8. Prevention of vascular and metabolic disease
Cardiovascular disease (CVD) occurs in 18% of Australians. It accounts for 36% of all deaths and 6.9% of all disability.1 The most important behavioural and physiological risk factors for CVD are smoking, diabetes, raised blood pressure (BP), dyslipidaemia, obesity, physical inactivity and poor diet.2 These risk factors are common in the Australian population: 90% of adults aged >45 years have at least one modifiable risk factor and 66% have three or more risk factors for CVD.3 In addition to these, a family history of premature heart disease in a first-degree relative,4 history of depression, social isolation and lack of quality social support are recognised risk factors for coronary heart disease (CHD).5
What are the key equity issues and who is at risk?
Cardiovascular disease (CVD)
Socioeconomic disadvantage is associated with higher rates of CVD. Aboriginal and Torres Strait Islander peoples, people living in rural and remote areas, and people in lower socioeconomic groups, all have an increased risk of cardiovascular disease.6Minority groups have high risk factor rates of cardiovascular disease globally.6,7
Type 2 diabetes (T2D)
There is a higher prevalence of T2D among Australians in the lower socioeconomic groups.8 T2D is more than twice as common in the most disadvantaged communities.9 Certain ethnic groups are more at risk.10 Aboriginal and Torres Strait Islander peoples are three times more likely to have diabetes than non-Indigenous Australians, and T2D is a direct or indirect cause for 20% of Aboriginal and Torres Strait Islander deaths.11
CVD risk factors
Biological and behavioural risk factors play a role in increasing cardiovascular risk (refer to Chapter 7. Prevention of chronic disease). However, while smoking, nutrition, alcohol and physical activity (SNAP) risk factors exhibit clear socioeconomic gradients,10,12 the higher prevalence of vascular and metabolic disease is only partly mediated by behavioural risk factors and is more consistently observed in women.13 Diabetes and CVD are more common in rural populations, and this is exacerbated by poorer access to healthcare.14 There is evidence that men from socioeconomically disadvantaged backgrounds may be less likely to be offered statins.15
Chronic kidney disease (CKD)
Disadvantaged groups have higher rates of CKDfor which type 2 diabetic nephropathy is a common cause.16,17 Over the past 25 years, the number of Aboriginal and Torres Strait Islander peoples commencing renal replacement therapy was 3.5 times greater than the majority of the population. CKD has an earlier onset in Indigenous peoples.18–20 Aboriginal and Torres Strait Islander peoples are 10 times more likely than non-Indigenous Australians to be hospitalised for CKD, and, from 2008 to 2012, CKD was responsible for or associated with 16% of Aboriginal and Torres Strait Islander deaths.11
What can GPs do?
- Inequities in diabetes care can be ameliorated using a structured systems-based approach to care targeting at-risk and minority populations using diabetes registries.21
- Social disadvantage may be a factor in poor medication adherence in patients with chronic disease.22,23 Interventions that can help improve medication adherence include those that target the barriers created by socioeconomic status (SES) and the treatment itself.23 Underuse of cardiovascular medications is common in older adults at high risk of CVD, and may be a factor in inequity in cardiovascular outcomes.24
- Effective chronic disease interventions are likely to be those that address the determinants of behavioural risk factors that arise from root social causes such as poverty and low health literacy.6 Interventions delivered in community settings that target families and are multifaceted to incorporate the social context are generally the most successful.25,26
- Trust is an important element in the delivery of culturally competent health service to patients with chronic diseases, particularly Aboriginal and Torres Strait Islander peoples. Key ways to improve healthcare delivery are to respond to social complexity; promote empowerment, trust and rapport; and reduce discrimination and racism. To do so requires not only practice-system change but also Aboriginal and Torres Strait Islander cultural training of health professionals to build culturally safe environments.27,28 Continuity of care and patient-centred care are also important. Culturally specific interventions are needed and there are ongoing initiatives to develop these.29–33
- Australian Institute of Health and Welfare. Australia’s health 2006. Canberra: AIHW, 2006.
- Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case control sudy. Lancet. 2004;364:937–52.
- Australian Institute of Health and Welfare. Health determinants, the key to preventing chronic disease. Canberra: AIHW, 2011.
- Chow CK, Pell AC, Walker A, O’Dowd C, Dominiczak AF, Pell JP. Families of patients with premature coronary heart disease: An obvious but neglected target for primary prevention. BMJ (Clinical research ed). 2007;335(7618):481–85.
- Bunker S, Colquhoun D, Esler M. ‘Stress’ and coronary heart disease: Psychosocial risk factors. National Heart Foundation of Australia position statement update. Med J Aust 2003;178:272–76.
- Mendis S, Banerjee A. Cardiovascular disease: Equity and social determinants. In: Blas E, Kurup AS, editors. Equity, social determinants and public health programmes. Geneva: World Health Organization, 2010.
- McGorrian C, Daly L, Fitzpatrick P, et al. Cardiovascular disease and risk factors in an indigenous minority population. The All-Ireland Traveller Health Study. Eur J Prev Cardiol 2012;19(6):1444–53.
- Australian Institute of Health and Welfare. Diabetes. Canberra: AIHW, 2016. Available at www.aihw.gov.au/diabetes [Accessed 16 February 2016].
- Australian Institute of Health and Welfare. Cardiovascular disease, diabetes and chronic kidney disease: Australian facts: Prevalence and incidence. Canberra: AIHW, 2014.
- Whiting D, Unwin N, Roglic G. Diabetes: Equity and social determinants. In: Blas E, Kurup AS, editors. Equity, social determinants and public health programmes. Geneva: World Health Organization, 2010.
- Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander Peoples 2015. Canberra: AIHW, 2015.
- Palomo L, Felix-Redondo FJ, Lozano-Mera L, Perez-Castan JF, Fernandez-Berges D, Buitrago F. Cardiovascular risk factors, lifestyle, and social determinants: A cross-sectional population study. Br J Gen Pract 2014;64(627):e627–33.
- Kavanagh A, Bentley RJ, Turrell G, Shaw J, Dunstan D, Subramanian SV. Socioeconomic position, gender, health behaviours and biomarkers of cardiovascular disease and diabetes. Soc Sci Med 2010;71(6):1150–60.
- O’Connor A, Wellenius G. Rural-urban disparities in the prevalence of diabetes and coronary heart disease. Public Health. 2012;126(10):813–20.
- Stocks N, Ryan P, Allan J, Williams S, Willson K. Gender, socioeconomic status, need or access? Differences in statin prescribing across urban, rural and remote Australia. Aust J Rural Health 2009;17(2):92–96.
- Jha V, Garcia-Garcia G, Iseki K, et al. Chronic kidney disease: Global dimension and perspectives. Lancet 2013;382(9888):260–72.
- Sabanayagam C, Lim SC, Wong TY, Lee J, Shankar A, Tai ES. Ethnic disparities in prevalence and impact of risk factors of chronic kidney disease. Nephrol Dial Transplant 2010;25(8):2564–70.
- Garcia-Garcia G, Jha V, World Kidney Day Steering C. Chronic kidney disease in disadvantaged populations. Brazil J Med Biol Res 2015;48(5):377–81.
- White A, Wong W, Sureshkumur P, Singh G. The burden of kidney disease in Indigenous children of Australia and New Zealand, epidemiology, antecedent factors and progression to chronic kidney disease. J Paediatr Child Health 2010;46(9):504–09.
- Hoy WE. Kidney disease in Aboriginal Australians: A perspective from the Northern Territory. Clin Kidney J 2014;7(6):524–30.
- Baty PJ, Viviano SK, Schiller MR, Wendling AL. A systematic approach to diabetes mellitus care in underserved populations: Improving care of minority and homeless persons. Fam Med 2010;42(9):623–27.
- Randall L, Begovic J, Hudson M, et al. Recurrent diabetic ketoacidosis in inner-city minority patients: Behavioral, socioeconomic, and psychosocial factors. Diabetes Care 2011;34(9):1891–96.
- Laba TL, Bleasel J, Brien JA, et al. Strategies to improve adherence to medications for cardiovascular diseases in socioeconomically disadvantaged populations: A systematic review. Int J Cardiol 2013;167(6):2430–40.
- Qato DM, Lindau ST, Conti RM, Schumm LP, Alexander GC. Racial and ethnic disparities in cardiovascular medication use among older adults in the United States. Pharmacoepidemiol Drug Saf 2010;19(8):834–42.
- Lirussi F. The global challenge of type 2 diabetes and the strategies for response in ethnic minority groups. Diabetes Metab Res Rev 2010;26(6):421–32.
- Wee LE, Wong J, Chin RT, et al. Hypertension management and lifestyle changes following screening for hypertension in an asian low socioeconomic status community: A prospective study. Ann Acad Med Singapore 2013;42(9):451–65.
- Department of Health and Ageing. National Aboriginal and Torres Strait Islander Health Plan 2013–2023. Canberra: DoHA, 2013.
- Rix EF, Barclay L, Wilson S, Stirling J, Tong A. Service providers’ perspectives, attitudes and beliefs on health services delivery for Aboriginal people receiving haemodialysis in rural Australia: A qualitative study. BMJ Open 2013;3(10):e00358–1
- Bradford D, Hansen D, Karunanithi M. Making an APPropriate care program for Indigenous cardiac disease: Customization of an existing cardiac rehabilitation program. Stud Health Technol Inform 2015;216:343–47.
- Brown A, O’Shea RL, Mott K, McBride KF, Lawson T, Jennings GL. Essential service standards for equitable national cardiovascular care for Aboriginal and Torres Strait Islander people. Heart Lung Circ 2015;24(2):126–41.
- Kritharides L, Lowe HC. Extracting the ESSENCE – Cardiovascular health for Aboriginal and Torres Strait Islander Australians. Heart Lung Circ 2015;24(2):107–09.
- Schembri L, Curran J, Collins L, et al. The effect of nutrition education on nutrition-related health outcomes of Aboriginal and Torres Strait Islander people: A systematic review. Aust N Z J Public Health 2016;40(Suppl 1):S42–47.
- Ski CF, Vale MJ, Bennett GR, et al. Improving access and equity in reducing cardiovascular risk: The Queensland Health model. Med J Aust 2015;202(3):148–52.