1. The Burden and Contributors to Cardiovascular Disease and Diabetes in Indigenous Australians Alex Brown Baker IDI

2. Years of Life Lost (YLL) for the leading disease and injury categories – Indigenous persons 2003 CVD & Diabetes The Health and Welfare of Australia’s Aboriginal and Torres Strait and Islander Peoples 2008 ABS Catalogue No. 4704.0 AIHW Catalogue No. IHW 21

3. Page 3: Baker IDI Contributors to the Gap 16.7 years 1996-200019.0 years 1996-2000 B/w 1996-2000 NCD - 77% Gap in LE Grp I - 15-16% CVD – 33% GUT – 9% DM – 9% Chronic Resp - 9% Injury – 8% Zhao and Dempsey, MJA 2006

4. Driving Life Expectancy Differentials Source: AIHW Chronic Disease and Associated Risk Factors in Australia, 2006.

5. Page 5: Baker IDI Risk factor prevalence in Australian populations - glucose intolerance Daniel M, Rowley KG, McDermott R, O’Dea K. Diabetes and impaired glucose tolerance in Aboriginal Australians: prevalence and risk. Diab Res Clin Pract 2002; 57: 23-33. Dunstan D et al. Diabesity and associated disorders in Australia 2000. International Diabetes Institute, Melbourne, 2000

6. DIABETES MORTALITY -AUSTRALIA Male Death Rates - DiabetesFemale Death Rates - Diabetes The Health and Welfare of Australia’s Aboriginal and Torres Strait and Islander Peoples 2008 ABS Catalogue No. 4704.0. AIHW Catalogue No. IHW 21

7. Cardiovascular Consequences of DM Clustered risk factors –MetS, dyslipidaemia, behavioural CHD - Diffuse /Multi-vessel Disease Silent Ischaemia Late diagnosis/recognition Complications of MI more frequent in DM –CHF Diabetic Cardiomyopathy PVD CVA Absolute risk equivalent to PMHx of CHD

8. Impact of DM on CHD Incidence – INTERHEART I

9. Page 9: Baker IDI DM, CKD and CHD in Indigenous Australians Wang and Hoy, Kidney Int 2005 Wang and Hoy. MJA 2005

10. CAD and Diabetes in Aboriginal People

11. Risk of Incident CVD in Aboriginal People – Central Australia (n=739) Rowley, Brown et al

12. DM AND CVD IN CENTRAL AUSTRALIA

13. Baseline Demographics and Clinical Characteristics, CASPA Cohort 2001-2002. Indigenous N=214 Non-Indigenous N=278 p-Value Mean age (± SD) years50.1 (12.5)59.3 (12.5)<0.001 Male (%)57.0%69.8%0.003 History of CHD39.3%45.5%0.166 Prior CABG3.3%9.4%0.008 Hypertension62.1%45.0%<0.001 Smoker (current)42.5%35.3%0.001 Dyslipidaemia34.1%38.5%0.318 Diabetes Mellitus55.6%30.2%<0.001 CKD (GFR <60)39.3%24.7%0.001 End stage renal failure16.4%1.8%<0.001 ACS Risk Stratification NSTEACS - High Risk STEMI 65.9% 22.9% 49.3% 20.5% <0.001 0.402 ACS onset in rural location112 (47.7%)23 (8.0%)< 0.001 Late Presentation >12hrs63 (28.5%)46 (17.1)0.002

14. ACS Co-Morbidity by Ethnicity 64 29 74 68 Indigenous (n=235) DM DM and CKD CKD 24 51 63 149 DM DM and CKD CKD Non-Indigenous (n=287) ACS and DM59% ACS + DM + CKD27% ACS + CKD12% ACS alone29% ACS + DM30% ACS + DM + CKD8% ACS + CKD18% ACS alone52% p=0.0001

15. Age Adjusted Survival and MACE-Free Survival – ACS [Males] Indigenous Non-Indigenous HR = 3.762 [2.15 - 6.58]; p < 0.001HR = 2.061 [1.40 - 3.02]; p < 0.001

16. CVD RISK PREDICTION AND DM WANG, ROWLEY, BROWN ET AL 2009

17. Page 17: Baker IDI Potential Pathophysiological Pathways linking Chronic Stress, Depression and Atherogenesis. Adapted from Rozanski et al Chronic Stress Negative Emotional States CNS Mediated Effects HPA Activation SNS Activation Adverse Behaviours ANS Dysfunction Insulin Resistance Obesity Inflammation Platelet Activation HPA Dysfunction Endothelial Dysfunction

18. Depression in Aboriginal men -MHM

20. INDEPENDANT CORRELATES OF OBESITY IN ABORIGINAL MEN

22. Diabetes and Heart Disease -The Rumsfeld Criteria “There are known knowns; there are things we know we know. We also know there are known unknowns; that is to say there are some things we know we do not know. But there are also unknown unknowns- the ones we don’t know we don’t know” Fmr US Sec Defence, Donald Rumsfeld

23. The Known Known's – CVD AND DM Extremely common DM is bad for your heart Independent contributor to CVD in men and women Independent predictor of adverse CVD outcomes Commonly co-morbid in Indigenous populations Accelerated atherogenesis the primary driver of excess death and morbidity in DM Same treatments are effective in DM We know what we have to do We know the system isn’t doing its job

24. Known Unknowns How to best deliver what needs to be done –Community based interventions –System level reforms –Reducing the evidence-practice gaps –Access Incorporating culture as a protective, preventative, management and palliative process SDIH Racism/Stress/Marginalisation – biopsychosocial pathways to DM/CVD Burden of CHF/interplay of DM among Indigenous peoples How best to engage the family as the unit of intervention Disadvantage across the life-course