Leanness and type 2 diabetes in a population of indigenous Australians

Cardiometabolic Risk Markers for Aboriginal and Torres Strait Islander Children and Youths: A Systematic Review of Data Quality and Population Prevalence

Cardiovascular disease and type 2 diabetes mellitus are leading contributors to the health inequity experienced by Aboriginal and Torres Strait Islander peoples, and their antecedents can be identified from early childhood. We aimed to establish the quality of available data and the prevalence of cardiometabolic risk markers among Aboriginal and Torres Strait Islander children and youths (0-24-year-olds) to inform public health approaches. A systematic review of the peer-reviewed and grey literature was conducted between 1 January 2000-28 February 2021. Included studies reported population prevalence of cardiometabolic risks, including elevated blood pressure, obesity, central adiposity, dyslipidaemia, hyperglycaemia, and 'metabolic syndrome' for Aboriginal and Torres Strait Islander people aged 0-24 years. Fifteen studies provided population estimates. Data quality was limited by low response rates (10/15 studies) and suboptimal outcome measurements. Obesity is the most reported risk (13/15 studies). Aboriginal and Torres Strait Islander children have an excess risk of obesity from early childhood and prevalence increases with age: 32.1% of Aboriginal and Torres Strait Islander 18-24-year-olds had obesity and 50.8% had central adiposity. In a cohort of 486 9-14-year-olds in Darwin, 70% had ≥1 component of metabolic syndrome; 14% met the full criteria for the syndrome. The prevalence of cardiometabolic risk in Aboriginal and Torres Strait Islander young people is difficult to estimate due to limitations in measurement quality and sampling representativeness. Available data suggest that cardiometabolic risk markers are evident from early childhood. The establishment of national and state-level datasets and a core outcome set for cardiometabolic screening would provide opportunities for preventative action.

Prevalence and incidence of diabetes among Aboriginal people in remote communities of the Northern Territory, Australia: a retrospective, longitudinal data-linkage study

OBJECTIVES

To assess the prevalence and incidence of diabetes among Aboriginal peoples in remote communities of the Northern Territory (NT), Australia.

DESIGN

Retrospective cohort analysis of linked clinical and administrative data sets from 1 July 2012 to 30 June 2019.

SETTING

Remote health centres using the NT Government Primary Care Information System (51 out of a total of 84 remote health centres in the NT).

PARTICIPANTS

All Aboriginal clients residing in remote communities serviced by these health centres (N=21 267).

PRIMARY OUTCOME MEASURES

Diabetes diagnoses were established using hospital and primary care coding, biochemistry and prescription data.

RESULTS

Diabetes prevalence across all ages increased from 14.4% (95% CI: 13.9% to 14.9%) to 17.0% (95% CI: 16.5% to 17.5%) over 7 years. Among adults (≥20 years), the 2018/2019 diabetes prevalence was 28.6% (95% CI: 27.8% to 29.4%), being higher in Central Australia (39.5%, 95% CI: 37.8% to 41.1%) compared with the Top End region (24.2%, 95% CI: 23.3% to 25.1%, p<0.001). Between 2016/2017 and 2018/2019, diabetes incidence across all ages was 7.9 per 1000 person-years (95% CI: 7.3 to 8.7 per 1000 person-years). The adult incidence of diabetes was 12.6 per 1000 person-years (95% CI: 11.5 to 13.8 per 1000 person-years).

CONCLUSIONS

The burden of diabetes in the remote Aboriginal population of the NT is among the highest in the world. Strengthened systems of care and public health prevention strategies, developed in partnership with Aboriginal communities, are needed.

Antioxidant biomarkers and cardiometabolic risk markers in an Aboriginal community in remote Australia: a cross-sectional study

OBJECTIVE

High-quality diets, characterised by nutrient-rich foods, are one of the foundations for health and well-being. Indicators of diet quality, antioxidants, are associated with protection against cardiometabolic diseases. The current study explores relationships between plasma antioxidants and cardiometabolic risk among Aboriginal people in Australia.

DESIGN

As part of a community-driven health promotion programme, we conducted a cross-sectional study including a health-behaviour questionnaire, plasma antioxidants and cardiometabolic risk markers (anthropometric, blood pressure measurements, fasting glucose, glycated Hb (HbA1c), lipids, C-reactive protein and albumin-creatinine-ratio) continuous and categorised into population-specific cut-offs. Antioxidants (β-carotene, β-cryptoxanthin, lycopene, lutein-zeaxanthin, retinol and α-tocopherol measured using HPLC) were applied to a principal component analysis, which aggregated these into a single component. Linear regression models were applied to investigate associations between the antioxidant component and cardiometabolic risk markers.

SETTING

Community in a remote area in Northern Territory, Australia.

PARTICIPANTS

A total of 324 Aboriginal people, mean age 35·5 (range 15-75) years.

RESULTS

Antioxidant component levels were higher among individuals with higher self-reported vegetable intake (P < 0·01), higher among individuals with higher self-reported fruit intake (P = 0·05) and lower among current smokers (P = 0·06). Linear regression revealed an inverse association between the antioxidant component and C-reactive protein (β = -0·01, P < 0·01) after adjusting for confounders.

CONCLUSION

Higher plasma antioxidant levels, indicators of diet quality, were associated with lower levels of high-sensitivity C-reactive protein in this Aboriginal population in remote Australia. This association suggests plasma antioxidants may be protective against inflammation; however, longitudinal studies are needed to examine this potentially protective relationship.

Using health check data to investigate cognitive function in Aboriginal and Torres Strait Islanders living with diabetes in the Torres Strait, Australia

Background

Type 2 Diabetes (T2DM) has a subtle deleterious effect on cognition and imposes a higher lifetime risk of cognitive impairment and dementia. In populations where both T2DM and dementia are highly prevalent, understanding more about the early effects of T2DM on cognition may provide insights into the lifetime risks of this disease.

Methods

In 2016, 186 Australian Aboriginal and/or Torres Strait Islander residents of the Torres Strait (54% female, mean age =38.9 years, SD =15.9, range =15–74) participated in a community health check. The effect of diabetes (Type 1 or Type 2) on speed of thinking and working memory was assessed with the Cogstate Brief Battery (CBB) during the health check.

Results

One third of participants had diabetes (n = 56, 30.1%). After adjusting for age, education and previous iPad/Tablet experience, participants with diabetes had a small, yet significant reduction in accuracy on the One Back working memory task (β = −.076, p = .010, r² = .042). The effect was most pronounced among participants with diabetes aged 20–49 years (n = 20), who also had evidence of poorer diabetes control (eg HbA1c% ≥6.5, 76.6%), relative to participants with diabetes aged 50 years and over (n = 31) (HbA1c% ≥6.5, 32.0%, p = .005).

Conclusions

Early and subtle decrements in working memory may be a potential complication of diabetes among Aboriginal and Torres Strait Islander residents of the Torres Strait. Several potentially influential variables were not captured in this study (eg medication and diabetes duration). Greater preventative health resources are required for this population, particularly given the emerging elevated dementia rates linked to chronic disease.

A Smartphone App to Reduce Sugar-Sweetened Beverage Consumption Among Young Adults in Australian Remote Indigenous Communities: Design, Formative Evaluation and User-Testing

BACKGROUND

The disproportionate burden of noncommunicable disease among Indigenous Australians living in remote Indigenous communities (RICs) is a complex and persistent problem. Smartphones are increasingly being used by young Indigenous adults and therefore represent a promising method to engage them in programs seeking to improve nutritional intake.

OBJECTIVE

This study aimed to consult RIC members to inform the content of a smartphone app that can be used to monitor and reduce sugar-sweetened beverage intake in RICs.

METHODS

The study was conducted in two phases. The formative phase involved a simulated grocery selection activity with think aloud ("think aloud shop"), a semistructured interview, a questionnaire outlining current smartphone and app use, and a paper prototyping activity. A preliminary end-user testing phase involved a think aloud prototype test and a semistructured interview regarding user satisfaction. Convenience sampling was used to recruit 20 18- to 35-year-old smartphone users for each phase from two RICs in the Northern Territory, Australia. Thematic analysis of transcribed audio recordings was used to identify determinants of food choice from the think aloud shop; themes related to the Theory of Planned Behavior (TPB) from the eating behaviors interview; and usability, comprehension, and satisfaction with the app from the preliminary end-user testing.

RESULTS

Smartphone use in RICs is currently different to that found in urban environments; in particular, extremely low use of Facebook, restricted variety of phone types, and limited Internet access. Findings regarding promoting app engagement indicate that utilizing an opt-in approach to social features such as leader boards and team challenges is essential. The inclusion of games was also shown to be important for satisfaction, as were the use of audio features, contextually embedded dissemination, and streamlined app design for comprehension in this target group.

CONCLUSIONS

This research provides critical insights and concrete recommendations for the development of lifestyle improvement apps targeted toward disadvantaged young adults in nonurban settings, specifically RICs. It serves as a framework for future app development projects using a consultative user-centered design approach, supporting calls for the increased use of this strategy in app development.

Nutritional predictors of successful chronic disease prevention for a community cohort in Central Australia

OBJECTIVE

To investigate biomarkers of nutrition associated with chronic disease absence for an Aboriginal cohort.

DESIGN

Screening for nutritional biomarkers was completed at baseline (1995). Evidence of chronic disease (diabetes, CVD, chronic kidney disease or hypertension) was sought from primary health-care clinics, hospitals and death records over 10 years of follow-up. Principal components analysis was used to group baseline nutritional biomarkers and logistic regression modelling used to investigate associations between the principal components and chronic disease absence.

SETTING

Three Central Australian Aboriginal communities.

SUBJECTS

Aboriginal people (n 444, 286 of whom were without chronic disease at baseline) aged 15-82 years.

RESULTS

Principal components analysis grouped twelve nutritional biomarkers into four components: 'lipids'; 'adiposity'; 'dietary quality'; and 'habitus with inverse quality diet'. For the 286 individuals free of chronic disease at baseline, lower adiposity, lower lipids and better dietary quality components were each associated with the absence at follow-up of most chronic diseases examined, with the exception of chronic kidney disease. Low 'adiposity' component was associated with absence of diabetes, hypertension and CVD at follow-up. Low 'lipid' component was associated with absence of hypertension and CVD, and high 'dietary quality' component was associated with absence of CVD at follow-up.

CONCLUSIONS

Lowering or maintenance of the factors related to 'adiposity' and 'lipids' to healthy thresholds and increasing access to a healthy diet appear useful targets for chronic disease prevention for Aboriginal people in Central Australia.

Similarities and differences in cardiometabolic risk factors among remote Aboriginal Australian and Canadian cohorts

AIM

Indigenous populations of Australia and Canada experience disproportionately high rates of chronic disease. We hypothesized that despite the common outcome of increased diabetes prevalence, differences in cardiometabolic risk profile may exist between these populations.

METHODS

We compared community-based data on cardiometabolic risks in Aboriginal Australians (n=297 without, 45 with diabetes), and Aboriginal Canadians (n=409 without, 87 with diabetes).

RESULTS

Despite strikingly lower weight (62 vs 83 kg, p<0.0001) and body mass index (BMI, 22 vs 29 kg/m(2), p<0.0001), Aboriginal Australians without diabetes had similar waist-hip ratio (WHR, 0.91 vs 0.91, p=0.732), lower HDL-cholesterol (0.97 vs 1.25 mmol/L, p<0.0001) and higher HbA1c (5.4 vs 5.2%, p<0.0001) than Aboriginal Canadians without diabetes. Waist was the obesity measure most strongly related to diabetes or cardiometabolic risk in Australians while BMI performed similarly to other obesity measures only in Canadians. Multiple regression of HbA1c revealed age and fasting glucose as independent predictors in each study group, with the addition of WHR in Aboriginal Australians.

CONCLUSION

The notable finding was that waist or WHR are preferred obesity measures to appropriately reflect cardiometabolic risk in Aboriginal Australians, who although leaner by BMI criteria, displayed a similarly adverse risk profile to Aboriginal Canadians. Waist or WHR should be routinely included in clinical assessment in these high-risk populations.

Cardiovascular disease risk profile and microvascular complications of diabetes: comparison of Indigenous cohorts with diabetes in Australia and Canada

BACKGROUND

Indigenous populations of Australia and Canada experience disproportionately high rates of chronic disease. Our goal was to compare cardiovascular (CVD) risk profile and diabetes complications from three recent comprehensive studies of diabetes complications in different Indigenous populations in Australia and Canada.

METHODS

We compared participants from three recent studies: remote Indigenous Australians (2002-2003, n = 37 known diabetes), urban Indigenous Australians (2003-2005, n = 99 known diabetes), and remote Aboriginal Canadians (2001-2002, n = 188 known diabetes).

RESULTS

The three groups were similar for HbA1c, systolic BP, diabetes duration. Although leaner by body-mass-index criteria, remote Indigenous Australians displayed a more adverse CVD risk profile with respect to: waist-hip-ratio (1.03, 0.99, 0.94, remote Indigenous Australians, urban Indigenous Australians, remote Canadians, p < 0.001); HDL-cholesterol (0.82, 0.96, 1.17 mmol/L, p < 0.001); urine albumin-creatinine-ratio (10.3, 2.4, 4.5 mg/mmol); and C-reactive protein. With respect to diabetes complications, microalbuminuria (50%, 25%, 41%, p = 0.001) was more common among both remote groups than urban Indigenous Australians, but there were no differences for peripheral neuropathy, retinopathy or peripheral vascular disease.

CONCLUSIONS

Although there are many similarities in diabetes phenotype in Indigenous populations, this comparison demonstrates that CVD risk profiles and diabetes complications may differ among groups. Irrespective, management and intervention strategies are required from a young age in Indigenous populations and need to be designed in consultation with communities and tailored to community and individual needs.

Diabetes prevalence and determinants in Indigenous Australian populations: A systematic review

AIMS

To perform a systematic review of the prevalence of diabetes and impaired glucose tolerance (IGT) in Indigenous Australians in order to clarify overall patterns, by determinants such as age, gender, region, ethnicity and remoteness.

METHODS

The OVID interface to Medline and the Australian Indigenous HealthInfoNet databases were systematically searched from years 1997 to 2010. Studies reporting diabetes prevalence were included if they used population-based samples of Indigenous Australians. Diagnosis of diabetes was based on self-report or standard diagnostic criteria.

RESULTS

Twenty-four studies were included. The diabetes prevalence ranged from 3.5 to 33.1%; IGT estimates ranged from 4.7 to 21.1%. Prevalence was greater among Indigenous Australian women compared to men, the Northern Territory's Top End compared to Central Australia, Torres Strait Islanders compared to Aboriginals, older (≥35 years) compared to younger (<35 years) age groups, and remote compared to urban settings. Patterns of IGT prevalence were similar to those observed for diabetes.

CONCLUSIONS

Although the prevalence of diabetes and IGT is high, there appears to be considerable variation in prevalence between different segments of the Australian Indigenous population. Data on diabetes prevalence in the urban Australian Indigenous population is lacking, despite accounting for almost three quarters of the total population.

The epidemiology of community acquired bacteremic pneumonia, due to Streptococcus pneumoniae, in the Top End of the Northern Territory, Australia--over 22 years

BACKGROUND

Diseases caused by Streptococcus pneumoniae continue to cause substantial morbidity and mortality throughout the world. Furthermore, detrimental outcomes are more pronounced in some populations--such as those living in third world poverty, and Indigenous people who live in developed nations.

METHODS

This study describes the epidemiology of blood culture positive S. pneumoniae community-acquired pneumonia (CAP) in the Top End of the Northern Territory of Australia. Demographics, indigenous status, medical risk factors, serotype and outcomes were collected from adults presenting to hospital with blood culture positive S. pneumoniae CAP, from 1987 to 2008.

RESULTS

We report 205 cases, with a median age of 40 years. The average overall incidence rate ratio was 10.3 for indigenous adults compared with non-indigenous adults. There was no statistical difference between incidence rates pre and post-23-valent pneumococcal polysaccharide vaccine (23vPPV) introduction. Serotypes in presenting cases were predominantly (84.7%) 23vPPV types. The whole-population logistic regression model identified significant adjusted relative risks: 95% CI, for age 45 and older 1.6: 1.1, 2.2, indigenous 5.9: 3.7, 9.5, diabetes 2.3: 1.6, 3.3, excess alcohol 4.8: 2.8, 8.3, smoking 2.7: 1.9, 3.7 with indigenous+excess alcohol 18.5: 17.3, 19.7 as predictive for bacteremic S. pneumoniae CAP presentation.

CONCLUSIONS

Our results suggest that, the national 23vPPV program appears to be under-utilized. An integrated Public Health approach vigorously targeting indigenous adolescents, before substances such as alcohol and smoking are habitual, together with increased vaccine coverage, will reduce the burden of pneumococcal disease in this population.

Integrating an ecological approach into an Aboriginal community-based chronic disease prevention program: a longitudinal process evaluation

Background

Public health promotes an ecological approach to chronic disease prevention, however, little research has been conducted to assess the integration of an ecological approach in community-based prevention programs. This study sought to contribute to the evidence base by assessing the extent to which an ecological approach was integrated into an Aboriginal community-based cardiovascular disease (CVD) and type 2 diabetes prevention program, across three-intervention years.

Methods

Activity implementation forms were completed by interview with implementers and participant observation across three intervention years. A standardised ecological coding procedure was applied to assess participant recruitment settings, intervention targets, intervention strategy types, extent of ecologicalness and organisational partnering. Inter-rater reliability for two coders was assessed at Kappa = 0.76 (p < .0.001), 95% CI (0.58, 0.94).

Results

215 activities were implemented across three intervention years by the health program (HP) with some activities implemented in multiple years. Participants were recruited most frequently through organisational settings in years 1 and 2, and organisational and community settings in year 3. The most commonly utilised intervention targets were the individual (IND) as a direct target, and interpersonal (INT) and organisational (ORG) environments as indirect targets; policy (POL), and community (COM) were targeted least. Direct (HP→ IND) and indirect intervention strategies (i.e., HP→ INT→ IND, HP→ POL → IND) were used most often; networking strategies, which link at least two targets (i.e., HP→[ORG-ORG]→IND), were used the least. The program did not become more ecological over time.

Conclusions

The quantity of activities with IND, INT and ORG targets and the proportion of participants recruited through informal cultural networking demonstrate community commitment to prevention. Integration of an ecological approach would have been facilitated by greater inter-organisational collaboration and centralised planning. The upfront time required for community stakeholders to develop their capacity to mobilise around chronic disease is at odds with short-term funding cycles that emphasise organisational accountability.

The role of energy cost in food choices for an Aboriginal population in northern Australia

OBJECTIVE

To explore the relationship between dietary quality and energy density of foods (MJ/kg) and energy cost ($/MJ) for an Aboriginal population living in a remote region of northern Australia.

DESIGN

For a 3-month period in 2005, we collected food and non-alcoholic beverage supply data from food outlets available to the study population. From these data, we compared the energy density of foods with their energy cost.

MAIN OUTCOME MEASURES

Energy density and energy cost of food purchases.

RESULTS

The diet of the study population was high in refined carbohydrates and low in fresh fruit and vegetables. Foods with high energy density were associated with lower costs and contributed disproportionately to energy availability.

CONCLUSION

The energy-cost differential between energy-dense, nutrient-poor foods and energy-dilute, nutrient-rich foods influences the capacity of Australian Aboriginal people living in remote communities to attain a healthy diet. This is consistent with the "economics of food choice" theory, whereby people on low incomes maximise energy availability per dollar in their food purchasing patterns, and has particular relevance for developing nutrition policy and strategies in Aboriginal communities, where poor nutrition is a major determinant of preventable chronic disease.

Development and preliminary validation of the 'Caring for Country' questionnaire: measurement of an Indigenous Australian health determinant

BACKGROUND

'Caring for Country' is defined as Indigenous participation in interrelated activities with the objective of promoting ecological and human health. Ecological services on Indigenous-owned lands are belatedly attracting some institutional investment. However, the health outcomes associated with Indigenous participation in 'caring for country' activities have never been investigated. The aims of this study were to pilot and validate a questionnaire measuring caring for country as an Indigenous health determinant and to relate it to an external reference, obesity.

METHODS

Purposively sampled participants were 301 Indigenous adults aged 15 to 54 years, recruited during a cross-sectional program of preventive health checks in a remote Australian community. Questionnaire validation was undertaken with psychometric tests of internal consistency, reliability, exploratory factor analysis and confirmatory one-factor congeneric modelling. Accurate item weightings were derived from the model and used to create a single weighted composite score for caring for country. Multiple linear regression modelling was used to test associations between the caring for country score and body mass index adjusting for socio-demographic factors and health behaviours.

RESULTS

The questionnaire demonstrated adequate internal consistency, test-retest validity and proxy-respondent validity. Exploratory factor analysis of the 'caring for country' items produced a single factor solution that was confirmed via one-factor congeneric modelling. A significant and substantial association between greater participation in caring for country activities and lower body mass index was demonstrated. Adjusting for socio-demographic factors and health behaviours, an inter-quartile range rise in caring for country scores was associated with 6.1 Kg and 5.3 Kg less body weight for non-pregnant women and men respectively.

CONCLUSION

This study indicates preliminary support for the validity of the caring for country concept and a questionnaire designed to measure it. This study also highlights the importance of investigating Indigenous-asserted health promotion activities. Further studies in similar populations are merited to test the generalisability of this questionnaire and to explore associations with other important Indigenous health outcomes.

Development and preliminary validation of the 'Caring for Country' questionnaire: measurement of an Indigenous Australian health determinant

BACKGROUND

'Caring for Country' is defined as Indigenous participation in interrelated activities with the objective of promoting ecological and human health. Ecological services on Indigenous-owned lands are belatedly attracting some institutional investment. However, the health outcomes associated with Indigenous participation in 'caring for country' activities have never been investigated. The aims of this study were to pilot and validate a questionnaire measuring caring for country as an Indigenous health determinant and to relate it to an external reference, obesity.

METHODS

Purposively sampled participants were 301 Indigenous adults aged 15 to 54 years, recruited during a cross-sectional program of preventive health checks in a remote Australian community. Questionnaire validation was undertaken with psychometric tests of internal consistency, reliability, exploratory factor analysis and confirmatory one-factor congeneric modelling. Accurate item weightings were derived from the model and used to create a single weighted composite score for caring for country. Multiple linear regression modelling was used to test associations between the caring for country score and body mass index adjusting for socio-demographic factors and health behaviours.

RESULTS

The questionnaire demonstrated adequate internal consistency, test-retest validity and proxy-respondent validity. Exploratory factor analysis of the 'caring for country' items produced a single factor solution that was confirmed via one-factor congeneric modelling. A significant and substantial association between greater participation in caring for country activities and lower body mass index was demonstrated. Adjusting for socio-demographic factors and health behaviours, an inter-quartile range rise in caring for country scores was associated with 6.1 Kg and 5.3 Kg less body weight for non-pregnant women and men respectively.

CONCLUSION

This study indicates preliminary support for the validity of the caring for country concept and a questionnaire designed to measure it. This study also highlights the importance of investigating Indigenous-asserted health promotion activities. Further studies in similar populations are merited to test the generalisability of this questionnaire and to explore associations with other important Indigenous health outcomes.

Increased carotid intima-media thickness in remote and urban Indigenous Australians: impact of diabetes and components of the metabolic syndrome

OBJECTIVE

Indigenous Australians have rates of cardiovascular (CVD) mortality some seven to 10-fold higher than non-Indigenous Australians aged 25-64 years. We aimed to evaluate the impact of type 2 diabetes and components of the metabolic syndrome on carotid intima-media thickness (CIMT) as a marker of cardiovascular risk in Indigenous Australians living in remote and urban environments and in Australians of European ancestry.

DESIGN, PATIENTS AND MEASUREMENTS

CIMT was measured by high-resolution B-mode ultrasound imaging of the common carotid artery in 119 remote Indigenous, 144 urban Indigenous and 122 urban European Australians with and without diabetes.

RESULTS

In nondiabetic participants, CIMT was lowest in Europeans (mean (SD) 0.64 mm (0.10)), higher in urban Indigenous Australians (0.67 mm (0.12)) and highest in remote Indigenous Australians (0.73 mm (0.15), P < 0.001). CIMT was higher with diabetes with the same pattern observed between populations: 0.73 mm, 0.79 mm and 0.82 mm, respectively (P < 0.001). Traditional risk factors (age, male gender, blood pressure and HbA1c) explained 35-45% of the variance of CIMT within each population group. However, differences in CIMT between population groups were maintained after adjustment for these cardiovascular risks plus cholesterol and smoking (P < 0.001). Factor analysis revealed that variables of the metabolic syndrome, together with smoking and elevated C-reactive protein (CRP) and urinary albumin-creatinine ratio (ACR), are likely to explain the higher CIMT in Indigenous Australians (and the urban-remote gradient). Unmeasured variables (genetic, psychosocial and socioeconomic) may also contribute to higher CIMT in these populations.

CONCLUSION

Glycaemic control and metabolic syndrome components contribute significantly to premature atherogenesis in Indigenous Australians and we recommend that therapy should be targeted accordingly.