Do worms protect against the metabolic syndrome? A systematic review and meta-analysis.

AIMS: There is increasing evidence on the role of helminth infections in modifying autoimmune and allergic diseases. These infections may have similar effect in other inflammatory processes, such as insulin resistance. This review aims to examine the literature on the effect of helminthic infections on metabolic outcomes in humans. METHODS: Using the PRISMA protocol, we searched the literature using PubMed, MEDLINE, and a manual review of reference lists. Human studies published in English after 1995 were included. Four papers were included in this review. Data was extracted and a meta-analysis was conducted using a random-effects model. Heterogeneity was assessed using Tau(2) and I(2) tests. RESULTS: The included studies found that infection was associated with lower glucose levels, less insulin resistance, and/or a lower prevalence of metabolic syndrome (MetS) or type 2 diabetes mellitus (T2DM). Meta-analysis showed that participants with a previous or current helminth infection were 50% less likely to have an endpoint of metabolic dysfunction in comparison to uninfected participants (OR 0.50; 95% CI 0.38-0.66). CONCLUSION: This review has shown that helminth infections can be associated with improved metabolic outcomes. Understanding of the mechanisms underlying this relationship could facilitate the development of novel strategies to prevent or delay T2DM.

Economic evaluation of Indigenous health worker management of poorly controlled type 2 diabetes in north Queensland.

OBJECTIVE: To conduct an economic evaluation of intensive management by Indigenous health workers (IHWs) of Indigenous adults with poorly controlled type 2 diabetes in rural and remote north Queensland. DESIGN: Cost-consequence analysis alongside a cluster randomised controlled trial of an intervention delivered between 1 March 2012 and 5 September 2013. SETTING: Twelve primary health care services in rural and remote north Queensland communities with predominantly Indigenous populations. PARTICIPANTS: Indigenous adults with poorly controlled type 2 diabetes (HbA1c ≥ 69 mmol/mol) and at least one comorbidity (87 people in six IHW-supported communities (IHW-S); 106 in six usual care (UC) communities). MAIN OUTCOME MEASURES: Per person cost of the intervention; differential changes in mean HbA1c levels, percentage with extremely poor HbA1c level control, quality of life, disease progression, and number of hospitalisations. RESULTS: The mean cost of the 18-month intervention trial was $10 060 per person ($6706 per year). The intervention was associated with a non-significantly greater reduction in mean HbA1c levels in the IHW-S group (-10.1 mmol/mol v -5.4 mmol/mol in the UC group; P = 0.17), a significant reduction in the proportion with extremely poor diabetes control (HbA1c ≥ 102 mmol/mol; P = 0.002), and a sub-significant differential reduction in hospitalisation rates for type 2 diabetes as primary diagnosis (-0.09 admissions/person/year; P = 0.06), with a net reduction in mean annual hospital costs of $646/person (P = 0.07). Quality of life utility scores declined in both groups (between-group difference, P = 0.62). Rates of disease progression were high in both groups (between-group difference, P = 0.73). CONCLUSION: Relative to the high cost of the intervention, the IHW-S model as implemented is probably a poor investment. Incremental cost-effectiveness might be improved by a higher caseload per IHW, a longer evaluation time frame, and improved service integration. Further approaches to improving chronic disease outcomes in this very unwell population need to be explored, including holistic approaches that address the complex psychosocial, pathophysiological and environmental problems of highly disadvantaged populations. TRIAL REGISTRATION: ANZCTR12610000812099.

Community health workers improve diabetes care in remote Australian Indigenous communities: results of a pragmatic cluster randomized controlled trial.

BACKGROUND: Health outcomes for Indigenous Australians with diabetes in remote areas remain poor, including high rates of avoidable complications which could be reduced with better primary level care. We aimed to evaluate the effectiveness of a community-based health-worker led case management approach to the care of Indigenous adults with poorly controlled type 2 diabetes in primary care services in remote northern Australia. METHODS: Two hundred and thirteen adults with poorly controlled diabetes (HbA1c > 8.5%) and significant comorbidities in 12 remote communities were randomly assigned by service cluster to receive chronic care co-ordination from a community-based health worker supported by a clinical outreach team, or to a waitlist control group which received usual care. RESULTS: At baseline, mean age of participants was 47.9 years, 62.4% were female, half were Aboriginal and half identified as Torres Strait Islander, 67% had less than 12 years of education, 39% were smokers, median income was $18,200 and 47% were unemployed. Mean HbA1c was 10.7% (93 mmol/mol) and BMI 32.5. At follow-up after 18 months, HbA1c reduction was significantly greater in the intervention group (-1.0% vs -0.2%, SE (diff) = 0.2, p = 0.02). There were no significant differences between the groups for blood pressure, lipid profile, BMI or renal function. Intervention group participants were more likely to receive nutrition and dental services according to scheduled care plans. Smoking rates were unchanged. CONCLUSIONS: A culturally safe, community level health-worker led model of diabetes care for high risk patients can be effective in improving diabetes control in remote Indigenous Australian communities where there is poor access to mainstream services. This approach can be effective in other remote settings, but requires longer term evaluation to capture accrued benefits. TRIAL REGISTRATION: ANZCTR 12610000812099, Registered 29 September 2010.

A systematic review of evidence on the association between hospitalisation for chronic disease related ambulatory care sensitive conditions and primary health care resourcing.

BACKGROUND: Primary health care is recognised as an integral part of a country's health care system. Measuring hospitalisations, that could potentially be avoided with high quality and accessible primary care, is one indicator of how well primary care services are performing. This review was interested in the association between chronic disease related hospitalisations and primary health care resourcing. METHODS: Studies were included if peer reviewed, written in English, published between 2002 and 2012, modelled hospitalisation as a function of PHC resourcing and identified hospitalisations for type 2 diabetes as a study outcome measure. Access and use of PHC services were used as a proxy for PHC resourcing. Studies in populations with a predominant user pay system were excluded to eliminate patient financial barriers to PHC access and utilisation. Articles were systematically excluded based on the inclusion criteria, to arrive at the final set of studies for review. RESULTS: The search strategy identified 1778 potential articles using EconLit, Medline and Google Scholar databases. Ten articles met the inclusion criteria and were subject to review. PHC resources were quantified by workforce (either medical or nursing) numbers, number of primary care episodes, service availability (e.g. operating hours), primary care practice size (e.g. single or group practitioner practice--a larger practice has more care disciplines onsite), or financial incentive to improve quality of diabetes care. The association between medical workforce numbers and ACSC hospitalisations was mixed. Four of six studies found that less patients per doctor was significantly associated with a decrease in ambulatory care sensitive hospitalisations, one study found the opposite and one study did not find a significant association between the two. When results were categorised by PHC access (e.g. GPs/capita, range of services) and use (e.g. n out-patient visits), better access to quality PHC resulted in fewer ACSC hospitalisations. This finding remained when only studies that adjusted for health status were categorised. Financial incentives to improve the quality of diabetes care were associated with less ACSC hospitalisations, reported in one study. CONCLUSION: Seven of 12 measures of the relationship between PHC resourcing and ACSC hospitalisations had a significant inverse association. As a collective body of evidence the studies provide inconclusive support that more PHC resourcing is associated with reduced hospitalisation for ACSC. Characteristics of improved or increased PHC access showed inverse significant associations with fewer ACSC hospitalisations after adjustment for health status. The varied measures of hospitalisation, PHC resourcing, and health status may contribute to inconsistent findings among studies and make it difficult to interpret findings.

Benefits of modest weight or waist circumference loss in a remote North Queensland Indigenous population.

OBJECTIVE: To quantify the potential benefit to individuals of differing magnitudes of weight or waist circumference loss in an Indigenous population. METHOD: Data were from the Well Person's Health Check, a cohort study in 19 rural Indigenous communities in Far North Queensland. Baseline data were collected between 1998 and 2000 from 2,583 people aged 15 to 75, an estimated participation rate of 44.5%. Follow-up data were collected between 2004 and 2007 from 729 participants. Associations between change in weight and waist circumference for those who were overweight or obese (n=486) with changes in serum lipids, fasting glucose, blood pressure and Gamma-Glutamyltransferase (GGT) were estimated using linear regression. RESULTS: Weight or waist circumference loss was associated in a dose response fashion with blood pressure reduction (e.g. 10% or greater weight loss compared with no weight loss was associated with reduction of 11.3 mmHg systolic (95% confidence interval -17.8, -4.8). Those with greater waist circumference loss had a greater reduction in GGT (-8.3, 95% confidence interval -23.5, 6.8) but there was no apparent increase in GGT reduction with increasing weight loss, although these were measured with low precision. There was no apparent effect of either weight or waist circumference loss on serum lipids and fasting glucose in this population. CONCLUSIONS: This study shows potentially large beneficial effects of weight or waist circumference loss over several years in a remote living Indigenous cohort. The associations were large enough to be of clinical benefit, despite weight loss being modest for most.

The metabolic syndrome and CVD outcomes for a central Australian cohort.

We investigated if the metabolic syndrome (MetS) and its component risk factors predict cardiovascular disease (CVD) for Aboriginal people from central Australia. WHO (HR 2.83), NCEP (1.80) and IDF (2.47) definitions of the MetS all had positive associations with CVD, however offered little above individual MetS components for hyperglycaemia.

Does antidepressant medication use affect persistence with diabetes medicines?

PURPOSE: This study aimed to examine the effect of antidepressant use on persistence with newly initiated oral antidiabetic medicines in older people. METHODS: A retrospective study of administrative claims data from the Australian Government Department of Veterans' Affairs, from 1 July 2000 to 30 June 2008 of new users of oral antidiabetic medicines (metformin or sulfonylurea). Antidepressant medicine use was determined in the 6 months preceding the index date of the first dispensing of an oral antidiabetic medicine. The outcome was time to discontinuation of diabetes therapy in those with antidepressant use compared with those without. Competing risks regression analyses were conducted with adjustment for covariates. RESULTS: A total of 29,710 new users of metformin or sulfonylurea were identified, with 7171 (24.2%) dispensed an antidepressant. Median duration of oral antidiabetic medicines was 1.81 years (95% CI 1.72­1.94) for those who received an antidepressant at the time of diabetes medicine initiation, by comparison to 3.23 years (95% CI 3.10­3.40) for those who did not receive an antidepressant. Competing risk analyses showed a 42% increased likelihood of discontinuation of diabetes medications in persons who received an antidepressant (subdistribution hazard ratio 1.42, 95% CI 1.37­1.47, p < 0.001). CONCLUSIONS: The results of this large population-based study demonstrate that depression may be contributing to non-compliance with medicines for diabetes and highlight the need to provide additional services to support appropriate medicine use in those initiating diabetes medicines with co-morbid depression.

Factors influencing attendance in a structured physical activity program for Aboriginal and Torres Strait Islander women in an urban setting: a mixed methods process evaluation.

BACKGROUND: Aboriginal and Torres Strait Islander women experience higher rates of obesity, chronic disease, and are less active than non-Indigenous Australian women. Lifestyle programs designed to increase physical activity and encourage healthy eating are needed to ameliorate this disparity. The aim of this study was to identify participants' perceived barriers and enablers to attend group exercise classes as part of a 12-week fitness program. METHODS: To understand the factors that influence attendance, a mixed method process evaluation was undertaken in which a quantitative measure of attendance in the group exercise classes was used to identify cases for further qualitative investigation. Aboriginal and/or Torres Strait Islander women aged 18 to 64 years were recruited to a research trial of a fitness program. The 12-week program included two 60-minute group exercise classes per week, and four nutrition education workshops. Semi-structured interviews were conducted at program completion. Participants were stratified by attendance, and interviews from the highest and lowest 25 percentiles analysed. Rigour was strengthened through use of multiple data analysts, member checking and prolonged engagement in the field. RESULTS: Analyses of the post-program interviews revealed that participants enrolled in the program primarily for the perceived health benefits and all (with one exception) found the program met their needs and expectations. The atmosphere of classes was positive and comfortable and they reported developing good relationships with their fellow participants and program staff. Low attendees described more barriers to attendance, such as illness and competing work and family obligations, and were more likely to report logistical issues, such as inconvenient venue or class times. CONCLUSIONS: Attendance to the 'Aboriginal and Torres Strait Islander Women's Fitness Program' was primarily influenced by the participant's personal health, logistics and competing obligations. Low attendees reported more barriers during the 12-week period and identified fewer enabling factors than high attendees. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12610000224022.

Exploring clinical predictors of cardiovascular disease in a central Australian Aboriginal cohort.

INTRODUCTION: For Aboriginal populations, predicting individuals at risk of cardiovascular disease (CVD) is difficult due to limitations and inaccuracy in existing risk-prediction algorithms. We examined conventional and novel risk factors associated with insulin resistance and the metabolic syndrome and assessed their relationships with subsequent CVD events. DESIGN: Longitudinal cohort. METHODS: Aboriginal people (n = 739) from Central Australia completed population-based risk-factor surveys in 1995 and were followed up in 2005. Principal components analysis (PCA), regression and univariate analyses (using ROC defined cut-off points) were used to identify useful clinical predictors of primary CVD. RESULTS: PCA yielded five components: (1) lipids and liver function; (2) insulin resistance; (3) blood pressure and kidney function; (4) glucose tolerance; and (5) anti-inflammatory (low fibrinogen, high HDL cholesterol). Components 2, 3 and 4, and age were significant independent predictors of incident CVD, and smoking approached significance. In univariate analysis fasting glucose ≥ 4.8 mmol/l, total:HDL cholesterol ratio ≥ 5.7, non-HDL cholesterol ≥ 4.3 mmol/l, gamma-glutamyl transferase ≥ 70 U/l, albumin creatinine ratio ≥ 5.7 mg/mmol, systolic blood pressure ≥ 120 mmHg and diastolic blood pressure ≥ 70 mmHg were useful predictors of CVD. The co-occurrence of three or more risk variables (fasting glucose ≥ 4.8 mmol/l, total:HDL cholesterol ratio ≥ 5.7, blood pressure (systolic ≥ 120 mmHg; diastolic ≥ 70 mmHg; albumin:creatinine ratio ≥ 5.7 mg/mmol and smoking) had sensitivity of 82.0% and specificity of 59.9% for predicting incident CVD. CONCLUSION: Age is the strongest predictor of CVD for this population. For clinical identification of individuals at high risk, screening for the combination of three or more of hyperglycaemia, dyslipidaemia, hypertension, albuminuria and smoking may prove a useful and efficient strategy.

Who uses complementary and alternative therapies in regional South Australia? Evidence from the Whyalla Intergenerational Study of Health.

OBJECTIVE: o assess the prevalence of complementary and alternative medicine (CAM) and service use for people with a chronic disease in rural and regional Australia, where reported prevalence of CAM use is higher. METHODS: ata were from the Whyalla Intergenerational Study of Health, a population representative cross sectional study of 1146 people recruited in 2008-2009. Self-reported chronic disease diagnosis and health service use including CAM use were collected. Complementary and other medicines were recorded at a clinic visit in a reduced sample (n=722) and SF36 data were collected by questionnaire. RESULTS: round 32% of respondents reported complementary medicine use and 27% CAM service use. There was no difference in the overall prevalence of CAM use among those with and without a chronic disease (OR 0.9, 95% CI 0.7-1.3). Greater age- and sex-adjusted use of complementary medicines was associated with the ability to save money (OR 1.75, 95% CI 1.17-2.63), but not with any other socioeconomic position indicator. Those who reported using prescribed medication were more likely to report using complementary medicines (OR 2.09, 95% CI 1.35-3.24). CONCLUSIONS: he prevalence of CAM use in this regional community appeared lower than reported in similar communities outside of South Australia. Mainstream medicine use was associated with complementary medicine use, increasing the risk of an adverse drug interaction. This suggests that doctors and pharmacists should be aware of the possibility that their clients may be using complementary medicines, and the need for vigilance regarding potential side effects and interactions between complementary and mainstream therapies.

A simple diabetes vascular severity staging instrument and its application to a Torres Strait Islander and Aboriginal adult cohort of north Australia.

BACKGROUND: To develop an instrument that predicts diabetes-related vascular disease severity using routinely collected data on Australian Aboriginal and Torres Strait Islander adults with type 2 diabetes, in the absence of diabetes duration. METHODS: A complex diabetes severity classification system was simplified and adapted for use with an Australian Aboriginal and Torres Strait Islander adult population with type 2 diabetes in north Queensland. Detailed vascular health risks and morbidities were mapped to routinely collected measures. Individual-level health screening, hospital separation and mortality data were linked and used to plot mean monthly in-patient hospital cost and percent mortality by disease severity as defined by the newly developed instrument, to test construct validity. RESULTS: The revised instrument consists of four combined diabetes-related microvascular and macrovascular stages that range from least severe (stage 1) to severe irreversible vascular impairment (stage 4). When applied to data of an Aboriginal and Torres Strait Islander Australian population the instrument showed good construct validity, predicting higher hospital cost and mortality as vascular disease severity increased. CONCLUSIONS: This instrument discriminates between levels of diabetes-related vascular disease severity, displays good construct validity by predicting increased hospital cost and mortality with worsening severity and can be populated with routinely collected data. It may assist with future health service research and its use could be extended to practice settings for health care planning for diabetes management programs and monitoring vascular disease progression.

Abdominal adiposity and obstructive airway disease: testing insulin resistance and sleep disordered breathing mechanisms.

BACKGROUND: This study examined associations of abdominal adiposity with lung function, asthma symptoms and current doctor-diagnosed asthma and mediation by insulin resistance (IR) and sleep disordered breathing (SDB). METHODS: A random sample of 2500 households was drawn from the community of Whyalla, South Australia (The Whyalla Intergenerational Study of Health, WISH February 2008 - July 2009). Seven-hundred twenty-two randomly selected adults (≥18 years) completed clinical protocols (32.2% response rate). Lung function was measured by spirometry. Post-bronchodilator FEV1/FVC was used to measure airway obstruction and reversibility of FEV1 was calculated. Current asthma was defined by self-reported doctor-diagnosis and evidence of currently active asthma. Symptom scores for asthma (CASS) and SDB were calculated. Intra-abdominal fat (IAF) was estimated using dual-energy x-ray absorptiometry (DXA). IR was calculated from fasting glucose and insulin concentrations. RESULTS: The prevalence of current doctor-diagnosed asthma was 19.9% (95% CI 16.7 - 23.5%). The ratio of observed to expected cases given the age and sex distribution of the population was 2.4 (95%CI 2.1, 2.9). IAF was not associated with current doctor-diagnosed asthma, FEV1/FVC or FEV1 reversibility in men or women but was positively associated with CASS independent of IR and SDB in women. A 1% increase in IAF was associated with decreases of 12 mL and 20 mL in FEV1 and FVC respectively in men, and 4 mL and 7 mL respectively in women. SDB mediated 12% and 26% of these associations respectively in men but had minimal effects in women. CONCLUSIONS: In this population with an excess of doctor-diagnosed asthma, IAF was not a major factor in airway obstruction or doctor-diagnosed asthma, although women with higher IAF perceived more severe asthma symptoms which did not correlate with lower FEV1. Higher IAF was significantly associated with lower FEV1 and FVC and in men SDB mechanisms may contribute up to one quarter of this association.

Major bleeding risk associated with warfarin and co-medications in the elderly population.

PURPOSE: Warfarin management in the elderly population is complex as medicines prescribed for concomitant diseases may further increase the risk of major bleeding associated with warfarin use. We aimed to quantify the excess risk of bleeding-related hospitalisation when warfarin was co-dispensed with potentially interacting medicines. METHODS: A retrospective cohort study was undertaken over a 4-year period from July 2002 to June 2006 to examine bleeding risk associated with medications co-administered in patients taking warfarin using an administrative claims database from the Australian Department of Veterans' Affairs. All veterans aged 65 years and over who were new users of warfarin were followed until death or study end. Risk of bleeding was assessed using a Poisson GEE model adjusting for age, gender, socioeconomic status, co-morbidity index, previous bleeding related hospitalisations and indicators of health service use. RESULTS: Overall, 17661 veterans who used warfarin at any time during the study period were included. The overall incidence rate of bleeding-related hospitalisations was 4.1 (95% CI 3.7-4.6) per 100 person-years in veterans who were not receiving potentially interacting medicines. Bleeding-related hospitalisation rates were significantly increased when warfarin was co-prescribed with low-dose aspirin (Adjusted rate ratio (AdjRR) 1.44, 95% CI 1.00-2.07), clopidogrel (AdjRR 2.23, 95% CI 1.48­3.36), clopidogrel with aspirin (AdjRR 3.44, 95% CI 1.28-9.23), amiodarone (AdjRR 3.33, 95% CI 1.38­8.00) and antibiotics (AdjRR 2.34, 95% CI 1.55-3.54). CONCLUSIONS: Models assessing bleeding risk with warfarin should take account of the range of potentially harmful medicine combinations used in elderly people with comorbid conditions.

Ageing well: improving the management of patients with multiple chronic health problems.

AIM: To identify and evaluate the management and care of older people with multiple chronic health problems (MCHP). METHODS: Administrative health data from the Department of Veterans' Affairs and bio-social data from the Australian Longitudinal Study of Ageing are used to determine prevalence of MCHP, treatment patterns and patient outcomes. Focus groups and semistructured interviews are used to gain patient and health practitioner perspectives. RESULTS: The prevalence of MCHP in older people is high (65%) and is associated with increased use of health services, mortality and poorer self-rated health. Australian disease-specific guidelines fail to address MCHP, and treatment conflicts with the potential to cause harm, were common. CONCLUSION: Improvements in the care and management of older people with MCHP requires: a multifaceted approach, across the health-care system; better coordination of holistic, patient-centred multidisciplinary care; and effective communication and education of all stakeholders. The Health reform agenda in Australia provides an opportunity for change.

Study protocol: a pragmatic randomised controlled trial of a 12-week physical activity and nutritional education program for overweight Aboriginal and Torres Strait Islander women.

BACKGROUND: Aboriginal and Torres Strait Islander women have a higher prevalence and incidence of obesity and type 2 diabetes than non-Indigenous Australian women. Physical inactivity is a key modifiable risk factor for obesity and evidence shows that even modest reductions in waist circumference (WC) have significant health benefits. Trialing physical activity programs in difficult-to-reach high risk groups, especially urban Indigenous Australians poses distinct implementation challenges. METHODS/DESIGN: The trial objective is to evaluate the effectiveness of a structured 12-week physical activity group program with nutritional advice. The design is a pragmatic randomised controlled trial. This study protocol describes the implementation and evaluation of the program. Participants are randomised into either an intervention or waitlisted group. The waitlisted group have a 12 month waiting period before commencing the 12-week program. Participant data is collected at baseline, 12, 24 and 52 weeks. Participants are Aboriginal and Torres Strait Islander women, aged 18-64 years with a waist circumference greater than 80 centimetres residing in Adelaide. The primary outcome measure is WC change immediately post program from baseline. Secondary outcomes include short term and long term changes in WC, weight, blood pressure, fasting blood glucose, insulin, insulin resistance (calculated HOMA), haemoglobin A1C (HbA1C), triglycerides and C-reactive protein (CRP). Behavioural and psychosocial surveys are administered to assess physical activity, dietary intake and the participant's motivation, self-efficacy and perceived social support for physical activity. Qualitative interviews focusing on participants' motivation, enablers and barriers to healthy eating and physical activity will be undertaken. Implementation fidelity and participation are also assessed. DISCUSSION: The Aboriginal and Torres Strait Islander Women's Fitness Program (WFP) is designed to provide a rigorous physiological and client-based evaluation of a structured 12-week program aimed to increase metabolic fitness and reduce WC in this high risk population. Evaluation results aim to provide the support necessary to design programs that are accessible, affordable and effective at reducing WC, while also improving the metabolic profile of overweight Aboriginal and Torres Strait Islander women. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12610000224022.

The beneficial effects of preschool attendance on adult cardiovascular disease risk.

OBJECTIVE: To assess the effect of South Australian Kindergarten Union participation on adult cardiovascular behavioural risk factors. METHODS: Using a retrospective cohort design, this study examined the effect of attendance at a Kindergarten Union preschool from 1940 to 1972 on behavioural risk factors for cardiovascular disease in adults 34-67 years. Dichotomous outcomes were analysed using a generalised linear model (Poisson distribution) with robust variance estimates. Outcomes with more than two categories were analysed with a multinomial logistic model. RESULTS: There was a beneficial effect of preschool on high physical activity relative to sedentary and on ever smoking, but a negative effect on fruit consumption. Preschool attendance was not associated with alcohol risk or vegetable consumption under traditional criteria, however the point estimate for vegetable consumption was in the beneficial direction. The point estimates from the multinomial model suggested a step-wise decreasing risk for preschool attendees to have less risk of experiencing multiple behavioural risk factors (e.g. risk of five risk factors for preschool participants compared with non-participants). CONCLUSIONS AND IMPLICATIONS: Attendance at a Kindergarten Union preschool was associated with a reduced risk of two and an indication of benefit in a third behavioural risk factor in adulthood. This study provides some evidence for the potential health benefit of interventions outside of the health sector to prevent cardiovascular diseases, which are strongly associated with lifelong social disadvantage.

Glycaemia and albuminuria as predictors of coronary heart disease in Aboriginal and Torres Strait Islander adults: a north Queensland cohort.

OBJECTIVE: To evaluate the contribution of non-traditional risk factors to coronary heart disease (CHD) incidence in Indigenous adults. DESIGN, SETTING AND PARTICIPANTS: Cohort study of 1706 Aboriginal and Torres Strait Islander adults from 26 remote communities in far north Queensland who were initially free of CHD, with a mean of 7.5 years of follow-up. MAIN OUTCOME MEASURES: CHD-related deaths and hospitalisations obtained by record matching. RESULTS: CHD incidence was similar in men and women and in Aboriginals and Torres Strait Islanders; overall incidence was 12.1 (95% CI, 10.1-14.1) events per 1000 person-years. At baseline, prevalence of diabetes was 12.4% in Aboriginals and 22.3% in Torres Strait Islanders, prevalence of any albuminuria was similarly high (33.5%) in both groups, and participants with diabetes were 5.5 (95% CI, 4.2-7.3) times more likely to have albuminuria than those without diabetes. At follow-up, adjusted hazard ratios for CHD were 1.7 (95% CI, 1.01-2.8) for obesity based on waist circumference; 1.5 (95% CI, 1.01-2.3) for hypertension; 1.4 (95% CI, 0.9-2.2) for previous or current smoking; 1.9 (95% CI, 1.3-2.7) for elevated triglycerides; 1.3 (95% CI, 0.9-1.9) for low high-density lipoprotein cholesterol; 1.3 (95% CI, 0.8-2.2) for impaired fasting glucose; 2.4 (95% CI, 1.7-3.5) for diabetes; and 4.6 (95% CI, 2.9-7.1) for macroalbuminuria. Baseline albuminuria without diabetes increased risk by 50% (adjusted rate ratio, 1.5 [95% CI, 0.9-2.4]) but diabetes with macroalbuminuria amplified risk sixfold (adjusted rate ratio, 5.9 [95% CI, 3.4-10.1]). CONCLUSION: High prevalence of glycaemia and albuminuria in this population, especially when combined, account for much of the excess CHD risk beyond the traditional Framingham risk factors. They can be measured simply, lend themselves to cardioprotective interventions, and should be used routinely to estimate risk and monitor effectiveness of treatment.

Early identification and preventive care for elevated cardiovascular disease risk within a remote Australian Aboriginal primary health care service.

BACKGROUND: Cardiovascular disease (CVD) is the single greatest contributor to the gap in life expectancy between Indigenous and non-Indigenous Australians. Our objective is to determine if holistic CVD risk assessment, introduced as part of the new Aboriginal and Torres Strait Islander Adult Health Check (AHC), results in better identification of elevated CVD risk, improved delivery of preventive care for CVD and improvements in the CVD risk profile for Aboriginal adults in a remote community. METHODS: Interrupted time series study over six years in a remote primary health care (PHC) service involving Aboriginal adults identified with elevated CVD risk (N = 64). Several process and outcome measures were audited at 6 monthly intervals for three years prior to the AHC (the intervention) and three years following: (i) the proportion of guideline scheduled CVD preventive care services delivered, (ii) mean CVD medications prescribed and dispensed, (iii) mean PHC consultations, (iv) changes in participants' CVD risk factors and estimated absolute CVD risk and (v) mean number of CVD events and iatrogenic events. RESULTS: Twenty-five percent of AHC participants were identified as having elevated CVD risk. Of these, 84% had not been previously identified during routine care. Following the intervention, there were significant improvements in the recorded delivery of preventive care services for CVD (30% to 53%), and prescription of CVD related medications (28% to 89%) (P < 0.001). Amongst participants there was a 20% relative reduction in estimated absolute CVD risk (P = 0.004) following the intervention. However, there were no significant changes in the mean number of PHC consultations or mean number of CVD events or iatrogenic events. CONCLUSIONS: Holistic CVD risk assessment during an AHC can lead to better and earlier identification of elevated CVD risk, improvement in the recorded delivery of preventive care services for CVD, intensification of treatment for CVD, and improvements in participants' CVD risk profile. Further research is required on strategies to reorient and restructure PHC services to the care of chronic illness for Aboriginal peoples in remote areas for there to be substantial progress in decreasing excess CVD related mortality.

Influence of comorbidities on therapeutic progression of diabetes treatment in Australian veterans: a cohort study.

BACKGROUND: This study assessed whether the number of comorbid conditions unrelated to diabetes was associated with a delay in therapeutic progression of diabetes treatment in Australian veterans. METHODOLOGY/PRINCIPAL FINDINGS: A retrospective cohort study was undertaken using data from the Australian Department of Veterans' Affairs (DVA) claims database between July 2000 and June 2008. The study included new users of metformin or sulfonylurea medicines. The outcome was the time to addition or switch to another antidiabetic treatment. The total number of comorbid conditions unrelated to diabetes was identified using the pharmaceutical-based comorbidity index, Rx-Risk-V. Competing risk regression analyses were conducted, with adjustments for a number of covariates that included age, gender, residential status, use of endocrinology service, number of hospitalisation episodes and adherence to diabetes medicines. Overall, 20,134 veterans were included in the study. At one year, 23.5% of patients with diabetes had a second medicine added or had switched to another medicine, with 41.4% progressing by 4 years. The number of unrelated comorbidities was significantly associated with the time to addition of an antidiabetic medicine or switch to insulin (subhazard ratio [SHR] 0.87 [95% CI 0.84-0.91], P<0.001). Depression, cancer, chronic obstructive pulmonary disease, dementia, and Parkinson's disease were individually associated with a decreased likelihood of therapeutic progression. Age, residential status, number of hospitalisations and adherence to anti-diabetic medicines delayed therapeutic progression. CONCLUSIONS/SIGNIFICANCE: Increasing numbers of unrelated conditions decreased the likelihood of therapeutic progression in veterans with diabetes. These results have implications for the development of quality measures, clinical guidelines and the construction of models of care for management of diabetes in elderly people with comorbidities.