Publications by authors named "Louise Maple-Brown"

85 Publications

Incorporating Aboriginal women's voices in improving care and reducing risk for women with diabetes in pregnancy - A phenomenological study.

BMC Pregnancy Childbirth 2021 Sep 16;21(1):624. Epub 2021 Sep 16.

Menzies School of Health Research, Charles Darwin University, NT, Darwin, Australia.

Background: There is a high burden of gestational diabetes (GDM) and type 2 diabetes in pregnancy for Aboriginal and Torres Strait Islander women. Postpartum diabetes programs have the potential to prevent recurrent GDM and improve management of type 2 diabetes. However, data on such programs are limited, particularly in the Indigenous context. We aimed to explore Aboriginal Australian women's and health providers' preferences for a program to prevent and improve diabetes after pregnancy.

Methods: A phenomenological methodology underpinned semi-structured in-depth interviews with eleven Aboriginal women and seven health professionals across the Northern Territory from October 2019- February 2020. Interviews were analysed using an inductive analysis framework to address the barriers and enablers of proposed diabetes prevention programs identified by participants.

Results: Identified structural barriers to lifestyle change included: food insecurity, persuasive marketing of unhealthy food options, lack of facilities and cultural inappropriateness of previous programs. Enablers to lifestyle change included: a strong link between a healthy lifestyle and connection with Country, family and community. Suggested strategies to improve lifestyle included: co-designed cooking classes or a community kitchen, team sports and structural change (targeting the social determinants of health). Lifestyle change was preferred over metformin to prevent and manage diabetes after pregnancy by participants and health care providers.

Conclusions: We recommend individual level programs be designed alongside policies that address systemic inequalities. A postpartum lifestyle program should be co-designed with community members and grounded in Aboriginal conceptions of health to adequality address the health disparities experienced by Aboriginal people in remote communities.
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http://dx.doi.org/10.1186/s12884-021-04055-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8445012PMC
September 2021

The Adaptation of a Youth Diabetes Prevention Program for Aboriginal Children in Central Australia: Community Perspectives.

Int J Environ Res Public Health 2021 Aug 31;18(17). Epub 2021 Aug 31.

Menzies School of Health Research, Charles Darwin University, Casuarina 0810, Australia.

This study reports on integrating community perspectives to adapt a family-focused, culturally appropriate behavioural intervention program to prevent diabetes among Aboriginal children (6-11 years) in Central Australia. A participatory action research approach was used to engage a range of service providers, cultural advisors, and family groups. Appropriateness, acceptability, content, and delivery of a prevention program within the Central Australian context were discussed through a series of workshops with twenty-five service providers and seven family groups separately. The data obtained were deductively coded for thematic analysis. Main findings included: (i) the strong need for a diabetes prevention program that is community owned, (ii) a flexible and culturally appropriate program delivered by upskilling community members as program facilitators, and (iii) consideration of social and environmental factors when implementing the program. It is recommended that a trial of the adapted prevention program for effectiveness and implementation is led by an Aboriginal community-controlled health service.
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http://dx.doi.org/10.3390/ijerph18179173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8430517PMC
August 2021

Improving systems of prenatal and postpartum care for hyperglycemia in pregnancy: A process evaluation.

Int J Gynaecol Obstet 2021 Jul 31. Epub 2021 Jul 31.

Division of Wellbeing and Preventable Chronic Disease, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.

Objective: To identify successes to date and opportunities for improvement in the implementation of a complex health systems intervention aiming to improve prenatal and postpartum care and health outcomes for women with hyperglycemia in pregnancy in regional and remote Australia.

Methods: A qualitative evaluation, underpinned by the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), was conducted mid-intervention. Semi-structured interviews were conducted with the participants, who included clinicians, regional policymakers and managers, and study implementation staff.

Results: Interviewees (n = 45) reported that the early phase of the intervention had resulted in the establishment of a clinician network, increased clinician awareness of hyperglycemia in pregnancy, and improvements in management, including earlier referral for specialist care and a focus on improving communication with women. Enablers of implementation included existing relationships with stakeholders and alignment of the intervention with health service priorities. Challenges included engaging remote clinicians and the labor-intensive nature of maintaining a clinical register of women with hyperglycemia in pregnancy.

Conclusion: The early phase of this health systems intervention has had a positive perceived impact on systems of care for women with hyperglycemia in pregnancy. Findings have informed modifications to the intervention, including the development of a communication and engagement strategy.
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http://dx.doi.org/10.1002/ijgo.13850DOI Listing
July 2021

Gestational diabetes is associated with postpartum hemorrhage in Indigenous Australian women in the PANDORA study: A prospective cohort.

Int J Gynaecol Obstet 2021 Jul 30. Epub 2021 Jul 30.

Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.

Objective: To assess associations of hyperglycemia in pregnancy with the risk of postpartum hemorrhage (PPH) in a prospective cohort of Indigenous and non-Indigenous women, compared with normoglycemia.

Methods: Data were from 1102 (48% Indigenous) women of the Pregnancy And Neonatal Diabetes Outcomes in Remote Australia (PANDORA) Study. Age-adjusted associations of gestational diabetes mellitus (GDM) or pre-existing type 2 diabetes mellitus (T2DM), obstetric and demographic covariables with PPH (blood loss ≥500 ml) were assessed using logistic regression. Multivariable-adjusted models included Indigenous ethnicity, diabetes type and their interaction.

Results: A higher proportion of Indigenous women developed PPH than non-Indigenous women (32% versus 22%; P < 0.001). Compared with non-Indigenous women with normoglycemia, risks of PPH for Indigenous women with GDM or T2DM were higher (odds ratio [OR] 1.83, 95% confidence intervals [CI] 1.11-3.02, and OR 1.72, 95% CI 0.99-3.00 after age adjustment, OR 1.84, 95% CI 1.06-3.19, and OR 1.33, 95% CI 0.70-2.54 after adjustment for school education and delivery mode, and OR 1.62, 95% CI 0.95-2.77, and OR 0.99, 95% CI 0.53-1.86 after adjustment for birth weight). Importantly, Indigenous women without hyperglycemia in pregnancy were not at increased risk of PPH.

Conclusion: The significantly higher rates of PPH experienced by Indigenous women compared with non-Indigenous women may be explained by a greater effect of GDM among Indigenous women that was only partly accounted for by birth weight.
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http://dx.doi.org/10.1002/ijgo.13846DOI Listing
July 2021

Diabetes during pregnancy and birthweight trends among Aboriginal and non-Aboriginal people in the Northern Territory of Australia over 30 years.

Lancet Reg Health West Pac 2020 Aug 24;1:100005. Epub 2020 Jul 24.

Wellbeing and Chronic Preventable Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.

Background: Early-life risk factors, including maternal hyperglycaemia and birthweight, are thought to contribute to the high burden of cardiometabolic disease experienced by Indigenous populations. We examined rates of pre-existing diabetes in pregnancy, gestational diabetes mellitus (GDM) and extremes of birthweight over three decades in the Northern Territory (NT) of Australia.

Methods: We performed a retrospective cohort analysis of the NT Perinatal Data Collection from 1987 to 2016, including all births >20 weeks gestation, stratified by maternal Aboriginal identification. Key outcomes were annual rates of pre-existing diabetes, GDM, small-for-gestational-age, large-for-gestational-age, low birthweight (<2500 g), and high birthweight (>4000 g). Logistic regression was used to assess trends and interactions.

Findings: 109 349 babies were born to 64 877 mothers, 36% of whom identified as Aboriginal ethnicity. Among Aboriginal women, rates of GDM and pre-existing diabetes, respectively, were 3 · 4% and 0 · 6% in 1987 and rose to 13% and 5 · 7% in 2016 (both trends <0 · 001). Among non-Aboriginal women, rates of GDM increased from 1 · 9% in 1987 to 11% in 2016 (<0 · 001), while pre-existing diabetes was uncommon (≤0 · 7% throughout). Rates of small-for-gestational-age decreased, while rates of large-for-gestational-age and high birthweight increased in both groups (all trends <0 · 001). Multivariable modelling suggests that hyperglycaemia was largely responsible for the growing rate of large-for-gestational-age births among Aboriginal women.

Interpretation: The burden of hyperglycaemia in pregnancy has grown substantially in the NT over three decades and is impacting birthweight trends. The prevalence of pre-gestational diabetes in Aboriginal women is among the highest in the world.

Funding: Diabetes Australia Research Program.
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http://dx.doi.org/10.1016/j.lanwpc.2020.100005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315488PMC
August 2020

Exploring differences in perceptions of child feeding practices between parents and health care professionals: a qualitative study.

BMC Public Health 2021 07 23;21(1):1449. Epub 2021 Jul 23.

Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, 0810, Australia.

Background: Evidence on child feeding practice is often based on the perspectives and experiences of parents and less that of health practitioners. In this study, we explored child feeding practice in Aboriginal communities in northern Australia from both the parents and health practitioners' perspectives with the aim of informing nutrition improvement programs.

Methods: Qualitative research methods were employed. Using semi-structured interviews, parents (n = 30) of children aged 2-5 years, and 29 service providers who were involved in the delivery of child health and nutrition programs in the same communities, were asked about child feeding attitudes and practices. Responses were analyzed through inductive and deductive analysis, recognizing that worldviews influence child feeding practices.

Results: Sharing food was a central practice within families. Parents highly valued development of child independence in food behavior but were conflicted with the easy access to unhealthy food in their communities. This easy access to unhealthy food and inadequate food storage and kitchen facilities for some families were major challenges to achieving optimal diets for children identified by Aboriginal families and service providers. The responsive style of parenting described by parents was often misunderstood by service providers as sub-optimal parenting when viewed through a dominant western lens.

Conclusions: Approaches to support healthy feeding practices and optimal child nutrition require health-enabling food environments. Along with a community-based Aboriginal health workforce, it is paramount that the non-Aboriginal workforce be supported to be reflective of the impact of worldview on their practice, to ensure a culturally safe environment for families where parenting styles are understood and appropriately supported.
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http://dx.doi.org/10.1186/s12889-021-11493-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8299622PMC
July 2021

Feasibility of once weekly exenatide-LAR and enhanced diabetes care in Indigenous Australians with type 2 diabetes. (Long-acting-Once-Weekly-Exenatide laR-SUGAR, "Lower SUGAR" study).

Intern Med J 2021 Jun 18. Epub 2021 Jun 18.

Baker Heart and Diabetes Institute, Level 4, 99 Commercial Rd, Melbourne, Victoria, 3004, Australia.

Aims: To assess the feasibility and metabolic effects of once weekly supervised injection of exenatide-LAR in addition to standard care in Indigenous Australians with type 2 diabetes.

Methods: Two communities in Central Australia with longstanding specialist clinical outreach services were allocated by random coin toss to receive once-weekly exenatide-LAR injection with weekly nurse review and adjustment of medication for 20 weeks (community with exenatide-LAR) or to weekly nurse review in addition to standard care over 20 weeks (community without exenatide-LAR). The primary outcome was the feasibility of the intensive diabetes management model of care with and without weekly supervised exenatide-LAR. Secondary outcomes included change in HbA1c.

Results: 13 participants from community with exenatide-LAR and 9 participants from the community without exenatide-LAR were analysed. 85% of individuals in the community with exenatide-LAR and 67% in the community without exenatide-LAR attended more than half of clinic visits. Median difference in the change in HbA1c from baseline to final visit, adjusted for baseline HbA1c, between the community with exenatide-LAR and the community without exenatide-LAR was -3.1%, 95% CI (-5.80%, -0.38%; p = 0.03).

Conclusions: Weekly exenatide-LAR combined with weekly nurse review demonstrated greater improvements in HbA1c, highlighting its potential for use in remote communities. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1111/imj.15428DOI Listing
June 2021

The ADIPS Pilot National Diabetes in Pregnancy Benchmarking Programme.

Int J Environ Res Public Health 2021 05 4;18(9). Epub 2021 May 4.

School of Medicine, Western Sydney University, 2560 Sydney, Australia.

Background: To test the feasibility of benchmarking the care of women with pregnancies complicated by hyperglycaemia.

Methods: A retrospective audit of volunteer diabetes services in Australia and New Zealand involving singleton pregnancies resulting in live births between 2014 and 2020. Ranges are shown and compared across services.

Results: The audit included 10,144 pregnancies (gestational diabetes mellitus (GDM) = 8696; type 1 diabetes (T1D) = 435; type 2 diabetes (T2D) = 1013) from 11 diabetes services. Among women with GDM, diet alone was used in 39.4% (ranging among centres from 28.8-57.3%), metformin alone in 18.8% (0.4-43.7%), and metformin and insulin in 10.1% (1.5-23.4%); when compared between sites, all < 0.001. Birth was by elective caesarean in 12.1% (3.6-23.7%) or emergency caesarean in 9.5% (3.5-21.2%) (all < 0.001). Preterm births (<37 weeks) ranged from 3.7% to 9.4% ( < 0.05), large for gestational age 10.3-26.7% ( < 0.001), admission to special care nursery 16.7-25.0% ( < 0.001), and neonatal hypoglycaemia (<2.6 mmol/L) 6.0-27.0% ( < 0.001). Many women with T1D and T2D had limited pregnancy planning including first trimester hyperglycaemia (HbA1c > 6.5% (48 mmol/mol)), 78.4% and 54.6%, respectively ( < 0.001).

Conclusion: Management of maternal hyperglycaemia and pregnancy outcomes varied significantly. The maintenance and extension of this benchmarking service provides opportunities to identify policy and clinical approaches to improve pregnancy outcomes among women with hyperglycaemia in pregnancy.
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http://dx.doi.org/10.3390/ijerph18094899DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8125192PMC
May 2021

Current evidence and practical guidance for the use of sodium-glucose co-transporter-2 inhibitors in type 2 diabetes.

Aust J Gen Pract 2021 04;50(4):225-230

MBBS, BMedSc, FRACP, Endocrinologist, Department of Endocrinology, Royal Darwin Hospital, NT; Menzies School of Health Research, Charles Darwin University, NT.

Background: The burden of type 2 diabetes (T2D) and its associated complications continues to grow in Australia. In recent years, sodium-glucose co-transporter-2 (SGLT2) inhibitors have become a key component of diabetes care with rapid uptake into routine clinical practice. There is growing evidence of their clinical efficacy, but also potential adverse effects.

Objective: The aim of this article is to review the use of SGLT2 inhibitors in T2D by exploring data surrounding clinical efficacy and safety as well as providing practical advice for prescribing clinicians.

Discussion: SGLT2 inhibitors have multiple metabolic benefits including reducing glycated haemoglobin, weight and blood pressure. Additionally, there are strong cardiovascular benefits and renoprotective effects in selected populations. Current evidence suggests that SGLT2 inhibitors should be considered for the secondary prevention of cardiovascular disease and to delay progression of early chronic kidney disease in people with T2D. Clinicians should also be aware of common side effects and potential rare severe complications.
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http://dx.doi.org/10.31128/AJGP-05-20-5432DOI Listing
April 2021

Oral health of aboriginal people with kidney disease living in Central Australia.

BMC Oral Health 2021 02 4;21(1):50. Epub 2021 Feb 4.

Australian Research Centre for Population Oral Health, Adelaide Dental School, The University of Adelaide, Adelaide, Australia.

Background: Associations between kidney disease and periodontal disease are not well documented among Aboriginal people of Australia. The purpose of this investigation was to report and compare demographic, oral health, anthropometric and systemic health status of Aboriginal Australians with kidney disease and to compare against relevant Aboriginal Australians and Australian population estimates. This provides much needed evidence to inform dental health service provision policies for Aboriginal Australians with kidney disease.

Methods: Sample frequencies and means were assessed in adults represented in six datasets including: (1) 102 Aboriginal Australians with kidney disease residing in Central Australia who participated in a detailed oral health assessment; (2) 312 Aboriginal participants of the Northern Territory's PerioCardio study; (3) weighted estimates from 4775 participants from Australia's National Survey of Adult Oral Health (NSAOH); (4) Australian 2016 Census (all Australians); (5) National Health Survey 2017-2018 (all Australians) and; (6) Australian Health Survey: Biomedical Results for Chronic Diseases, 2011-2012 (all Australians). Oral health status was described by periodontal disease and experience of dental caries (tooth decay). Statistically significant differences were determined via non-overlapping 95% confidence intervals.

Results: Aboriginal Australians with kidney disease were significantly older, less likely to have a tertiary qualification or be employed compared with both PerioCardio study counterparts and NSAOH participants. Severe periodontitis was found in 54.3% of Aboriginal Australians with kidney disease, almost 20 times the 2.8% reported in NSAOH. A higher proportion of Aboriginal Australians with kidney disease had teeth with untreated caries and fewer dental restorations when compared to NSAOH participants. The extent of periodontal attachment loss and periodontal pocketing among Aboriginal Australians with kidney disease (51.0%, 21.4% respectively) was several magnitudes greater than PerioCardio study (22.0%, 12.3% respectively) and NSAOH (5.4%, 1.3% respectively) estimates.

Conclusions: Aboriginal Australians with kidney disease exhibited more indicators of poorer oral health than both the general Australian population and a general Aboriginal population from Australia's Northern Territory. It is imperative that management of oral health among Aboriginal Australians with kidney disease be included as part of their ongoing medical care.
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http://dx.doi.org/10.1186/s12903-021-01415-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7863237PMC
February 2021

Rethinking third trimester ultrasound measurements and risk of adverse neonatal outcomes in pregnancies complicated by hyperglycaemia: A retrospective study.

Aust N Z J Obstet Gynaecol 2021 06 3;61(3):366-372. Epub 2021 Jan 3.

Wellbeing and Chronic Preventable Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia.

Background: Antenatal ultrasound is used frequently in pregnancies complicated by hyperglycaemia; however, it is unclear which measurements have the greatest association with adverse neonatal outcomes.

Aim: To assess the association between third trimester ultrasound parameters with adverse neonatal outcomes in pregnancies complicated by hyperglycaemia.

Method: All pregnant women with gestational or type 2 diabetes who birthed in a regional hospital over 12 months were included. A composite adverse neonatal outcome was defined by one or more: admission to special care nursery, acidosis, hypoglycaemia, jaundice, shoulder dystocia, respiratory distress syndrome or 5-minute Apgar score < 5. Logistic regression was used to determine odds ratios (OR) for an adverse neonatal outcome, according to pre-specified cut points in both lower and upper percentiles of abdominal circumference (AC) and estimated fetal weight (EFW).

Results: Of 275 births an adverse outcome occurred in 122 (44%). Unadjusted OR (95% CI) for AC ≤30 was 3.2 (1.1-8.8) and >95 percentile was 3.1 (1.5-6.0) compared with the reference group of 31-70 percentile. Unadjusted OR for EFW ≤30 was 1.5 (0.7-3.1) and >95 percentile was 3.0 (1.4-6.3). After adjusting for maternal age, body mass index, diabetes type, ethnicity, gravidity, mode of delivery and gestation at birth the OR (95% CI) were as follows: AC ≤30 percentile, 3.7 (1.1-12.4); AC >95 , 2.2 (1.1-4.8); EFW ≤30 , 2.6 (1.1-6.1); EFW >95 , 2.5 (1.1-6.1).

Conclusion: An AC and EFW up to the 30 percentile may pose just as great a risk to the fetus as an AC or EFW >95 percentile in pregnancies complicated by hyperglycaemia.
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http://dx.doi.org/10.1111/ajo.13281DOI Listing
June 2021

Baseline liver function tests and full blood count indices and their association with progression of chronic kidney disease and renal outcomes in Aboriginal and Torres Strait Islander people: the eGFR follow- up study.

BMC Nephrol 2020 12 1;21(1):523. Epub 2020 Dec 1.

Department of Nephrology, Division of Medicine, Royal Darwin Hospital, P.O. Box 41326, Casuarina, Darwin, Northern Territory, Australia.

Background: Determination of risks for chronic kidney disease (CKD) progression could improve strategies to reduce progression to ESKD. The eGFR Study recruited a cohort of adult Aboriginal and Torres Strait Islander people (Indigenous Australians) from Northern Queensland, Northern Territory and Western Australia, aiming to address the heavy CKD burden experienced within these communities.

Methods: Using data from the eGFR study, we explored the association of baseline liver function tests (LFTs) (alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT), bilirubin and albumin) and full blood count (FBC) indices (white blood cell and red blood cell counts and haemoglobin) with annual eGFR decline and renal outcomes (first of 30% decline in eGFR with a follow-up eGFR < 60 mL/min/1.73 m, initiation of renal replacement therapy, or renal death). Comparisons of baseline variables across eGFR categories were calculated using analysis of variance and logistic regression as appropriate. Linear and multivariable regression models were used to estimate the annual change in eGFR for changes in FBC indices and LFTs. Cox proportional hazard models were used to estimate the hazard ratio for developing renal outcome for changes in baseline FBC indices and LFTs.

Results: Of 547 participants, 540 had at least one baseline measure of LFTs and FBC indices. The mean age was 46.1 (14.7) years and 63.6% were female. The median follow-up was 3.1 (IQR 2.8-3.6) years. Annual decline in eGFR was associated with low serum albumin (p < 0.001) and haemoglobin (p = 0.007). After adjustment for age, gender, urine albumin/creatinine ratio, diabetes, BMI, CRP, WHR, alcohol consumption, cholesterol and triglycerides, low serum albumin (p < 0.001), haemoglobin (p = 0.012) and bilirubin (p = 0.011) were associated with annual decline in eGFR. Renal outcomes were inversely associated with serum albumin (p < 0.001), bilirubin (p = 0.012) and haemoglobin (p < 0.001) and directly with GGT (p = 0.007) and ALP (p < 0.001). Other FBC indices and LFTs were not associated with annual decline in eGFR or renal outcomes.

Conclusions: GGT, ALP, bilirubin, albumin and haemoglobin independently associate with renal outcomes. Contrary to findings from other studies, no association was found between renal outcomes and other FBC indices. These findings may help focus strategies to prevent disease progression in this high-risk population.
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http://dx.doi.org/10.1186/s12882-020-02185-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7709437PMC
December 2020

Lessons learned from a periodontal intervention to reduce progression of chronic kidney disease among Aboriginal Australians.

BMC Res Notes 2020 Oct 15;13(1):483. Epub 2020 Oct 15.

Menzies School of Health Research, Charles Darwin University, Casuarina, NT, Australia.

Objective: Periodontal disease is associated with chronic kidney disease (CKD), with both conditions being highly prevalent among Australia's Aboriginal population. This paper reflects on the lessons learned following implementation of a periodontal intervention in the Central Australian region of the Northern Territory among Aboriginal adults with CKD.

Results: Between Oct 2016 and May 2019, research staff recruited 102 eligible participants. This was far below the anticipated recruitment rate. The challenges faced, and lessons learned, were conceptualised into five specific domains. These included: (1) insufficient engagement with the Aboriginal community and Aboriginal community-controlled organisations; (2) an under-appreciation of the existing and competing patient commitments with respect to general health and wellbeing, and medical treatment to enable all study commitments; (3) most study staff employed from outside the region; (4) potential participants not having the required number of teeth; (5) invasive intervention that involved travel to, and time at, a dental clinic. A more feasible research model, which addresses the divergent needs of participants, communities and service partners is required. This type of approach, with sufficient time and resourcing to ensure ongoing engagement, partnership and collaboration in co-design throughout the conduct of research, challenges current models of competitive, national research funding.
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http://dx.doi.org/10.1186/s13104-020-05317-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7566020PMC
October 2020

Associations of gestational diabetes and type 2 diabetes during pregnancy with breastfeeding at hospital discharge and up to 6 months: the PANDORA study.

Diabetologia 2020 12 10;63(12):2571-2581. Epub 2020 Sep 10.

Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.

Aims/hypothesis: Women with gestational diabetes mellitus (GDM) and obesity experience lower rates of breastfeeding. Little is known about breastfeeding among mothers with type 2 diabetes. Australian Indigenous women have a high prevalence of type 2 diabetes in pregnancy. We aimed to evaluate the association of hyperglycaemia, including type 2 diabetes, with breastfeeding outcomes.

Methods: Indigenous (n = 495) and non-Indigenous (n = 555) participants of the Pregnancy And Neonatal Diabetes Outcomes in Remote Australia (PANDORA) cohort included women without hyperglycaemia in pregnancy (n = 222), with GDM (n = 684) and with type 2 diabetes (n = 144). The associations of hyperglycaemia in pregnancy and breastfeeding at hospital discharge, 6 weeks and 6 months post-partum were evaluated with logistic regression, after adjustment for maternal obesity, ethnicity, maternal and neonatal characteristics.

Results: Indigenous women were more likely to predominantly breastfeed at 6 weeks across all levels of hyperglycaemia. Compared with women with no hyperglycaemia in pregnancy, women with type 2 diabetes had lower odds for exclusive breastfeeding at discharge (adjusted OR for exclusive breastfeeding 0.4 [95% CI 0.2, 0.8] p = 0.006). At 6 weeks and 6 months, the relationship between type 2 diabetes and predominant breastfeeding was not statistically significant (6 weeks 0.7 [0.3, 1.6] p = 0.40, 6 months 0.8 [0.4, 1.6] p = 0.60). Women with gestational diabetes were as likely to achieve predominant breastfeeding at 6 weeks and 6 months as women without hyperglycaemia in pregnancy.

Conclusions/interpretation: Indigenous women had high rates of breastfeeding. Women with type 2 diabetes had difficulty establishing exclusive breastfeeding at hospital discharge. Further research is needed to assess the impact on long-term breastfeeding outcomes. Graphical abstract.
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http://dx.doi.org/10.1007/s00125-020-05271-9DOI Listing
December 2020

Using co-design to develop a culturally responsive reproductive health learning resource for Aboriginal and Torres Strait Islander youth.

Health Promot J Austr 2021 Feb 1;32 Suppl 1:179-185. Epub 2020 Sep 1.

Menzies School of Health Research, Casuarina, NT, Australia.

Issue Addressed: Healthy behaviours prior to conception can improve pregnancy outcomes and intergenerational health. Adolescence is an important period to promote preconception health, but education resources need to be age and culturally appropriate. Few studies have addressed preconception awareness and knowledge among Aboriginal and Torres Strait Islander youth, and few culturally appropriate resources exist.

Methods: A mixed methods, co-design process engaging Aboriginal and Torres Strait Islander youth and an Indigenous Reference Group (IRG). Additionally, a survey was carried out to identify preconception health awareness and interest among a broader youth audience.

Results: Several main themes emerged from consultation meetings with youth reflecting an awareness of preconception health, but limited understanding. Youth revealed an interest in fertility, and a need for more information on lifestyle factors associated with infertility. Preconception information related to the opposite sex was seen as important as well as information incorporating current local knowledge and world views. Among the survey respondents, 46% (11/24) had a pre-existing understanding of preconception health. Optimising lifestyle behaviours prior to pregnancy was perceived as important for women (21/24; 88%), but less so for men (16/24; 67%), highlighting a gap in knowledge regarding the importance of preconception health for men.

Conclusion: The co-designed resource "Getting healthy before pregnancy" is available in print and electronically, with illustrations and synchronised audio overlay in Aboriginal English or East-side Kriol. The resource includes information on preconception health and behavioural risk factors.

So What: We present a co-designed preconception health resource for evaluation with Aboriginal and Torres Strait Islander youth.
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http://dx.doi.org/10.1002/hpja.392DOI Listing
February 2021

Walking the path together: incorporating Indigenous knowledge in diabetes research.

Lancet Diabetes Endocrinol 2020 07;8(7):559-560

Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada; Pediatrics and Child Health, Pediatric Endocrinology, University of Manitoba, Winnipeg, MB, Canada.

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http://dx.doi.org/10.1016/S2213-8587(20)30188-1DOI Listing
July 2020

'Turning the tide' on hyperglycemia in pregnancy: insights from multiscale dynamic simulation modeling.

BMJ Open Diabetes Res Care 2020 05;8(1)

Computational Epidemiology and Public Health Informatics Laboratory, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Introduction: Hyperglycemia in pregnancy (HIP, including gestational diabetes and pre-existing type 1 and type 2 diabetes) is increasing, with associated risks to the health of women and their babies. Strategies to manage and prevent this condition are contested. Dynamic simulation models (DSM) can test policy and program scenarios before implementation in the real world. This paper reports the development and use of an advanced DSM exploring the impact of maternal weight status interventions on incidence of HIP.

Methods: A consortium of experts collaboratively developed a hybrid DSM of HIP, comprising system dynamics, agent-based and discrete event model components. The structure and parameterization drew on a range of evidence and data sources. Scenarios comparing population-level and targeted prevention interventions were simulated from 2018 to identify the intervention combination that would deliver the greatest impact.

Results: Population interventions promoting weight loss in early adulthood were found to be effective, reducing the population incidence of HIP by 17.3% by 2030 (baseline ('business as usual' scenario)=16.1%, 95% CI 15.8 to 16.4; population intervention=13.3%, 95% CI 13.0 to 13.6), more than targeted prepregnancy (5.2% reduction; incidence=15.3%, 95% CI 15.0 to 15.6) and interpregnancy (4.2% reduction; incidence=15.5%, 95% CI 15.2 to 15.8) interventions. Combining targeted interventions for high-risk groups with population interventions promoting healthy weight was most effective in reducing HIP incidence (28.8% reduction by 2030; incidence=11.5, 95% CI 11.2 to 11.8). Scenarios exploring the effect of childhood weight status on entry to adulthood demonstrated significant impact in the selected outcome measure for glycemic regulation, insulin sensitivity in the short term and HIP in the long term.

Discussion: Population-level weight reduction interventions will be necessary to 'turn the tide' on HIP. Weight reduction interventions targeting high-risk individuals, while beneficial for those individuals, did not significantly impact forecasted HIP incidence rates. The importance of maintaining interventions promoting healthy weight in childhood was demonstrated.
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http://dx.doi.org/10.1136/bmjdrc-2019-000975DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265040PMC
May 2020

A position statement on screening and management of prediabetes in adults in primary care in Australia.

Diabetes Res Clin Pract 2020 Jun 1;164:108188. Epub 2020 May 1.

Holsworth Research Initiative, La Trobe University, VIC, Australia. Electronic address:

Prediabetes has a high prevalence, with early detection essential to facilitate optimal management to prevent the development of conditions such as type 2 diabetes and cardiovascular disease. Prediabetes can include impaired fasting glucose, impaired glucose tolerance and elevated HbA1c. This position statement outlines the approaches to screening and management of prediabetes in primary care. There is good evidence to implement intensive, structured lifestyle interventions for individuals with impaired glucose tolerance. The evidence for those with impaired fasting glucose or elevated HbA1c is less clear, but individuals should still be provided with generalised healthy lifestyle strategies. A multidisciplinary approach is recommended to implement healthy lifestyle changes through education, nutrition and physical activity. Individuals should aim to lose weight (5-10% of body mass) using realistic and sustainable dietary approaches supported by an accredited practising dietitian, where possible. Physical activity and exercise should be used to facilitate weight maintenance and reduce blood glucose. Moderate-vigorous intensity aerobic exercise and resistance training should be prescribed by an accredited exercise physiologist, where possible. When indicated, pharmacotherapy, metabolic surgery and psychosocial care should be considered, in order to enhance the outcomes associated with lifestyle change. Individuals with prediabetes should generally be evaluated annually for their diabetes status.
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http://dx.doi.org/10.1016/j.diabres.2020.108188DOI Listing
June 2020

Indigenous cultures in countries with similar colonisation histories share the challenge of intergenerational diabetes.

Lancet Glob Health 2020 May;8(5):e619-e620

Indigenous Reference Group, Diabetes across the Lifecourse Northern Australia Partnership, Charles Darwin University, Darwin, NT 0811, Australia; Central Australian Aboriginal Congress Aboriginal Corporation, Alice Springs, NT, Australia.

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http://dx.doi.org/10.1016/S2214-109X(20)30072-3DOI Listing
May 2020

Primary Health Care for Aboriginal Australian Women in Remote Communities after a Pregnancy with Hyperglycaemia.

Int J Environ Res Public Health 2020 01 22;17(3). Epub 2020 Jan 22.

Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810, Australia.

Background: Hyperglycaemia in pregnancy contributes to adverse outcomes for women and their children. The postpartum period is an opportune time to support women to reduce cardiometabolic and diabetes risk in subsequent pregnancies.

Aims: To identify strengths and gaps in current care for Aboriginal women after a pregnancy complicated by hyperglycaemia.

Methods: A retrospective review of the 12 month postpartum care provided by primary health centres in remote Australia in 2013-2014 identified 195 women who experienced hyperglycaemia in pregnancy (gestational diabetes (GDM) (n = 147), type 2 diabetes (T2D) (n = 39), and unclear diabetes status (n = 9)).

Results: Only 80 women (54%) with GDM had postpartum glycaemic checks. Of these, 32 women were diagnosed with prediabetes (n = 24) or diabetes (n = 8). Compared to women with GDM, women with T2D were more likely to have their weight measured (75% vs. 52%, p <0.01), and smoking status documented as "discussed" (65% vs. 34%, p < 0.01). Most women (97%) accessed the health centre at least once in the 12 month postpartum period but, during these visits, only 52% of women had service provision, either structured or opportunistic, related to diabetes.

Conclusion: High rates of dysglycaemia among women screened for T2D after GDM in the 12 month postpartum period highlight the need for increased screening and early intervention to prevent the development of T2D and its complications. Whilst a clear strength was high postpartum attendance, many women did not attend health services for diabetes screening or management.
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http://dx.doi.org/10.3390/ijerph17030720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7037226PMC
January 2020

Social and economic factors, maternal behaviours in pregnancy and neonatal adiposity in the PANDORA cohort.

Diabetes Res Clin Pract 2020 Mar 19;161:108028. Epub 2020 Jan 19.

Menzies School of Health Research, Charles Darwin University, NT, Australia; Division of Medicine, Royal Darwin Hospital, NT, Australia. Electronic address:

Background: Australian Indigenous women experience high rates of social disadvantage and type 2 diabetes (T2D) in pregnancy, but it is not known how social factors and maternal behaviours impact neonatal adiposity in offspring of women with hyperglycaemia in pregnancy.

Methods: Participants were Indigenous (n = 404) and Europid (n = 240) women with gestational diabetes mellitus (GDM) or T2D in pregnancy and their offspring in the Pregnancy and Neonatal Diabetes Outcomes in Remote Australia (PANDORA) study. Social, economic factors, and maternal behaviours were measured in pregnancy and six neonatal anthropometric outcomes were examined after birth.

Results: On univariate analysis, maternal education < 12 years (p = 0.03), unemployment (p = 0.001), welfare income vs no welfare income (p = 0.001), lower area based socio-economic score (p < 0.001), and fast food intake > 2 times/week (p = 0.002) were associated with increased sum of skinfolds (SSF) in offspring. Smoking was significantly associated with a reduction in anthropometric measures, except SSF. In multivariable models adjusted for ethnicity, BMI and hyperglycaemia, social and economic factors were no longer significant predictors of neonatal outcomes. Smoking was independently associated with a reduction in length, head circumference and fat free mass. Frequent fast food intake remained independently associated with SSF (β-coefficient 1.08 mm, p = 0.02).

Conclusion: In women with hyperglycaemia in pregnancy, social factors were associated with neonatal adiposity, particularly skinfold measures. Promoting smoking cessation and limited intake of energy-dense, nutrient-poor foods in pregnancy are important to improve neonatal adiposity and lean mass outcomes. Addressing inequities in social and economic factors are likely to be important, particularly for Indigenous women or women experiencing social disadvantage.
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http://dx.doi.org/10.1016/j.diabres.2020.108028DOI Listing
March 2020

Performance of cardiovascular risk prediction equations in Indigenous Australians.

Heart 2020 08 16;106(16):1252-1260. Epub 2020 Jan 16.

Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research Charles Darwin University, Casuarina, Northern Territory, Australia.

Objective: To assess the performance of cardiovascular disease (CVD) risk equations in Indigenous Australians.

Methods: We conducted an individual participant meta-analysis using longitudinal data of 3618 Indigenous Australians (55% women) aged 30-74 years without CVD from population-based cohorts of the Cardiovascular Risk in IndigenouS People(CRISP) consortium. Predicted risk was calculated using: 1991 and 2008 Framingham Heart Study (FHS), the Pooled Cohorts (PC), GloboRisk and the Central Australian Rural Practitioners Association (CARPA) modification of the FHS equation. Calibration, discrimination and diagnostic accuracy were evaluated. Risks were calculated with and without the use of clinical criteria to identify high-risk individuals.

Results: When applied without clinical criteria, all equations, except the CARPA-adjusted FHS, underestimated CVD risk (range of percentage difference between observed and predicted CVD risks: -55% to -14%), with underestimation greater in women (-63% to -13%) than men (-47% to -18%) and in younger age groups. Discrimination ranged from 0.66 to 0.72. The CARPA-adjusted FHS equation showed good calibration but overestimated risk in younger people, those without diabetes and those not at high clinical risk. When clinical criteria were used with risk equations, the CARPA-adjusted FHS algorithm scored 64% of those who had CVD events as high risk; corresponding figures for the 1991-FHS were 58% and were 87% for the PC equation for non-Hispanic whites. However, specificity fell.

Conclusion: The CARPA-adjusted FHS CVD risk equation and clinical criteria performed the best, achieving higher combined sensitivity and specificity than other equations. However, future research should investigate whether modifications to this algorithm combination might lead to improved risk prediction.
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http://dx.doi.org/10.1136/heartjnl-2019-315889DOI Listing
August 2020

Chronic condition risk factor change over time in a remote Indigenous community.

Rural Remote Health 2020 01 13;20(1):4452. Epub 2020 Jan 13.

Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT 0811, Australia; and Baker Heart and Diabetes Institute, PO Box 6492, Melbourne, Vic., Australia

Introduction: This study sought to determine change in chronic condition risk factors in a remote Indigenous community following a 3-year period of community-led health promotion initiatives.

Methods: Data were compared between two cross-sectional surveys of Indigenous Australian community residents before and after health promotion activities, and longitudinal analysis of participants present at both surveys using multilevel mixed-effects regression.

Results: At baseline, 294 (53% women; mean age 35 years) participated and 218 attended the second survey (56% women, mean age 40 years), and 87 attended both. Body composition, blood pressure and urinary albumin-to-creatinine ratio remained stable between baseline and follow-up. After adjusting for age and sex, haemoglobin A1c significantly increased (from 57 to 63 mmol/mol (7.5% to 8.1%), p=0.021) for those with diabetes. Increases were also observed for total cholesterol (from 4.4 to 4.6 mmol/L, p=0.006) and triglycerides (from 1.5 to 1.6 mmol/L, p=0.019), and high-density lipoprotein cholesterol levels improved (from 0.98 to 1.02 mmol/L, p=0.018). Self-reported smoking prevalence was high but stable between baseline (57%) and follow-up (56%). Similar results were observed in the longitudinal analysis to the cross-sectional survey comparison.

Conclusion: Community-led health promotion initiatives may have had some benefits on chronic condition risk factors, including stabilisation of body composition, in this remote Indigenous community. Given that less favourable trends were observed for diabetes and total cholesterol over a short time period and smoking prevalence remained high, policy initiatives that address social and economic disadvantage are needed alongside community-led health promotion initiatives.
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http://dx.doi.org/10.22605/RRH4452DOI Listing
January 2020

Cord blood metabolic markers are strong mediators of the effect of maternal adiposity on fetal growth in pregnancies across the glucose tolerance spectrum: the PANDORA study.

Diabetologia 2020 03 8;63(3):497-507. Epub 2020 Jan 8.

Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT, 0811, Australia.

Aims/hypothesis: We aimed to assess associations between cord blood metabolic markers and fetal overgrowth, and whether cord markers mediated the impact of maternal adiposity on neonatal anthropometric outcomes among children born to Indigenous and Non-Indigenous Australian women with normal glucose tolerance (NGT), gestational diabetes mellitus (GDM) and pregestational type 2 diabetes mellitus.

Methods: From the Pregnancy and Neonatal Outcomes in Remote Australia (PANDORA) study, an observational cohort of 1135 mother-baby pairs, venous cord blood was available for 645 singleton babies (49% Indigenous Australian) of women with NGT (n = 129), GDM (n = 419) and type 2 diabetes (n = 97). Cord glucose, triacylglycerol, HDL-cholesterol, C-reactive protein (CRP) and C-peptide were measured. Multivariable logistic and linear regression were used to assess the associations between cord blood metabolic markers and the outcomes of birthweight z score, sum of skinfold thickness (SSF), being large for gestational age (LGA) and percentage of body fat. Pathway analysis assessed whether cord markers mediated the associations between maternal and neonatal adiposity.

Results: Elevated cord C-peptide was significantly associated with increasing birthweight z score (β 0.57 [95% CI 0.42, 0.71]), SSF (β 0.83 [95% CI 0.41, 1.25]), percentage of body fat (β 1.20 [95% CI 0.69, 1.71]) and risk for LGA [OR 3.14 [95% CI 2.11, 4.68]), after adjusting for age, ethnicity and diabetes type. Cord triacylglycerol was negatively associated with birthweight z score for Indigenous Australian women only. No associations between cord glucose, HDL-cholesterol and CRP >0.3 mg/l (2.9 nmol/l) with neonatal outcomes were observed. C-peptide mediated 18% (95% CI 13, 36) of the association of maternal BMI with LGA and 11% (95% CI 8, 17) of the association with per cent neonatal fat.

Conclusions/interpretation: Cord blood C-peptide is an important mediator of the association between maternal and infant adiposity, across the spectrum of maternal glucose tolerance.
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http://dx.doi.org/10.1007/s00125-019-05079-2DOI Listing
March 2020

All-cause mortality following low-dose aspirin treatment for patients with high cardiovascular risk in remote Australian Aboriginal communities: an observational study.

BMJ Open 2020 01 2;10(1):e030034. Epub 2020 Jan 2.

Department of Endocrinology, Royal Darwin Hospital, Darwin, Northern Territory, Australia

Objectives: To evaluate the benefit and risk of low-dose acetylsalicylic acid (aspirin) in patients from remote Aboriginal communities in the Northern Territory, Australia.

Design: Retrospective cohort study using primary care and hospital data routinely used for healthcare. Aspirin users and non-users were compared before and after controlling confounders by matching. Marginal structural models (MSM) were applied to ascertain the benefit and risk.

Setting: The benefit and harm of aspirin were investigated in patients aged ≥18 years from 54 remote Aboriginal communities.

Participants: None had a previous cardiovascular event or major bleeds. Patients on anticoagulants or other antiplatelets were excluded.

Intervention: Aspirin at a dose of 75-162 mg/day.

Outcome Measures: Endpoints were all-cause, cardiovascular mortality and incidences of cardiovascular events and major bleeds.

Results: 8167 predominantly Aboriginal adults were included and followed between July 2009 and June 2017 (aspirin users n=1865, non-users n=6302, mean follow-up 4 years with hospitalisations 6.4 per person). Univariate analysis found material differences in demographics, prevalence of chronic diseases and outcome measures between aspirin users and non-users before matching. After matching, aspirin was significantly associated with reduced all-cause mortality (HR=0.45: 95% CI 0.34 to 0.60; p<0.001), but not bleeding (HR=1.13: 95% CI 0.39 to 3.26; p=0.820). After using MSMs to eliminate the effects of confounders, loss of follow-up and time dependency of treatment, aspirin was associated with reduced all-cause mortality (HR=0.60: 95% CI 0.47 to 0.76; p<0.001), independent of age (HR=1.06; p<0.001), presence of diabetes (HR=1.42; p<0.001), hypertension (HR=1.61; p<0.001) and alcohol abuse (HR=1.81; p<0.001). No association between aspirin and major bleeding was found (HR=1.14: 95% CI 0.48 to 2.73; p=0.765). Sensitivity analysis suggested these findings were unlikely to have been the result of unmeasured confounding.

Conclusion: Aspirin was associated with reduced all-cause mortality. Bleeding risk was less compared with survival benefits. Aspirin should be considered for primary prevention in Aboriginal people with high cardiovascular risk.
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http://dx.doi.org/10.1136/bmjopen-2019-030034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6955566PMC
January 2020

My experiences with kidney care: A qualitative study of adults in the Northern Territory of Australia living with chronic kidney disease, dialysis and transplantation.

PLoS One 2019 19;14(12):e0225722. Epub 2019 Dec 19.

Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.

Background: Australian healthcare quality and safety accreditation standards recommend health services partner with health care users, to ensure the highest quality of care. Aboriginal Australians with chronic and end stage kidney disease have high health care access needs.

Aim: To describe the experiences of health care users of a large government kidney healthcare service provider.

Methods: Within a government renal health service in the Top-End of the Northern Territory, we undertook a qualitative study involving in-depth interviews with 26 adult clients from urban, regional and remote settings who were living with kidney health conditions.

Results: Client characteristics included a mean age of 55 years, 55% female and 81% identifying as Aboriginal. The kidney related conditions of client participants included CKD (11, 42.3%), haemodialysis (12, 46.2%), peritoneal dialysis (1, 3.9%), and transplant (2, 7.7%). Key themes emerging from patient interviews related to perceived gaps for clients and carers including: 1) knowledge gaps about the health condition, 2) the impact of relocation in order to access centrally-based renal care, 3) healthcare staff professionalism and qualities and 4) service environments. Overall, the experiences centred on a greater need for client-centred, respectful and culturally based healthcare support. Clients recommended the need for patient-led collective care, including sustaining an Indigenous Patient Reference Group to support ongoing healthcare service decision processes. Participants included in almost equal proportion, clients with CKD (without dialysis) and clients utilising renal replacement therapy, which adds significant weight to the client-identified recommendations for highest quality of kidney care across a wide spectrum of kidney function.

Conclusion: Four major themes identified by clients related to their experience with renal care provided by this major regional health care provider: knowledge gaps of their own condition, the lived impacts of relocating to access health care, service environments, and Health Care Provider Quality. An Indigenous Patient Reference Group was one mechanism recommended to support the co-design of preferred care models.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0225722PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6922340PMC
March 2020

Improving Models of Care for Diabetes in Pregnancy: Experience of Current Practice in Far North Queensland, Australia.

Front Public Health 2019 19;7:192. Epub 2019 Jul 19.

Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, University Drive North, Casuarina, NT, Australia.

To map health practitioners' experiences and describe knowledge regarding screening and management of Diabetes in Pregnancy (DIP) in Far North Queensland, Australia. Mixed methods including a cross-sectional survey (101 respondents) and 8 focus groups with 61 health practitioners. All participants provided clinical care for women with DIP. A wide range of healthcare professionals participated; 96% worked with Indigenous women, and 63% were from regional or remote work settings. Universal screening for gestational diabetes at 24-28 weeks gestation was reported as routine with 87% using a 75 g Oral Glucose Tolerance Test. Early screening for DIP was reported by 61% although there was large variation in screening methods and who should be screened <24 weeks. Health practitioners were confident providing lifestyle advice (88%), dietary, and blood glucose monitoring education (67%, 81%) but only 50% were confident giving insulin education. Electronic medical records were used by 80% but 55% also used paper records. Dissatisfaction with information from hospitals was reported by 40%. In the focus groups improving communication and information technology systems were identified as key areas. Other barriers described were difficulties in care coordination and access for remote women. Communication, information technology systems, coordination of care, and education for health professionals are key areas that will be addressed by a complex health systems intervention being undertaken by the DIP Partnership in North Queensland.
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http://dx.doi.org/10.3389/fpubh.2019.00192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6659099PMC
July 2019

Diabetes in pregnancy and epigenetic mechanisms-how the first 9 months from conception might affect the child's epigenome and later risk of disease.

Lancet Diabetes Endocrinol 2019 10 22;7(10):796-806. Epub 2019 May 22.

Cancer and Disease Epigenetics, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Pediatrics, Melbourne University, Melbourne, VIC, Australia.

Diabetes in pregnancy is not only associated with increased risk of pregnancy complications and subsequent maternal metabolic disease, but also increases the risk of long-term metabolic disease in the offspring. At the interface between genetic and environmental factors, epigenetic variation established in utero represents a plausible link between the in utero environment and later disease susceptibility. The identification of an epigenetic fingerprint of diabetes in pregnancy linked to the metabolic health of the offspring might provide novel biomarkers for the identification of offspring most at risk, before the onset of metabolic dysfunction, for targeted monitoring and intervention. In this Personal View, we (1) highlight the scale of the problem of diabetes in pregnancy, (2) summarise evidence for the variation in offspring epigenetic profiles following exposure to diabetes in utero, and (3) outline potential future approaches to further understand the mechanisms by which exposure to maternal metabolic dysfunction in pregnancy is transmitted through generations.
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http://dx.doi.org/10.1016/S2213-8587(19)30078-6DOI Listing
October 2019

Is hyperfiltration associated with higher urine albumin-to-creatinine ratio at follow up among Indigenous Australians? The eGFR follow-up study.

J Diabetes Complications 2019 05 21;33(5):343-349. Epub 2019 Feb 21.

Menzies School of Health Research, Charles Darwin University, Australia; Division of Medicine, Royal Darwin Hospital, Darwin, Australia. Electronic address:

Background: Glomerular hyperfiltration is not able to be detected in clinical practice. We assessed whether hyperfiltration is associated with albuminuria progression among Indigenous Australians at high risk of diabetes and kidney disease to determine its role in kidney disease progression.

Methods: Longitudinal observational study of Indigenous Australians aged ≥18 years recruited from >20 sites, across diabetes and/or kidney function strata. At baseline, iohexol clearance was used to measure glomerular filtration rate (mGFR) and hyperfiltration was defined as (i) a mGFR of ≥125 mL/min/1.73 m, and (ii) an age-adjusted definition, with the top 10% of the mGFR for each 10 year age group at baseline. Baseline and follow-up urine albumin-to-creatinine ratio (uACR) was collected, and linear regression was used to assess the associations of hyperfiltration and uACR at follow up.

Results: 407 individuals (33% men, mean age 47 years) were followed-up for a median of 3 years. At baseline, 234 had normoalbuminuria and 173 had albuminuria. Among participants with normoalbuminuria, those with mGFR ≥125 mL/min/1.73 m had 32% higher uACR at follow-up (p = 0.08), and those with age-adjusted hyperfiltration had 60% higher uACR (p = 0.037) compared to those who had normofiltration. These associations were independent of uACR at baseline, but attenuated by HbA. Associations were stronger among those without than those with albuminuria at baseline.

Conclusions: Although not available for assessment in current clinical practice, hyperfiltration may represent a marker of subsequent albuminuria progression among individuals who have not yet developed albuminuria.
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http://dx.doi.org/10.1016/j.jdiacomp.2019.02.005DOI Listing
May 2019
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