Diabetes in New Zealand

Incidence and predictors of iron deficiency anaemia in parturients undergoing elective caesarean section at a tertiary hospital in New Zealand: a retrospective, observational cohort study

Background

Worldwide, iron deficiency anaemia in pregnancy is a significant problem which can be especially problematic when delivery is by caesarean section, a procedure associated with significant blood loss. Optimising iron stores pre-delivery remains an overarching goal. We aim to measure the incidence of iron deficiency anaemia in patients undergoing elective caesarean section at our institution and determine any associated predictors, as well as adverse outcomes.

Methods

A retrospective, observational cohort study of patients presenting for elective caesarean section over a two-year period. Patient data was collected from hospital electronic records. Iron deficiency anaemia was defined a haemoglobin < 110 g/L and a ferritin < 30 μg/L in the three-month period prior to delivery. The primary aim was to establish the incidence of iron deficiency anaemia at the time of delivery and any associated predictors. Secondary outcomes included any association between the primary outcome and complications defined by the hospital discharge complication coding system, as well as an evaluation of the number of blood tests carried out antenatally per trimester.

Results

One thousand and ninety-three women underwent caesarean section over the study period and 16.2% had iron deficiency anaemia. Patients with iron deficiency anaemia were more likely to be of Māori and Pacific Island ethnicity, have a greater booking body mass index, be younger and have a greater parity. Pre-operative anaemia was associated with a greater likelihood of post-operative blood transfusion.

Conclusions

There remains potential for optimisation of iron deficiency anaemia in our local population undergoing elective caesarean section.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04121-9.

Profile of diabetes and cardiovascular risk factors in adults Anjouan Island (Comoros)

Introduction

The aim of this study was to estimate the prevalence of Diabetes Mellitus (DM) and Impaired Fasting Glucose (IFG) in the peri-urban adult population living in the island of Anjouan, Comoros and to investigate the factors associated with diabetes mellitus.

Methods

The survey was a cross-sectional study, in which a sample of 902 individuals (540 women and 362 men) aged 25 to 64 was selected using empirical sampling "quotas" or "reasoned choice" survey method. Hypertension and obesity abdominal measurements of these subjects were collected during face-to-face interviews and following day fasting blood glucose was measured in capillary blood.

Results

Participation rate was 83.5%. The mean age of subjects was 39.5 ± 11.63 years. The sex ratio was 0.67. Overall crude diabetes and IFG prevalence were 8.5% and 8.1%, respectively. The risk factors for diabetes type 2 onset were a family history of diabetes (P = 0.006), older age (P = 0.000), glycemic control (P = 0.010), excess waist circumference (P = 0.03) and hypertension (p = 0.000), were significantly positively associated with DM, contrary to sex (P = 0.142).

Conclusion

These high figures confirm that diabetes and factors associated do not spare Anjouan population. Awareness, primary prevention, are to set up for a better control of non-communicable diseases.

A Longitudinal Study of Interactions Between Health Professionals and People With Newly Diagnosed Diabetes

PURPOSE

We undertook a study to observe in detail the primary care interactions and communications of patients with newly diagnosed diabetes over time. In addition, we sought to identify key points in the process where miscommunication might occur.

METHODS

All health interactions of 32 patients with newly diagnosed type 2 diabetes were recorded and tracked as they moved through the New Zealand health care system for a period of approximately 6 months. Data included video recordings of patient interactions with the health professionals involved in their care (eg, general practitioners, nurses, dietitians). We analyzed data with ethnography and interaction analysis.

RESULTS

Challenges to effective communication in diabetes care were identified. Although clinicians showed high levels of technical knowledge and general communication skill, initial consultations were often driven by biomedical explanations out of context from patient experience. There was a perception of time pressure, but considerable time was spent with patients by health professionals repeating information that may not be relevant to patient need. Health professionals had little knowledge of what disciplines other than their own do and how their contributions to patient care may differ.

CONCLUSIONS

Despite current high skill levels of primary care professionals, opportunities exist to increase the effectiveness of communication and consultation in diabetes care. The various health professionals involved in patient care should agree on the length and focus of each consultation.

Diabetes among Māori women with self-reported past gestational diabetes mellitus in a New Zealand Māori community

BACKGROUND

Gestational diabetes mellitus (GDM) is a risk factor for subsequent development of type 2 diabetes mellitus (T2DM). We have investigated the extent of this risk among Māori women without known diabetes.

MATERIALS AND METHODS

We recruited 2786 Māori women aged 28-86 years between 2004 and 2006, without diagnosed diabetes from the Waikato and Southern Lakes regions, via media, community and general practitioner channels, and invited them for an oral glucose tolerance test (OGTT).

RESULTS

Fifty (1.8%) women reported previous GDM (pGDM). The prevalence decreased significantly with age (P = 0.009). Women aged <50 years with pGDM had higher body mass index (35.6 ± 6.7 vs 32.4 ± 7.7 kg/m2 , P < 0.01), waist circumference (105.3 ± 18.8 vs 96.9 ± 16.6 cm, P < 0.01), fasting blood glucose (5.5 ± 1.0 vs 5.1 ± 0.8 mmol/L, P ≤ 0.01), two-hour post-prandial blood glucose (6.6 ± 3.0 vs 5.6 ± 2.1 mmol/L, P < 0.01) and HbA1c (6.0 ± 0.8 vs 5.8 ± 0.6%, P < 0.05) than women without pGDM. PGDM was a significant risk factor for undiagnosed diabetes (odds ratio 4.0; (5% confidence interval 1.67-9.71). Undiagnosed diabetes was significantly more prevalent among women with than without pGDM aged <40 years (20.0% vs 1.5%).

CONCLUSION

Self-reported past GDM was a significant risk factor for undiagnosed diabetes in this Māori population, particularly among women aged <40 years, highlighting the importance of targeting this group for more intensive screening.

Pedobarography as a clinical tool in the management of diabetic feet in New Zealand: a feasibility study

Background

The peripheral complications of diabetes mellitus remain a significant risk to lower-limb morbidity. In New Zealand, risk of diabetes, comorbidity and lower-limb amputation are highly-differential between demographic groups, particularly ethnicity. There is growing and convincing evidence that the use of pedobarography – or plantar pressure measurement – can usefully inform diabetic foot care, particularly with respect to the prevention of re-ulceration among high-risk patients.

Methods

For the current feasibility study, we embedded pedobarographic measurements into three unique diabetic foot clinic settings in the New Zealand context, and collected pedobarographic data from n = 38 patients with diabetes using a platform-based (Novel Emed) and/or in-shoe-based system (Novel Pedar). Our aim was to assess the feasibility of incorporating pedobarographic testing into the clinical care of diabetic feet in New Zealand.

Results and Conclusions

We observed a high response rate and positive self-reported experience from participants. As part of our engagement with participants, we observed a high degree of lower-limb morbidity, including current ulceration and chronic foot deformities. The median time for pedobarographic testing (including study introduction and consenting) was 25 min. Despite working with a high-risk population, there were no adverse events in this study. In terms of application of pedobarography as a clinical tool in the New Zealand context, the current feasibility study leads us to believe that there are two avenues that deserve further investigation: a) the use of pedobarography to inform the design and effectiveness of offloading devices among high-risk diabetic patients; and b) the use of pedobarography as a means to increase offloading footwear and/or orthoses compliance among high-risk diabetic patients. Both of these objectives deserve further examination in New Zealand via clinical trial.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-017-0205-6) contains supplementary material, which is available to authorized users.

Cancer in Māori: lessons from prostate, colorectal and gastric cancer and progress in hereditary stomach cancer in New Zealand

Persisting ethnic disparities in cancer incidence and outcomes exist between Māori and non-Māori in Aotearoa/New Zealand. It is difficult to disentangle the complex interplay of environmental and genetic factors that contribute to the variation in cancer statistics between these two groups. In Māori, the sites of highest cancer incidence are the prostate in men, breast in women and lung in both - the next most common cancers in Māori are colorectal and stomach cancer. This paper discusses colorectal, prostate and stomach cancer in Māori to illustrate selected issues that impact on cancer care. Colorectal cancer is discussed to illustrate the importance of accurate cancer statistics to focus management strategies. Prostate cancer in Māori is reviewed - an area where cultural factors impact on care delivery. Sporadic stomach cancer in New Zealand is used to show how sub-classification of different types of cancer can be important and illustrate the breadth of putative causal factors. Then follows an overview of developments in hereditary gastric cancer in New Zealand in the last 15 years, showing how successful clinical and research partnerships can improve patient outcomes. One example is the Kimi Hauora Clinic, which provides support to cancer patients, mutation carriers and their families, helping them navigate the interface with the many health-care professionals involved in the multidisciplinary care of cancer patients in the 21st century.

The incidence, clinical features, and treatment of type 2 diabetes in children <15 yr in a population-based cohort from Auckland, New Zealand, 1995–2007

BACKGROUND

The incidence of type 2 diabetes mellitus (T2DM) is increasing in adolescents in most western countries. The time-course of glycemic control and impact of early treatment remain poorly understood.

OBJECTIVES

To determine the change in incidence of T2DM, and the time-course of glycemic control in a regional pediatric cohort with T2DM.

METHODS

Retrospective analysis of prospectively collected data on 52 patients with T2DM from a population-based treatment referral cohort from 1 January 1995 to 31 December 2007.

RESULTS

The annual incidence of new cases of T2DM in children <15 yr increased fivefold in the Auckland region of New Zealand from 1995 [0.5/100,000; 95% confidence interval (CI) 0.0–2.2] to 2007 (2.5/100,000; 95% CI 1.0–5.5). The average annual incidence per 100,000 over the entire period was 1.3 (95% CI 1.0–1.8) overall, 0.1 (0.0–0.4) in Europeans, and 3.4 in both Maori (2.0–5.3) and Pacifica (2.2–5.0). Fifty-seven percent of children were symptomatic at presentation. Fifty-eight percent of patients were treated with insulin from diagnosis, most of whom were symptomatic (p = 0.003). Follow-up data were available for 48 patients with a mean of 2.4 yr. Although insulin therapy was associated with a greater fall in HbA1c values in the first 12 months of treatment (to a nadir of 7.1 vs. 8.1%, p < 0.05), there was a rapid deterioration after 12 months, and subsequent mean HbA1c values were >9% in both groups. Therapy did not affect body mass index standard deviation score (BMI SDS).

CONCLUSIONS

The incidence of T2DM in childhood or adolescence increased markedly over a 13-yr period in the Auckland region. Long-

Prevalence of diabetic retinopathy in various ethnic groups: a worldwide perspective

The alarming rise in diabetes prevalence is a global public health and economic problem. Diabetic retinopathy is the most common complication of diabetes and the leading cause of blindness among working-age populations in the Western world. Screening and prompt treatment of diabetic retinopathy are not top priorities in many regions of the world, because the impacts of other causes of preventable blindness remain an issue. Ethnicity is a complex, independent risk factor for diabetic retinopathy. Observations from white populations cannot be extrapolated fully to other ethnic groups. The prevalence of diabetic retinopathy, sight-threatening diabetic retinopathy, and clinically significant macular edema are higher in people of South Asian, African, Latin American, and indigenous tribal descent compared to the white population. Although all ethnic groups are susceptible to the established risk factors of diabetic retinopathy-such as length of exposure and severity of hyperglycemia, hypertension, and hyperlipidemia-ethnic-specific risk factors also may influence these rates. Such risk factors may include differential susceptibility to conventional risk factors, insulin resistance, differences in anthropometric measurements, truncal obesity, urbanization, variations in access to healthcare systems, genetic susceptibility, and epigenetics. The rates of nonproliferative diabetic retinopathy appear to be declining in the United States, supporting the observation that better medical management of diabetes and prompt treatment of sight-threatening diabetic retinopathy substantially improve the long-term diabetic retinopathy incidence; studies from other parts of the world are limited and do not mirror this finding, however. We examine the ethnicity and region-based prevalence of diabetic retinopathy around the world and highlight the need to reinforce ethnicity-based screening and treatment thresholds in diabetic retinopathy.

Comparative study on the efficacy of pioglitazone in Caucasian and Maori-Polynesian patients with poorly controlled type 2 diabetes

AIM

Although the pharmodynamic properties of the thiazolidinedione (TZD) insulin-sensitizing agents in the treatment of type 2 diabetes are well established, there are no studies comparing the pharmacoefficacy of these drugs in different ethnic groups. The aim of this pilot, prospective study was to examine the hypothesis that the efficacy of TZDs may vary depending on ethnicity. This aim was achieved by comparing the effects of 6-months treatment with pioglitazone (45 mg/day) on glucose control and metabolic and cardiovascular risk factors in Caucasian and Maori-Polynesian patients with poorly controlled type 2 diabetes.

METHODS

Ninety-seven patients (40 Caucasian and 57 Maori-Polynesian) with type 2 diabetes were selected for the study from our clinical databases if they were on the maximum tolerated dose of oral agents and had a haemoglobin A(1c) (HbA(1c)) > 8.0% for at least 2 months. All the patients received pioglitazone (45 mg/day) for 6 months in addition to their regular diabetes therapy. Clinical data and blood samples were collected at monthly intervals and the following indices measured: weight, blood pressure, oedema score, HbA(1c), plasma glucose, alanine amino transferase and adiponectin levels and plasma lipid profile, including low-density lipoprotein (LDL)-cholesterol particle size and atherogenic index of plasma (AIP). The data of the 81 patients who finished the study were analysed using analysis of variance, chi-square analysis and multiple regression methods.

RESULTS

The absolute change from baseline in mean HbA(1c) (Caucasian -1.4% vs. Maori-Polynesian -1.3%) and fasting glucose levels (Caucasian -2.1 mmol/l vs. Maori-Polynesian -2.8 mmol/l) was similar in the two groups. Pioglitazone caused an improvement in lipid profile in both ethnic groups, with a reduction in mean values of atherogenic fractions (triglyceride: Caucasian -0.5 mmol/l, p < 0.001 vs. Maori-Polynesian -0.3 mmol/l, p = 0.05; very low-density lipoprotein (VLDL)-cholesterol: Caucasian -0.11 mmol/l, p = 0.001 vs. Maori-Polynesian -0.04 mmol/l, p = 0.85; VLDL-triglyceride: Caucasian -0.36 mmol/l, p < 0.001 vs. Maori-Polynesian -0.22 mmol/l, p = 0.14; apolipoprotein B: Caucasian -0.09 mmol/l, p = 0.03 vs. Maori-Polynesian -0.08 mmol/l, p = 0.18). These changes were associated with an increase in LDL-cholesterol particle size (Caucasian +0.23 nm, p = 0.05 vs. Maori-Polynesian +0.26 nm, p = 0.04) and a decrease in AIP (Caucasian -0.14, p < 0.001 vs. Maori-Polynesian -0.08, p = 0.04). While the changes in the lipid indices tended to be greater in the Caucasian group, the difference in lipid response between the two ethnic groups was not statistically significant. Multiple regression analyses showed that the baseline value of the individual lipid fractions was the main determinant of the changes in lipid levels.

CONCLUSIONS

These results demonstrated that pioglitazone has similar beneficial effects on glucose control and plasma lipid profile in Caucasian and Maori-Polynesian patients with poorly controlled type 2 diabetes. Our data showed that while the improvement in lipid profile was more pronounced in Caucasian patients than in Maori-Polynesian patients, this difference was not statistically significant.

‘Help, educate, encourage?’: Geographical variations in the provision and utilisation of diabetes education in New Zealand

In New Zealand, as elsewhere, it is argued that a diabetes epidemic is underway. With careful management from individuals and professionals and appropriate levels of education, it is possible to prevent many complications of diabetes. The overall objective of the paper is to evaluate the role and impact of Diabetes New Zealand (DNZ), the key voluntary sector provider of diabetes education and support services, with respect to four criteria: (i) the extent to which DNZ is reaching groups most at risk of diabetes; (ii) the degree to which it has encouraged levels of member involvement; (iii) whether voluntary group provision of education is that most preferred by members; and (iv) the extent to which members see the voluntary sector model as being effective in combating the growth of diabetes. A survey of members of six of the 41 affiliated societies of DNZ suggests that such organisations, although having a high proportion of older members, have generally failed to target more deprived groups. While the societies generally score more positively in encouraging member involvement and being perceived as effective by their members, they do not always utilise the preferred form of educational provision. However, there are significant contextual variations by urban-rural location and according to the organisational structure of the societies. Rural societies and those with decentralised organisational structures generally score highest on the above criteria. The results pose a problem for DNZ which, like many other voluntary sector organisations, is facing pressures of increased corporatisation and centralisation. We see this as an important challenge that DNZ needs to address if New Zealand is going to better cope with the emerging diabetes epidemic.

Assessment of ethnic variation in serum levels of total, complexed and free prostate specific antigen. Comparison of Maori, Pacific Island and New Zealand European populations

AIMS

To determine whether age-adjusted levels of serum total (tPSA) and complexed (cPSA) prostate specific antigen and the ratio of free to tPSA (%fPSA) differ by ethnic group independent of symptomatic disease.

METHODS

The serum levels of tPSA, cPSA, and %fPSA in relation to age, ethnicity and obstructive urinary symptoms were examined in 1405 Maori, Pacific Island and New Zealand European men in the Wellington region of New Zealand, and indicative reference range estimates produced. Participants were non-randomly selected from two study populations.

RESULTS

tPSA and cPSA increased with age while %fPSA decreased with age in all ethnic groups. Maori showed higher tPSA values in the 60-69 age group than other ethnic groups. cPSA increased more rapidly with age in Maori than in New Zealand Europeans or Pacific Islanders. %fPSA differed according to age across all three ethnic groups. The median and 5th percentile Pacific Island %fPSA values were higher in comparison to the %fPSA reference ranges of all other ethnic groups and were also higher than those reported in other studies. Once adjusted for urinary symptom score, only %fPSA in Pacific Island subjects remained significantly higher than that in New Zealand Europeans (P<0.001).

CONCLUSIONS

Our study indicates that %fPSA differs by ethnicity independent of symptomatic prostate disease.

The burden of type 2 diabetes: are we doing enough?

Increasing levels of obesity, arising from energy-rich diets and sedentary lifestyles, are driving a global pandemic of type 2 diabetes. The prevalence of type 2 diabetes worldwide is set to increase from its present level of 150 million, to 225 million by the end of the decade and to as many as 300 million by 2025. Shocking as they are, these figures represent only clinically diagnosed diabetes, and many more cases of diabetes remain undiagnosed and untreated. In addition, up to one-quarter of western populations have impaired glucose tolerance or the dysmetabolic syndrome, which are considered to represent pre-diabetic states. Type 2 diabetes is appearing increasingly in children and adolescents, and the frequency of diagnosis of paediatric type 2 diabetes is outstripping that of type 1 diabetes in some areas. The long-term complications associated with type 2 diabetes carries a crushing burden of morbidity and mortality, and most type 2 diabetic patients die prematurely from a cardiovascular event. Diabetic patients are more than twice as costly to manage as non-diabetic patients, due mainly to the high costs associated with management of diabetic complications. Indeed, diabetes care already accounts for about 2-7% of the total national health care budgets of western European countries. Controlling the type 2 diabetes epidemic will require changes to the structure of healthcare delivery. Well-resourced interventions will be required, with effective co-ordination between all levels of government, health care agencies, multidisciplinary health care teams, professional organisations, and patient advocacy groups. Above all, intervention is needed today.