates are high and cessation rates are low among individuals at greater socioeconomic disadvantage (11) and that indigenous people in remote Queensland communities are among the most disadvantaged in Queensland (12–14). Little is known about the effectiveness of smoking cessation interventions in patients with diabetes (4); assumptions have been made that existing interventions will be as effective in diabetic patients as in nondiabetic patients. Evidence from Australian general practice suggests that physicians are unlikely to apply wellcharacterized interventions to diabetic patients, beyond advising cessation of cease smoking (10). Whether smoking cessation interventions are being applied and/or are effective in Australian indigenous community settings is unknown. The aim of this study is to examine differences in health behaviors between indigenous people who are aware of having diabetes and those in whom diabetes has not been diagnosed. RESEARCH DESIGN AND METHODS Study design The Well Person’s Health Check (WPHC) was a cross-sectional survey conducted in 26 remote indigenous communities in northern Queensland, Australia, between March 1998 and October 2000. Data were collected regarding chronic disease 397

Self-reported diabetes and health behavior

Table 1—Age- and sex-stratified prevalence of self-reported diabetes in WPHC participants, compared with AusDiab results Aboriginal Age (years) 15–24 25–34 35–44 45–54 55–64 65–74 75⫹ Total

Men

Aboriginal and Islander

Women

1/172 (0.5) 2/206 (0.9) 7/193 (3.6) 11/214 (5.1) 14/165 (8.4) 37/184 (20.1) 20/104 (19.2) 24/118 (20.3) 6/67 (8.9) 38/84 (45.2) 6/34 (17.6) 11/44 (25) 1/5 (20) 5/12 (41.6) 55/740 (7.4) 128/862 (14.8)

Men

Islander

Women

Men

1/29 (3.4) 0/33 (0) 0/25 (0) 1/25 (4) 1/19 (5.2) 2/21 (9.5) 0/8 (0) 4/8 (50) 0/2 (0) 1/8 (12.5) 2/2 (100) 2/4 (50) 0/2 (0) 0/0 4/87 (4.5) 10/99 (10.1)

AusDiab 2000 Women

Men

Women

1/134 (0.7) 0/119 (0) NA NA 3/132 (2.2) 5/138 (3.6) 0/585 (0) 2/799 (0.3) 17/119 (14.2) 12/98 (12.2) 12/1,091 (1.1) 13/1,462 (0.9) 17/91 (18.6) 38/76 (50) 38/1,350 (2.8) 54/1,541 (3.5) 13/38 (34.2) 18/43 (41.8) 80/93 (8.6) 50/1,091 (4.6) 10/32 (31.2) 22/36 (61.1) 94/731 (12.8) 61/832 (7.3) 4/8 (50) 5/10 (50) 50/360 (13.8) 46/472 (9.7) 65/554 (11.7) 100/520 (19.2) 217/5,050 (4.3) 205/6,197 (3.3)

Data are n (%).

risk factors and sexually transmissible infection (STI). A treatment service was offered for persons with positive results for STI. Subjects The target population for the WPHC was indigenous persons aged ⱖ13 years. Participation was voluntary, and the survey was open to all residents of the community. The WPHC was advertised through printed media (posters, pamphlets), local radio, and word of mouth via the local health service, community council, and community groups. Qualitative feasibility studies were

conducted in many communities to provide information to local residents about the WPHC and to assess barriers to participation. Information from these studies assisted in determining when and where the WPHC was held, the level of involvement of local and visiting staff, and issues such as transportation to the screening site. These feasibility studies also provided information about health perceptions and priorities in the community, which was useful in tailoring local promotional strategies. Of the 3,507 participants, 474 nonindigenous participants were excluded from this analysis, along with 171 indi-

viduals aged ⬍15 years, leaving 2,862 individuals to participate in the study. Individuals aged ⬍15 years were excluded from the analysis because participation in this age group was dependent on the time of year and the presence of a secondary school in the community. Based on local census data, this represents a participation rate of ⬃44.5%. Participation rates varied from 19 to 92% among the communities; greater participation was noted in smaller communities. The study complied with the National Health and Medical Research Council guidelines for research in Aboriginal and Torres Strait Islander Health (15), and

Table 2—Age- and sex-stratified prevalence of self-reported inadequate fruit consumption in WPHC participants, by self-reported diabetes status compared with National Nutrition Survey results Aborigines Age (years) Men 15–24 25–34 35–44 45–54 55–64 65–74 75⫹ Total Women 15–24 25–34 35–44 45–54 55–64 65–74 75⫹ Total

Torres Strait Islanders

Joint descent

Self-reported diabetes

Other

Self-reported diabetes

Other

Self-reported diabetes

Other

National Nutrition Survey (%)

1/1 (100) 2/7 (29) 6/14 (43) 4/20 (20) 2/6 (33) 2/6 (33) 0/1 (0) 17/55 (31)

46/171 (27) 27/185 (15) 28/151 (19) 16/82 (20) 13/61 (21) 8/28 (29) 0/4 (0) 138/682 (20)

0/1 (0) 0/3 (0) 6/17 (35) 3/17 (18) 5/13 (38) 4/10 (40) 0/4 (0) 18/65 (28)

38/133 (29) 38/128 (30) 27/102 (26) 19/74 (26) 9/25 (36) 3/22 (14) 1/4 (25) 135/488 (28)

0/1 (0) — 1/1 (100) — — 1/2 (50) — 2/4 (50)

7/28 (25) 9/25 (36) 6/18 (33) 2/8 (25) 0/2 (0) 0/2 (0) — 24/83 (29)

90.05 85.62 85.01 79.85

0/2 (0) 2/11 (18) 5/36 (14) 7/24 (29) 10/38 (26) 5/11 (45) 2/5 (40) 31/127 (24)

48/203 (24) 43/203 (21) 36/147 (24) 26/94 (28) 13/46 (28) 10/33 (30) 2/7 (29) 178/733 (24)

— 0/5 (0) 7/12 (58) 17/38 (45) 5/18 (28) 10/22 (45) 1/5 (20) 40/100 (40)

29/119 (24) 34/132 (26) 25/86 (29) 18/38 (47) 10/25 (40) 5/14 (36) 1/5 (20) 122/419 (29)

— 0/1 (0) 2/2 (100) 4/4 (100) 1/1 (100) 1/2 (50) — 8/10 (80)

6/33 (18) 7/24 (29) 10/19 (53) 3/4 (75) 4/7 (57) 1/2 (50) — 31/89 (35)

90.34 86.95 83.41 81.33

78.46 83.7

78.41 83.7

Data are n (%) unless otherwise indicated.

398

DIABETES CARE, VOLUME 26, NUMBER 2, FEBRUARY 2003

McCulloch and Associates

Table 3—Age- and sex-stratified prevalence of self-reported inadequate exercise in WPHC participants, by self-reported diabetes status compared with National Health Survey results Aborigines Age (years)

Self-reported diabetes

Men 15–24 25–34 35–44 45–54

Torres Strait Islanders Other

Self-reported diabetes

0/1 (0) 4/7 (57) 10/14 (71) 13/20 (65)

73/171 (43) 88/184 (48) 76/151 (50) 37/84 (44)

2/6 (33) 3/6 (50) 1/1 (100) 33/55 (60)

Joint descent

Other

Self-reported diabetes

Other

0/1 (0) 2/3 (67) 11/17 (65) 6/17 (35)

35/133 (26) 47/128 (37) 51/101 (50) 35/74 (47)

0/1 (0) — 1/1 (100) —

9/28 (32) 10/25 (40) 11/17 (65) 4/8 (50)

26/61 (43) 16/27 (59) 2/4 (50) 318/682 (47)

5/13 (38) 5/10 (50) 3/4 (75) 32/65 (49)

7/25 (28) 12/22 (55) 3/4 (75) 190/487 (39)

— 2/2 (100) — 3/4 (75)

1/2 (50) 2/2 (100) — 37/82 (45)

1/2 (50) 8/11 (73) 20/37 (54) 13/24 (54)

117/204 (57) 120/202 (59) 93/146 (64) 57/94 (61)

— 2/5 (40) 6/12 (50) 19/38 (50)

80/119 (67) 67/132 (51) 48/86 (56) 19/37 (51)

— 1/1 (100) 1/2 (50) 4/4 (100)

19/33 (58) 11/24 (46) 16/19 (84) 3/4 (75)

27/38 (71) 9/11 (82) 3/5 (60) 81/128 (63)

30/45 (67) 20/33 (61) 6/7 (86) 443/731 (61)

12/18 (67) 11/22 (50) 3/5 (60) 53/100 (53)

12/25 (48) 6/14 (43) 2/5 (40) 234/418 (56)

0/1 (0) 2/2 (100) — 8/10 (80)

3/7 (43) 2/2 (100) — 54/89 (61)

National Health Survey 1995* (%) 56.2* 65.4* 70.4* 70.1*

55–64 65–74 75⫹ Total Women 15–24 25–34 35–44 45–54

57* 78.5* 62.1 56.2* 65.4* 70.4* 70.1*

55–64 65–74 75⫹ Total

57* 78.5* 71.7

Data are n (%) unless otherwise indicated. *The National Health Survey data were unavailable in age- and sex-specific strata; results shown for age groups include men and women.

ethics approval was granted by the Cairns Base Hospital Ethics Committee in March 1998. All participants and community councils gave written informed consent. Anthropometric measurements Participants were asked to remove any heavy clothing (jackets, etc.) and footwear and were then weighed to the nearest 0.1 kg and measured for height to the nearest centimeter. Waist and hip circumferences were measured to the nearest centimeter. Waist-to-hip ratio was calculated as waist circumference divided by hip circumference. BMI was calculated as weight (kg) divided by height squared (m2). Interview questions Interviews took the form of a standardized questionnaire administered in a faceto-face interview. Five specifically trained interviewers performed interviews and measurements. Regular meetings were held regarding standardization of interview techniques. Participants were asked to recall all food eaten the day before the screening, and the number of servings of fruits and

vegetables was recorded. A serving was defined as “about a handful of fruit or vegetables, or half a cup,” which is equivalent to ⬃150 g of fruit or 75 g of vegetables. This 24-h recall method of assessing food intake has been validated elsewhere (16 – 18). Exercise was measured using a 7-day recall method in which each participant was asked to recall all exercise performed the week before the interview. The interviewer assessed the intensity and duration of that exercise. The interviewer recorded the number of days in the past week on which the participant was deemed to have exercised moderately for ⱖ30 min. Participants were asked if they had diabetes diagnosed by a doctor (selfreported diabetes) and/or chronic heart, lung, or kidney conditions, as well as the year in which these conditions were diagnosed. Participants were asked if they were taking any vitamin supplements or medications. Participants were asked if they currently smoked tobacco. Smokers were asked how many cigarettes they smoked daily. Nonsmokers were asked if they had ever smoked and, if so, when they had

DIABETES CARE, VOLUME 26, NUMBER 2, FEBRUARY 2003

ceased smoking. The same questions were asked with respect to alcohol consumption; drinkers were asked to recall the types and quantities of alcohol consumed in the previous 7 days. These methods of collecting information regarding drinking, smoking, fruit consumption, and exercise have been widely used elsewhere (18 –22). Blood sample collection and analysis Fasting venous blood samples were collected by a medical officer, registered nurse, or trained phlebotomist from 2,779 of the 2,862 participants, and the following biochemical measurements were made: triglycerides, total cholesterol, HDL cholesterol, LDL cholesterol, ␥-glutamyl transferase (GGT), red cell folate (RCF), and glucose. Participants with a fasting glucose concentration of 5.5 mmol/l were followed-up within 1 month of the screening and were tested with a 75-g oral glucose tolerance test. Statistical analysis Statistical analyses were performed using SPSS statistical software (version 10; SPSS, Chicago, IL) (23). Odds ratios were 399

Self-reported diabetes and health behavior

Table 4—Age- and sex-stratified prevalence of self-reported smoking in WPHC participants, by self-reported diabetes status compared with the AusDiab results Aborigines Age (years) Men 15–24 25–34 35–44 45–54 55–64 65–74 75⫹ Total Women 15–24 25–34 35–44 45–54 55–64 65–74 75⫹ Total

Torres Strait Islanders

Joint descent

Self-reported diabetes

Other

Self-reported diabetes

Other

Self-reported diabetes

Other

AusDiab 2000

0/1 (0) 5/7 (71) 11/14 (79) 14/20 (70) 3/6 (50) 4/6 (67) 0/1 (0) 37/55 (67)

119/171 (70) 147/184 (80) 110/151 (73) 61/84 (73) 40/61 (66) 16/27 (59) 3/4 (75) 496/682 (73)

1/1 (100) 2/3 (67) 9/17 (53) 6/17 (35) 0/13 (0) 1/10 (10) 1/4 (25) 20/65 (31)

96/133 (72) 86/129 (67) 59/102 (58) 45/74 (61) 11/25 (44) 9/22 (41) 0/4 (0) 306/489 (63)

1/1 (100) — 1/1 (100) — — 1/2 (50) — 3/4 (75)

21/28 (75) 11/25 (44) 9/17 (53) 4/8 (50) 0/2 (0) 0/2 (0) — 45/82 (55)

NA 131/584 (22.5) 257/1,090 (23.6) 245/1,349 (18.2) 125/933 (13.4) 67/731 (9.2) 16/359 (4.6) 843/5,049 (18.2)

2/2 (100) 4/11 (36) 24/37 (65) 11/24 (46) 12/38 (32) 2/11 (18) 1/5 (20) 56/128 (44)

140/204 (69) 127/202 (63) 92/147 (63) 56/94 (60) 19/46 (41) 10/33 (30) 3/7 (43) 447/733 (61)

— 3/5 (60) 6/12 (50) 8/38 (21) 2/18 (11) 5/22 (23) 1/5 (20) 25/100 (25)

79/119 (66) 78/132 (59) 43/86 (50) 13/37 (35) 8/25 (32) 2/14 (14) 0/5 (0) 223/418 (53)

— 1/1 (100) 1/2 (50) 2/4 (50) 0/1 (0) 1/2 (50) — 5/10 (50)

20/33 (61) 18/24 (75) 6/19 (32) 0/4 (0) 1/7 (14) 0/2 (0) — 45/89 (51)

NA 148/798 (18.6) 238/1,462 (16.3) 209/1,540 (13.6) 96/1,090 (8.8) 48/832 (5.8) 20/449 (4.5) 760/6,174 (13.1)

Data are n (%).

calculated from 2 ⫻ 2 tables, and logistic regression models were used to adjust for age, sex, and ethnicity. Two-sided P values are given. Among drinkers, the proportion of individuals with known diabetes who drank at hazardous levels was compared with that in other persons, using both an age-, sex-, and smoking-stratified crosstabulation and ␹2 test. A logistic regression model was used to adjust for age, sex, and ethnicity. Classifications of data Two servings of fruit per day were considered the minimum for sufficient intake, as were five servings of vegetables, in accordance with national guidelines (24). Participants who exercised moderately on three or more days were classified as having exercised adequately. Exercise in the National Health Survey (NHS) (25) was classified into “No Exercise,” “Low Exercise Level,” “Medium Exercise Level,” and “High Exercise Level.” For the purpose of comparison with the results of this study, the NHS “No Exercise” and “Low Exercise Level” results have been aggregated as “insufficient exercise.” Smoking and alcohol consumption status was categorized as either “Current,” “Recent,” “Past,” or “Never.” Recent 400

smoking or drinking was defined, in the WPHC, as self-reported cessation in the previous 12 months. RESULTS — Self-reported age-stratified prevalence of diabetes is shown in Table 1, along with national comparisons from the Australian Diabetes, Obesity, and Lifestyle Study (AusDiab) 2000 (21). In the sample, diabetes was less prevalent in men than in women: age-adjusted OR 0.501 (95% CI 0.391– 0.642), P ⬍ 0.001. The highest rates were found among Torres Strait Islanders. Fruit consumption Self-reported rates of low fruit consumption (fewer than two servings per day) are shown in Table 2, along with national comparisons from the National Nutrition Survey (26). In a bivariate analysis, individuals with self-reported diabetes were significantly more likely to have eaten enough fruit than other persons: 32 vs. 25%, OR 1.407 (95% CI 1.108 –1.786), P ⫽ 0.006. After adjusting for sex, age, and ethnicity, this difference was found to be no longer significant: adjusted OR 1.22 (0.944 – 1.574), P ⫽ 0.128.

Exercise The proportions of individuals reporting insufficient exercise (fewer than 3 days in the week before the screening in which ⱖ30 min of moderate exercise was undertaken) are shown in Table 3. Without accounting for other factors, individuals with self-reported diabetes were less likely than other subjects to exercise adequately: 58 vs. 51%, OR 0.761 (95% CI 0.609 – 0.952), P ⫽ 0.018. After adjusting for sex, age, and ethnicity, no significant difference was found between individuals with self-reported diabetes and other participants: adjusted OR 0.896 (0.705–1.14), P ⫽ 0.370. Tobacco smoking Tobacco smoking rates are shown in Table 4, along with national comparison data from the AusDiab 2000 survey (21). Smoking rates in indigenous study participants were almost three times those of the mostly nonindigenous sample used in the AusDiab 2000 survey (21). Smoking prevalence in individuals with self-reported diabetes was lower than in other participants: crude analysis 40 vs. 63%, OR 0.403 (95% CI 0.322– 0.505), P ⬍ 0.001. Although this observed effect was attenuated by adjustment for age, sex, and ethnicity, in-

DIABETES CARE, VOLUME 26, NUMBER 2, FEBRUARY 2003

McCulloch and Associates

Table 5—Age- and sex-stratified prevalence of self-reported alcohol consumption in WPHC participants, by self-reported diabetes status compared with National Health Survey results Aborigines

Torres Strait Islanders

Joint descent

Age (years)

Self-reported diabetes

Other

Self-reported diabetes

Other

Self-reported diabetes

Other

Men 15–24 25–34 35–44 45–54

0/1 (0) 7/7 (100) 12/13 (92) 13/20 (65)

124/171 (73) 172/184 (93) 131/151 (87) 76/84 (90)

1/1 (100) 3/3 (100) 13/17 (76) 9/17 (53)

119/133 (89) 110/129 (85) 76/102 (75) 56/74 (76)

1/1 (100) — 1/1 (100) —

23/28 (82) 19/25 (76) 14/17 (82) 5/8 (63)

2/6 (33) 0/6 (0) 1/1 (100) 35/54 (65)

47/61 (77) 18/27 (67) 1/4 (25) 569/682 (83)

5/13 (38) 2/10 (20) 2/4 (50) 35/65 (54)

13/25 (52) 13/22 (59) 1/4 (25) 388/489 (79)

— 1/2 (50) — 3/4 (75)

2/2 (100) 0/2 (0) — 63/82 (77)

2/2 (100) 9/11 (82) 25/37 (68) 15/24 (63)

139/204 (68) 144/202 (71) 104/147 (71) 58/94 (62)

— 4/5 (80) 2/12 (17) 5/38 (13)

87/119 (73) 90/132 (68) 44/86 (51) 14/37 (38)

— 1/1 (100) 2/2 (100) 3/4 (75)

22/33 (67) 17/24 (71) 8/19 (42) 0/4 (0)

9/38 (24) 3/11 (27) 0/5 (0) 63/128 (49)

23/45 (51) 6/33 (18) 2/7 (29) 476/732 (65)

2/18 (11) 0/22 (0) 0/5 (0) 13/100 (13)

9/25 (36) 3/14 (21) 0/5 (0) 247/418 (59)

0/1 (0) 0/2 (0) — 6/10 (60)

1/7 (14) 0/2 (0) — 48/89 (54)

National Health Survey 1995 68% (aged 18–24 year)* 59* 60* 56*

55–64 65–74 75⫹ Total Women 15–24 25–34 35–44 45–54

58* 39* 68* 68% (aged 18–24 years)* 59* 60* 56*

55–64 65–74 75⫹ Total

58 39 48

Data are n (%) unless otherwise indicated. *The National Health Survey data were unavailable in age- and sex-specific strata; results shown for age groups include men and women.

dividuals with self-reported diabetes still were significantly less likely to smoke tobacco than other participants: adjusted OR 0.666 (0.521– 0.852), P ⫽ 0.001. Additional analysis was performed in which individuals with self-reported diabetes were excluded. Smoking rates were compared in individuals in whom diabetes was diagnosed at the WPHC (n ⫽ 126) and individuals whose glucose pathology did not indicate diabetes (n ⫽ 2,295). No significant difference in smoking patterns between these two groups could be found after adjustment for age, sex, and ethnicity: adjusted OR 0.889 (95% CI 0.614 – 1.289), P ⫽ 0.535. Alcohol consumption Self-reported consumption of alcohol is shown in Table 5, with national comparison data from the NHS 1995 (22). Individuals with self-reported diabetes were significantly less likely to drink alcohol than other participants, both in a crude analysis (43 vs. 72%, OR 0.295 [95% CI 0.235– 0.369], P ⬍ 0.001) and after adjustment for age, sex, and ethnicity (adjusted OR 0.550 [0.428 – 0.709], P ⬍ 0.001).

Hazardous and harmful alcohol consumption For men and women, diabetic drinkers were as likely to drink at hazardous or harmful levels as other drinkers, after adjustment for age, sex, and smoking: adjusted OR 1.075 (95% CI 0.753–1.535), P ⫽ 0.691. Potential participation bias When diabetes management audits have been conducted for a contemporaneous study (27), comprehensive registers of diabetic patients have been compiled. Data from these registers were matched to WPHC data to identify possible participation bias. In the 11 communities in which both the diabetes management audits and the WPHC were conducted, 172 of 362 (47.3%) patients with diabetes attended the WPHC, which is similar to the overall community participation (49%). In the 362 individuals studied, WPHC participants and nonparticipants were similar in age [mean (SD) 52.7 (13.4) in participants vs. 51.6 (14.6) in nonparticipants, P ⫽ 0.466], sex (63% women in participants vs. 59% women in nonparticipants, P ⫽ 0.392), and BMI

DIABETES CARE, VOLUME 26, NUMBER 2, FEBRUARY 2003

[mean (SD) 33.8 (6.0) in participants vs. 32.2 (5.4) in nonparticipants, P ⫽ 0.054]. A total of 53% of participants with diabetes and 57% of nonparticipants with diabetes had a comorbidity (P ⫽ 0.529). The participant and nonparticipant diabetic patient groups both had a median duration of diagnosed diabetes of 5 years (P ⫽ 0.594). A total of 28% of nonparticipants with diabetes had been admitted to the hospital at least once in the 12 months before the audit, compared with 15% of participants with diabetes (P ⫽ 0.005). CONCLUSIONS — In summary, we found that Australian indigenous people in remote north Queensland communities who know they have diabetes have fruit consumption and exercise habits similar to other indigenous persons in those communities. Those who know they have diabetes are more likely to abstain from tobacco smoking and alcohol consumption, but diabetic drinkers consumed alcohol at harmful and hazardous levels similar to indigenous nondiabetic drinkers. Our results for exercise and alcohol 401

Self-reported diabetes and health behavior

consumption are similar to studies in other populations (4,28), indicating that the problem of risk behaviors in individuals with diabetes is widespread. The result for tobacco consumption contradicts other studies, in which persons with and without diabetes were reported to have similar prevalence of smoking (28). There are few reported studies of association between fruit consumption and diabetes. Smoking rates among diabetic indigenous people remain two to three times those recorded in a national study (21) in which the participants were predominantly nonindigenous. Because of the relatively low participation, we explored possible selection bias among known diabetic patients. It is possible that those with more or less healthy behavior did not participate because the survey was labeled a “well persons” health check. The data from the comparison of participating and nonparticipating diabetic patients suggest a participation bias in the WPHC in favor of healthier individuals with diabetes. This suggests that diabetic participants may be healthier and, therefore, may have more favorable health behaviors than diabetic nonparticipants. If these persons had participated in the study, the health behavior differences between participants with and without self-reported diabetes found in this study may have been even less significant. Given that diabetes-associated mortality in areas of Queensland with high indigenous populations has been reported to be 10 times that in Queensland overall (14), there is a compelling need for effective interventions to achieve further smoking reduction in indigenous individuals with diabetes. Moderate consumption of alcohol has been reported as protective against coronary heart disease mortality in patients with diabetes (29,30). However, most studies examining this association are performed in populations in which the cultural aspects of alcohol consumption are very different from those experienced by the Australian indigenous population. Very few persons who consume alcohol in these populations do so at moderate levels (12,13). This study suggests that the behavioral changes needed for optimal selfmanagement of diabetes are not being undertaken by remote indigenous Australians. This contributes to the large excess 402

of mortality and morbidity experienced by this population. Further research into the effectiveness of behavior modification interventions is required to determine what interventions are efficacious and the extent to which these interventions are being applied. Acknowledgments — Funding was provided through the Commonwealth Department of Health and Aged Care, Australia. We thank Apunipima Cape York Health Council, Torres Strait and Northern Peninsula Area Health Council, Andy Duke, and Dr. Ross Spark for their contributions

11.

12.

13.

14. References 1. O’Dea K, Patel M, Kubisch D, Hopper J, Traianedes K: Obesity, diabetes, and hyperlipidemia in a central Australian aboriginal community with a long history of acculturation. Diabetes Care 16:1004 – 1010, 1993 2. Rowley KG, Best JD, McDermott R, Green EA, Piers LS, O’Dea K: Insulin resistance syndrome in Australian aboriginal people. Clin Exp Pharmacol Physiol 24:776 –781, 1997 3. Daniel M, Rowley KG, McDermott R, Mylvaganam A, O’Dea K: Diabetes incidence in an Australian aboriginal population: an 8-year follow-up study. Diabetes Care 22: 1993–1998, 1999 4. Haire-Joshu D, Glasgow RE, Tibbs TL: Smoking and diabetes. Diabetes Care 22: 1887–1898, 1999 5. Colditz GA, Willett WC, Rotnitzky A, Manson JE: Weight gain as a risk factor for clinical diabetes mellitus in women. Ann Intern Med 122:481– 486, 1995 6. Hu FB, Manson JE, Stampfer MJ, Colditz G, Liu S, Solomon CG, Willett WC: Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. N Engl J Med 345:790 –797, 2001 7. Riste L, Khan F, Cruickshank K: High prevalence of type 2 diabetes in all ethnic groups, including Europeans, in a British inner city: relative poverty, history, inactivity, or 21st century Europe? Diabetes Care 24:1377–1383, 2001 8. Uchimoto S, Tsumura K, Hayashi T, Suematsu C, Endo G, Fujii S, Okada K: Impact of cigarette smoking on the incidence of type 2 diabetes mellitus in middle-aged Japanese men: the Osaka Health Survey. Diabet Med 16:951–955, 1999 9. Wannamethee SG, Shaper AG, Perry IJ: Smoking as a modifiable risk factor for type 2 diabetes in middle-aged men. Diabetes Care 24:1590 –1595, 2001 10. Phillips P, Wilson D, Beilby J, Taylor A, Rosenfeld E, Hill W, Parsons J: Diabetes

15.

16.

17.

18.

19.

20.

21.

22.

complications and risk factors in an Australian population: how well are they managed? Int J Epidemiol 27:853– 859, 1998 Jarvis JJ, Wardle J: Social patterning of individual behaviours: the case of cigarette smoking. In Social Determinants of Health. Wilkinson RC, Ed. Oxford, UK, Oxford University Press, 1999, p. 240 –255 Queensland Health: Health Indicators for the Cape York Health Service District 2001. Cairns, Australia, Queensland Health, 2001 Queensland Health: Health Indicators for the Torres Strait and Northern Peninsula Area Health Service District 2001. Cairns, Australia, Queensland Health, 2001 Queensland Health: Health Indicators for Queensland, Northern Zone 2001. Cairns, Australia, Queensland Health, 2001 National Health and Medical Research Council: Guidelines on Ethical Matters in Aborginal and Torres Strait Islander Health Research. Brisbane, Australia, National Health and Medical Research Council, 1991 Johansson G, Wikman A, Ahren AM, Hallmans G, Johansson I: Underreporting of energy intake in repeated 24-hour recalls related to gender, age, weight status, day of interview, educational level, reported food intake, smoking habits and area of living. Public Health Nutr 4:919 – 927, 2001 Knutsen SF, Fraser GE, Linsted KD, Beeson WL, Shavlik DJ: Comparing biological measurements of vitamin C, folate, alpha-tocopherol and carotene with 24hour dietary recall information in nonhispanic blacks and whites. Ann Epidemiol 11:406 – 416, 2001 Subar AF, Thompson FE, Kipnis V, Midthune D, Hurwitz P, McNutt S, McIntosh A, Rosenfeld S: Comparative validation of the Block, Willett, and National Cancer Institute food frequency questionnaires: the Eating at America’s Table Study. Am J Epidemiol 154:1089 –1099, 2001 From Attebring M, Herlitz J, Berndt AK, Karlsson T, Hjalmarson A: Are patients truthful about their smoking habits? A validation of self-report about smoking cessation with biochemical markers of smoking activity amongst patients with ischaemic heart disease. J Intern Med 249: 145–151, 2001 Harada ND, Chiu V, King AC, Stewart AL: An evaluation of three self-report physical activity instruments for older adults. Med Sci Sports Exerc 33:962–970, 2001 International Diabetes Institute: Diabesity and Associated Disorders in Australia: 2000. Melbourne, Australia, International Diabetes Institute, 2001 Australian Bureau of Statistics: National

DIABETES CARE, VOLUME 26, NUMBER 2, FEBRUARY 2003

McCulloch and Associates

Health Survey: Summary of Results 1995. Canberra, Australia, Australian Bureau of Statistics, 1997 23. SPSS: SPSS for Windows version 10.0.7. Chicago, SPSS, 2000 24. Smith A, Kellet E, Schmerlaib Y: The Australian Guide to Health Eating. Melbourne, Australia, Commonwealth of Australia, 1998 25. McLennan W, Podger A: National Nutrition Survey User’s Guide. Canberra, Australia, Australian Bureau of Statistics, 1998

26. McLennan W, Podger A: National Nutrition Survey: Nutrient Intakes and Physical Measurements. Canberra, Australia, Australian Bureau of Statistics, 1998 27. McDermott RA, Schmidt BA, Sinha A, Mills P: Improving diabetes care in the primary healthcare setting: a randomised cluster trial in remote indigenous communities. Med J Aust 174:497–502, 2001 28. Knuiman MW, Welborn TA, Bartholomew HC: Self-reported: health and use of health services: a comparison of diabetic and nondiabetic persons from a national

DIABETES CARE, VOLUME 26, NUMBER 2, FEBRUARY 2003

sample. Aust N Z J Public Health 20:241– 247, 1996 29. Tanasescu M, Hu FB, Willett WC, Stampfer MJ, Rimm EB: Alcohol consumption and risk of coronary heart disease among men with type 2 diabetes mellitus. J Am Coll Cardiol 38:1836 – 1842, 2001 30. Valmadrid CT, Klein R, Moss SE, Klein BE, Cruickshanks KJ: Alcohol intake and the risk of coronary heart disease mortality in persons with older-onset diabetes mellitus. JAMA 282:239 –246, 1999

403