Australian facts Diabetes 2008 D

Australian facts Diabetes 2008

Diabetes series no. 8

Australian Institute of Health and Welfare Canberra
Cat. no. CVD 40
Diabetes: Australian facts 2008 ii
The Australian Institute of Health and Welfare is Australia’s national health and welfare statistics and information agency. The Institute’s mission is better information and statistics for better health and wellbeing.
© Australian Institute of Health and Welfare 2008
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced without prior written permission from the Australian Institute of Health and Welfare. Requests and enquiries concerning reproduction and rights should be directed to the Head, Media and Communications Unit, Australian Institute of Health and Welfare, GPO Box 570, Canberra ACT 2601.
This publication is part of the Australian Institute of Health and Welfare’s Diabetes series. A complete list of the Institute’s publications is available from the Institute’s website <www.aihw.gov.au>.
ISSN 1444-8033
ISBN 978 174024 763 4
Suggested citation
Australian Institute of Health and Welfare 2008. Diabetes: Australian facts 2008. Diabetes series no. 8. Cat. no. CVD 40. Canberra: AIHW.
Australian Institute of Health and Welfare
Board Chair
Hon. Peter Collins, AM, QC
Director
Penny Allbon
Any enquiries about or comments on this publication should be directed to:
Dr Indrani Pieris-Caldwell
Cardiovascular Disease and Diabetes Unit
Australian Institute of Health and Welfare
GPO Box 570
Canberra ACT 2601
Phone: (02) 6244 1000
Email: diabetes@aihw.gov.au
Published by the Australian Institute of Health and Welfare
Printed by Pirion Pty Ltd, Canberra
Please note that as with all statistical reports there is the potential for minor revisions of data in this report over its life.
Please refer to the online version at <www.aihw.gov.au>.
iii
DIABETES AUSTRALIAN FACTS 2008
Contents
Acknowledgments ..................................................................................................... v
Abbreviations ........................................................................................................... vi
Symbols .................................................................................................................... vi
Summary and key ﬁndings .......................................................................................vii
1 Introduction ..........................................................................................................1
Background ....................2
Purpose and structure of the report ............................................................................................................2
2 How many people have diabetes? ............................................................................7
Introduction ...................8
Prevalence of diabetes ...8
Incidence of diabetes ...11
Type 1 diabetes ............12
Type 2 diabetes ............15
Gestational diabetes ....16
3 Risk factors for diabetes and its complications ..................................................... 19
Introduction .................20
Impaired glucose regulation .......................................................................................................................21
Physical inactivity .......23
Unhealthy diet .............24
Overweight ...................26
Tobacco smoking ..........29
High blood pressure .....30
High cholesterol and high triglycerides .....................................................................................................31
4 Complications of diabetes .................................................................................... 33
Introduction .................34
Cardiovascular disease 34
Eye disease ...................38
Kidney disease ............ 40
Nerve damage ..............42
Foot complications ..... 44
Oral complications ...... 46
Complications in pregnancy .......................................................................................................................47
Diabetes: Australian facts 2008 iv
5 Population groups ................................................................................................ 49
Aboriginal and Torres Strait Islander people ............................................................................................50
Socioeconomic position ...............................................................................................................................54
Geographical location ..58
Overseas-born ..............63
6 Use of health services ........................................................................................... 69
Introduction .................70
Medical and allied health services..............................................................................................................70
Hospitalisations ...........72
Medicines use ...............74
Pathology and other tests ...........................................................................................................................77
Programs and services 77
7 Impact ................................................................................................................. 79
Introduction .................80
Quality of life ...............80
Burden of disease .........83
Costs ........................... 84
8 Mortality ............................................................................................................. 87
Diabetes as the underlying cause of death................................................................................................ 88
Diabetes as an underlying or associated cause of death ...........................................................................90
Diabetes-related deaths ..............................................................................................................................91
Causes of death commonly listed with diabetes .......................................................................................91
Deaths of people on the National Diabetes Register ...............................................................................92
Appendixes .............................................................................................................. 93
Appendix 1: Methods, deﬁnitions and main data sources .......................................................................94
Appendix 2: Diabetes indicator data reference table ..............................................................................102
Glossary ................................................................................................................ 105
References ............................................................................................................. 109
List of tables .......................................................................................................... 117
List of ﬁgures ........................................................................................................ 118
v
Acknowledgments
This report was authored by Indrani Pieris-Caldwell, Mardi Templeton, Claire Ryan and Lynelle Moon of the National Centre for Monitoring Diabetes at the Australian Institute of Health and Welfare.
Contributions of Kathleen O’Brien in the early stages of the project and Sandra Ofei, who carried
out extensive analysis and drafting of sections, are gratefully acknowledged. Assistance received
from Anne-Marie Waters, Elizabeth Penm, Bin Tong and Therese Bourke is also greatly
appreciated.
Refereeing of various sections by Stephen Colagiuri, Maria Craig, Jeﬀ Flack, Mark Harris, Jonathan Shaw, Tim Mathew, Paul Magnus, Fadwa Al-Yaman, Helena Britt, Maxine Robinson and Glynis Ross was invaluable in ﬁnalising this report.
The following individuals are acknowledged for their valuable comments on the analysis and presentations of data that were in the domain of their expertise: Louise Catanzariti, Susana Senes, Wen Xingyan, George Bodilsen, Robert Van der
Hoek, Ilona Brockway, Lyle Baker, Gary Hanson, Maxine Robinson and Vanna Mabbott. Valuable comments from individuals of the Australian Government Department of Health and Ageing are also acknowledged.
This report was prepared under the guidance of the National Diabetes Data Working Group (NDDWG), chaired by Associate Professor Jeff Flack.
Members of the NDDWG at the time
of publication were: Daryl Cathro, Stephen
Colagiuri, Maria Craig, Rhonda Griffiths, Robert
Guthrie, Mark Harris, Lynelle Moon, Glynis Ross,
Jonathan Shaw and Annette Gath.
Funding from the Australian Government
Department of Health and Ageing contributed to
the production of this report.
Finally, thanks go to staff of the AIHW
‘Information Services and Publishing’ and
‘Business Promotion and Media’ units, in
particular Peter Nolan and Belinda Hellyer, for
their assistance with publishing and releasing
this report.
Diabetes: Australian facts 2008 vi
Abbreviations
ABS Australian Bureau of Statistics
AIHW Australian Institute of Health and Welfare
ANDIAB Australian National Diabetes Information Audit and Benchmarking
ANZDATA Australia and New Zealand Dialysis and Transplant Registry
APEG Australasian Paediatric Endocrine Group
AusDiab Australian Diabetes, Obesity and Lifestyle study
BEACH The Bettering the Evaluation and Care of Health study
BMI body mass index
CHD coronary heart disease
CVD cardiovascular disease
DoHA Australian Government Department of Health and Ageing
DDD defined daily dose
ESKD end-stage kidney disease
GDM gestational diabetes mellitus
GP General Practitioner
HbA1c glycosylated haemoglobin
HDL high-density lipoprotein
ICD-10 International Statistical Classification of Diseases and Related Health Problems, 10th revision
ICD-10-AM International Statistical Classification of Diseases and Related Health Problems, 10th revision, Australian modification
IFG impaired fasting glucose
LDL low-density lipoprotein
NATSIHS National Aboriginal and Torres Strait Islander Health Survey
NDR National Diabetes Register
NDS National Diabetes Strategy
NDSS National Diabetes Services Scheme
NHS National Health Survey
OGTT oral glucose tolerance test
PVD peripheral vascular disease
WHO World Health Organization
Symbols
$ Australian dollars, unless otherwise specified
– nil or rounded to zero
% per cent
g gram
kJ kilojoule
mmHg millimetres of mercury
mmol/L millimoles per litre
n.a. not available
> greater than
≥ greater than or equal to
< less than
≤ less than or equal to
n.r not reported
Summary vii
Summary

Summary and key findings
Diabetes: Australian facts 2008 is the second in the
series of national reports providing an overview
of diabetes, a serious chronic disease affecting
many Australians. The report contains the most
recent national data on prevalence, incidence,
risk factors, and complications of diabetes. In this
edition, a separate chapter on diabetes in speciﬁc
population groups is also included.
Some of the main ﬁndings about the impact of
diabetes on the Australian community are given
below.
Its prevalence continues to rise. The most
recent national data show that the prevalence
of diagnosed diabetes more than doubled
between 1989–90 and 2004–05. Diabetes and its
complications were responsible for around 8% of
the total burden of disease in Australia in 2003.
It can have severe complications. Notably
a person with diabetes is at greater risk of
developing cardiovascular, eye and kidney
diseases. In 2004–05 people with diabetes were
twice as likely as those without it to have a heart
attack and four times as likely to have a stroke.
People with diabetes were twice as likely to have
cataract or glaucoma as those without diabetes
and nearly a third of people starting treatment
for end stage kidney disease did so because of
diabetic nephropathy.
Type 2 diabetes is largely preventable. Control
of modiﬁable risk factors, such as overweight
and obesity and physical inactivity, are central
to preventing Type 2 diabetes and can help
reduce the complications associated with
diabetes. However, prevalence of a key risk factor,
overweight and obesity, is increasing.
Some population groups are at much higher
risk. Aboriginal and Torres Strait Islander
peoples are 3 times as likely as non-Indigenous
people to have diabetes and have much greater
hospitalisation and death rates than other
Australians. Diabetes prevalence and death
rates for the worst-oﬀ ﬁfth of the population are
nearly twice as high as for the best-oﬀ ﬁfth of the
population.
More detailed ﬁndings of the report are given in
the next section ‘Key ﬁndings’.
Diabetes: Australian facts 2008 viii
Key findings
… which reduces quality of life
People with diabetes were more likely to rate
their own health as fair or poor (48%) than
those without diabetes (15%) in 2004–05.
People with diabetes were more likely than
those without diabetes to report high or very
high levels of psychological distress (18%
compared with 12% respectively).
… and has serious complications
Heart disease rates are higher in people with
diabetes. In 2004–05 people with diabetes
were twice as likely as those without it to have
a heart attack (age-standardised rate of 3% and
1.5% respectively) and over 3 times as likely to
have a stroke (age-standardised rate of 9% and
2%).
People with diabetes are much more likely to
suffer eye problems:
About 22% of people with previously
diagnosed Type 2 diabetes and 6.2% of
people with newly diagnosed Type 2 had
retinopathy in 1999–2000.
Self-reported data for 2004–05 showed that
9% of people with diabetes had cataracts and
6% had glaucoma, twice the rates reported by
people without diabetes.
Visual disturbances or loss of vision, or
complete or partial blindness was reported
by 7% of people with diabetes. About 2%
of people with diabetes were completely or
partially blind.
In 2005, nearly a third of people starting
treatment for end stage kidney disease (ESKD)
did so because of diabetic nephropathy. This
was an increase of 28% since 2001.
Nerve damage is a common complication of
diabetes and in extreme situations can lead
to leg or foot amputations. In 1999–2000,
over 10% of males and 9.4% of females with
newly diagnosed diabetes had clinical signs of
neuropathy.
Diabetes is one of the leading chronic
diseases affecting Australians…
An estimated 700,000 Australians (3.6% of
the population) had diagnosed diabetes in
2004–05.
In addition, there are many more cases of
diabetes that have not been diagnosed. The
most recent national data on this indicate one
undiagnosed case for every one diagnosed case.
In 2005, nearly 3% of deaths in Australia were
directly due to diabetes and it contributed to
another 6% of deaths—nearly 12,000 deaths in
total.
Diabetes was responsible for 5.5% of the total
burden of disease in Australia in 2003; 92% of
this burden was due to Type 2 diabetes, which
is by far the most common type. When the
contribution of diabetes to stroke and heart
disease is also included, it accounted for 8.3%
of the total disease burden.
Diabetes in Australia continues to rise…
Between 1989–90 and 2004–05, the
proportion of people with diagnosed diabetes
more than doubled from 1.3% to 3.6%.
The rise is largely driven by an increase in the
prevalence of Type 2 diabetes; however, Type 1
diabetes and gestational diabetes are also on
the rise.
Between 2000–01 and 2004–05, the rates of
diabetes hospitalisation increased by 35%,
from 1,932 hospitalisations per 100,000 people
to 2,608 per 100,000.
It is a serious disease….
It was treated in over 500,000 hospitalisations
in 2004–05.
More than half (56%) of the people with
diagnosed diabetes in 2003 also had a
disability. A quarter considered diabetes as the
main condition causing their disability.

Key findings ix

In 2004–05 there were 3,394 lower limb
amputations among people with diabetes.
More males than females had lower
limb amputations in that period (70% of
amputations were for males).
In 1999–2000 about 30% of men with
self-reported diabetes were suffering from
impotence which is likely to be linked to their
diabetes.
Diabetes and its complications incur
substantial health system costs
The direct health-care expenditure on diabetes
in 2004–05 was $907 million, which accounted
for nearly 2% of the allocatable recurrent
health expenditure in that year.
Not all diabetes is the same…
Type 1 affects 10%–15% of people with
diabetes. It requires daily insulin therapy for survival.
In 2005, nearly 1,700 persons under age 40
years were ﬁrst diagnosed with Type 1 diabetes
in that year. This equates to 23 new cases per
100,000 children aged 0–14 years and 11 new
cases per 100,000 for people aged 15–39 years.
About 83% of self-reported cases of diagnosed
diabetes in 2004–05 were Type 2. Type 2
diabetes is more common among people aged
45 years or over and is marked by the inability
of the body to use insulin properly (insulin
resistance) and reduced levels of insulin.
Around 1 in 20 pregnant women are affected by
gestational diabetes mellitus (GDM)—a form
of diabetes that develops during pregnancy
in some women and is a strong marker for the
later development of Type 2 diabetes.
Of women giving birth in Australian hospitals
in 2004–05, 4.2% (10,900 births) had GDM.

Control of modifiable risk factors is the
key to prevention
Overweight and physical inactivity are the
main modiﬁable risk factors responsible for
Type 2 diabetes.
In 2004–05, an estimated 51% of Australians
aged 15 years and over were overweight or
obese (based on self-reported information).
People with diabetes are more likely than
those without diabetes to be overweight or
obese (69% compared with 51%, respectively,
in 2004–05). Being overweight or obese also
increases their risk of diabetes complications
such as coronary heart disease (CHD), stroke
and peripheral vascular disease (PVD).
An estimated 70% of Australians aged 15 years
or over in 2004–05 did insuffcient physical
activity, as did two out of three people with
diabetes.
Some population groups are more
susceptible to diabetes than others
Aboriginal and Torres Strait Islander peoples
In 2004–05, the prevalence of diabetes among
Indigenous people was estimated to be over 3
times the rate of non-Indigenous people.
In the same year, 62% of Indigenous people
aged 15 years and over were estimated to be
either overweight or obese, compared with 51%
of non-Indigenous people.
Diabetes hospitalisations for Indigenous
people were nearly 11 times as high as for other
Australians in 2004–05. Hospitalisations for
kidney complications among Indigenous people
were 29 times as high as for other Australian
people.
The death rate from diabetes among Indigenous
people was almost 12 times that experienced
by non-Indigenous Australians.

KEY FINDINGS CONTINUED OVERLEAF
Diabetes: Australian facts 2008 x
Death rates from renal complications among
Indigenous people were 19 times that of
non-Indigenous people and deaths from
CHD, stroke, PVD and lower limb ulcers were
approximately 7 times as high.
People from lower socioeconomic groups
Diabetes prevalence rates among people in
the ﬁfth of the population with the lowest
socioeconomic position are nearly twice as high
as those in the ﬁfth of the population with the
highest socioeconomic position.
Diabetes death rates increased with decreasing
socioeconomic position. During 2003–2005,
the diabetes death rate in the lowest
socioeconomic group was nearly twice the rate
in highest socioeconomic group.
People from different geographical areas
In 2004–05, the respective hospitalisation
rates for diabetes among people living in
Remote and Very Remote areas were 2 and 3
times as high as the rate for people living in
Major Cities.

The death rate from diabetes among people
living in Remote and Very Remote areas was
2 and 4 times that experienced by people in
Major Cities.
People born overseas
People born in some overseas countries have
higher rates of diabetes than those born
in Australia: diabetes prevalence was 7%
among those born in North Africa and the
Middle-East, 6% among those born in South-
East Asia and 5% in each of the populations
born in Southern and Eastern Europe and
Oceanic countries (excludes Australia), while
Australian-born people had a prevalence rate
of 3%.
Death rates from diabetes among people born
overseas were higher than the rate among
Australian-born people. The highest rates were
recorded for those born in South-East Europe
and North Africa and the Middle-East (60%
and 50% as high as the rate for Australian born).

1
1 Introduction
Background ..........................................................................2
Purpose and structure of the report ................................2
Diabetes: Australian facts 2008 2
Background
Diabetes is one of the leading chronic diseases
in many countries, and is now reaching epidemic
levels. If left unchecked, 1 in 14 adults or
an estimated 380 million people worldwide
are predicted to have diabetes by 2025 (IDF
2006). Diabetes is associated with a range of
complications including coronary artery and
peripheral vascular disease, stroke, diabetic
neuropathy, amputations, renal failure and
blindness, and can cause much disability, poor
quality of life and premature death, especially if
left undiagnosed or poorly controlled (IDF 2006).
Diabetes imposes a large burden on the health
system and on some communities and in 2003,
diabetes accounted for over 5% of the disease
burden in Australia (AIHW: Begg et al. 2007).
Diabetes also carries with it an increased risk
of ischaemic heart disease and stroke and the
associated burden has not been included in the
above ﬁgures. When this risk was accounted for,
the burden attributable to diabetes increased to
8.3% of total disease burden.
Purpose and structure of the report
Diabetes: Australian facts 2008 provides an
overview of diabetes and its impact on the
Australian community. The report presents the
latest available statistics on diabetes, including
information on risk factors, complications,
health service use, and the impact of the disease
(including mortality) on Australians. The report
includes both summary and trend data related to
diabetes in Australia and information useful for
health professionals, policy makers, academics
and other interested readers. However, the report
is not designed to be a source of personal medical
advice.
This is the second national report on diabetes
compiled by the National Centre for Monitoring
Diabetes, at the Australian Institute of Health
and Welfare (AIHW). As part of the National
Health Priority Area program, the Australian
Government Department of Health and Ageing
(DoHA) allocated funding for the establishment
of the National System for Monitoring Diabetes.
Although Australia previously had national data
sources relevant to the monitoring of diabetes, it
lacked an integrated system to coordinate these
resources and their analysis. The National Centre
for Monitoring Diabetes, with advice from an
expert advisory committee, fullﬁlls this function
by producing reports and other information on
various aspects of diabetes.
The lack of good quality national data in many
areas limits a full understanding of the true
impact of diabetes on Australian society and
has also inﬂuenced the structure and content of
this report. For example, current information
examining the psychosocial effect of the disease
on people with diabetes and their carers are
not available. Importantly, the most recent
information on diabetes prevalence and risk
factors from a national blood survey is now
becoming quite dated, having been collected in
1999–2000.
More information on data gaps and deﬁciencies
for monitoring diabetes can be found in the latest
publication National indicators for monitoring
diabetes: Report of the Diabetes Indicators Review
Subcommittee of the National Diabetes Data
Working Group (AIHW 2007).
What is diabetes?
Diabetes mellitus (diabetes) is a disease marked
by high blood glucose levels resulting from
defective insulin production, insulin action
or both (WHO 1999). There are several types
of diabetes, with different causes and clinical
histories: Type 1, Type 2, gestational diabetes and
other types (Box 1.1). Other types of diabetes
are relatively uncommon therefore only the
three main types of diabetes—Type 1, Type 2
and gestational diabetes—are discussed in this
report.
Diabetes in the Australian population
Based on self-reported data from the most recent
National Health Survey (NHS), an estimated
700,000 people (3.6% of Australians) had
diagnosed diabetes in 2004–05. Of those people
reporting long-term diabetes, -
* 13% had Type 1 diabetes,
* 83% had Type 2 diabetes; and
* 4% had an unknown type of diabetes.

Type 2 diabetes occurs mainly among people aged 40 years or more
(WHO 1999) but in recent times Type 2 diabetes
has been increasingly seen in children and young
people (Craig et al. 2007; McMahon et al. 2004).
There is evidence that the incidence of Type 1
diabetes is increasing among children (AIHW:
2007; Haynes et al. 2004; Taplin et al. 2005).
Although only a small proportion of children
are affected by diabetes, the impact of diabetes
on their health is often severe, both during
childhood and later in life.
Some population groups including Aboriginal
and Torres Strait Islander, and people born in
some other countries, are at an increased risk
of Type 2 diabetes (AIHW: Dixon & Webbie
2005; Craig et al. 2007), which is due to a
combination of genetic, biological, behavioural
and environmental risk factors (AIHW: Thow &
Waters 2005; Zimmet et al. 2001). In 2004–05,
the age standardised-rate of diabetes among
Aboriginal and Torres Strait Islander peoples
was over 3 times the rate in non-Indigenous
people (ABS 2006b). During the same period, the
age-standardised prevalence of diabetes among
people born in Southern and Central Asia was
8.7%, North Africa and the Middle East 6.6%,
South East Asia 5.7% and Southern and Eastern
Europe 4.9%. In contrast, the prevalence rate of
diabetes among Australian-born people was 3.3%
(ABS 2006a).
Untreated diabetes can lead to complications
involving many parts of the body, particularly
the heart, kidneys, eyes and feet. In Australia,
diabetes is the most common reason for renal
dialysis, and the most common cause of blindness
in people under age 60 years, non-traumatic
lower-limb amputation and cardiovascular
disease (Barr et al. 2006).
The national strategy
In recognition of the impact that diabetes has on
the Australian community, and the potential for
improved health outcomes, Australian Health
Ministers agreed in 1996 to make diabetes
mellitus a National Health Priority Area. The aim
of this initiative was to focus public attention on
diseases that present a signiﬁcant health burden,
where there is a potential for health gain through
prevention and treatment programs.
In 1999, the National Diabetes Strategy (NDS)
was endorsed by all Australian Health Ministers.
The NDS was developed to assist governments
and service providers in identifying key areas
for action aimed at improving the health of
Australians with, or at risk of, diabetes. The NDS
aims to achieve this by coordinating the wide
range of activities undertaken across Australia
Box 1.1: Types of diabetes
Type 1 diabetes mostly arises in children or young adults, though it can occur at any age. It is marked by the inability to produce insulin. People with Type 1 diabetes need insulin replacement for survival.
Type 1 diabetes accounts for approximately 10–15% of all diabetes cases.
Type 2 diabetes is the most common form of diabetes, which occurs mostly in people aged 50 years or over. Although uncommon in childhood, it is becoming increasingly recognised in that group.
People with Type 2 diabetes produce insulin but may not produce enough or cannot use it effectively.
Type 2 diabetes may be managed with changes to diet and exercise, oral glucose-lowering drugs, insulin injections, or a combination of these.
Gestational diabetes is a form of diabetes that develops during pregnancy in some women. It involves high blood sugar levels appearing for the first time during pregnancy among women who have not previously been diagnosed with other forms of diabetes. It usually disappears after the baby is born; however, it can recur in later pregnancies. It is also a marker of increased risk of developing Type 2 diabetes later in life. Some cases of gestational diabetes are managed with changes to diet and exercise alone and some may require insulin treatment.
Diabetes: Australian facts 2008 4
to improve the prevention, early detection and
management of diabetes.
Key initiatives under the National Diabetes
Strategy (NDS) include:
National Service Improvement Framework for Diabetes
National Integrated Diabetes Program
National Diabetes Services Scheme (NDSS)
Diabetes Prevention Pilot Initiative
Evidence-based guidelines for the management of diabetes
The Australian Diabetes, Obesity and Lifestyle Study
support for diabetes research
National Centre for Monitoring Diabetes
National Diabetes Register (NDR)
National Diabetes Improvement Projects
Australian National Diabetes Information
Audit and Benchmarking (ANDIAB) project.
Information on these initiatives can be found at
the DoHA website <www.health.gov.au>.
Structure of the report
This report presents information in eight
thematic chapters. This introductory chapter
provides some background information, describes
what diabetes is and its different types, and
summarises its overall level and impact. Chapter
2 provides information on the number of people
with diabetes and Chapter 3 presents information
on risk factors for diabetes and its complications.
The major complications of diabetes are discussed
in Chapter 4. Diabetes prevalence, complications
and risk factors of diabetes for speciﬁc population
groups are discussed in Chapter 5, and Chapter
6 presents available data on the use of health
services in diabetes management.
Chapter 7 covers the impact of diabetes, including information on quality of life, disability, disease burden and economic costs.
Mortality from diabetes is presented as a separate chapter
(Chapter 8) in this edition of the report.
Appendix 1 describes the methods and main data
sources used in this report. Appendix 2 refers the
reader to where information related to national
indicators for monitoring diabetes can be found.
Some epidemiological concepts used in the report
are described in the glossary.
What is new in this edition?
This second edition of this report on diabetes in
Australia updates information presented in the
2002 edition, wherever possible. More extensive
data and analysis have been able to be included in
many areas of the report.
Considerable new information on the number of
people with diabetes has been incorporated, and
this information on the incidence and prevalence
of diabetes is contained in Chapter 2. This chapter
also includes several years of data from the NDR,
which was only very new at the time of the ﬁrst
edition of this report. Thus trends in incidence
of Type 1 diabetes can now be examined at the
national level.
Another major change in this edition is the
inclusion of a separate chapter on diabetes in
speciﬁc population groups. The ﬁrst edition
contains this information throughout the report,
but in this edition separate sections on diabetes
in Indigenous people, people living in regional
areas, people born overseas and people from
different socioeconomic groups are included in
Chapter 5.
Main data sources used in the report
A brief summary of the data sources is
provided below. Further details are provided in
Appendix 1.
The 2004–05 NHS data are used extensively
throughout the report and provide self-reported
information on diabetes, including prevalence,
risk factors and some complications.
The National Aboriginal and Torres Strait
Islander Health Survey (NATSIHS) 2004–05
collected information relating to Indigenous
peoples, including health status, health action
taken and lifestyle factors that may inﬂuence
health. This survey covered information similar
to the NHS including health status, health risk
factors, long-term conditions, health service
use, social and emotional wellbeing and basic
demographic information. Information from
this survey is mainly presented in Chapter 5
(Aboriginal and Torres Strait Islander peoples
section).
The 1999–2000 Australian Diabetes and Lifestyle
Study (AusDiab) collected actual physical
measurements (such as blood pressure) and
blood specimens in people aged 25 years and
over and thus provided more accurate estimates
of diabetes prevalence, its risk factors and
complications for this age group. Although the
AusDiab study is older than the 2004–05 NHS,
it is the most recent national source providing
measured data on various aspects of diabetes in
Australia.
The NDR collects information about people
who use insulin as part of their treatment of
diabetes. It includes data for persons who began
to use insulin from 1 January 1999. Data for the
register are obtained from two main sources:
the National Diabetes Services Scheme, which is
administered by Diabetes Australia Ltd, and the
Australasian Paediatric Endocrine Group (APEG)
state-based registers. APEG registers collect
information about children with diabetes aged
less than 15 years.
The 2004 National Drug Strategy Household
Survey (NDSHS) includes data on the drug use,
perceptions and attitudes of almost 30,000
Australians aged 12 years and older. Data from
the NDSHS are self-reported. In this report, the
prevalence of tobacco smoking was obtained from
this source.
The Australian National Diabetes Information
Audit and Benchmarking (ANDIAB) data
collection compiles information from audits
of patients attending a selection of specialist
diabetes centres and specialist endocrinologists
in private practice. It reports data on over 5,000
persons with diabetes requiring specialist clinical
management, in particular those who have had
poor control of their diabetes.
The AIHW National Hospital Morbidity Database
contains demographic, diagnostic, procedural and
duration-of-stay information on episodes of care
for patients admitted to hospital. In this report,
disease data relate to the principal diagnosis
unless otherwise speciﬁed.
The AIHW National Mortality Database contains
information on the underlying and additional
causes of death, along with demographic
information about deceased persons based on
information supplied by the medical practitioner
certifying the death or by a coroner.

7
2 How many people have diabetes?
Introduction .........................................................................8
Prevalence of diabetes .......................................................8
Incidence of diabetes .......................................................11
Type 1 diabetes ..................................................................12
Type 2 diabetes ................................................................. 15
Gestational diabetes ........................................................ 16
Diabetes: Australian facts 2008 8
Introduction
Recent increases in the number of people with
diabetes have led to a number of claims that
we are in an ‘epidemic’ of diabetes (Colagiuri
et al. 2005). There is much concern about the
likely effect of this epidemic on individual and
population health, and its wider social and
economic impacts. Therefore our estimates on
the magnitude of the problem are essential
for monitoring the impact of the disease and
prevention strategies, and for planning and
providing services to people with diabetes.
Two measures of disease occurrence are included
here: prevalence and incidence. Both of these
measures described below are important in
describing the occurrence of diabetes.
Prevalence is the number of people with diabetes
at a point in time. In this report, the time
point is a single day in the case of continuous
data collections such as the National Diabetes
Services Scheme, or the day the respondent was
questioned in the case of the various surveys.
Information is presented here both in terms of
the absolute number of cases, and as a percentage
of the population.
Incidence is the number of new cases of diabetes
during a period of time. The period of time
used in this report is calendar years. As well as
the absolute number of new cases, this is also
expressed as a rate: the number of new cases
during the year divided by the population at risk
(multiplied by 100,000).
This chapter has ﬁve sections. The ﬁrst provides
information on the prevalence of all diabetes—
how many people have any type of diabetes. The
second section contains available information
on the incidence of all diabetes regardless of
type. Then three sections that follow describe the
prevalence and incidence of the main types of
diabetes—Type 1, Type 2 and gestational diabetes.
Prevalence of diabetes
There are two main data sources of national
diabetes prevalence in Australia. The ﬁrst is
the 1999–2000 Australian Diabetes, Obesity
and Lifestyle Study (AusDiab study), in which
diabetes prevalence was estimated on the basis
of measured blood sugar levels. The second is
the Australian Bureau of Statistics (ABS) series
of National Health Surveys, in which prevalence
estimates are based on self-reported information.
Note that gestational diabetes is excluded from
the NHS estimates in this chapter.
Measured data, such as those collected in the
AusDiab study, provide more accurate estimates
of the prevalence of diabetes than self-reported
survey data. Diabetes prevalence derived
from measured data can be estimated for both
diagnosed and previously undiagnosed cases.
The accuracy of self-reported data, such as those
collected in the NHS, relies on respondents being
aware of and accurately reporting their health
status, and therefore will not include previously
undiagnosed cases of diabetes. However, because
the NHS is conducted regularly, it is able to
provide recent information and produce trends on
the prevalence of diagnosed diabetes over time.
Measurement data
The latest available national information on the
prevalence of diabetes using data collected as
part of a survey that included blood samples is
the 1999–2000 AusDiab study. Based on data
from that study, it has been estimated that nearly
880,000 Australian adults aged 25 or over had
diabetes in 1999–2000, constituting 7.4% of the
population (more than 1 in 14 people). The vast
majority (96%) of diabetes cases in adults aged 25
years and over were Type 2.
The proportion of people with diabetes increased
with age (Figure 2.1). Fewer than 3% of adults
aged 35–44 years had diabetes. The rate then
steadily increased to 23% for people aged 75 years
and over.
The rates were higher for males than females
in most age groups, particularly for the middle
groups between 55 and 74 years of age.
The AusDiab study found that a large proportion
of total diabetes cases were undiagnosed—half of
the cases detected in the survey had not previously
been diagnosed. There was little variation in this
pattern across age groups (Figure 2.2).
Another estimate of the proportion of undiagnosed
diabetes cases was obtained in the Northwest
Adelaide Health Study (NWAHS) conducted during
2000–2003. This study found fewer undiagnosed
cases than the AusDiab study (see Box 2.1).
In 2000–2003, the NWAHS found that 6.6%
of the population aged 18 years and over had
diabetes. Blood measurements were taken;
however, there are a number of reasons why
this estimate cannot be directly compared with
the AusDiab estimate. These include the use of
different blood tests (outlined in Box 2.1) and
different scopes (age range and geographical
populations covered).
The NWAHS found similar age and sex patterns
to the AusDiab study. The percentage of people
in the population with diabetes was higher in
males compared with females, and the percentage
increased with age.
Little information is available on trends
in diabetes based on measurement data.
Comparisons can be made between the National
Heart Foundation (NHF) Risk Factor Prevalence
Survey conducted in 1983 and the 1999–2000
AusDiab survey. The valid comparison is for the
overlapping population of 25–64 year olds living
in capital cities. Diabetes cases are included if the
fasting plasma sugar was 7.0 mmol/l or more.
Using this comparison and adjusting for age,
1.2% of this population had diabetes in 1983. By
1999–2000, this had increased to 3.2%.
0
5
10
15
20
25
25–34 35–44 45–54 55–64 65–74 75+
Age group (years)
Males
Females
Per cent
Source: AIHW analysis of the 1999–2000 AusDiab study.
Figure 2.1: Age-specific prevalence of diabetes, by sex,
1999–2000
0
5
10
15
20
25
25–34 35–44 45–54 55–64 65–74 75+
Age group (years)
Undiagnosed
Diagnosed
Per cent
Source: AIHW analysis of the 1999–2000 AusDiab study.
Figure 2.2: Age-specific prevalence of diagnosed and
undiagnosed diabetes, 1999–2000
Box 2.1: Diagnosed versus undiagnosed
diabetes?
The following two Australian studies have
examined the ratio of diagnosed versus
undiagnosed diabetes.
1999–2000 Australian Diabetes and Lifestyle
Study (AusDiab) In the 1999–2000 AusDiab
study, people with known (diagnosed)
diabetes were defined as those receiving
treatment in the form of tablets or insulin at
the time of the study or who had been told by
a doctor or nurse that they had diabetes and
had a fasting blood sugar level of at least 7.0
mmol/L or a 2-hr post load sugar level of at
least 11.1 mmol/L. People with undiagnosed
diabetes were defined as those who had never
been diagnosed with diabetes and were not
receiving treatment and who had a fasting
blood sugar level of at least 7.0 mmol/L or a 2-hr
post load sugar level of at least 11.1 mmol/L.
The study found a ratio of 1:1 for diagnosed
versus undiagnosed diabetes; in other words,
for every known case of diabetes there was one
newly diagnosed case (Dunstan et al. 2002).
North West Adelaide Health Study (NWAHS) In
the NWAHS, people with diagnosed diabetes
were defined as those reporting that they had
been told by a doctor that they had diabetes.
People with previously undiagnosed diabetes
were defined as having a fasting plasma sugar
level of at least 7.0 mmol/L but did not report
having been told by a doctor that they had
diabetes. The study found a ratio of 1:5–6 for
diagnosed versus undiagnosed diabetes; in
other words, for approximately every five or six
people with diagnosed diabetes, one person
had undiagnosed diabetes (Grant 2005).
Diabetes: Australian facts 2008 10
Self-reported data
Self-reported data are easier to collect than
measurement data but have certain limitations:
the data cannot identify undiagnosed cases, and
they rely on the respondent accurately reporting
that they have been diagnosed with diabetes.
From self-reported data in the 2004–05
NHS, about 700,000 Australians (3.6% of the
population) had been diagnosed with diabetes
(ABS 2006b). The proportion of people with
diabetes increased with age, and the highest
prevalence rates were for those aged 65–74 years
(Figure 2.3). Males had a higher prevalence than
females (4.0% and 3.2%, respectively).
The NHS found that, among people with diabetes,
13% had Type 1 diabetes, while 83% had Type 2 and
a further 4% did not know which type they had.
The number of people with diabetes has increased
substantially in recent years. Results from the
four National Health Surveys indicate that
the number of people with diagnosed diabetes
more than doubled between 1989–90 and
2004–05 from around 250,000 to 640,000 (agestandardised).
The corresponding percentage of
the population with diabetes increased from 1.3%
to 3.3% (Figure 2.4). This is a substantial increase,
believed to be related to more people developing
diabetes, people living longer with the disease,
and potentially better detection of the disease
(Colaguiri et al. 2005).
International comparisons
Comparisons of the percentage of people with
diabetes in 20 other OECD countries show
that Australia, with a prevalence rate of 5%, is
towards the bottom of this group of countries
(Figure 2.5). These estimates of the prevalence
for people aged 20 to 79 years of age have been
adjusted for differences in the age structure of the
populations. The highest rate (>10%) was found in
Mexico, while the lowest rate (around 3%) was in
the United Kingdom.
Per cent
Age group (years)
0
3
6
9
12
15
75+ 65–74 55–64 45–54 35–44 25–34 <25
Note: Based on self-reported data.
Source: AIHW analysis of the ABS 2004–05 National Health Survey data.
Figure 2.3: Age-specific prevalence of diagnosed
diabetes, 2004–05
Per cent
Year
0
1
2
3
4
2004–05 2001 1995 1989–90
Notes
1. Directly age-standardised to the 2001 Australian population.
2. Based on self-reported data.
Sources: AIHW analysis of the 1989–90, 1995, 2001 and 2004–05 ABS
National Health Survey data.
Figure 2.4: Trends in the prevalence of diagnosed
diabetes, 1989–90 to 2004–05
How many people have diabetes? 11
How many people have diabetes?

Incidence of diabetes
There is limited national information on the
incidence of diabetes in Australia. The exception
is Type 1 diabetes for which there are good
incidence data from 1999 onwards from the NDR.
In addition state-level incidence data has been
published from Western Australia since the 1980s
and New South Wales since 1990 (Haynes et al.
2004; Taplin 2005; Craig 2007).
This section presents available information on
the incidence of all diabetes, while subsequent
sections present more detail on different types of
diabetes where available.
Disease register and administrative data
Recent evidence from disease registers and
administrative data shows that there are at least
45,000 new cases—about 1 new case for every
450 people—of diagnosed diabetes (excluding
gestational diabetes) each year (Table 2.1). This
includes around 5,000 new cases of diabetes
that are insulin-treated (new cases of Type 1
diabetes and new cases of Type 2 and ‘other
diabetes’ starting insulin treatment within
approximately a year of diagnosis). Registration
data for the NDSS show that, by 30 September
2006, there were at least another 40,000 people
newly diagnosed in 2003 who do not use insulin.
There is also a sizeable proportion of NDSS
registrations where diagnosis year is missing:
19% of people registered since 2003 do not
have a diagnosis year recorded. At least some
of these cases are likely to have been diagnosed
in 2003. Distributing the registrations without
diagnosis year according to the distribution of
the cases that did have a diagnosis year leads to
another 12,000 registrations that may have been
diagnosed in 2003.
Using the latest available national hospital
data, each year there are around 11,000 cases
of diagnosed gestational diabetes. This estimate
comes from counting the number of deliveries in
hospital where gestational diabetes was recorded
in the hospital record (see Gestational diabetes
section for more information).
Per cent
0 1 2 3 4 5 6 7 8 9 10 11 12
Mexico
Austria
Germany
Switerland
Hungary
Czech Republic
Poland
Slovak Republic
New Zealand
Finland
France
Spain
Portugal
Denmark
Sweden
Belgium
Luxembourg
Ireland
Australia
Japan
United Kingdom
Source: International Diabetes Federation 2006.
Figure 2.5: Estimated diabetes prevalence, 20–79 year olds, 2007
Diabetes: Australian facts 2008 12
Cohort study
The AusDiab 5-year follow-up study determined
that 0.8% of Australian adults aged 25 years and
over developed diabetes (excluding gestational
diabetes) each year between 2000 and 2005.
This corresponds to an estimated 275 people
developing the disease each day, or around
100,000 per year. Overall, there were more
new cases of diabetes per year for males than
for females; for males the incidence of diabetes
peaked between the ages of 55 and 74 years while
for females the incidence was highest for those
aged 65 years and over (Barr et al. 2006). Note
that only around 75% of these cases identiﬁed
using only one blood sample (the standard
practice in these types of surveys) would be
expected to be true clinical cases (WHO 2006).
Therefore this number should be seen as an upper
limit of the number of cases developing.
It is unlikely that 100,000 people will be diagnosed
with diabetes in a year. However, for a number
of reasons it is diffcult to compare this estimate
of newly developed cases of diabetes with the
ones presented above on new cases of diagnosed
diabetes. First, a proportion of the estimated new
cases found in a survey would not be true cases
(as explained above). Second, a proportion would
also remain undiagnosed, though for an unknown
period of time. It is also not known whether the
proportion of undiagnosed cases is changing over
time. Third, there are complex ﬂows of people
moving from not having diabetes to having it,
then from being undiagnosed to being diagnosed.
People are not necessarily diagnosed in the year
they develop diabetes, and the gap between
developing diabetes and being diagnosed is likely
to vary between individuals.
Type 1 diabetes
Type 1 diabetes usually arises in childhood
or youth (though it can occur at any age) and
is characterised by the inability to produce
insulin. People with Type 1 diabetes need insulin
replacement for survival.
Risk factors
No modiﬁable risk factors have been clearly
identiﬁed for Type 1 diabetes. It is currently
thought that a combination of genetic and
environmental factors are involved in the
Table 2.1: New cases of diagnosed diabetes recorded in disease register and administrative data by year of diagnosis,
2003–2005
Type of diabetes(b)
New insulin-treated
diabetes per year
National Diabetes Services
Scheme registrants(a)
Deliveries in hospital with
gestational diabetes per year
Estimate of total
new cases(c)
National Diabetes
Register, 2003–2005
NDSS database, diagnosed
2003
AIHW National Hospital
Morbidity Database,
2003–04 to 2004–05(c)
Type 1 2,000 (refer to NDR data) – 2,000
Type 2 3,100 43,100 – 43,100
Gestational 1,700 6,700 10,800 10,800
Other 100 300 – 300
Total excl gestational 5,200 45,400 – 45,400
Total 6,900 52,100 10,800 56,200
(a) As at 30 September 2006. Excluding NDSS registrations with missing diagnosis year information (19% of registrations occurring since 1 January 2003). Only
cases diagnosed in 2003 have been used in this estimate due to the known time delay between diagnosis and registration for a proportion of people with
Type 2 diabetes.
(b) Data from the National Diabetes Register and the National Diabetes Services Scheme data are grouped using ‘derived type of diabetes’ (AIHW: Catanzariti
et al. 2007). Gestational diabetes cases in the hospital data are identified using ICD-10-AM code O24.4, and have only been counted when present at the
time of delivery.
(c) Estimate of the number of new cases as recorded in these databases.
Note: Numbers rounded to nearest 100.
Sources: National Diabetes Register, AIHW analysis of National Diabetes Services Scheme database, AIHW analysis of AIHW National Hospital Morbidity Database.
How many people have diabetes? 13
How many people have diabetes?

development of the disease (Daneman 2006;
Devendra et al. 2004), though research continues
into the exact nature of these risk factors.
Some environmental risk factors being
researched include: viruses, nutrition including
early consumption of cow’s milk and vitamin D
exposure (Yoon et al. 1999; Vaarala 2005; Greer
et al. 2007; Littorin et al. 2006).
How many Australians have Type 1
diabetes?
Prevalence
There is limited information available that can
be used to accurately determine the number of
people in Australia with Type 1 diabetes. An
indication of Type 1 diabetes prevalence can be
obtained from four sources—the NHS, the NDSS,
the NDR, and the Australian Diabetes, Obesity
and Lifestyle Study (AusDiab). However each of
these has limitations, as indicated below. Due to
the nature of Type 1 diabetes, undiagnosed cases
will not complicate the assessment of prevalence.
Based on self-reported data from the NHS,
Type 1 diabetes accounted for 13% of all diabetes
cases reported in 2004–05. This corresponds
to an estimated 91,900 (0.4%) Australians
affected by the disease in 2004–05. However,
the type of diabetes is not accurately reported by
participants in population surveys. Validation of
the 1995 NHS using other information collected
in the survey indicated that only around half
of the people reporting Type 1 diabetes were
estimated to have Type 1 diabetes.
Another indication of prevalence can be obtained
using the NDSS data. As at 30 September 2006,
there was an estimated maximum of 122,300
people registered with Type 1 diabetes on
the NDSS (AIHW analysis of the NDSS data).
However, it is likely that a proportion of these
people have Type 2 diabetes rather than Type 1.
The proportion falling into this category cannot
be estimated from the database due to missing
diagnosis information.
Further information on the number of people with
Type 1 diabetes in particular subgroups can be
obtained from the NDR (people diagnosed since
1999) and AusDiab (people aged 25 years and over).
There were 12,700 registrants on the NDR with
derived Type 1 diabetes who were still alive at the
end of 2005. This represents the total number
of people diagnosed with Type 1 diabetes in the
7 years between 1999 and 2005 who did not die
during that period.
Based on data from the 1999–2000 AusDiab
study, Type 1 diabetes accounted for around
8.1% of all diagnosed diabetes in people aged 25
years and over—affecting approximately 35,500
Australians in this age group.
Incidence
The NDR collects information on new cases
of insulin-treated diabetes. NDR records for
0–14 year olds are received from the NDSS and
the Australasian Paediatric Endocrine Group
(APEG) state and territory databases. As a
result, coverage of new cases of insulin-treated
diabetes under 15 years of age is considered to
be high thus producing reliable estimates of
Type 1 diabetes incidence (AIHW: Catanzariti
et al. 2007). For 15–39 year olds, the incidence
estimates are adjusted to account for NDSS
registrants not consenting to be on the NDR.
According the NDR, there were 1,689 new cases
of Type 1 diabetes diagnosed in 2005 among
people aged less than 40 years (Table 2.2). The
annual incidence of Type 1 diabetes for 0–14 year
olds was 22.6 cases per 100,000 population and
10.9 cases per 100,000 population for people
aged 15–39. There is substantial variation within
these broad age ranges. For children, the highest
rates were for the 10–14 year age group (28.0
per 100,000). For young adults, the highest rate
occurred in the 15–19 year age group (17.5 per
100,000). Males accounted for 58% of cases,
and incidence rates were higher for males than
females across nearly all age groups.
Trends
There was a signiﬁcant increase in the incidence
of Type 1 diabetes between 1999 and 2005; over
the seven years, the age-adjusted rate of new
cases among those aged 0–14 increased from 18.1
per 100,000 population in 1999, to 22.6 in 2005
(AIHW: Catanzariti et al. 2007). The incidence
remained relatively stable for people aged 15–39
years (around 15 per 100,000 for males and 10
per 100,000 for females).
Diabetes: Australian facts 2008 14
International comparisons
Australia’s incidence rate for Type 1 diabetes in
the late 1990s to early 2000s was at the upper
end of the range of estimates for OECD countries
(Figure 2.6). Three of the Nordic countries had
the highest rates (up to 41 per 100,000), followed
by Australia, the United Kingdom and Canada
with rates around 22–23 per 100,000. The lowest
rate was 8.4 per 100,000 in Italy.
Table 2.2: Incidence of Type 1 diabetes among those aged 0–39 years at their first insulin use, by age and sex, 2005
Males Females Persons
Number Rate Number Rate Number Rate
0–4 years 109 16.8 92 14.9 201 15.9
5–9 years 156 23.0 154 23.9 310 23.5
10–14 years 207 29.0 183 27.0 390 28.0
Total 0–14(a) 472 23.0 429 22.1 901 22.6
15–19 years 150 21.1 93 13.7 243 17.5
20–24 years 112 15.3 70 10.0 182 12.7
25–29 years 96 13.9 48 7.1 144 10.6
30–34 years 101 13.5 38 5.0 139 9.2
35–39 years 54 7.4 26 3.5 80 5.4
Total 15–39(a) 513 14.1 275 7.7 788 10.9
Total 0–39 985 704 1,689
(a) Directly age-standardised to the 2001 Austalian population.
Source: AIHW: Catanzariti et al. 2007.
Per cent
0 5 10 15 20 25 30 35 40 45
Finland
Sweden
Norway
Australia
United Kingdom
Canada
Denmark
Netherlands
Germany
New Zealand
Czech Republic
United States
Luxembourg
Slovak Republic
Austria
Poland
Spain
Hungary
Greece
Switzerland
Italy
Sources: International Diabetes Federation 2006, National Diabetes Register.
Figure 2.6: Incidence of Type 1 diabetes in OECD countries, 0–14 year olds, late 1990s to early 2000s
How many people have diabetes? 15
How many people have diabetes?

Type 2 diabetes
Type 2 is the most common form of diabetes. It
occurs mostly in people aged 40 years and over
and is marked by reduced or less effective insulin.
Although uncommon in childhood, it is becoming
increasingly recognised in that group.
Risk factors
A number of risk factors are implicated in the
development of Type 2 diabetes. These may act
alone, but often act together in complex interplay.
Consideration of combinations of risk factors is
important as it may explain why some population
subgroups have higher rates of diabetes than
others. Table 2.3 outlines the risk factors for
Type 2 diabetes.
How many Australians have Type 2 diabetes?
Prevalence
From the 1999–2000 AusDiab study, it has been
estimated that nearly 840,000 Australian adults
aged 25 years or above had Type 2 diabetes
in 1999–2000, which constitutes 7.1% of the
population. These cases represent the vast
majority (96%) of cases identiﬁed in the survey.
Based on self-reported data from the NHS,
Type 2 diabetes accounted for 83% of all diabetes
in 2004–05. This corresponds to an estimated
582,800 (3%) Australians.
Prevalence estimates based on measured data
are much higher than those based on self-reports
because they include people with undiagnosed
diabetes. In addition, the ﬁgures from the NHS
apply to the whole population, while AusDiab
only covers adults aged 25 years and over.
Sex and age
As the vast majority of diabetes cases detected
in AusDiab were Type 2, the age and sex patterns
shown in the overall prevalence results earlier
in this chapter also hold for Type 2 diabetes.
There was a higher prevalence of Type 2 diabetes
in males than females (age-standardised rate
of 7.6% compared with 6.5%). Type 2 diabetes
increased with age: being highest in the age group
75 years and over (22%).
Based on 2004–05 NHS data, the agestandardised
prevalence of self-reported
Type 2 diabetes in the general population was 1%
higher for males than for females: 3% and 2%,
respectively. The proportion of people reporting
Type 2 diabetes increased with age, and the
highest prevalence rates appeared for those aged
65 years and over (Figure 2.7).
Per cent
Age group (years)
0
3
6
9
12
15
Females
Males
75+ 65–74 55–64 45–54 35–44 25–34 <25
Note: Based on self-reported data.
Source: AIHW analysis of ABS 2004–05 National Health Survey data.
Figure 2.7: Age-specific prevalence of diagnosed Type 2
diabetes 2004–05
Trends
The prevalence of diagnosed Type 2 diabetes has
increased substantially in recent years. From the
National Health Surveys, it has increased from
Table 2.3: Risk factors for Type 2 diabetes
Demographic Genetic Lifestyle and behavioural Biomedical/metabolic
Age Ethnicity Diet Intra-uterine growth retardation
Urbanisation Family history Obesity (especially abdominal) Previous gestational diabetes
Specific genes have
been identified
Physical inactivity
Foetal nutrition
Impaired sugar regulation (i.e. impaired
fasting sugar, impaired sugar tolerance)
Diabetes: Australian facts 2008 16
1.7% of the Australian population in 1995 to
2.9% in 2004–05 (Figure 2.8). This increase in
the age-standardised rate reﬂects a likely increase
in the incidence of Type 2 diabetes, better
survival for people with Type 2 diabetes, and also
potentially an increase in the detection of the
disease (Colagiuri et al. 2005).
Per cent
Year
0.0
0.5
1.0
1.5
2.0
2.5
3.0
2004–05 2001 1995
Note: Based on self-reported data.
Sources: AIHW analysis of ABS 1995, 2001 and 2004–05 National Health
Survey data.
Figure 2.8: Trends in the prevalence of diagnosed Type 2
diabetes, 1995 to 2004–05
Less information is available on trends in the
prevalence of Type 2 diabetes including the
undiagnosed cases. As the majority of diabetes
cases are Type 2, it is likely that much of the
increase in overall diabetes between 1983 and
1999–2000 described in the prevalence section
earlier in this chapter (from 1.1 to 2.9% for
people aged 25–64 years living in capital cities)
was in the Type 2 subgroup.
Incidence
The NDR provides information on the incidence
of the subset of Type 2 diabetes that is insulin treated.
In 2005, around 11,400 with Type 2
diabetes used insulin to treat their condition for
the ﬁrst time. Just over 2,700 of these were also
newly diagnosed Type 2 cases in that year.
The 5-year follow-up AusDiab study provides an
estimate of diabetes incidence (Barr et al. 2006).
Results for Type 1 and Type 2 diabetes were not
reported separately as the vast majority of cases
were for Type 2 diabetes. Thus the results outlined
in the prevalence of diabetes section earlier in this
chapter are largely about Type 2 diabetes.
Gestational diabetes
Gestational diabetes is diabetes ﬁrst diagnosed
during pregnancy (gestation). It may disappear
after pregnancy, but signals a high risk of
diabetes occurring later in life.
Risk factors
Pregnant women who are at higher risk of
developing gestational diabetes include:
older mothers (risk increases with age)
those with a history of sugar intolerance or
gestational diabetes
those from certain high-risk ethnic groups,
such as Indigenous Australians, and people
from the Indian subcontinent, the Paciﬁc
Islands, Asia or the Middle East
women with a family history of diabetes
women with a history of ‘large for gestational
age’ babies
women who are overweight or obese before
their pregnancy.
Gestational diabetes may occur in women who
have no identiﬁable risk factors, which is why
the Australasian Diabetes in Pregnancy Society
(ADIPS) recommends screening for all women.
How many Australian women are
affected by gestational diabetes?
The Australasian Diabetes in Pregnancy Society
estimates that about 5% of pregnant women are
affected by gestational diabetes (ADIPS 2007).
Based on self-reported data from the NHS,
gestational diabetes accounted for approximately
3% of all diabetes identiﬁed in 2004–05
NHS; this corresponds to an estimated 7,930
Australian women affected by the disease at the
time of the survey.
Another assessment of the number of women
diagnosed with gestational diabetes can be
obtained using the AIHW National Hospital
Morbidity Database. During 2004–05, around
10,900 women giving birth in hospital also
had diagnosed gestational diabetes, which is
4.2% of hospital births in that year. A third
(32.7%) of these gestational diabetes cases were
in women over the age of 35 years, while only
one-ﬁfth (19.9%) of the deliveries occurred in
this age group. As not all pregnant women are
screened for gestational diabetes, it is likely that
a proportion of cases remains undiagnosed, and
therefore would not be included in these ﬁgures.
Trends
Trends in hospitalisations indicate that
gestational diabetes as any diagnosis has
increased over the last 5 years, from 12,300 in
2000–01 to 14,900 in 2004–05 (Figure 2.9).
Similarly, the number of deliveries in hospital
where gestational diabetes was diagnosed has
increased over the same period. In 2000–01,
8,900 women delivering babies in hospital had
diagnosed gestational diabetes (3.6% of these
births). By 2004–05, this had increased to almost
10,900 (4.2% of births in hospital). Some of
this increase is likely to be due to the increasing
average age of mothers (Laws et al. 2006).
Number of hospitalisations
Year
0
2,500
5,000
7,500
10,000
12,500
15,000
Deliveries with gestational diabetes
Hospitalisations with gestational diabetes
2004–05 2003–04 2002–03 2001–02 2000–01
Note: Gestational diabetes is classified according to ICD-10-AM code
O244, for principal or additional diagnosis. Deliveries are classified
according to ICD-10-AM code Z37.
Source: AIHW National Hospital Morbidity Database.
Figure 2.9: Trends in hospitalisations with gestational
diabetes, 2000–01 to 2004–05

19
3 Risk factors for diabetes and its
complications
Introduction ...................................................................... 20
Impaired glucose regulation .......................................... 21
Physical inactivity............................................................. 23
Unhealthy diet .................................................................. 24
Overweight ....................................................................... 26
Tobacco smoking ............................................................. 29
High blood pressure ........................................................ 30
High cholesterol and high triglycerides ....................... 31
Diabetes: Australian facts 2008 20
Introduction
A risk factor is the term given to a range of
health-related behaviours and biomedical
conditions that can impact on the health of an
individual in a negative way. Risk factors include
both modiﬁable and non-modiﬁable factors and
for diabetes and its complications, they include
genetic, behavioural and biomedical factors
(Centers for Disease Control and Prevention
2005; WHO 1999). The determinants of health,
however, go beyond these to the underlying
social, economic, psychological and cultural
factors that can contribute to disease (AIHW
2006a).
Assessing the prevalence of risk factors in the
population is useful in understanding trends
in disease prevalence, incidence and deaths, as
well as predicting future trends, and can help
explain why some groups have better or worse
health than others. Monitoring prevalence
can also provide insight into the success
of health-related campaigns or the need to
initiate health-promotion interventions.
What are the risk factors for
diabetes and its complications?
Many factors contribute to the onset and
development of diabetes. Type 1 diabetes is
believed to be caused by particular biological
interactions and exposure to environment agents
among people genetically predisposed to diabetes
(Atkinson & Eisenbarth 2001; Daneman 2006).
Several behavioural and modiﬁable risk factors
play a role in the onset of Type 2 diabetes,
including obesity, physical inactivity and
unhealthy diet, as does genetic predisposition
such as family history, ethnic background and
age (Shaw & Chisholm 2003). In 2003, high body
mass and physical inactivity together explained
60% of the disease burden (in terms of Disability
Adjusted Life Years) from Type 2 diabetes (See
Chapter 7 for more information). High body
mass was the largest contributor (55%) to
Type 2 diabetes while the contribution of physical
inactivity was 24% (AIHW: Begg et al. 2007).
There is some evidence that depression can
increase the risk of developing Type 2 diabetes
and diabetes complications (Arroyo et al. 2004;
Brown et al. 2005b; Carnethon et al. 2003;
Golden et al. 2004). The increased risk for Type 2
diabetes may be due to elevated stress levels and
weight gain (Diabetes Australia 2006b).
Poor foetal nutrition leading to low birth-weight
for gestational age is another factor that may
predispose some individuals to Type 2 diabetes. If
these individuals are exposed to other risk factors
(such as obesity and physical inactivity) the
likelihood of developing Type 2 diabetes becomes
greater (Forsen et al. 2000; WHO 1999; Barker
1999; Hales & Barker 2001).
The risk factors for gestational diabetes are
similar to those for Type 2 diabetes: women are at
higher risk if they are of relatively advanced age
or obese when pregnant (Virjee et al. 2001).
There are also a number of additional risk
factors for diabetes complications (see Chapter
4), including high blood pressure, high blood
cholesterol and tobacco smoking (WHO 1999).
Recent studies have suggested that tobacco
smoking may also be a risk factor for developing
insulin-resistant Type 2 diabetes (Meisinger et al.
2006), although the evidence for this is far more
limited compared with other recognised risk
factors.
The metabolic syndrome—the clustering of a
number of risk factors including abdominal
obesity, impaired fasting blood glucose, raised
blood pressure, raised blood triglycerides and
reduced blood HDL-cholesterol—substantially
increases the risk of Type 2 diabetes. The
prevalence of the metabolic syndrome among
Australians aged 25 years and over was 29% in
the AusDiab stucy, conducted in 1999–2000. The
2004–05 AusDiab follow-up study showed an
annual incidence rate for the metabolic syndrome
of 3% (3.8% in males and 2.4% in females) (Barr
et al. 2006).
Risk factors such as physical inactivity, poor diet
and tobacco smoking can inﬂuence biomedical
risk factors, including impaired glucose
regulation, overweight, high blood pressure and
high cholesterol. Behavioural and biomedical risk
factors have the potential to be modiﬁed.
The risk factors presented in this chapter are:
* impaired glucose regulation
* physical inactivity
* unhealthy diet
* overweight
* tobacco smoking
* high blood pressure
* high blood cholesterol and triglycerides.
Impaired glucose regulation
Impaired glucose regulation is the metabolic
state between normal glucose regulation and
diabetes (WHO 1999). There are two categories
of impaired glucose regulation: impaired fasting
glucose (IFG) and impaired glucose tolerance
(IGT). IFG and IGT are not considered to be
clinical entities in their own right but rather risk
factors for the future development of diabetes
and cardiovascular disease (Twigg et al. 2007;
NHMRC 2001).
Early treatment and improved management of
impaired glucose regulation could reduce the
incidence of Type 2 diabetes (Bennett 1999; Shaw
& Chisholm 2003). In a review of six studies
exploring IFG and IGT as predictors of future
diabetes, it was found that in the majority of
the populations studied, 60% of people who
developed diabetes had either IGT or IFG ﬁve
years before they were diagnosed with diabetes
(Unwin et al. 2002).
There is some evidence that lifestyle changes
incorporating increased physical activity
and healthy eating could reduce or stop the
progression of IFG and IGT to diabetes. For
example, results from a longitudinal study by
Tuomilehto et al. (2001) showed that lifestyle
intervention such as counselling aimed at
reducing weight and total fat intake and
increasing ﬁbre intake and physical activity
among obese adults with IGT reduced the rate of
progression to diabetes by 40–60% over a 3 to 6
year period.

How is impaired glucose regulation defined?
IFG and IGT are measured using an Oral Glucose
Tolerance Test (OGTT)—the same test used
to measure diabetes. In the OGTT a blood
glucose measurement is taken after a period
of approximately 8 hours of fasting. Another
measurement is taken 2 hours after consuming
75 g of glucose. IFG represents abnormalities
of glucose regulation immediately after an
overnight fast while IGT represents abnormalities
of glucose regulation 2 hours after consuming
75 g of glucose, often in the form of a high sugar drink.
IFG is diagnosed when the OGTT results show
that the fasting blood glucose level (that is the
measurement taken immediately after fasting)
is more than 6.1 mmol/L but less than 7.0
mmol/L, and the blood glucose level 2 hours after
consuming the glucose is less than 7.8 mmol/L.
This means that the fasting blood glucose level is
higher than normal but does not rise abnormally
after taking 75 g of glucose (Diabetes Australia
2003).
IGT is diagnosed when OGTT results show that
the fasting blood glucose level is less than 7.0
mmol/L and the blood glucose level 2 hours after
consuming the glucose is more than 7.8 mmol/L,
but less than or equal to 11.0 mmol/L.
Diabetes is detected when the fasting blood
glucose level is greater than or equal to 7.0 mmol/
L and the 2 hour 75 g OGTT blood glucose level is
greater than or equal to 11.1 mmol/L.
Who is affected by impaired
glucose regulation?
As with Type 2 diabetes, impaired glucose
regulation is most common in people who
are overweight or obese, physically inactive,
have high levels of triglycerides, low high
density lipoprotein (HDL) cholesterol, high
total cholesterol and high blood pressure. The
prevention of risk factors for impaired glucose
regulation can reduce the progression to Type 2
diabetes.
Diabetes: Australian facts 2008 22
How many Australians have
impaired glucose regulation?
Prevalence
Based on measured data from the 1999–
2000 AusDiab study, it was estimated that
approximately one in six Australians aged 25
years or over had impaired glucose regulation,
with IGT more prevalent than IFG (10.6% and
5.8%, respectively) (Table 3.1).
Table 3.1: Prevalence of impaired glucose regulation
among adults aged 25 years and over, 1999–2000
Males Females Persons
Per cent
Impaired glucose regulation 17.4 15.4 16.4
Impaired glucose tolerance 9.2 11.9 10.6
Impaired fasting glucose 8.1 3.4 5.8
Source: AIHW analysis of the 1999–2000 AusDiab study.
A comparison of results from the 1981 Busselton
Study and 1999–2000 AusDiab study suggests a
substantial increase for both males (3% to 10%)
and females (3% to 12%) in the age-standardised
prevalence of IGT (Dunstan et al. 2001).
Age and sex
The prevalence of impaired glucose regulation
varies with sex and age as well as the category of
glucose regulation. For example, the 1999–2000
AusDiab study found that the overall prevalence
of IFG was signiﬁcantly higher in males than
females (8.1% compared with 3.4%) (Table 3.1).
This pattern is consistent with results of other
studies which report IFG in males being 1.5 to
3 times as high as in females (DECODE Study
Group 2003; DECODA Study Group 2003).
The age distribution of IFG indicates that the
prevalence of IFG peaks in females aged 75
years and over and in males aged 55–64 years
(Figure 3.1). The prevalence of IFG declines for
males from age 65 years. There is a rapid increase
in IFG in females aged 75 years and over, at which
point the female prevalence of IFG exceeds that
of males.
In contrast, the prevalence of IGT was higher
in females than males for ages 25 to 74 years.
However, from age 75 years the prevalence of IGT
was higher for males than for females. Unlike
the distribution of IFG by age, the prevalence of
IGT increased steadily with age for both sexes
(Figure 3.2).
Per cent
Age group (years)
0
2
4
6
8
10
12
14
Females
Males
75+ 65–74 55–64 45–54 35–44 25–34
Source: AIHW analysis of the 1999–2000 AusDiab study.
Figure 3.1: Age-specific prevalence of impaired fasting
glucose (IFG) in adults, 1999–2000
Per cent
Age group (years)
0
5
10
15
20
25
Females
Males
75+ 65–74 55–64 45–54 35–44 25–34
Source: AIHW analysis of the 1999–2000 AusDiab study.
Figure 3.2: Age-specific prevalence of impaired glucose
tolerance (IGT) in adults, 1999–2000
Risk factors for diabetes and its complications 23
Risk factors for diabetes and its complications

Page 23
Physical inactivity
Physical activity is important for maintaining
good health. Regular participation in moderate-
to vigorous-intensity physical activity is
protective against a range of diseases and
conditions, including diabetes, heart disease and
some forms of cancer (AIHW 2006a).
Participation in regular physical activity is one
of the major recommendations of the evidence based
guidelines for the primary prevention of
Type 2 diabetes. Exercise was found to reduce
the risk of developing Type 2 diabetes, slow the
progression from impaired glucose regulation
to Type 2 diabetes, and reduce diabetes-related
mortality (NHMRC 2001).
Exercise has been shown to signiﬁcantly improve
blood sugar control in people with Type 2
diabetes (Thomas et al. 2006). Also, resistance
exercise, such as lifting weights, has been shown
to be beneﬁcial for the health of older people
with diabetes through improving control of blood
sugar levels (Castaneda et al. 2002; Dunstan et al.
2002a).
Participation in sufficient physical activity
can modify, or reduce the impact of, other risk
factors for diabetes and its complications such as
obesity and high blood cholesterol. Furthermore,
insuffcient physical activity is itself a risk factor
for cardiovascular disease, one of the major
complications of diabetes (AIHW 2006a). People
with diabetes—particularly those taking insulin
or oral blood glucose–lowering medicines—need
to monitor their response to exercise and
may need to adjust their diet or medication
(Harris et al. 2006; Williams & Pickup 1999).
What is physical activity?
Physical activity includes moderate or vigorous
exercise, resistance exercise and ﬂexibility
training. Recommended physical activity levels
for both adults and children have been outlined
in the National Physical Activity Guidelines for
Australians (see Box 3.1).
The recommendations for children and adolescents
also state that no more than 2 hours a day should
be spent using electronic media for entertainment
(such as computer games, the internet and
television), particularly during daylight hours.
Studies have found an association between
increased time watching television and the risk of
abnormal glucose metabolism or diabetes in adults
(Dunstan et al. 2004; Hu et al. 2003).
For this report, suffcient physical activity is
deﬁned as 30 minutes of moderate physical
activity on at least ﬁve days of the week, or 150
minutes spread out over ﬁve sessions in a week.
Box 3.1: What is sufficient physical activity for health?
The National Physical Activity Guidelines for Australians (AIHW 2003a; DHAC 1999; DoHA 2004a,
2004b) recommend at least 30 minutes of moderate-intensity activity on most, preferably all, days
of the week to obtain health benefits. This is generally interpreted as 30 minutes on at least five days
of the week — a total of 150 minutes of moderate activity per week. The guidelines for children and
adolescents recommend at least 60 minutes of moderate to vigorous physical activity every day.
Examples of moderate-intensity activity are brisk walking, swimming, doubles tennis and medium paced
cycling. More vigorous physical activity includes jogging and active sports such as football and
basketball.
There are two ways of calculating ‘sufficient’ activity for health benefits in the Australian Guidelines.
These are: ‘sufficient time’—at least 150 minutes of moderate-intensity physical activity per week, and
‘sufficient time and sessions’—at least 150 minutes of moderate-intensity physical activity accrued
over at least five sessions per week, with vigorous activity counted double. For population-monitoring
purposes, sufficient time and sessions is the preferred measure of activity for health as it takes into
account the frequency, as well as duration of physical activity. Research suggests that even shorter
sessions (down to 10 minutes) can be beneficial as well, provided they add up to the required total
over the week.

How many Australians are physically inactive?
Prevalence
The most recent source of national data for physical activity levels is the 2004–05 NHS.
According to this survey, the majority (about 70%) of Australians aged 15 years and over
undertook insuffcient (sedentary or low) levels of physical activity. Overall physical activity levels
were slightly lower in people with diabetes: nearly three out of every four people with diabetes were
classiﬁed as being sedentary (36%) or having low exercise levels (39%) compared with just
over two-thirds (32% sedentary and 37% low) of people without diabetes.
In 2004–05, a similar proportion of males with diabetes had insuffcient exercise levels as males
without diabetes (67% and 66%, respectively).
The main differences were found among females, where the prevalence of insuffcient exercise was
higher among those with diabetes (78%) than those without diabetes (73%) (Figure 3.3).
Per cent
Males Females
0
10
20
30
40
50
60
70
80
Low/Sedentary High/Moderate

Notes
1. See appendix 1 for a definition of exercise level.
2. Based on self-reported data.
3. Directly age-standardised to the 2001 Australian population.
Source: AIHW analysis of ABS 2004–05 National Health Survey data.
Figure 3.3: Prevalence of physical activity among people
aged 15 years and over, 2004–05
Trends
Published trend information indicates that the
proportion of people in the low/sedentary group
remained fairly constant, at about 70%, over the
period 1995 to 2004–05 (ABS 2006c).
Unhealthy diet
Diet plays an important role in the prevention
and development of chronic diseases such as
diabetes (WHO 2003). The promotion of good
health and prevention of chronic diseases
through dietary behaviour may be achieved, in
the ﬁrst instance, by following dietary guidelines
such as those developed by the National Health
and Medical Research Council (NHMRC).
According to these guidelines, Australian adults
and children should consume a wide variety of
nutritious foods including a high intake of plant
foods and limit salt, saturated fat and alcohol
intake (NHMRC 2003a) (see Box 3.2).
Nutrition plays an important part in the
management of diabetes (ADA 2004). Poor
nutrition is a risk factor for Type 2 and
gestational diabetes largely through its inﬂuence
on body weight, particularly obesity (NHMRC
2001; WHO 2003). Reducing total fat intake
has been found to reduce the risk of developing
diabetes independent of weight loss (Franz et al.
2002) however, evidence supporting claims that
individual dietary factors can have an eﬀect on
diabetes, independent of obesity, is inconclusive
(WHO 2003).
Dietary risk factors for diabetes and its complications
Both fat and ﬁbre intake are associated with
diabetes (WHO 2003). Dietary fat has received
particular attention in relation to diabetes
because of its strong association with overweight
and obesity— a major risk factor for the
development of diabetes (Howard 1999).
Dietary fat intake
It is recommended that people consume a diet
with less than 30% energy as fat and less than
10% energy as saturated fat (NHMRC 2003a).
This is especially important for those at risk
of Type 2 and gestational diabetes. Reducing
saturated fat intake can decrease the risk of
developing diabetes by increasing the body’s
ability to use insulin properly, promoting weight
loss (in people who are overweight or obese),
and reducing low-density lipoprotein (LDL)
cholesterol (the ‘bad’ cholesterol) (NHMRC 2001).
Risk factors for diabetes and its complications 25

It can also help reduce the risk of cardiovascular
disease — a major complication of both Type 1
and Type 2 diabetes (Howard 1999). Replacing
saturated fats with monounsaturated fats can
also lead to improved blood glucose control if
total fat intake is less than 37% of total energy
intake (WHO 2003).
Dairy products contribute signiﬁcantly to
saturated fat intake, therefore, the proportion
of people consuming skim or reduced fat milk
compared with whole cow’s milk can be used as an
indicator of lower total and saturated fat intake
(AIHW 2006b).
In 2004–05, 45% of the Australian population
drank whole milk, 49% drank other types of milk
(including soy) and 5.1% did not drink milk. A
smaller proportion of people with diabetes (40%)
drank whole milk compared with people without
diabetes (46%). A higher proportion of males
consumed whole milk than females, although
these sex differences were greater among people
without diabetes (Figure 3.4).
Per cent
0
20
40
60
80
100
Inadequate vegetable
intake
Inadequate fruit intake
Whole milk intake
People without
diabetes
Males Females
People with
diabetes
People without
diabetes
People with
diabetes
Notes
1. Inadequate fruit intake is defined as less than two serves of fruit
per day for adults and less than three serves a day for children and
adolescents aged 12–18 years.
2. Inadequate vegetable intake is defined as less than five serves of
vegetables per day for adults and less than four serves a day for
children and adolescents aged 12–18 years.
3. Directly age-standardised to the 2001 Australian population.
Source: AIHW analysis of ABS 2004–05 National Health Survey data.
Figure 3.4: Prevalence of whole milk consumption, and
inadequate fruit and vegetable intake among people
aged 12 years and over, 2004–05
Dietary fibre intake
A high ﬁbre diet is recommended to reduce
the risk of developing Type 2 diabetes and
complications commonly associated with both
Type 1 and Type 2 diabetes (ADA 2002; Mann
et al. 2004; NHMRC 2001; WHO 2003). The
increased consumption of foods rich in dietary
ﬁbre (such as cereals, fruits, vegetables and
legumes) has been found to reduce the incidence
of cardiovascular disease in people with and
without diabetes (Mann et al. 2004). It is also
associated with lower body mass index in
people with Type 1 diabetes and higher insulin sensitivity
in people without diabetes (Mann
et al. 2004). The protective effect of dietary
Box 3.2: Dietary guidelines for
Australian adults
Enjoy a wide variety of nutritious foods
eat plenty of vegetables, legumes and fruit
eat plenty of cereals (including breads,
rice, pasta and noodles), preferably wholegrain
include lean meat, fish, poultry and/or
alternatives include milks, yoghurts, cheeses and/or
alternatives: reduced fat varieties should
be chosen where possible drink plenty of water
and take care to:
limit saturated fat and moderate total fat
intake choose foods low in salt
limit your alcohol intake if you choose to
drink consume only moderate amounts of
sugars and foods containing added
sugars prevent weight gain: be physically active
and eat according to your energy needs
care for your food: prepare and store it
safely encourage and support breastfeeding.
Source: NHMRC 2003a.

Diabetes: Australian facts 2008 26
ﬁbre against diabetes has been shown to be
independent of age, body mass index, smoking
and physical activity (WHO 2003). Fruit and
vegetable intake can be used as an indicator of
dietary ﬁbre intake.
In 2004–05, 49% of Australians did not eat
the recommended serves of fruit and 84% of
Australians did not eat the recommended serves
of vegetables each day.
More males and females with diabetes met the
daily requirement for fruit intake compared
with males and females without diabetes. In
2004–05, 41% of people with diabetes and 50%
of people without diabetes were consuming less
than the recommended daily serves of fruit.
Overall, a greater proportion of males with
diabetes (43%) and males without diabetes (55%)
had inadequate fruit intake compared with their
female counterparts (38% and 44% respectively)
(Figure 3.4).
In 2004–05, the majority of people with diabetes
(73%) and without diabetes (84%) were not
meeting the recommended daily intake of
vegetables (Figure 3.4). Overall, only about 1 out
of 10 males with and without diabetes consumed
the recommended daily serves of vegetables. A
higher proportion of females with diabetes met
the recommenced daily serves of vegetables (36%)
than females without diabetes (17%).
Other dietary factors
The glycaemic index Foods with a particular glycaemic index (GI)—a
ranking of carbohydrate foods based on their
overall eﬀect on blood glucose levels—may also
be associated with Type 2 diabetes. Some studies
indicate that high GI diets may contribute to the
risk of Type 2 diabetes, while low GI diets may
play a protective role. Other studies have found
no relationship at all (Sheard et al. 2004). Low
GI foods are considered good carbohydrate-rich
sources as long as other attributes of the food
(such as saturated fat, salt and sugar content) are
appropriate (Mann et al. 2004; Sheard et al. 2004).
Alcohol consumption
High alcohol consumption is associated with an
increased risk of diabetes complications such as
heart, stroke and vascular disease (Mann et al.
2004). Moderate alcohol consumption has been
found to reduce the risk of hypoglycaemia (low
blood glucose levels); however, there is currently
insuffcient evidence to conﬁrm or refute
suggestions that alcohol might protect against
the development of Type 2 diabetes (Mann et al.
2004; WHO 2003). Furthermore, drinking too
much alcohol can cause hypoglycaemia in people
who are taking insulin or certain diabetes tablets
(Diabetes Australia 2006a).
Overweight
Overweight, and in particular obesity, are key
risk factors for the development of diabetes, with
the escalating prevalence of obesity believed to be
a signiﬁcant contributing factor to the rapid rise
of Type 2 diabetes (Dunstan et al. 2001; Eckel et
al. 2006). There is evidence that the risk of Type 2
diabetes increases with increasing excess weight
(Chan et al. 1994; Colditz et al. 1995; Golay &
Ybarra 2005).
Overweight also increases the risk of developing
cardiovascular diseases in people with and
without diabetes. Because diabetes is a risk factor
for cardiovascular diseases, people who are both
overweight and have diabetes are at an even
greater risk than those who are just overweight or
just have diabetes (Eckel et al. 2006).
Increased body weight can lead to increased
insulin resistance and defects in insulin
secretion. Type 2 diabetes occurs when insulin
resistance declines to a level at which it cannot
compensate for insulin secretion (Golay & Ybarra
2005; Sharma 2006). Weight loss reduces the
risk of diabetes in people who are overweight
by improving insulin sensitivity and glycaemic
control. People at risk of or who already have
Type 2 diabetes can achieve weight reduction
through diet and physical activity (Sharma 2006)
(for further information see sections on physical
activity and dietary behaviour).
What is overweight?
Overweight is a condition of excess weight
that normally results from a sustained energy
imbalance. Energy imbalance occurs when dietary
energy intake exceeds energy expenditure over
a period of time. Obesity is a severe form of
overweight.
Risk factors for diabetes and its complications 27

A combination of body mass index (BMI) and
waist circumference is recommended for the
clinical measurement of overweight and obesity
(see Box 3.3) (NHMRC 2003b; 2003c). BMI is an
acceptable approximation of total body fat at the
population level and can be used to estimate the risk
of disease in most people; however, because BMI
does not distinguish between weight attributable
to fat and weight attributable to muscle, it should
be interpreted with caution when assessing an
individual’s body weight (NHMRC 2003b).
People tend to overestimate their height and
underestimate their weight, leading to an
underestimate of BMI. As a result, self-reported
data is likely to underestimate the true prevalence
of overweight and obesity based on BMI and
therefore should not be directly compared with
prevalence estimates based on measured data.
Although measured data provide more accurate
estimates of the prevalence of excess body weight
among people with diabetes, the self-reported
information on BMI from the 2004–05 NHS is
also reported here as it is the most recent source
of national prevalence information.
Waist circumference is an indicator of excess
abdominal weight, which is a risk factor for
Type 2 diabetes and cardiovascular disease. Waist
circumference is a valid measure of abdominal fat
and disease risk in people with a BMI of less than
35 (NHMRC 2003b).
Box 3.3: Monitoring body weight
There are two main methods used for monitoring body weight in settings such as population health
surveys: body mass index (BMI) and waist circumference. Both provide an acceptable alternative to more
accurate measurement of total body fat, which is only feasible for specialised clinical or other settings.
Body mass index
The most common measure of body weight is the BMI, which is calculated by dividing weight in
kilograms by the square of height in metres (kg/m2). The standard recommended by the WHO (WHO
2000) and included in the National Health Data Dictionary for adults aged 18 years and over is:
underweight (BMI <18.5)
healthy weight (BMI ≥18.5 and BMI <25)
overweight (BMI ≥25; includes obese)
overweight but not obese (BMI ≥25 and BMI <30)
obese (BMI ≥30).
For children and adolescents aged 2–17 years, Cole et al. (2000) have developed a separate classification
of overweight and obesity based on age and sex.
Waist circumference
For monitoring overweight, waist circumference is a useful addition to BMI because abdominal
fat mass can vary greatly within a narrow range of total body fat or BMI. The National Health Data
Dictionary defines waist circumference cut-offs for increased and substantially increased risk of illhealth.
Waist circumferences of 94 cm or more in men and 80 cm or more in women indicate increased
risk (referred to here as abdominal overweight). Waist circumferences of 102 cm or more in men and
88 cm or more in women indicate substantially increased risk (referred to here as abdominal obesity)
(NHDC 2003). This classification is not suitable for use in people aged less than 18 years and the cut-off
points may not be suitable for all ethnic groups.
Self-reported versus measured data
Height and weight data may be collected in surveys as measured or self-reported data. People tend to
overestimate their height and underestimate their weight, leading to an underestimate of BMI. Thus,
rates of overweight and obesity based on self-reported data are likely to be underestimates of the
true rates, and should not be directly compared with rates based on measured data (Flood et al. 2000;
Niedhammer et al. 2000).

How many Australians are overweight?
Body mass index
Prevalence
Estimates from the 1999–2000 AusDiab study
suggest that about 60% of Australians aged 25
years and over were overweight, as measured by
the BMI. Approximately one third of them were
obese. Being overweight or obese increases the
risk of developing diabetes in individuals without
diabetes and it increases the risk of developing
diabetes-related complications in persons with
diabetes.
People with diabetes are on average more likely
than those without diabetes to be overweight.
In 1999–2000, based on measured data, 80% of
people with diabetes were overweight (BMI of 25
or more) compared with 59% of people without
diabetes. The prevalence of obesity among people
with diabetes was 3 times that of those without
diabetes (Table 3.2).
In 1999–2000, the prevalence of obesity was
similar among males (58%) and females (59%) with
diabetes. A slightly higher proportion of females
(20%) without diabetes were obese compared with
males without diabetes (17%). A greater proportion
of males than females were overweight regardless
of diabetes status (Table 3.2).
Based on self-reported information, 51%
of Australians aged 15 years and over were
overweight or obese (BMI of 25 or more)
in 2004–05. A higher proportion of males
than females were overweight; 61% and 42%
respectively, with a higher prevalence of obesity in
males and females with diabetes compared with
people who do not have the disease (Figure 3.5).
Trends
Published data, based on self-reported
information, indicate that the prevalence of
overweight and obesity in adults increased
from 41% in 1995 to 49% in 2004–05. The agestandardised
prevalence of overweight (but not
obese) among Australian adults aged 18 years and
over in 1995, 2001 and 2004–05 was 30%, 31%
and 33%, respectively and obesity was 11%, 15%
and 16% respectively (ABS 2006c).
Waist circumference
The only source of national data for overweight
based on waist circumference is the 1999–2000
AusDiab study. In this study, 23% of Australians
aged 25 years and over had an increased risk of
health problems and 30% had a substantially
increased risk of health problems, based on their
waist circumference. A higher proportion of
males (81%) and females (83%) aged 25 years and
over with measured diabetes were abdominally
overweight compared with males and females
without diabetes (53%) (Figure 3.6).
Table 3.2: Prevalence of overweight (measured) based on body mass index(a), people aged 25 years and over, 1999–2000
(per cent)
People with diabetes
People without diabetes
Males Females Persons Males Females Persons
Not overweight 15.7 21.0 19.9 33.0 49.6 41.4
Overweight but not obese 26.4 19.6 23.4 49.7 30.5 39.9
Obese 58.0 59.4 56.7 17.3 20.0 18.7
Overweight(b) 84.4 79.0 80.1 66.9 50.4 58.6
(a) See Box 3.3 for classification of body mass index.
(b) Includes both overweight and obese, classified as BMI >25.0.
Notes
1. Based on measured data.
2. Directly age-standardised to the 2001 Australian population.
3. Column totals may not add to 100.0 due to rounding.
4. Missing values were excluded from the numerator and the denominator.
Source: AIHW analysis of the 1999–2000 AusDiab study.
Risk factors for diabetes and its complications 29

Results from the 1999–2000 AusDiab study
indicated that more people with diabetes were on
the upper spectrum of the abdominal overweight
scale (substantially increased risk of health
problems) compared with those without diabetes
(Figure 3.6).
Tobacco smoking
Tobacco smoking increases the risk of developing
diabetes-related complications such as coronary
heart disease, stroke, peripheral vascular disease
and kidney disease (AIHW 2005a; ACDS 2004;
Eliasson 2003). Exposure to environmental
smoke, or passive smoking, has also been found
to increase the risk of coronary heart disease
in non-smokers (National Drug Strategy 2002;
USDHHS 2006).
Research from a range of prospective studies has
shown that quitting tobacco smoking can reduce
the risk of developing Type 2 diabetes (Foy et
al. 2005; Patja et al. 2005; Carlsson et al. 2004;
Eliasson 2003; Wannamethee et al. 2001).
People who stop smoking may reduce their risk
of developing Type 2 diabetes to that of people
who have never smoked (Foy et al. 2005). In their
analysis of the British Regional Health Study,
Wannamethee et al. (2001) found that the risk
of developing diabetes decreased with time since
quitting smoking tobacco, and the beneﬁts were
apparent within about 5 years.
What is tobacco smoking?
Tobacco smoking includes the smoking of tobacco
products such as packet cigarettes, roll-your-own
cigarettes, pipes and cigars.
People who smoke inhale a range of chemicals.
The addictive substance in cigarettes is nicotine,
but a range of other noxious substances, such as
carbon monoxide and cadmium are also inhaled
(Foy et al. 2005).
How many Australians smoke?
Prevalence
According to the 2004 National Drug Strategy
Household Survey (NDSHS), just over one in six
Australians aged 14 years and over (17.4%, 2.9
million) smoked on a daily basis (AIHW 2005e).
More than half had never smoked (52.9%).
Trends
Smoking rates have been declining since the
1950s (AIHW 2006a). Between 1995 and 2004,
Per cent
Males Females
0
10
20
30
40
50
60
70
80 Substantially increased risk
Increased risk Healthy waist

Notes
1. See Box 3.3 for classification of body mass index.
2. Directly age-standardised to the 2001 Australian population.
3. Subtotals may not add to 100.0 due to rounding.
4. Missing values were excluded from the numerator and the
denominator.
Source: AIHW analysis of the 1999–2000 AusDiab Study.
Figure 3.6: Prevalence of overweight (measured) based
on waist circumference among people aged 25 years and
over, 1999–2000
Per cent
Males Females
0
10
20
30
40
50
60
Obese
Overweight but not obese
Not overweight

Notes
1. See Box 3.3 for classification of body mass index.
2. Directly age-standardised to the 2001 Australian population.
3. Missing values were excluded from the numerator and the
denominator
Source: AIHW analysis of ABS 2004–05 National Health Survey data.
Figure 3.5: Prevalence of overweight (self-reported)
based on body mass index, people aged 15 years and
over, 2004–05
Diabetes: Australian facts 2008 30
the prevalence of smoking for males and females
declined by 7.3 and 5.5 percentage points,
respectively (AIHW 2005e).
Smoking and people with diabetes
The 2004–05 NHS also provides information
on the prevalence of smoking among people
aged 18 years and over and, unlike the NDSHS,
the 2004–05 NHS can be used to compare the
prevalence of smoking among people with and
without diabetes.
In 2004–05, among people with diagnosed
diabetes more females currently smoked
(24%) than males (16%). This is in contrast to
people without diabetes where more males
(27%) currently smoked than females (20%)
(Figure 3.7).
In 2004–05, 34% of males and 28% of females
with diabetes were ex-smokers compared with
35% of males and 25% of females without
diabetes. A further 51% of males and 48%
of females with diabetes had never smoked,
compared with 39% and 54% of males and
females without diabetes (Figure 3.7).
Per cent
Males Females
0
10
20
30
40
50
60
Never smoked
Ex-smoker
Current smoker
People without
diabetes
People with
diabetes
People without
diabetes
People with
diabetes
Notes
1. Current smoker includes people who reported smoking daily, at least
once a week or less than weekly.
2. Based on self-reported data.
3. Directly age-standardised to the 2001 Australian population.
Source: AIHW analysis of ABS 2004–05 National Health Survey data.
Figure 3.7: Prevalence of smoking among people aged
18 years and over, 2004–05
High blood pressure
High blood pressure (also known as
hypertension) is a major risk factor known to
contribute to, or lead to, the development of
diabetes complications including cardiovascular
disease, kidney disease and diabetic eye disease.
The risk of cardiovascular disease increases
as the level of blood pressure increases. When
high blood pressure is controlled, the risk of
cardiovascular disease and overall mortality
is reduced, but not necessarily to the levels of
unaffected people (WHO–ISH 1999).
High blood pressure is more likely to occur in
people who are obese, physically inactive and
consume high levels of dietary salt and/or alcohol
(NHMRC 2004). Psychological stress is likely to
have an indirect effect by inﬂuencing harmful
health behaviours associated with high blood
pressure (WHO 2002). Lifestyle modiﬁcation
plays an important role in preventing and
managing high blood pressure.
What is blood pressure?
Blood pressure is the force of blood on the artery
walls as the heart pumps it around the body. It is
expressed as a ratio, for example 120/80 mmHg,
stated as ‘120 over 80’. The ﬁrst number is the
systolic blood pressure, which represents the
maximum pressure in the arteries when the heart
contracts to pump blood. The second number is
the diastolic blood pressure, which represents the
minimum pressure in the arteries when the heart
relaxes.
The WHO (1999) deﬁnes high blood pressure as:
systolic blood pressure of 140 mm Hg or more
or diastolic blood pressure of 90 mm Hg or more
or receiving medication for high blood pressure.
There is evidence that people with diabetes
are at greater risk of cardiovascular disease
at equivalent blood pressure levels than
people without diabetes; as such, the NHMRC
recommends that high blood pressure in people
with Type 2 diabetes be deﬁned as more than
130/80 mmHg (NHMRC 2004).

Risk factors for diabetes and its complications 31

How many Australians have high blood pressure?
Prevalence
Based on measured data from the 1999–2000
AusDiab study, 30% of Australians had high blood
pressure. People with diabetes (60%) had much
higher rates of high blood pressure compared
with people without diabetes (28%). Overall,
males with and without diabetes (62% and 31%,
respectively) had slightly higher rates of high
blood pressure than their female counterparts
(60% and 26%, respectively) (Figure 3.8).
Per cent
Males Females
0
10
20
30
40
50
60
70
80
High blood pressure Normal blood pressure

Notes
1. Based on measured data.
2. Directly age-standardised to the 2001 Australian population.
3. Subtotals may not add to 100.0 due to rounding.
4. Missing values were excluded from the numerator and the denominator.
Source: AIHW analysis of the 1999–2000 AusDiab study.
Figure 3.8: Prevalence of high blood pressure among
people aged 25 years and over, 1999–2000
Another source of information for the prevalence
of measured high blood pressure is the North
West Adelaide Health Study. In this study, 27%
of study participants had high blood pressure
and the prevalence of high blood pressure was
signiﬁcantly higher among people with diabetes
than people without diabetes (Grant et al. 2005).
Trends
Between 1995 and 1999–2000, the prevalence of
high blood pressure among people aged 25 years
or over remained about the same—31% in 1995
and 30% in 1999–2000 (AIHW 2006a).
Longer-term trends are available only for
the urban population. They indicate that the
prevalence of high blood pressure more than
halved for males aged 25 to 64 years (from 47%
in 1980 to 21% in 1999–2000) and halved for
females of the same ages (from 32% in 1980 to
16% in 1999–2000) (AIHW 2006a).
High cholesterol and high triglycerides
People with diabetes, particularly those with
Type 2 diabetes, often have high levels of LDL
cholesterol (‘bad’ cholesterol) and triglycerides.
Both of these conditions are risk factors for
diabetes-related complications, coronary heart
disease and stroke (Rewers and Hamman 1995).
For most people, saturated animal fat in the diet
is the main cause of raised cholesterol levels,
although genetic factors may also play a role
(NHFA 1999). Maintaining a healthy lifestyle
through moderate physical activity and balanced
nutrition plays an important role in reducing the
risks associated with high LDL-cholesterol and
triglycerides (NHFA & CSANZ 2001).
What are cholesterol and
triglycerides?
Cholesterol is a fatty substance produced by the
liver and carried by the blood to the rest of the
body. Its natural function is to provide material
for cell walls and for steroid hormones. If levels
in the blood are too high, this can lead to the
artery-clogging process known as atherosclerosis
that can trigger heart attacks, angina or stroke.
This process may be intensiﬁed by diabetes. The
risk of heart disease increases steadily from a low
base with increasing blood cholesterol levels. A
total cholesterol level of 5.5 mmol/L or more is
considered ‘high’.
Total cholesterol has several parts:
LDL cholesterol, often known as ‘bad’
cholesterol. Excess levels of LDL cholesterol are
the main way that cholesterol contributes to
atherosclerosis.
High-density lipoprotein (HDL) cholesterol,
often known as ‘good’ cholesterol. High levels
•
•
Diabetes: Australian facts 2008 32
of HDL have a protective eﬀect against heart
disease by helping reduce atherosclerosis.
Triglyceride is another form of fat that is made
by the body. Its levels can ﬂuctuate according
to dietary fat intake and under some conditions
excess levels may contribute to atherosclerosis.
How many Australians have high
cholesterol and triglycerides?
Prevalence
According the AusDiab study, among
Australians aged 25 years and over, 51% had
high total cholesterol, 11.5% had low levels of
HDL-cholesterol, 46% had high levels of LDLcholesterol
and 21% had high triglyceride levels in
1999–2000.
Using the same data source, total cholesterol
levels were higher in people with diabetes: 56%
of males and 63% of females with diabetes had
high total cholesterol compared with 53% of
males and 51% of females without diabetes. Even
larger diﬀerences were found for HDL-cholesterol
and triglycerides. The prevalence of low levels
of HDL-cholesterol was 47% in males and 15%
in females with diabetes compared with 17%
and 4% respectively in people without diabetes.
High triglyceride levels were observed among
59% of males and 50% of females with diabetes
compared with 23% of males and 15% of females
without diabetes (Figure 3.9).
The North West Adelaide Health Study also found
that the prevalence of high blood cholesterol was
signiﬁcantly higher among people with diabetes
than people without diabetes (Grant et al. 2005).
Trends
Trends in the prevalence of high blood cholesterol
are only available to the year 2000 for people
aged 25–64 years living in capital cities and show
that there has been no apparent change in the
prevalence of high blood cholesterol since 1980
(AIHW 2006a).
Per cent
Males Females
0
10
20
30
40
50
60
70
80
High triglycerides
Low HDL-cholesterol
High LDL-cholesterol
High total cholesterol
People without
diabetes
People with
diabetes
People without
diabetes
People with
diabetes
Notes
1. See Appendix 1 for definitions of blood lipid risk factors.
2. Based on measured data.
3. Directly age-standardised to the 2001 Australian population.
4. Missing values were excluded from the numerator and the
denominator.
Source: AIHW analysis of the 1999–2000 AusDiab study.
Figure 3.9: Prevalence of blood lipid risk factors among
adults, 1999–2000

33
4
Introduction ...................................................................... 34
Cardiovascular disease .................................................... 34
Eye disease ........................................................................ 38
Kidney disease .................................................................. 40
Nerve damage .................................................................. 42
Foot complications .......................................................... 44
Oral complications ........................................................... 46
Complications in pregnancy .......................................... 47
Diabetes: Australian facts 2008 34
Introduction
Diabetes can result in a range of short- and
long-term complications which are the major
causes of associated morbidity and mortality in
people with diabetes. These complications are
responsible for loss of working ability, invalidism,
shortened life expectancy and reduced quality of
life among people with diabetes. The presence of
complications also greatly increases the cost of
managing diabetes.
Short-term complications include diabetic
ketoacidosis which results from a severe lack
of insulin and hypoglycaemia (low blood sugar)
—a complication of insulin or sulphonylurea
treatment. Other short-term complications
include increased susceptibility to infections
and poor wound healing when diabetes is poorly
controlled (Flack & Colagiuri 2005).
Long-term complications include disease of
the large blood vessels (macrovascular disease)
such as coronary heart disease (CHD), stroke
and peripheral vascular disease (PVD) as well as
diseases of the small blood vessels (microvascular
disease) such as retinopathy, kidney diseases
and neuropathy (peripheral nerve disease)
(Bate & Jerums 2003). Other complications of
or conditions associated with diabetes include
digestive diseases (ulcers, coeliac disease, cancer
of the pancreas, constipation, diarrhoea, liver
disease and gallstones), infections, oral diseases,
mental problems (depression and anxiety) and
problems in pregnancy (ADA 2007b, 2007c;
AIHW 2002).
Complications arising from the treatment
for diabetes can also occur. These include:
hypoglycaemia from insulin or oral
hypoglycaemic agents and side eﬀects of
hypoglycaemic agents (gastro-intestinal, liver
toxicity, lactic acidosis and allergic skin reactions)
(Hussein et al. 2004).
The underlying causes of diabetes complications
remain controversial, although persistent high
blood sugar is strongly implicated. The Diabetes
Control and Complications Trial, involving
participants with Type 1 diabetes, showed that
keeping blood sugar levels as close to normal as
possible slows the onset and progression of eye,
kidney and nerve diseases (DCCT Research Group
1993). The United Kingdom Prospective Diabetes
Study of people with Type 2 diabetes found that
tight blood sugar control reduces the risk of
major diabetic eye disorder by a quarter and early
kidney damage by a third. Moreover, tight blood
pressure control in people with high blood pressure
reduces the risk of strokes, serious deterioration of
vision and death from long term complications in
diabetes, all by at least a third (UKPDS 1998).
Improving the management and care of diabetes,
particularly the early identiﬁcation and reduction
of risk factors, can delay the onset or slow the
progression of complications.
This chapter presents information on diabetes
complications from many diﬀerent data sources:
self-reported and measured surveys and
administrative collections. Data on a number of
diabetes-related complications, including kidney,
eye, nervous system and peripheral circulatory
complications are available in hospital and deaths
databases. However, other conditions such as CHD,
stroke, PVD and ESKD are not available speciﬁcally
identiﬁed as being related to diabetes. For these
conditions, it was necessary to derive information
assuming that the presence of diabetes may have
contributed to them. The method of deriving such
data is described in Box 4.1.
Cardiovascular disease
Cardiovascular disease (CVD) is a major
complication of, and leading cause of death
in, diabetes (Ali & Maron 2006). People with
diabetes have twice the risk of CVD, including
stroke and myocardial infarction (heart attack)
compared with the general population. People
with diabetes have higher mortality as a result of
their ﬁrst cardiovascular event (such as stroke or
heart attack), and poorer outcomes in the months
and years following such an event, compared
with the general population (Buse et al. 2007). In
people with diabetes, CVD has an earlier onset
and is more resistant to treatment and therapies
compared wutg those without diabetes (Weisfeldt
& Zieman 2007).
This section focuses on coronary heart disease,
stroke and peripheral vascular disease, as
they are the most common cardiovascular
complications associated with diabetes.
35

Coronary heart disease
Coronary heart disease (CHD) is the most
common cause of sudden death in Australia. It
consists mainly of acute myocardial infarction
(heart attack) and angina. A heart attack occurs
when a blood vessel supplying the heart itself
is suddenly blocked completely, threatening to
disrupt the heart and its functions, whereas
angina is a temporary chest pain or discomfort
caused by a reduced blood supply to the heart
muscle.
Stroke
Cerebrovascular disease comprises disorders
in which there is a disturbance of blood supply
to the brain. Stroke is the most important
manifestation of cerebrovascular disease. A
stroke occurs when an artery supplying blood
to a part of the brain suddenly becomes blocked
(ischaemic stroke) or bleeds (haemorrhagic
stroke), which account for about 85% and 15%
of cases respectively. One in ﬁve people having
a ﬁrst-ever stroke die as a result within 1 month
of its occurrence and one in three die within 12
months of their stroke (Thrift et al. 2000). Stroke
also causes a large degree of disability and nearly
all patients are disabled immediately following a
stroke event. There may be permanent paralysis
of one side of the body, speech or swallowing
diﬃculties, problems with memory, personality
changes or a range of other diﬃculties.
Depression, anxiety and cognitive impairment are
also common after stroke (Srikanth et al. 2004).
Peripheral vascular disease
Peripheral vascular disease (PVD) occurs due
to a reduced arterial blood supply to the legs. It
ranges from asymptomatic disease, through pain
on walking, to pain at rest. It can also result in
reduced blood supply that may lead to amputation
if severe enough. While this is a signiﬁcant cause
of disability among people with PVD, the major
cause of death in people with PVD is coronary
heart disease.
How does diabetes increase the risk of developing cardiovascular disease?
The reasons why diabetes increases the risk
of CVD are only partially understood. The
prevailing explanation is that diabetes increases
atherosclerosis (thickening of the walls of a
blood vessel with deposits of plaque). Studies
have shown that people with diabetes have a
high prevalence of sub-clinical coronary heart
disease (disease without symptoms) and it can be
assumed that a person with diabetes would have
some level of coronary pathology (Ali & Maron,
2006; Buse et al. 2007). Other factors possibly
Box 4.1 Identifying diabetes complications in hospitalisations and deaths data
The method described below is used to identify diabetes hospitalisations and deaths that occurred
with CVD, stroke, PVD, kidney complications of diabetes (including ESKD), oral, neurological and
ophthalmic complications of diabetes and lower limb ulcers.
The first step in analysing the hospitalisations data was to identify people with diabetes: that is,
hospitalisations where diabetes was mentioned as either the principal or an additional diagnosis (ICD
10 codes: E10-E14 and O24).
The next step was to identify which of these diabetes hospitalisations also had the selected
complication listed as the principal or an additional diagnosis.
Similarly, mortality analysis for diabetes complications for these conditions include any death where
diabetes was mentioned along with the selected complication, either as the underlying or the
additional cause of death.
It is possible for a single person with diabetes to have multiple complication types and consequently,
there may be multiple complication types listed among the diagnoses for a single hospitalisation
event or as a cause of death for an individual.
Diabetes: Australian facts 2008 36
contributing to the excess risk of cardiovascular
disease in people with diabetes include high blood
pressure and dyslipidaemia (low levels of HDLcholesterol
and high levels of LDL-cholesterol
and triglycerides). Both are risk factors for
cardiovascular disease and their prevalence is
higher among people with diabetes (Wu et al.
1999).
Many aspects of the development of
macrovascular complications such as
cardiovascular disease in people with diabetes
are not yet fully understood. It is not clear,
for example, whether the development of the
disease is the same in Type 1 and Type 2 diabetes,
although both types are associated with an
increased risk.
Risk factors
The risk of developing CVD increases when
diabetes is present with other risk factors such as
tobacco smoking, physical inactivity, high blood
pressure, high blood cholesterol, and overweight
and obesity.
Prevention and treatment of macrovascular
complications in people with diabetes is
not as well deﬁned or as straight forward as
microvascular disease (eye disease and kidney
disease). A ‘broad-based’ regime involving weight
reduction, increased physical activity, blood
pressure control, blood lipid reduction, cessation
of tobacco use and aspirin therapy have been
shown to be eﬀective primary Preventive and
treatment measures. Blood sugar control has
also been shown to be eﬀective in preventing
microvascular disease, but there is no strong
evidence suggesting that it lowers the risk of CVD
in people with diabetes (Buse et al. 2007).
How many Australians with
diabetes also have cardiovascular
disease?
Coronary heart disease
The 1999–2000 AusDiab study showed that
nearly 10% of Australians aged 25 years and
over with diabetes had coronary heart disease
compared with 6% of people without diabetes. In
the same survey, 5% of people with diabetes had
had a heart attack and 8% had angina while the
corresponding rates for people without diabetes
were 3% and 5%.
According to the 2004–05 NHS self-reports,
an estimated 11% of people with diabetes had
had a heart attack and 12% had angina. These
proportions were greater among people with
diabetes than among those without diabetes.
The age-standardised rate of heart attack among
people with diabetes was more than twice as
high as that among people without diabetes
(3.1% and 1.5% respectively). The respective agestandardised
rates of angina were 4.1% and 1.6%
for people with and without diabetes.
A greater proportion of males with diabetes
had suffered a heart attack (4%) than females
(2.1%). The reverse was true for angina: 3.6% of
males and 4.8% of females with diabetes had
experienced the condition.
Stroke
Based on information from the 2003 Survey
of Disability, Ageing and Carers, people aged
over 50 had higher rates of stroke than younger
people. In the 50 years and over age group, about
23,400 (7.2%) of males and 31,300 (10%) of
females with diabetes had had a stroke. When the
diﬀerent age-structures of the male and female
populations were taken into account, females
with diabetes (10.2%) still had a higher rate of
stroke than males with diabetes (7.7%). People
with diabetes over 50 had a higher rate of stroke
(7.8%) than people without diabetes (5.2%). Based
on 1999–2000 AusDiab survey data, an estimated
5% of people aged 25 years and over with diabetes
had had a stroke compared with 2% of people
without diabetes.
Peripheral vascular disease
There are limited national data on the number
of Australians who have diabetes and PVD.
Data collected through the Australian National
Diabetes Information Audit and Benchmarking
(ANDIAB) in 2004 revealed that 12.4% of adults
attending specialist diabetes services also had
peripheral vascular disease (NADC 2005).
Complications of diabetes 37
Hospitalisations
In 2004–05, there were over 81,000
hospitalisations where both diabetes and CHD
were present and this accounted for 15.3%
of all diabetes hospitalisations. Diabetes
hospitalisations with stroke in 2004–05
amounted to 11,750 or 2.2% of all diabetes
hospitalisations and PVD was present in
more than 31,000 (5.9% of all diabetes
hospitalisations. A greater proportion of males
than females with diabetes also had CHD, PVD
and stroke (Table 4.1).
The rate of diabetes hospitalisations with CHD,
stroke and PVD increased progressively with
age for both sexes, although more males than
females across all age groups were hospitalised
with diabetes and these complications. Diabetes
hospitalisations with CHD started to accelerate
for males at ages 45–49 years onwards, while
for females the acceleration occurred from ages
60 to 64 years. For both males and females,
diabetes hospitalisations with stroke did not
start to increase until ages 70–74 years. Diabetes
hospitalisations with PVD increased for males
from ages 60–64 years of age and for females
aged 65–69 years.
Deaths
In 2005, diabetes was mentioned as an
underlying or an associated cause of death in
nearly 11,900 deaths (9% of all deaths in that
year). Almost half of these deaths also involved
CHD (48%), while stroke was mentioned in 16%,
and PVD in 6%of diabetes deaths (Table 4.2).
Males had higher age-adjusted rates of mortality
from diabetes with CHD, stroke and PVD
compared with females.
During 1999–05, CVD was the underlying cause
in approximately 3 in 10 (29%) deaths of people
on the NDR. Of all CVD deaths, 68% were due
Table 4.1: Hospitalisations with diabetes and CHD, stroke or PVD, 2004–05
Males Females Persons(a)
Number Per cent Number Per cent Number Per cent
Coronary heart disease 49,802 17.3 31,551 13.0 81,360 15.3
Stroke 6,697 2.3 5,052 2.1 11,750 2.2
Peripheral vascular disease 20,684 7.2 10,755 4.4 31,439 5.9
Total diabetes hospitalisations 288,444 242,614 531,069
(a) Includes sex not stated.
Notes
1. Diabetes and related complications are classified according to ICD-10-AM codes. See Appendix 1.
2. Hospitalisations include diabetes as a principal or additional diagnosis.
Source: AIHW National Hospital Morbidity Database.
Table 4.2: Diabetes deaths also involving CHD, stroke or PVD, 2005
Males Females Persons
Number Per cent Number Per cent Number Per cent
Coronary heart disease 3,216 50.8 2,499 45.1 5,715 48.2
Stroke 931 14.7 971 17.5 1,902 16.0
Peripheral vascular disease 352 5.6 326 5.9 678 5.7
Total diabetes deaths 6,325 5,539 11,864
Notes
1. Diabetes and related complications are classified according to ICD-10 codes. See Appendix 1.
2. Diabetes deaths include diabetes as an underlying or associated cause of death where CHD, stroke and PVD are also mentioned as an underlying or
additional cause of death.
Source: AIHW National Mortality Database.
Diabetes: Australian facts 2008 38
to coronary heart disease and 14% were from
cerebrovascular diseases. Diabetes itself was
the underlying cause in 14% of deaths of NDR
registrants. The NDR contains information
on people who started using insulin to treat
their diabetes after 1 January 1999 (AIHW:
Catanzariti et al. 2007).
Trends
Over the period 1997 to 2005, the contribution
of CHD and PVD to diabetes deaths has declined
while the contribution of stroke has remained
steady. The proportion of diabetes deaths where
CHD was also present declined by 5% and for
PVD by 27% between 1997 and 2005. Over this
period the proportion of diabetes deaths with
CHD was consistently higher among males than
females whereas diabetes deaths with PVD or
stroke were higher among females.
Eye disease
People with diabetes are at an increased risk of
developing diabetic retinopathy (retinal disease),
cataract and glaucoma—leading to a loss of vision
or blindness—than people without diabetes
(Williams et al. 2004). Diabetic retinopathy is the
leading cause of blindness in adults aged 20–74
years (Aylward 2005; Fong et al. 2004). Cataracts
and glaucoma are also major causes of vision
impairment and blindness among adults.
Diabetic retinopathy
Diabetic retinopathy is a microvascular
complication of diabetes caused by damage to
the capillaries of the retina (the light-sensitive
tissues at the back of the eye). In the early stages,
the retinal capillaries swell and leak ﬂuid. At
this stage there is usually no visual impairment.
As the disease progresses, abnormal new
capillaries grow on the surface of the retina.
Without treatment, these capillaries can bleed
causing cloudy vision or blindness. Abnormal
ﬁbrous tissue can also develop, leading to retinal
detachment with severe vision loss.
Diabetic retinopathy is symptomless in its early
phases, and can be treated successfully by laser
surgery if identiﬁed early. Although it cannot
be cured completely, it is estimated that early
detection and timely treatment can prevent
nearly 100% of severe vision loss and blindness
due to diabetic retinopathy (Lee et al. 2001).
Despite this, the disease is estimated to account
for 17% of all blindness and vision impairment in
Australia (Resnikoﬀ et al. 2004).
Cataracts and glaucoma
Cataracts and glaucoma, along with diabetic
retinopathy, are the leading causes of blindness
and visual impairment in people with diabetes
(Williams et al. 2004).
A cataract is a clouding of the normally clear lens
of the eye leading to vision loss. A cloudy lens
prevents light from entering the eye. Cataracts
are more common and progress more rapidly in
people with diabetes (Klein & Klein 1995).
Glaucoma is a condition where pressure builds
up in the eye, pinching the capillaries that carry
blood to the retina and optic nerve. Over time,
the retina and optic nerve become damaged
and vision is lost. People with diabetes are
signiﬁcantly more likely to develop glaucoma
than people without diabetes (Klein & Klein
1995).
Timely identiﬁcation and treatment can prevent
serious vision loss due to cataracts and glaucoma.
Risk factors
Age at onset and duration of diabetes are key
factors inﬂuencing the development of diabetic
retinopathy. In young people with diabetes
(aged <30 years at diagnosis), the prevalence
is as high as 25% during the ﬁrst 5 years after
diagnosis, increasing to 50% after 15 years since
diagnosis. In older people (aged 30 years or more
at diabetes diagnosis), up to 20% may have signs
of retinopathy, rising to 60% after 15 years with
diabetes (Mensah & Kohner 2002).
In addition to duration of diabetes, the risk
of developing eye complications and visual
impairment increases with coexisting medical
problems or complications (such as high blood
pressure and nephropathy), poor blood sugar
control, pregnancy, elevated blood lipids and
smoking (Cohen et al. 1998; NHMRC 1997).
Consequently, good glycaemic control, blood
pressure control, management of kidney
impairment, blood lipid reduction and increased
screening before conception and during
pregnancy are key Preventive measures and
treatment options for reducing the prevalence
and serious consequences of diabetic retinopathy
(Fong et al. 2004; Williams et al. 2004).
How many Australians with
diabetes also have eye disease?
Diabetic retinopathy
In the 1999–2000 AusDiab study, 22% of people
with known diabetes and 6.2% of people with
new diabetes had retinopathy (Tapp et al. 2003b).
The National Divisions Diabetes Program (NDDP)
Data Collation Project found that approximately
11% of patients examined in 2000, 10% in 2001
and 9% in 2002 had retinopathy detected in at
least one eye.
Data on the prevalence of diabetic retinopathy
among patients attending diabetes clinics are
also available from the ANDIAB data. According
to ANDIAB, of those patients who had a retinal
assessment in 2004, approximately 30% had a
diabetes-related abnormality at least one eye
(NADC 2005). ANDIAB data report on people
with diabetes requiring specialist clinical
management, in particular those who have
had poor control of their diabetes, so ANDIAB
ﬁgures are likely to be higher than the rate of this
condition among all people with diabetes.
Cataracts and glaucoma
From self-reports in the 2004–05 NHS, about
12% of people with diabetes had sight problems
due to diabetes. Overall, 9% of people with
diabetes (7% males and 11% females) had
cataracts as a long-term condition while 6% (4%
males and 7% females) had glaucoma.
The age-standardised rates showed that compared
with people without diabetes, those with diabetes
were over twice as likely to have glaucoma and
nearly two times as likely to have cataracts.
The prevalence of cataracts and glaucoma were
high in older ages: over 80% and 52% of people
with diabetes aged 65 years and above were
estimated to have cataracts and glaucoma,
respectively, in 2004–05.
Blindness and visual problems
In 2004–05, 7% of people (7% males and 8%
females) with diabetes had visual disturbances or
loss of vision, or complete or partial blindness in
one or both eyes, based on self-reported data. Of
these, 2% had complete or partial blindness and
5% had visual disturbances or loss of vision.
People with diabetes were 1.3 times as likely to
be blind or have visual disturbances as people
without diabetes according to age-standardised
rates.
In 2004–05, among people with diabetes,
blindness or visual disturbance was most
prevalent among those aged 65 years and over:
over 60% of blindness occurred in this age group.
A greater proportion of females than males
aged 65 years and above was blind or had visual
disturbances.
Based on ANDIAB data for 2006, the incidence
rate for blindness was 0.7% of all people with
clinically diagnosed diabetes (NADC 2007).
Hospitalisations
In 2004–05, there were around 38,700
hospitalisations for diabetes-related eye
complications (including retinopathy, glaucoma
and cataract) which accounted for approximately
7% of all hospitalisations with diabetes.
Hospitalisations for diabetes-related eye
complications were higher for females than
for males (8.2% and 7%, respectively). These
hospitalisations increased with age: people
with diabetes aged 65 years and over accounted
for 78% of diabetes hospitalisations with eye
complications (Figure 4.1).
Diabetes: Australian facts 2008 40
Kidney disease
Diabetes can aﬀect the kidneys in a variety of
ways, leading to serious and even life-threatening
conditions. This section focuses on diabetic
nephropathy and chronic kidney failure including
ESKD, as these are the most common kidney
complications associated with diabetes.
Diabetic nephropathy
Diabetic nephropathy results from high blood
sugar levels damaging the blood-ﬁltering
capillaries in the kidneys. As a result the ﬁltering
effciency of these capillaries declines and blood
proteins such as albumin leak into the urine
(albuminuria).
In the early stages of diabetic nephropathy,
small quantities of albumin leak into the
urine (this is known as microalbuminuria). As
diabetic nephropathy progresses, the kidneys
leak larger amounts of albumin — this is
known as macroalbuminuria or proteinuria.
Microalbuminuria is a strong predictor of
developing proteinuria, ESKD, high blood
pressure and cardiovascular disease. Proteinuria
is usually associated with kidney damage
(Chadban et al. 2003). Diabetic nephropathy is
often asymptomatic until late in the disease when
therapeutic interventions are less eﬀective. If
detected early, intervention may slow or halt its
progression.
Chronic kidney failure (end-stage kidney disease)
In severe cases of diabetic nephropathy, kidney
function may deteriorate to the extent that it
is no longer suﬃcient to sustain life and if left
untreated is fatal within weeks. This terminal
condition is called end-stage kidney disease
(ESKD) —a type of chronic kidney failure.
Diabetic nephropathy is the most common cause
of ESKD in Australia (McDonald et al. 2006).
Risk factors
Factors that may determine whether diabetic
nephropathy develops and progresses to ESKD
include long duration of diabetes, poor blood
sugar control, high blood pressure, anaemia,
genetic susceptibility to diabetic kidney disease
and smoking (Rossing et al. 2004).
Hospitalisations
Age group (years)
0
1,000
2,000
3,000
4,000
5,000
Females
Males
85+ 80–84 75–79 70–74 65–69 60–64 55–59 50–54 45–49 40–44 35–39 30–34 25–29 20–24 15–19
Note: Diabetes and related complications are classified according to ICD-10-AM codes. See Appendix 1.
Source: AIHW National Hospital Morbidity Database.
Figure 4.1: Number of hospitalisations for diabetes with ophthalmic complications, 2004–05

How many Australians with
diabetes also have kidney disease?
The most recent available data on the prevalence
of kidney disease among people with diabetes is
from the 1999–2000 AusDiab study. According to
self-reported data from this study, approximately
6.3% of Australians aged 45 or over with diabetes
were treated for, or suﬀering, from kidney
disease. Signiﬁcantly more women with diabetes
reported being treated for, or suﬀering from,
kidney disease than men (11% compared with
3%).
Diabetic nephropathy
Examining the prevalence of diabetic
nephropathy is problematic due to diﬀerent
methodologies. In this report we have used
albuminuria and proteinuria (protein in
the urine) as a proxy measures for diabetic
nephropathy. These are indicators of kidney
damage, which may be caused by high blood sugar
in people with diabetes.
Data on the prevalence of diabetic nephropathy
based on urinary albumin measurements is
available from the 1999–2000 AusDiab study.
The prevalence of proteinuria in those with
diabetes was over 4 times as high as in those
without diabetes (8.7% versus 1.9% respectively)
(Chadban et al. 2003).
Data on the prevalence of albuminuria among
patients attending diabetes clinics is available
from the ANDIAB data. Two thirds of these
patients had a urinary albumin assessment in
2006. Of them, 58.9% had normal albumin levels,
31.1% had microalbuminuria and 10.0% had
macroalbuminuria (NADC 2007).
Similar data are also available from the National
Divisions Diabetes Program (NDDP) Data
Collation Project. In 2002, 3,548 of the 13,325
registered NDDP patients had albuminuria
assessed. Of those, 76.9% had normal albumin
levels, 19.9% had microalbuminuria and 3.1% had
macroalbuminuria.
End-stage kidney disease (ESKD)
Evidence of the burden of ESKD caused by
diabetes is available from the Australia and New
Zealand Dialysis and Transplant (ANZDATA)
Registry — a registry of people receiving kidney
dialysis or a kidney transplant. New cases of
ESKD with diabetic nephropathy as the primary
cause have increased dramatically over the past
decade. This increase has been most evident
among patients with Type 2 diabetes.
In Australia during 2006, diabetic nephropathy
was the most common cause of primary kidney
disease among ANZDATA patients, which
accounted for one third (32%) of new patients
(McDonald et al. 2007). This represents an
increase in the proportion of new ESKD cases
with diabetes—from 25%, in 2001. The burden of
ESKD from diabetes, particularly Type 2 diabetes,
is likely to increase further as both the age of
the population and prevalence of diabetes are
projected to rise.
Hospitalisations
Kidney complications
In 2004–05, there were nearly 112,100 diabetes
hospitalisations with kidney complications
(excludes hospitalisations for dialysis) which
accounted for 21% of all diabetes hospitalisations.
Nearly 58% of those hospitalisations were for
males. Hospitalisations for diabetes with kidney
complications increased with age for both men
and women (Figure 4.2).
Hospitalisations
Age group (years)
0
5,000
10,000
15,000
20,000
Females
Males
75+ 65–74 55–64 45–54 35–44 25–34 <25
Note: Diabetes and related complications are classified according to ICD-
10-AM codes. See Appendix 1.
Source: AIHW National Hospital Morbidity Database.
Figure 4.2: Number of hospitalisations for diabetes with
kidney complications, 2004–05
Diabetes: Australian facts 2008 42
Hospitalisation rates for diabetes with kidney
complications increased 3-fold over the period
2000–01 to 2004–05 from about 37,400 to
112,100. Part of this increase may be the result of
changes made to the way complications are coded
in hospitalisations data (see Appendix 1).
The average length of stay in hospital for diabetes
with a principal diagnosis of kidney complication
was 11 days for both males and females (this
excludes day stay for regular dialysis). The average
length of stay was 5 days for males and females
for hospitalisations involving any diagnosis of
kidney complications.
Chronic kidney failure
In 2004–05 there were over 102,000
hospitalisations with diabetes and chronic kidney
failure (this excludes day admissions for dialysis,
but includes admissions for ESKD) and 57% of
these were for males. These represented 19% of
all diabetes hospitalisations in that year.
Between 2000–01 and 2004–05, there has been
a 4-fold increase in the number of diabetes
hospitalisations with chronic kidney failure
(about 23,600 and 102,000, respectively). The
proportion of male hospitalisations with diabetes
and a diagnosis of chronic kidney failure has
always been higher than that of females.
The average length of stay in hospital for people
with chronic kidney failure as the principal and
diabetes as an additional diagnosis was 9 days.
Length of stay in hospital was generally higher
for females than for males (11 days compared
with 7 days).
Deaths
In 2005, chronic kidney diseases were responsible
for 13% (1,552 deaths) of all diabetes deaths and
ESKD was mentioned in the majority (90%) of
these deaths.
The rate of kidney-related diabetes mortality was
higher for males compared with females in 2005
(10 and 6 deaths per 100,000, respectively).
Between 1997 and 2005, the kidney-related
diabetes death rate increased by nearly 70% from
5 to 8 per 100,000 people. Males experienced a
slightly higher increase than females between the
two periods (71% and 62%, respectively).
Nerve damage
Nerve damage (neuropathy) is a frequent
complication of diabetes (Boulton et al. 2005). It
is not certain how nerve damage occurs. However,
there is some evidence suggesting that diabetic
neuropathy may be the result of chronically high
blood sugar levels, which aﬀect the metabolism of
nerves, causing reduced blood ﬂow to the nerve.
This, in turn, causes the accumulation of toxins
which damage nerve structure and function.
Diabetic neuropathy aﬀects both peripheral
(peripheral neuropathy) and autonomic (autonomic
neuropathy) nervous systems and is associated
with reduced quality of life and increased
mortality (Boulton et al. 2005; Vinik et al. 2003).
Peripheral neuropathy
Peripheral neuropathy is ‘the presence of symptoms
and/or signs of peripheral nerve dysfunction
in people with diabetes after the exclusion of
other causes’ (Boulton et al. 2005). The condition
commonly causes damage to the nerves in the toes,
feet and legs; however, damage can also occur in
the hands and arms. Peripheral neuropathy can
cause a diverse range of symptoms, depending on
the nerve(s) affected, although some people will
experience no obvious symptoms.
There are two broad types of peripheral
neuropathy:
Sensory neuropathy—affects the nerves that
carry information to the brain about sensations
from various parts of the body. Symptoms may
include pain, tingling in the limbs, extreme
sensitivity to touch, or absence of feeling in the
feet (which predisposes people with diabetes to
foot trauma).
Motor neuropathy—affects the nerves that
carry signals to muscles to allow the muscles to
move and is characterised by loss of strength
and inability to control movement. Motor
neuropathy can lead to muscle weakness,
particularly in the feet, which may become
deformed as a result.
Autonomic neuropathy
Autonomic neuropathy is manifested by
dysfunction of one or more organ systems, and
affects the nerves controlling the heart and
blood vessels, digestive system, urinary tract,
sex organs, sweat glands and eyes (Boulton et al.
2005; Vinik et al. 2003). Symptoms may include
dizziness and fainting, nausea, vomiting and
diarrhoea, constipation, loss of bladder control,
sexual dysfunction in women and erectile
dysfunction in men (see Box 4.2).
Risk factors
The risk of developing neuropathy increases
with duration of diabetes, poor blood sugar
control, and age. Strict glycaemic control has
been shown to reduce or prevent the development
of neuropathy, and may alleviate neuropathic
symptoms. Early identiﬁcation is essential,
especially in people with no obvious symptoms,
to prevent the late sequelae of neuropathy. A
combination of clinical observations and complex
nerve function tests are often required to conﬁrm
the presence of diabetic neuropathy.
How many Australians with diabetes also have neuropathy?
According to the 1999–2000 AusDiab study,
10.3% of males and 8.6% of females with diabetes
had clinical signs of neuropathy.
In the 2004 ANDIAB study, approximately
one quarter (25.5%) of adults attending
specialist diabetes clinics were recorded as
having peripheral neuropathy following clinical
assessment (NADC 2005). However, it should
be noted that ANDIAB data are obtained from
specialist diabetes clinics that are likely to see
more patients with complications.
In the 1999–2000 AusDiab study, 30.2% of men
with diabetes suffered from or received treatment
for impotence (diffculty getting or sustaining
an erection). This is probably due to neuropathy,
but could be due to other factors (see Box 4.2).
According to the ANDIAB Study, 2.2% of all
males attending specialist diabetes clinics in
2006 had erectile dysfunction in the previous
12 months and 26.7% had erectile dysfunction
before the previous 12 months (NADC 2007).
Hospitalisations
In 2004–05, there were around 14,500 diabetes
hospitalisations where nervous system
complications were also mentioned. These
complications accounted for nearly 3% of all
diabetes hospitalisations.
More males than females with diabetes had
nervous system complications (58% of these
hospitalisations were for males). For both males
and females, diabetes hospitalisations with
nervous system complications increased with
age until 75–79 years and declined thereafter
(Figure 4.3).
During 2004–05 the average length of stay in
hospital for people with diabetes and a principal
diagnosis of nervous system complication was
5 days. When nervous system complication was
considered as a principal or additional diagnosis
the average length of stay was 9 days for males
and females.
Deaths
In 2005, nervous system complications were
mentioned in 26 deaths where diabetes was an
underlying or an associated cause of death.
Box 4.2: Erectile dysfunction
What is erectile dysfunction?
Erectile dysfunction is the inability to achieve
and/or sustain an erection sufficient for
sexual intercourse. Research indicates that the
prevalence of erectile dysfunction is significantly
higher among men with diabetes than men
without diabetes, with prevalence estimates
ranging from 35–75% and age of onset occurring
10–15 years earlier in men with diabetes.
Risk factors for erectile dysfunction
Neuropathy is a major risk factor for developing
erectile dysfunction among men with diabetes.
Other risk factors include poor glycaemic
control, vascular disease, nutrition, psychogenic
factors and anti-diabetes medication.
Sources: Chu & Edelmanl 2001; Vinik et al. 2003;
Brown et al. 2005a.
Diabetes: Australian facts 2008 44
Foot complications
Diabetes is associated with nerve damage
(peripheral neuropathy) and poor circulation
(peripheral vascular disease) in the lower limbs.
These factors increase the risk of developing
foot ulcers and infections. Progression of these
conditions in people with diabetes often leads
to lower extremity amputations. Amputations
are associated with increased morbidity and
mortality and high treatment costs. Diabetes is
estimated to account for approximately half of all
non-traumatic amputations (ADA 2007a).
Foot ulcer
Over time, diabetes can damage the nerves in
the feet, resulting in a loss of sensation. Reduced
sensation of pain and discomfort from foreign
bodies, injury or even tightly ﬁtting shoes can
predispose people to foot trauma and ulceration
(ADA 2007a). Damage to nerves also causes
wasting of the foot muscles, reduced joint
mobility and foot deformities such as claw or
hammer toes that are vulnerable to ulceration.
High blood sugar can also damage blood vessels
in the lower limbs. Without a healthy supply of
oxygen and nutrients, feet are predisposed to
ulceration and infection.
Foot ulceration is a common reason for hospital
admission for people with diabetes and is
estimated to precede more than half of all
diabetes-related amputations.
Lower extremity amputation
The combination of diabetic neuropathy,
peripheral vascular disease (PVD) and foot
deformity increases the risk of lower limb
ulcers. Non-healing ulcers can result in gangrene
(chronic infection resulting in tissue death).
Amputation of the aﬀected area may be necessary
as a limb-saving procedure if medical treatment is
unsuccessful.
Amputation is estimated to be 15 times more
common in people with diabetes compared with
other people. Nearly half of the amputations in
people with diabetes are minor (involving toes,
feet and ankles); the other half are major (below
Hospitalisations
Age group (years)
0
200
400
600
800
1,000
1,200
1,400
Females
Males
85+ 80–84 75–79 70–74 65–69 60–64 55–59 50–54 45–49 40–44 35–39 30–34 25–29 20–24 15–19
Note: Diabetes and related complications are classified according to ICD-10-AM codes. See Appendix 1.
Source: AIHW National Hospital Morbidity Database.
Figure 4.3: Number of hospitalisations for diabetes with neurological complications, 2004–05
knee or above knee) (Campbell et al. 2000). Major
amputations are associated with greater loss of
limb function and greater rehabilitation following
amputation (Oyibo et al. 2002).
Many diabetic patients who undergo amputation
will have a subsequent amputation on the other
side within a few years. The remaining limb
becomes more vulnerable to ulceration and
infection because it has to bear extra pressure.
Risk factors
The risk of lower limb ulcers and amputations is
higher in people who have had diabetes for 10
years or more, are male, have poor blood sugar
control, have cardiovascular, visual, or kidney
complications or smoke. Certain foot-related
conditions are associated with an increased
risk of foot ulcer and amputation: peripheral
neuropathy (particularly loss of protective
sensation), peripheral vascular disease (PVD),
foot deformity, and prior history of foot ulcers or
amputation (Lavery et al. 2006).
How many Australians with
diabetes also have foot
complications?
Foot ulcer
The 1999–2000 AusDiab study found that, among
people with diabetes, 2.1% had had aprevious foot
ulceration and 19.6% were found to be at risk of
foot ulcer (deﬁned by the presence of any one of
neuropathy, PVD or history of foot ulceration).
The greatest risk was evident in those with a
diabetes duration of 20 years or more where more
than half (53%) were at risk (Tapp et al. 2003a).
Based on the ANDIAB data for 2004, the
prevalence of current foot ulcers among adult
patients attending diabetes clinics was 1.9%. In
addition, 5.3% of patients had a past history of
foot ulcers. The vast majority (77.2%) of patients
with a current foot ulcer had a past history of
foot ulceration (NADC 2005). Also indicative of
potential foot problems, peripheral neuropathy,
PVD and foot deformity were recorded for a
total of 25.5%, 12.7% and 4.4% of adult patients,
respectively.
Among patients registered in the NDDP
Data Collation Project during 2002, 20.8%
were identiﬁed with foot risk (indicated by a
history of foot problems, and/or presence of
peripheral neuropathy, PVD or foot deformity on
examination).
Lower limb amputation
In 2004, the incidence of lower limb amputation
among adult ANDIAB patients was estimated to
be 0.6%. Further analysis revealed that 76.5% of
patients undergoing a lower limb amputation in
the previous 12 months had a past history of foot
ulceration (NADC 2005).
Hospitalisations
The majority of foot ulcers are treated in
outpatient settings, which limits eﬀective
surveillance of the problem due to lack of
available data relating to these visits (DHAC &
AIHW 1999). However, some information on
the extent of lower limb ulcer and amputation is
available from hospital data that cover admitted
patient episodes.
Lower limb ulcer
In 2004–05 there were approximately 9,900
diabetes hospitalisations in which patients were
treated for lower limb ulcers and this represented
2% of all diabetes hospitalisations in that year.
Over 56% of these hospitalisations were for
males. Diabetes hospitalisations with lower limb
ulcers increased with age, with over two-thirds of
such cases being among people aged 65 and over
in 2004–05.
People hospitalised with lower limb ulcer and
diabetes required long hospitalisations: the
average length of stay was 12 days for males and
13 days for females.
Lower limb amputation
In 2004–05, there were close to 3,400 lower
limb amputations, which accounted for 0.6%
of all diabetes hospitalisations. Overall,
hospitalisations for lower limb amputations
among people with diabetes were more
common among males than females (70% of
the amputations were for males); this pattern
Diabetes: Australian facts 2008 46
occurred across all age groups. The number
of diabetes-related amputations in hospital
increased with age, with people aged 65
years and over accounting for 61% of all such
hospitalisations (Figure 4.4).
People with diabetes hospitalised for lower limb
amputation tended to stay considerably longer
than those hospitalised for other diabetes-related
conditions. The average length of stay in hospital
for lower limb amputation among people with
diabetes was 26 days.
Deaths
In 2005, there were 1,001 diabetes deaths where
lower limb ulcers were recorded as a cause of
death, which accounted for 8% of all diabetes
deaths. Males had a death rate of 6 per 100,000
people and females half that at 3 per 100,000
people. Between 1997 and 2005, diabetes death
rates where lower limb ulcers were also implicated
decreased by 12%, from 5.2 to 4.6 deaths per
100,000 people.
Oral complications
Diabetes can lead to oral complications. Diabetes
may manifest initially with oral symptoms other
than thirst. For instance, burning tongue, gum
bleeding and excessive salivation have been found
in people with undiagnosed diabetes and resolved
on treatment to improve glycaemic control. This
is very uncommon in Westernised societies but
is more common in underdeveloped countries or
in lower socioeconomic groups, especially where
there is poor hygiene and delayed diagnosis of
diabetes.
Periodontal disease
There is growing acceptance that diabetes is
associated with increased occurrence, extent
and severity of periodontitis (inﬂammation of
the tissues supporting the teeth). The risk is
independent of whether the diabetes is Type 1 or
Type 2 (Lalla et al. 2006; Southerland et al. 2005).
Some researchers point to a two-way connection
between diabetes and periodontal disease,
proposing that not only are diabetic patients
more prone to periodontal disease, but the
presence of periodontal disease aﬀects control of
blood sugar.
International studies have shown that people
with Type 2 diabetes are at increased risk of more
severe periodontal disease compared with those
without diabetes (Campus et al. 2005). Diabetes
can aﬀect the tissues supporting the teeth
(periodontium) and the treatment of periodontal
diseases. Patients with long-term poor control
Hospitalisations
Age group (years)
0
25
50
75
100
125
150
Females
Males
85+ 80–84 75–79 70–74 65–69 60–64 55–59 50–54 45–49 40–44 35–39 30–34 25–29 20–24
Note: Diabetes and related complications are classified according to ICD-10-AM codes. See appendix 1.
Source: AIHW National Hospital Morbidity Database.
Figure 4.4: Number of diabetes hospitalisations where a lower limb amputation was performed, 2004–05
of diabetes have increased extent and severity
of periodontal disease, whereas those who
maintain good metabolic control have minimal
periodontal problems. Integrated medical and
dental management of these conditions is
essential for the general health and quality of life
of patients. Treatment of periodontal infections
with systemic antibiotics can contribute to the
control of diabetes.
Other oral problems
Caries (tooth decay) in the crowns of teeth appear
to be more frequent in adults with poor control
of insulin-dependent diabetes. Oral infections
other than dental caries and periodontal disease
are often more severe in people with diabetes.
Examples of these are life-threatening deep neck
infections and fatal ulcers of the palate.
Risk factors
Risk factors for oral complications in people with
diabetes include poor oral hygiene, poor control
of blood sugar levels, smoking and inadequate
nutrition.
How many Australians with diabetes also have oral complications?
Currently there are no national data on the dental
visits of people with diabetes or the prevalence of
oral complications among people with diabetes.
Hospitalisations data are presented in this report
as they give some indication of the number of
people using the hospital system to deal with
such problems.
In 2004–05, there were 98 hospitalisations for
periodontal complications where diabetes was the
principal diagnosis and 202 hospitalisations for
periodontal complications where diabetes was the
principal or additional diagnosis (Table 4.3).
The average length of stay for diabetes with
periodontal complications was 3 days when
diabetes was a principal diagnosis and 7 days as
any diagnosis.
Table 4.3: Number of diabetes hospitalisations with
periodontal complications, 2004–05
Diabetes as
Principal
diagnosis Any diagnosis(a)
Males 50 106
Females 48 96
Persons 98 202
(a) Includes principal and additional diagnosis.
Note: Diabetes and related complications are classified according to ICD-10-
AM codes. See Appendix 1.
Source: AIHW National Hospital Morbidity Database.
Complications in
pregnancy
Pregnancy complicated by diabetes can be divided
into 2 main groups: pre-gestational diabetes and
gestational diabetes. Pre-gestational diabetes
is deﬁned as pre-existing diabetes in pregnancy
among women who had Type 1 or Type 2 diabetes
before conception. Pre-gestational diabetes
represents about 10% of cases of pregnancy
complicated by diabetes. Gestational diabetes is
the more common type of diabetes complicating
pregnancy. Gestational diabetes is deﬁned as
diabetes ﬁrst diagnosed during pregnancy, and is
a transient condition that usually develops late
in the second trimester and resolves shortly after
the birth (Barbour & Friedman 2003).
What is diabetes in pregnancy?
In all pregnant women, pregnancy hormones
induce insulin resistance, which means there is a
higher insulin requirement in order to keep the
blood sugar levels in the ‘normal range’. In women
without diabetes there is on average a 3-fold
increase in insulin production by late pregnancy.
Gestational diabetes occurs when the pancreas is
not able to adequately increase insulin production
to overcome the eﬀects of insulin resistance. Pregestational
Type 1 diabetes leads to an average
50% increase in insulin requirements by late
pregnancy. Women with pre-gestational Type 2
diabetes are likely to require insulin therapy
during pregnancy (Barbour & Friedman 2003).
Diabetes: Australian facts 2008 48
Effect of diabetes in pregnancy
Diabetes in pregnancy has potential eﬀects on
the mother’s health as well as on the foetus and
newborn baby. Women with well-controlled
diabetes lower the risk of complications for
themselves and their babies.
Maternal risks
Some diabetes complications may be exacerbated
by pregnancy. Retinopathy may worsen during
pregnancy and the risk is particularly increased
with longer duration of diabetes and with the
degree of blood sugar control. Laser therapy may
be needed during pregnancy (Van Impe 2005).
Pregnancy can lead to a reduction in kidney
function in about one-third of women with pre-existing
kidney disease (Willams 2007).
Common pregnancy complications are more
common in women with diabetes. Pregnancy induced
hypertension is more common in
women with pre-existing diabetes than in
women without diabetes (Leguizamon et al.
2006) and caesarean delivery is more frequent in
pregnancies complicated by diabetes (Gonzalez-
Quintero et al. 2007).
Women with gestational diabetes are at
signiﬁcantly increased risk of developing
Type 2 diabetes and at an increased risk of
developing cardiovascular disease later in life
(Lee et al. 2007).
Foetal risks
Babies of women with gestational diabetes
may have a greater risk of perinatal death, and
newborn problems including: hypoglycaemia
in the newborn, low birth-weight, jaundice,
respiratory distress and birth trauma due to very
high birth-weight (Gonzalez-Quintero et al. 2007).
Pre-gestational diabetes is also associated with an
increased rate of major congenital malformations
in the foetus and a higher rate of spontaneous
abortions (Barbour & Friedman 2003).
How many Australian women are
affected by maternal diabetes?
Nearly 11,000 Australian women giving birth in
hospital in 2004–05 had gestational diabetes,
which is 4.2% of all deliveries. For more details
refer to Chapter 2 of this report. Another 1,200
women giving birth in hospital in that year had
pre-existing diabetes and a further 800 women
had diabetes at the time of delivery, though it
was not speciﬁed whether it was pre-existing or
gestational diabetes.
Table 4.4: Pre-existing and gestational diabetes, 2004–05
Number Per cent(d)
Pre-existing diabetes in
pregnancy(a) 1,257 0.5
Gestational diabetes(b) 10,861 4.2
Diabetes of unknown onset in
pregnancy(c) 826 0.3
(a) Pre-existing diabetes in pregnancy defined by ICD-10-AM codes
O240–O243.
(b) Gestational diabetes defined by ICD-10-AM code O244.
(c) Diabetes of unknown onset in pregnancy defined by ICD-10-AM code
O249.
(d) Percentage of all births in hospital, defined by ICD-10-AM code Z37.
Source: AIHW National Hospital Morbidity Database.
Information is also available from state and
territory midwives data collections. These data
are not yet available as national estimates;
however, the development of a nationally
consistent scope, collection methods and
classiﬁcations of gestational diabetes and pre-existing
diabetes in pregnancy is progressing
(NPSU 2006). The available state and territory
data (excluding Tasmania) show that in most
jurisdictions pre-existing diabetes was present
in less than 1% of women giving birth in 2004.
Gestational diabetes was reported in 4.0 to 6.3%
of women across these states and territories.
Population groups
Aboriginal and Torres Strait Islander people .............. 50
Socioeconomic position.................................................. 54
Geographical location ..................................................... 58
Overseas-born .................................................................. 63
Diabetes: Australian facts 2008 50
Aboriginal and Torres
Strait Islander people
Aboriginal and Torres Strait Islander peoples
suffer a greater burden of chronic disease
than the rest of the Australian population
and the current diabetes epidemic has had a
disproportionate impact on the Australian
Indigenous population compared with the total
Australian population (Daniel et al. 1999). The
greater burden of diabetes in the Australian
Indigenous population is largely due to higher
rates of modiﬁable risk factors, such as obesity,
which are related to the social disadvantage
experienced by Aboriginal and Torres Strait
Islander peoples. Reduced or limited availability
and accessibility of health-care services for
diagnosis and treatment may also adversely
inﬂuence health outcomes for Indigenous people
with diabetes and related complications.
Aboriginal and Torres Strait Islander people do
not use health services with the same frequency
as other Australians, and many communities and
individuals may not have ready access to services.
Diffculties with spoken and written English, lack
of available transport, ﬁnancial diffculties and
the proximity of culturally appropriate healthcare
services present barriers to Aboriginal and
Torres Strait Islander people accessing health
care, and feelings of marginalisation also present
barriers to the effcacy of diabetes prevention
strategies and treatment (ABS & AIHW 2005).
Incidence
A recent population-based study among 180,481
Indigenous and nearly 5 million non-Indigenous
adolescents, aged 10–18 years, in New South
Wales has shown that Indigenous adolescents are
diagnosed with Type 2 diabetes at 6 times the
rate of non-Indigenous adolescents. The incidence
of Type 1 diabetes was not different between the
two populations (incidence rate ratio=0.7) (Craig
et al. 2007).
Prevalence
According to self-reported data from the
2004–05 NATSIHS, neary 30,000 Indigenous
people (6.3% of the total Indigenous population)
had diabetes: 57% of whom were male.
When the diﬀerent age structures of the
populations were taken into account, the rate of
diabetes among Indigenous people was just over
3 times that of non-Indigenous people. The age adjusted
rate of diabetes among Indigenous males
was 3 times the rate of non-Indigenous males and
the rate among Indigenous females was 4 times
that of non-Indigenous females (Figure 5.1).
Per cent
Sex
0
2
4
6
8
10
12
14
16 Non-Indigenous Indigenous
Persons Females Males
Notes
1. Based on self-reported data.
2. Directly age-standardised to the 2001 Australian population.
Source: AIHW analysis of ABS 2004–05 NATSIHS data.
Figure 5.1: Prevalence of diabetes by Indigenous status
and sex, 2004–05
Risk factors
National data on diabetes risk factors for
Aboriginal and Torres Strait Islander people
are available for body weight and diet. Data on
tobacco smoking—which is a risk factor for some
diabetes complications—are also presented.
According to data from the 2004–05 NATSIHS,
57% of Aboriginal and Torres Strait Islander
people aged 15 years and over were overweight
Box 5.1: Age standardisation
In this chapter survey data are directly
standardised. Hospitals and mortality data
are indirectly age standardised, except for
reporting of trends and comparisons between
socioeconomic groups. For a detailed discussion
on age-standardisation methods and reference
populations, see Appendix 1.

or obese. Of all Indigenous people aged 12 years
and over, 5% did not eat vegetables on a daily
basis and 14% did not eat fruit on a daily basis. In
2004–05, 50% of Indigenous people aged 18 years
or over were current daily smokers.
The age-standardised rates indicate that a higher
proportion of Indigenous people aged 15 years
and over were overweight or obese compared
with non-Indigenous people (62% compared with
51%). Indigenous people aged 12 years and over
ate fewer fruit and vegetables each day compared
with non-Indigenous people: Indigenous people
were 7 times as likely as non-Indigenous people
not to eat vegetables and twice as likely not to eat
fruit. The rate of current daily smoking among
Indigenous adults was more than twice that of
non-Indigenous adults.
Self-reported data from the Well Person’s
Health Check study, which was undertaken in
Queensland between 1998 and 2000, showed
that 30% of Indigenous males and 33% of
Indigenous females with diabetes consumed
inadequate serves of fruit (fewer than 2 serves
per day) (McCulloch et al. 2003). Also, 55% of
Indigenous males and 60% of Indigenous females
with diabetes did not do adequate exercise in the
week before the survey (less than 3 days with
30 minutes of activity per day). The same survey
indicated that 48% of Indigenous males and 36%
of Indigenous females with diabetes smoked
tobacco.
For more national information on speciﬁc risk
factors, refer to Chapter 3.
Hospitalisations
In 2004–05, in Qld, WA, SA and the NT, there
were approximately 2,900 hospitalisations of
Aboriginal and Torres Strait Islander people
where diabetes was a principal diagnosis. This
accounted for 1.5% of all hospitalisations
among Indigenous people. Diabetes was
an additional diagnosis in a further 27,182
Indigenous hospitalisations, increasing the total
diabetes hospitalisations to 30,055 or 16% of all
Indigenous hospitalisations. Indigenous people
were hospitalised with diabetes as a principal
diagnosis at 6 times the rate and with diabetes
as any diagnosis at 11 times the rate of other
Australian persons in 2004–05 (Figure 5.2).
Hospitalisation rates among Indigenous people
were higher that among other Australians
for all types of diabetes: twice as high for a
diagnosis of Type 1 diabetes, 15 times as high
for a diagnosis of Type 2 diabetes and 6 times
as high for a diagnosis of other/unspeciﬁed
diabetes. Indigenous women were hospitalised for
gestational diabetes at more than 5 times the rate
of other Australian women.
Hospitalisations per 1,000 population
0
50
100
150
200
250
300
Non-Indigenous
Indigenous
Any diagnosis Principal diagnosis
Notes
1. Diabetes and related complications are classified according to ICD-10-
AM codes. See Appendix 1.
2. Indirectly age-standardised to the 2004–05 non-Indigenous
population.
3. Data are from Queensland, Western Australia, South Australia and
public hospitals in the Northern Territory only.
Source: AIHW National Hospital Morbidity Database.
Figure 5.2: Diabetes hospitalisations by Indigenous
status, 2004–05
Trends
In 2000–01 the rate of hospitalisation with
any diagnosis of diabetes among Indigenous
Australians was 8 times that for other
Australians. In 2004–05 this increased to
11 times the rate of hospitalisation for other
Australians (Figure 5.3).
Deaths
Among Aboriginal and Torres Strait Islander
people, diabetes was the underlying cause of 346
deaths, and an associated cause of a further 492
deaths in Queensland, Western Australia, South
Australia and the Northern Territory, for the years
2003–2005. Diabetes deaths among Indigenous
persons accounted for 9% of total diabetes deaths
and nearly 8% of all Indigenous deaths in the
four jurisdictions during this period. Indigenous
Diabetes: Australian facts 2008 52
Australians died from diabetes as an underlying
cause of death at 12 times, and from diabetes
as any cause of death at 9 times the rate of non-
Indigenous Australians (Figure 5.4).
Hospitalisations per 1,000 population
Year
0
50
100
150
200
250
Indigenous
Other
2004–05 2003–04 2002–03 2001–02 2000–01
Notes
1. Diabetes and related complications are classified according to ICD-10-
AM codes. See Appendix 1.
2. Directly age-standardised to the 2001 Australian population.
3. Data are from Queensland, Western Australia, South Australia and
public hospitals in the Northern Territory only.
Source: AIHW National Hospital Morbidity Database.
Figure 5.3: Diabetes hospitalisations by Indigenous
status, 2000–01 to 2004–05
Deaths per 10,000 population
0
10
20
30
40
50
Non-Indigenous
Indigenous
Any cause
of death
Underlying cause
of death
Notes
1. Diabetes and related complications are classified according to ICD-10
codes. See Appendix 1.
2. Indirectly age-standardised to the 2003–2005 non-Indigenous
population.
3. Data are based on year of registration of death in Queensland,
Western Australia, South Australia and the Northern Territory.
4. Data with missing/not stated Indigenous status were excluded from
this analysis.
Source: AIHW National Mortality Database.
Figure 5.4: Diabetes deaths by Indigenous status, 2003–2005
Trends
Between 2000 and 2005 there was no consistent
pattern in diabetes deaths among Indigenous
people.
Complications
Common complications of diabetes include
cardiovascular disease and kidney disease,
and the prevalence rates of these diseases in
the Australian community are presented in
Chapter 4.
Prevalence
According to the self-reported 2004–05
NATSIHS, approximately 53% of Aboriginal and
Torres Strait Islander people with diagnosed
diabetes also had heart and circulatory disease
and 10% also had kidney disease.
The age-standardised rate of heart and circulatory
disease in the Indigenous population was
1.3 times that of the non-Indigenous population.
For kidney disease, the prevalence was 10 times
that of their non-Indigenous counterparts.
Hospitalisations
Of the approximately 30,100 diabetes
hospitalisations among Aboriginal and Torres
Strait Islander Australians in 2004–05, just over
18,300 (61%) also involved kidney complications
of diabetes (including chronic kidney failure),
and nearly 2,300 (8%) also had coronary heart
disease (CHD). When the diﬀerent age-structures
of the two populations were accounted for,
hospitalisation rates for kidney complications
among Indigenous people were nearly 30 times as
high and CHD hospitalisation rates were 8 times as
high as those among other Australians (Table 5.1).
One of the highest disparities in hospitalisation
rates was for oral complications of diabetes, for
which hospitalisations among Indigenous people
were 17 times that among other Australians.
Deaths
Diabetes deaths where complications were
mentioned were much higher among Indigenous
persons than among non-Indigenous Australians
(Table 5.2).
During the period 2003–2005, Indigenous
people had a diabetes death rate with kidney
complications 19 times that of the non-
Indigenous Australians. Diabetes deaths with
CHD, stroke, PVD and lower limb ulcers among
Indigenous people were about 7 times as high as
that of non-Indigenous people.
Table 5.1: Hospitalisations for diabetes complications among Indigenous Australians, 2004–05
Complication Observed Expected
Standardised
hospitalisation ratio
CHD 2,289 278 8.1(a)
Stroke 314 34 9.1(a)
PVD 604 129 4.7(a)
Kidney 18,319 620 29.5(a)
Eye 758 138 5.5(a)
Nervous system 359 76 4.7(a)
Oral 26 1 17.4(a)
Limb ulcer 424 41 10.3(a)
(a) Denotes that the rate of hospitalisations for any diagnosis of diabetes complications is significantly higher among Indigenous Australians than among
Other Australians.
Notes
1. Diabetes and related complications are classified according to ICD-10-AM codes. See Appendix 1.
2. Indirectly age-standardised to the 2004–05 Other Australian population.
3. Data are based on hospitalisations in Queensland, South Australia, Western Australia and public hospitals in the Northern Territory only.
4. Diabetes hospitalisations include those for which diabetes is a principal or additional diagnosis.
5. A single diabetes hospitalisation may include multiple complication types among the diagnoses.
Source: AIHW National Hospital Morbidity Database.
Table 5.2: Deaths from diabetes complications among Indigenous Australians, 2003–2005
Type of complication Observed Expected
Standardised
mortality ratio
CHD 347 47 7.3(a)
Stroke 97 14 7.0(a)
PVD 37 5 6.7(a)
Kidney 216 11 19.3(a)
Limb ulcer 55 8 7.3(a)
(a) Denotes that the rate of deaths with any mention of diabetes complications are significantly higher among Indigenous Australians than among other
Australians.
Notes
1. Diabetes and related complications are classified according to ICD-10 codes. See Appendix 1.
2. Indirectly age-standardised to 2003–2005 non-Indigenous Australian population.
3. Data are based on year of registration of death in Queensland, South Australia, Western Australia and the Northern Territory.
4. A total of 141 deaths in 2003–2005 where diabetes was mentioned as any cause of death had a missing/not stated Indigenous status and were excluded
from the analysis.
5. A single person may have multiple complication types listed as a cause of death.
Source: AIHW National Mortality Database.
Diabetes: Australian facts 2008 54
Socioeconomic position
Socioeconomic position is a complex concept, and
it is well established that it has a strong inﬂuence
on health. It is often conceptualised around three
main features: education, employment status and
income. Disadvantage in any of these areas has
the potential to have an impact on the prevalence
of diabetes and diabetes risk factors, as well as
diabetes morbidity and mortality.
The measure of socioeconomic disadvantage—the
ABS Socioeconomic Index for Areas (SEIFA)—
used in this section is a measure constructed
at the level of geographic area of residence.
Although it does not necessarily represent the
socioeconomic position of all households or
individuals living within that area, it is a valid
measure of socioeconomic position (Dutton
et al. 2005). For the analysis presented here,
the population was divided into ﬁve equalsized
groups based on the area-measure of
socioeconomic position. That is, the group with
the lowest socioeconomic position is the ﬁfth of
the population living in the least-well-offareas.
And similarly, the highest socioeconomic group
is the ﬁfth of the population living in the mostwell-
off areas.
Prevalence
In 2004–05, the NHS showed a pattern of
increasing diabetes prevalence with decreasing
socioeconomic position. The age-adjusted
prevalence rate of diabetes was 2.3% for
people from the highest socioeconomic group.
The prevalence of diabetes in the lowest
socioeconomic group was nearly twice this rate.
Across all socioeconomic groups males had higher
rates of diabetes compared with females.
Risk factors
The prevalence of diabetes risk factors such as
overweight and obesity and physical inactivity
is higher in groups with lower socioeconomic
position compared with groups with higher
socioeconomic position. Based on data from
the 2004–05 NHS, a higher proportion of
people in the lowest socioeconomic groups were
overweight or obese (53%) and physically inactive
(76%), compared with people in the highest
socioeconomic group (47% and 62%, respectively)
(Table 5.3).
The pattern was mixed in relation to diet. While
the proportions not eating suﬃcient amounts of
vegetables were similar across all socioeconomic
groups, a higher proportion of people in the least
well-oﬀ group (54%) ate insuﬃcient amounts of
fruit compared with people in the most well-oﬀ
group (44%).
People with diabetes were 20–50% as likely to be
overweight or obese compared with those without
diabetes across all socioeconomic groups. Except
for those from the highest socioeconomic group,
a higher proportion of people with diabetes than
those without diabetes in all other socioeconomic
groups were estimated to be physically inactive.
For more information on speciﬁc risk factors,
refer to Chapter 3.
Table 5.3: Prevalence of diabetes risk factors by socioeconomic position, 2004–05 (per cent)
Socioeconomic groups
First (highest
socioeconomic
position) Second Third Fourth
Fifth (lowest
socioeconomic
position)
Overweight/obese 46.7 50.8 52.2 54.1 53.0
Physical inactivity(a) 62.3 68.0 71.0 72.3 75.9
Insufficient fruit(b) 43.7 47.3 50.2 52.6 54.0
Insufficient vegetable(c) 84.9 84.1 83.4 83.1 85.5
(a) Sedentary or low exercise level.
(b) Insufficient fruit is fewer than 3 serves per day for children aged 12–18 years, and fewer than 2 serves per day for adults aged 19 years and over.
(c) Insufficient vegetable is fewer than 4 serves per day for children aged 12–18 years, and fewer than 5 serves per day for adults aged 19 years and over.
Note: Directly age-standardised to the 2001 Australian population.
Source: AIHW analysis of ABS 2004–05 National Health Survey data.
55
Hospitalisations
In 2004–05, diabetes hospitalisations increased
with decreasing socioeconomic position
(Figure 5.5). When diabetes was considered as
any diagnosis, the rate of diabetes hospitalisation
among people from the lowest socioeconomic
group (341 per 10,000) was nearly twice as
high as that among people from the highest
socioeconomic group (180 per 10,000). When
diabetes was the principal diagnosis, the rates
ranged from 25 per 10,000 people among the
most well-off to 47 per 10,000 for the least
well-off.
Hospitalisations per 10,000 population
Socioeconomic groups
0
5
10
15
20
25
30
35
40
Persons
Females
Males
Fifth
(lowest
socioeconomic
position)
Fourth Third Second First
(highest
socioeconomic
position)
Notes
1. Diabetes and related complications are classified according to ICD-10-
AM codes. See Appendix 1.
2. Directly age-standardised to the 2001 Australian population.
Source: AIHW National Hospital Morbidity Database.
Figure 5.5: Diabetes hospitalisations by socioeconomic
position and sex, 2004–05
In 2004–05, hospitalisation rates for Type 2
diabetes among people from the lowest and the
highest socioeconomic groups were 152 and 291
per 10,000 people, respectively. Females from the
lowest socioeconomic group had hospitalisation
rates for gestational diabetes that were twice that
of females from the highest socioeconomic group
(22 and 11 per 10,000 females, respectively).
Trends
Across the period 2001–02 to 2004–05, the
diabetes hospitalisation rate increased for
all socioeconomic groups (Figure 5.6). People
from the highest socioeconomic group were
hospitalised at a rate of 149 per 10,000 in
2001–02. This rate increased by 21% to 180 per
10,000 in 2004–05. In 2000–01, people from the
lowest socioeconomic group were hospitalised
with diabetes at a rate of 264 per 10,000, and this
increased by 29% to a rate of 341 per 10,000 in
2004–05.
Hospitalisations per 10,000 population
Year
0
50
100
150
200
250
300
350
Fifth (lowest socioeconomic position)
First (highest socioeconomic position)
2004–05 2003–04 2002–03 2001–02
Notes
1. Diabetes and related complications are classified according to ICD-10-
AM codes. See Appendix 1.
2. Directly age-standardised to the 2001 Australian population.
Source: AIHW National Hospital Morbidity Database.
Figure 5.6: Diabetes hospitalisations by socioeconomic
position, 2000–01 to 2004–05
Deaths
In the period 2003–2005, lower socioeconomic
position correlated with higher diabetes
mortality. When diabetes was the underlying
cause of death, there were 1,589 deaths among
people in the highest socioeconomic group (13
deaths per 100,000) and 2,623 deaths among
people in the lowest socioeconomic group (23
deaths per 100,000). There were 5,305 deaths
from diabetes as an underlying or associated
cause among people in the highest socioeconomic
group—a rate of 40 deaths per 100,000. In the
lowest socioeconomic group 8,298 deaths were
recorded in 2003–2005—a rate of 72 per 100,000
(Figure 5.7).
During the period 2003–2005, people in the
lowest socioeconomic group died from Type 1
diabetes at 1.4 times the rate, and Type 2 and
other/unspeciﬁed diabetes at 1.7 times the rate of
people in the highest socioeconomic group.
Diabetes: Australian facts 2008 56
Trends
The diabetes death rate increased for all
socioeconomic groups, by between 4% and 16%,
across the period from 2001 to 2005 (Figure 5.8).
Deaths per 100,000 population
Year
0
10
20
30
40
50
60
70
80
First (highest socioeconomic position)
Fifth (lowest socioeconomic position)
2005 2004 2003 2002 2001
Notes
1. Diabetes and related complications are classified according to ICD-10
codes. See Appendix 1.
2. Directly age-standardised to the 2001 Australian population.
Source: AIHW National Mortality Database.
Figure 5.8: Diabetes deaths by socioeconomic position,
2001 to 2005
Deaths per 100,000 population
Socioeconomic group
0
10
20
30
40
50
60
70
80
Associated cause of death
Underlying cause of death
Fifth
(lowest
socioeconomic
position)
Fourth Third Second First
(highest
socioeconomic
position)
Notes
1. Diabetes and related complications are classified according to ICD-10
codes. See Appendix 1.
2. Directly age-standardised to the 2001 Australian population.
Source: AIHW National Mortality Database.
Figure 5.7: Diabetes deaths by socioeconomic position,
2003–2005
Complications
Hospitalisations
There was a consistent pattern of higher
hospitalisation rates in lower socioeconomic
groups for all complication types (Figure 5.9).
Of the 75,741 hospitalisations for diabetes
among people in the lowest socioeconomic
group, 29% were also treated for coronary heart
disease (CHD) and 46% were treated for kidney
complications (including chronic kidney failure).
These were twice and 3 times the corresponding
rates among people in the highest socioeconomic
group.
Deaths
Over the period 2003 to 2005, there was a
consistent pattern of higher diabetes-related
death rates in lower socioeconomic groups
compared with higher socioeconomic groups
for all complication types (Figure 5.10). The
difference was greater for some complications
than for others. For example, the diabetes death
rate with kidney complications was twice as high
among people in the lowest socioeconomic group
as among those in the highest group. Similarly,
the rate of diabetes deaths with CHD was
also higher in the lowest socioeconomic group
compared with the highest group (35 and 19
deaths per 100,000, respectively).
For more information on speciﬁc complications of
diabetes, see Chapter 4.
57
Hospitalisations per 10,000 population
Type of complication
0
20
40
60
80
100
Fifth (lowest socioeconomic position)
Fourth
Third
Second
First (highest socioeconomic position)
Limb ulcers Nervous system Eye Kidney PVD Stroke CHD
Notes
1. Diabetes and related complications are classified according to ICD-10-AM codes. See Appendix 1.
2. Directly age-standardised to the 2001 Australian population.
3. These data include hospitalisations for any diagnosis of diabetes, and related complications as either principal or additional diagnosis.
Source: AIHW National Hospital Morbidity Database.
Figure 5.9: Hospitalisations for diabetes complications by socioeconomic position, 2004–05
Deaths per 100,000 population
Type of complication
0
5
10
15
20
25
30
35
Fifth (lowest socioeconomic position)
Fourth
Third
Second
First (highest socioeconomic position)
Limb ulcers Kidney PVD Stroke CHD
Notes
1. Diabetes and related complications are classified according to ICD-10 codes. See Appendix 1.
2. Directly age-standardised to the 2001 Australian population.
3. These data include deaths with diabetes as any cause, and related complications as either underlying or additional cause of death.
Source: AIHW National Mortality Database.
Figure 5.10: Deaths from diabetes complications by socioeconomic position, 2003–2005
Diabetes: Australian facts 2008 58
Geographical location
Persons living in rural and remote regions of
Australia generally have worse health, in terms of
mortality, hospitalisation rates and risk factors
compared with those living in metropolitan
regions (Wilkinson & Blue 2002). This difference
may be related to fewer educational and
employment opportunities, poorer access to
health services and the availability of necessities
such as sewerage, clean water and a safe food
supply (AIHW 2006a).
The relatively large proportion of Indigenous
people living in Remote and Very Remote areas
(12% and 45%, respectively) compared with Major
Cities, together with their poorer overall health,
is reﬂected in high rates of death in Remote areas
(AIHW 2006a; Draper et al. 2004; Coory 2003).
In 2005, 57% of diabetes deaths registered in
Remote areas were for persons of Aboriginal and
Torres Strait Islander origin, compared with only
3% of diabetes deaths registered in Major Cities
or regional areas. Similarly, 78% of diabetes
hospitalisations in 2004–05 among people from
Remote areas were for Aboriginal and Torres
Strait Islander persons, compared with only 9%
of diabetes hospitalisations among people from
Major Cities or regional areas.
Prevalence
According to self-reported data from the
2004–05 NHS, there were small diﬀerences in
diabetes prevalence between regions: the ageadjusted
rate was 3.4% in Major Cities, 3.5% in
Inner Regional Australia and 3.6% in all other
regions (Outer Regional, Remote and Very
Remote combined). The prevalence of Type 2
diabetes was 2.9% for all regions.
As data for persons living in Remote and Very
Remote Australia needed to be combined in the
analysis, the inﬂuence of remoteness on diabetes
prevalence could not be determined.
Risk factors
Based on the estimates from the 2004–05
NHS, a number of differences in diabetes risk
factors were seen among people from different
geographical regions. Over 50% of people living in
Major Cities, Inner Regional and other areas were
overweight or obese, thus being at increased risk
of diabetes. Approximately a third of the Major
Cities and Inner Regional population—and four
out of ten people in other areas—were estimated
to be sedentary or exercising at a low level. Just
under one half of people in Major Cities, half of
people in Inner Regional areas and 54% of people
in other areas consumed insuffcient fruit in
2004–05. The amount of vegetables consumed by
those living in all geographical areas were much
less than the level recommended by Australian
dietary guidelines. Over three-quarters of the
populations in these areas consumed insuffcient
amounts of vegetables, with people living in
Major Cities having the highest rate of 87%.
When the risk factors for diabetes in populations
with and without diabetes in different
geographical regions were compared, the
proportion that was overweight or obese was
consistently higher among people in all areas
with diabetes than among those without diabetes
(Table 5.4). For people with diabetes, higher rates
of overweight were seen in the Major Cities, but
for people without diabetes the situation was reversed.
While people with diabetes in Major Cities and
Inner Regional areas had higher rates of physical
inactivity than their counterparts without
diabetes, there was no difference between the two
groups in other areas (Table 5.4).
People with diabetes living in other areas were
less likely to eat insufficient fruit and vegetables
each day, compared with their counterparts
without diabetes. People with diabetes in Major
Cities and Inner Regional areas had higher
rates of insufficient vegetable consumption
compared with their counterparts without
diabetes; however people without diabetes in
these areas had higher rates of insufficient fruit
consumption. (Table 5.4).
For more information on speciﬁc risk factors,
refer to Chapter 3.
Hospitalisations
Hospitalisation rates for diabetes rose
with increasing remoteness. In 2004–05,
hospitalisation rates for diabetes as a principal
diagnosis in Very Remote areas were 3 times as
high as in Major Cities (Table 5.5). Hospitalisation
rates for any diagnosis of diabetes in Remote
areas were nearly twice the rate in Major Cities
and in Very Remote areas they were 3 times
as high as in Major Cities. This may partly be a
reﬂection of the high proportion of Indigenous
people living in Remote and Very Remote areas,
which contributes to but does not completely
account for, the poorer health of people living in
remote areas. As shown in the previous section
of this chapter, the prevalence of diabetes is high
among Indigenous people compared with the
non-Indigenous population across all geographic
areas.
In 2004–05 in Remote and Very Remote areas,
females were hospitalised for diabetes at higher
rates than males, either as the principal diagnosis
or as any diagnosis (Table 5.5).
The majority of diabetes hospitalisations in all
regions were for Type 2 diabetes. People living in
Very Remote areas had hospitalisation rates for
Type 2 diabetes over 3 times that of people living
in Major Cities. There was a 4-fold difference for
gestational diabetes. Hospitalisations for Type 1
diabetes among people living in Very Remote
areas is signiﬁcantly lower than among people
living in Major Cities. (Table 5.6).
Trends
There was a signiﬁcant increase in the diabetes
hospitalisation rate in all regions of Australia
Table 5.4: Risk factors by diabetes status and geographical location, 2004–05 (per cent)
General population With diabetes Without diabetes
Major
Cities
Inner
Regional
Other
areas(a)
Major
Cities
Inner
Regional
Other
areas(a)
Major
Cities
Inner
Regional
Other
areas(a)
Overweight/obese 50.6 51.9 54.4 75.0 63.4 65.2 49.6 51.5 53.9
Physical inactivity(b) 32.0 35.0 39.7 39.9 36.2 38.6 31.7 34.6 39.8
Insufficient fruit(c) 48.6 49.9 53.9 42.5 31.6 45.3 48.6 50.1 53.7
Insufficient
vegetables(d) 86.8 79.3 78.4 86.8 79.5 78.1 75.1 59.7 86.5
(a) Other areas include Outer Regional, Remote and Very Remote Australia.
(b) Sedentary or low exercise level.
(c) Insuffi cient fruit is fewer than 3 serves per day for children aged 12–18 years, and fewer than 2 serves per day for adults aged 19 years and over.
(d) Insufficient vegetable is fewer than 4 serves per day for children aged 12–18 years, and fewer than 5 serves per day for adults aged 19 years and over.
Note: Directly age-standardised to the 2001 Australian population.
Source: AIHW analysis of ABS 2004–05 National Health Survey data.
Table 5.5: Diabetes hospitalisations by sex and
geographical location, 2004–05 (per 10,000)
Males Females Persons
Principal diagnosis
Major Cities 32.8 35.3 34.1
Inner Regional 36.9 33.0 34.8
Outer Regional 45.6 18.7 43.6
Remote 46.9 50.3 48.5
Very Remote 76.8 139.0 105.8
Any diagnosis
Major Cities 268.8 240.2 254.3
Inner Regional 292.5 211.0 249.3
Outer Regional 319.4 126.0 301.1
Remote 419.4 534.6 474.5
Very Remote 582.6 899.1 729.2
Notes
1. Diabetes and related complications are classified according to ICD-10-
AM codes. See Appendix 1.
2. Indirectly age-standardised to the 2004–05 Major Cities population.
Source: AIHW National Hospital Morbidity Database.
between 2000–01 and 2004–05 (Figure 5.11).
Major cities, Remote and Very Remote Australia
had a 38% increase and regional Australia had a
36% increase over the period. Remote and Very
Remote areas had higher hospitalisation rates
than Major Cities and the diﬀerence between
these areas has lessened in recent years.
Diabetes: Australian facts 2008 60
Hospitalisations per 10,000 population
Year
0
100
200
300
400
500
600
700 Very Remote
Remote
Outer Regional
Inner Regional
Major Cities
2004–05 2003–04 2002–03 2001–02 2000–01
Notes
1. Diabetes and related complications are classified according to ICD-10-
AM codes. See Appendix 1.
2. Directly age-standardised to the 2001 Australian population.
Source: AIHW National Hospital Morbidity Database.
Figure 5.11: Diabetes hospitalisations by geographical
location, 2000–01 to 2004–05
Deaths
In the period 2003–2005, the death rate from
diabetes as the underlying cause of death for
people living in Major Cities was 16 per 100,000
people. The rate increased with increasing
remoteness, with people in Remote areas
experiencing deaths rates nearly twice that
of people in Major Cities while people in Very
Remote areas had rates over 4 times the rate in
Major Cities (Table 5.7).
Deaths where diabetes was the underlying or an
additional cause of death were also high in more
remote areas than in Major Cities or regional
areas. During 2003–2005, the diabetes death
rate in Very Remote areas was 3 times the rate in
Major Cities (Table 5.7).
Again, the disparity in death rates by region
could be a reﬂection of the higher proportion
of Indigenous Australians in Remote and Very
Remote areas compared with urban and regional
centres. In 2001, 13% of people living in Remote
areas and 44% of people living in Very Remote
areas of Australia were of Indigenous origin.
As discussed earlier in this chapter, the higher
proportion of Indigenous Australians in remote
areas does not completely account for the
generally poorer health of people living in remote
areas.
In 2003–2005, death rates from Type 2 and
Other/Unspeciﬁed types of diabetes were
signiﬁcantly higher in Remote and Very Remote
areas compared with Major Cities (Table 5.8).
There is also evidence of some rates being higher
in regional areas than in Major Cities.
Table 5.6: Diabetes hospitalisations by geographical location and type of diabetes, 2004–05
Major Cities Inner Regional Outer Regional Remote Very Remote
Number
Type 1 33,695 13,771 7,314 747 296
Type 2 290,895 99,797 55,758 11,778 7,797
Gestational(a) 10,767 2,263 1,290 228 308
Other/unspecified 5,147 1,966 1,068 235 159
Standardised hospitalisation ratio
Type 1 1.0 1.2(b) 1.4(b) 1.0 0.8(b)
Type 2 1.0 1.0 1.2(b) 2.0(b) 3.3(b)
Gestational(a) 1.0 1.6(b) 0.9 1.8(b) 4.2(b)
Other/unspecified 1.0 1.1(b) 1.3(b) 2.1(b) 3.0(b)
(a) Females only.
(b) Significantly different to Major Cities.
Notes
1. Diabetes and related complications are classified according to ICD-10-AM codes. See Appendix 1.
2. Indirectly age-standardised to the 2004–05 Major Cities population.
Source: AIHW National Hospital Morbidity Database.
Trends
There was no major change in diabetes death rates
for any region across the six year period 2000 to
2005 (Figure 5.12). There were small reductions
for regional and Very Remote areas and a 15%
increase in remote areas.
Across the same period, there was no signiﬁcant
change in the relative difference in diabetes
death rates for people living in regional areas
compared with people in Major Cities. However,
there was a signiﬁcant increase (18%) in the
difference between Remote areas and Major Cities
and a 13% decrease for Very Remote Australia
compared with Major Cities.
Table 5.7: Diabetes deaths by sex and geographical
location, 2003–2005 (per 100,000)
Males Females Persons
Underlying cause of death
Major Cities 16.4 15.0 15.7
Inner Regional 20.6 14.9 17.3
Outer Regional 26.1 18.1 21.6
Remote 36.9 28.7 32.6
Very Remote 68.9 61.7 65.3
Any cause of death
Major Cities 57.7 50.7 54.2
Inner Regional 70.6 45.8 56.4
Outer Regional 83.6 52.9 66.5
Remote 97.4 71.7 84.1
Very Remote 159.4 165.9 162.6
Notes
1. Diabetes and related complications are classified according to ICD-10
codes. See Appendix 1.
2. Indirectly age-standardised to the 2003–2005 Major Cities population.
Source: AIHW National Mortality Database.
Table 5.8: Diabetes deaths as any cause of death, by geographical location and type of diabetes, 2003–05
Major Cities Inner Regional Outer Regional Remote Very Remote
Number
Type 1 1,695 717 336 41 16
Type 2 10,114 3,800 2,048 283 242
Other/unspecified 9,830 3,472 1,802 266 170
Standardised mortality ratio
Type 1 1.0 1.2(a) 1.2(a) 1.3 1.3
Type 2 1.0 1.1 1.3(a) 1.6(a) 3.7(a)
Other/unspecified 1.0 1.0 1.2(a) 1.5(a) 2.6(a)
(a) Significantly different to Major Cities.
Notes
1. Diabetes and related complications are classified according to ICD-10 codes. See Appendix 1.
2. Indirectly age-standardised to the 2003–2005 Major Cities population.
Source: AIHW National Mortality Database.
Deaths per 100,000 population
Year
0
20
40
60
80
100
120
140
Very Remote
Remote
Outer Regional
Inner Regional
Major Cities
2005 2004 2003 2002 2001 2000
Notes
1. Diabetes and related complications are classified according to ICD-10
codes. See Appendix 1.
2. Directly age-standardised to the 2001 Australian population.
Source: AIHW National Mortality Database.
Figure 5.12: Diabetes death rates by geographical
location 2000 to 2005
Diabetes: Australian facts 2008 62
Complications
Hospitalisations
In 2004–05, hospitalisation rates for various
diabetes complications in most regions were
similar. The notable diﬀerence was in Very
Remote areas where rates for nearly all diabetes
complications were substantially higher than
in other areas. The exception is for kidney
complications where the rates for both Remote
and Very Remote areas were higher than in other
regions (Figure 5.13).
Deaths
There is inequality in death rates from diabetes
complications across regions, particularly between
people in Very Remote areas compared with other
regions. Compared with people living in Major
Cities, people living in Very Remote Australia were 7
times as likely to die with both diabetes and kidney
complications as causes of death and 3 times as
likely to die with diabetes and any of CHD, stroke
and lower limb ulcers in 2003–2005 (Figure 5.14).
For more information on speciﬁc complications of
diabetes, see Chapter 4.
Standardised hospitalisation ratio
Type of complication
0
1
2
3
4
5
6
7
8
Very Remote
Remote
Outer Regional
Inner Regional
Major Cities
Limb ulcers Oral Nervous system Eye Kidney PVD Stroke CHD
Notes
1. Diabetes and related complications are classified according to ICD-10-AM codes. See Appendix 1.
2. 2004–05 Major Cities males, females and persons used as the standard population in the calculation of the rates.
Source: AIHW National Hospital Morbidity Database.
Figure 5.13: Hospitalisations for diabetes complications by geographic location, 2004–05
Standardised mortality ratio (SMR)
Type of complication
0
1
2
3
4
5
6
7
8
Very Remote
Remote
Outer Regional
Inner Regional
Major Cities
Limb ulcers Kidney PVD Stroke CHD
Notes
1. Diabetes and related complications are classified according to ICD-10 codes. See Appendix 1.
2. Indirectly age-standardised to the 2003–2005 Major Cities population.
Source: AIHW National Mortality Database.
Figure 5.14: Deaths from diabetes complications by geographic location, 2003–2005

Overseas-born
Australia is a multicultural nation, with 28%
of its population having been born overseas.
However, previous analysis has shown that
proportionally more overseas-born people than
Australian-born people have diabetes. Rates of
diabetes, hospitalisations and/or mortality are
more common among people born in the South
Paciﬁc Islands, Southern Europe, Middle East,
North Africa and Southern Asia (AIHW 2003a).
Data on ethnicity are not commonly collected
in Australian health statistics, and so country
of birth is used as a proxy for ethnicity in this
section.
Prevalence
In 2004–05, according to NHS self-reported data,
the age-adjusted prevalence of diabetes was 3%
for people born in Australia and 4% for those
born overseas. However, people born in speciﬁc
country groups (regions) had much higher rates
of diabetes than those born in Australia. For
example, the prevalence among people born in
North Africa and the Middle East was about
7%. For those born in South-East Asia it was
close to 6% and for people born in both Oceania
(excluding Australia) and Southern and Eastern
Europe the prevalence of diabetes was around 5%.
Risk factors
According to the 2004–05 NHS data, the age adjusted
prevalence of overweight and obesity
among people born in Australia was estimated
to be 63%. In the same survey, 58% of those
born in the United Kingdom, 62% born in other
Oceania and 67% born in Southern and Eastern
Europe were estimated to be overweight or obese
(Table 5.9).
Over two-thirds of people born in Australia
(69%), other Oceania (68%),the United Kingdom
(66%) and over three-quarters of those born
in Southern and Eastern Europe (79%) were
estimated to be physically inactive.
Other risk factors for diabetes, such as poor
dietary habits, as measured by low intake of fruit
and vegetables, also appeared to be of concern
among these populations. In 2004–05, just over
half the Australian-born population consumed
less than the daily requirement of fruit and 83%
consumed fewer vegetables than their daily
requirement. Of those born overseas, fewer than
half the population from each region consumed
insuffcient amounts of fruit each day; however,
over 80% consumed insuffcient amounts of
vegetables (Table 5.9).
For more information on speciﬁc risk factors,
refer to Chapter 3.
Hospitalisations
In 2004–05, there were almost 42,100
hospitalisations among people born in Australia
where diabetes was the principal diagnosis—a rate
of 27 hospitalisations per 10,000. Hospitalisation
rates for diabetes among people born in South-
East Europe and in Africa and the Middle East
were 20% higher than that among Australian-born
people. People born in North-Western Europe
and the Americas had lower rates of diabetes
hospitalisations than Australian-born people.
Table 5.9: Prevalence of diabetes risk factors by region of birth, 2004–05 (per cent)
Overweight/ obesity Physical inactivity(a) Insufficient fruit(b)
Insufficient vegetables(c)
Australia 62.9 68.7 50.5 82.6
Oceania (excluding Australia) 61.8 67.5 46.9 88.5
United Kingdom 58.1 66.3 49.1 86.8
Southern and Eastern Europe 67.2 78.9 36.0 88.6
(a) Sedentary or low exercise level.
(b) Insufficient fruit is fewer than 3 serves per day for children aged 12–18 years, and fewer than 2 serves per day for adults aged 19 years and over.
(c) Insufficient vegetable is fewer than 4 serves per day for children aged 12–18 years, and fewer than 5 serves per day for adults aged 19 years and over.
Note: Directly age-standardised to the 2001 Australian population.
Source: AIHW analysis of ABS 2004–05 National Health Survey data.
Diabetes: Australian facts 2008 64
People born in Oceania (excluding Australia) and
Asia had similar hospitalisation rates compared
with people born in Australia. This pattern was
similar for hospitalisations where any diagnosis of
diabetes was considered (Figure 5.15).
In 2004–05, hospitalisations for Type 1 diabetes
among people born overseas were only half those
of Australian-born people. Hospitalisations for
Type 2 diabetes among overseas-born people
were 10% higher than those among people born
in Australia. However, women born overseas had
hospitalisation rates for gestational diabetes 3
times that of women born in Australia (Table 5.10).
Trends
Between 2000–01 and 2004–05, the rate of
diabetes hospitalisations increased for both
Australian and overseas-born people, by around
40% (Figure 5.16).
Deaths
In the period 2003–2005, there were 6,693
deaths from diabetes as the underlying cause of
death among people born in Australia: a rate of
15 deaths per 100,000. In contrast, people born
overseas had a slightly higher diabetes death rate
of 18 deaths per 100,000.
Hospitalisations per 10,000 population
Region of birth
0
50
100
150
200
250
300
350
Any diagnosis
Principal diagnosis
The Americas Asia Africa and
the Middle East
South-East Europe North-West Europe Oceania Australia
Notes
1. Diabetes and related complications are classified according to ICD-10-AM codes. See Appendix 1.
2. Indirectly age-standardised to the 2004 Australian-born population.
Source: AIHW National Hospital Morbidity Database.
Figure 5.15: Diabetes hospitalisations by region of birth, 2004–05
Table 5.10: Hospitalisations by type of diabetes, Australian
and overseas-born populations, 2004–05
Type of
diabetes
Number Standardised
hospitalisation
ratio
(Overseas-born/
Australian-born)
Australian born
Overseas born
Principal diagnosis
Type 1 12,050 2,321 0.6(b)
Type 2 25,645 13,883 1.1(b)
Gestational(a) 3,485 1,865 3.3(b)
Other/
unspecified 901 372 1.0
Any diagnosis
Type 1 44,538 11,431 0.6(b)
Type 2 300,223 166,878 1.1(b)
Gestational(a) 9,522 5,341 3.4(b)
Other/
unspecified 6,033 2,568 1.0(b)
(a) Females only.
(b) Significantly different compared with Australian-born rates.
Notes
1. Diabetes is classified according to ICD-10-AM codes: E10–E14 and O24.
2. Indirectly age-standardised to the 2004 Australian-born population.
Source: AIHW National Hospital Morbidity Database.

Diabetes was the underlying or an associated cause
of death in 22,259 deaths (48 per 100,000 people)
among people born in Australia. (Figure 5.17).
There were 12,741 deaths (58 per 100,000) among
overseas-born people with diabetes as a cause
of death. Speciﬁcally, people born in South-East
Europe or Africa and the Middle East had the
highest rates of death from diabetes (76 and 74
deaths per 100,000, respectively).
Hospitalisations per 10,000 population
Year
150
200
250
300
Overseas born
Australian born
2004–05 2003–04 2002–03 2001–02 2000–01
Notes
1. Diabetes and related complications are classified according to ICD-10-
AM codes. See Appendix 1.
2. Directly age-standardised to the 2001 Australian population.
Source: AIHW National Hospital Morbidity Database.
Figure 5.16: Diabetes hospitalisations, Australian-born
and overseas-born people, 2000–01 to 2004–05
In 2003–2005, Australian-born and overseasborn
people had similar rates of death from
Type 1 diabetes. Death rates from Type 2 and
other/unspeciﬁed diabetes among people born
overseas were 20% higher than those among
Australian-born people (Table 5.11).
Table 5.11: Diabetes deaths for overseas-born and
Australian-born people by type of diabetes, 2003–2005
Number Standardised
Mortality Ratio
(Overseas-born/
Australian-born
Australian-born
Overseas-born
Underlying cause of death
Type 1 704 350 1.0
Type 2 2,642 1,516 1.2(a)
Other/
unspecified 3,347 1,950 1.2(a)
Any cause of death
Type 1 1,887 927 1.0
Type 2 10,452 6,114 1.2(a)
Other/
unspecified 9,930 5,699 1.2(a)
(a) Significantly different compared with Australian-born rates.
Notes
1. Diabetes and related complications are classified according to ICD-10
codes. See Appendix 1.
2. Indirectly age-standardised to the 2003–2005 Australian-born population.
Source: AIHW National Hospital Morbidity Database.
Deaths per 100,000 population
Region of birth
0
10
20
30
40
50
60
70
80
Any cause of death
Underlying cause of death
The Americas Asia Africa and
the Middle East
South-East Europe North-West Europe Oceania Australia
Notes
1. Diabetes and related complications are classified according to ICD-10 codes. See Appendix 1.
2. Indirectly age-standardised to the 2003–2005 Australian-born population.
Source: AIHW National Mortality Database.
Figure 5.17: Diabetes deaths by region of birth, 2003–2005
Diabetes: Australian facts 2008 66
Trends
Diabetes death rates among Australian and
overseas-born populations remained largely
unchanged over the period 2000–2005. However,
overseas-born people experienced higher rates
of deaths from diabetes than did people born in
Australia, across all years (Figure 5.18). A large
part of the disparity in deaths between the two
populations can be attributed to the high rates of
diabetes mortality experienced by people born in
Africa and the Middle East.
Deaths per 100,000 population
Year of registration
0
10
20
30
40
50
60
70
All overseas-born
Australian-born
2005 2004 2003 2002 2001 2000
Notes
1. Diabetes and related complications are classified according to ICD-10
codes. See Appendix 1.
2. Directly age-standardised to the 2001 Australian population.
Source: AIHW National Mortality Database.
Figure 5.18: Diabetes deaths as any cause of death,
selected regions of birth, 2000 to 2005
Complications
Hospitalisations
Of the 360,348 diabetes hospitalisations among
Australian-born people in 2004–05, almost one
quarter (24%) also had a diagnosis of kidney
complications (including chronic kidney failure)
and 14% had a coronary heart disease (CHD)
diagnosis. There is very little difference in the
hospitalisation rates between the Australian-born
and overseas-born populations when the
different age-structure of the two populations are
accounted for (Figure 5.19).
Deaths
In the period 2003–2005, death rates from
certain diabetes complications were signiﬁcantly
higher among people born overseas compared
with that among people born in Australia;
including CHD, stroke, kidney complications
and lower limb ulcers (Figure 5.20). The highest
mortality rates were for diabetes deaths with
CHD: a rate of 24 deaths per 100,000 persons
born among Australian-born people, and a rate of
28 deaths per 100,000 for people born overseas.
For more information on speciﬁc complications of
diabetes, see Chapter 4.

Hospitalisations per 10,000 population
Type of complication
0
10
20
30
40
50
60
70
Overseas-born
Australian-born
Limb ulcers Nervous system Eye Kidney PVD Stroke CHD
Notes
1. Diabetes and related complications are classified according to ICD-10-AM codes. See Appendix 1.
2. Indirectly age-standardised to the 2004 Australian-born population.
3. Hospitalisations with diabetes as any diagnosis, and related complications as either principal or additional diagnosis.
Source: AIHW National Hospital Morbidity Database.
Figure 5.19: Diabetes hospitalisations among Australian-born and overseas-born people, by type of diabetes-related
complication, 2004–05
Deaths per 100,000 population
Type of complication
0
5
10
15
20
25
30
Overseas-born
Australian-born
Limb ulcers Kidney PVD Stroke CHD
Notes
1. Diabetes and related complications are classified according to ICD-10 codes. See Appendix 1.
2. Indirectly age-standardised to the 2003–2005 Australian-born population.
3. Deaths with diabetes as any cause, and related complications as either underlying or additional cause of death.
Source: AIHW National Mortality Database.
Figure 5.20: Diabetes deaths among Australian-born and overseas-born persons, by type of diabetes-related
complication, 2003–2005

6 Use of health services
Introduction ...................................................................... 70
Medical and allied health services ................................ 70
Hospitalisations ................................................................ 72
Medicines use ....................................................................74
Pathology and other tests .............................................. 77
Programs and services .................................................... 77
Diabetes: Australian facts 2008 70
Introduction
Living with diabetes is challenging because it
aﬀects every aspect of a person’s life. Support
from family, multidisciplinary health-care
teams, peers and various organisations, such as
Diabetes Australia, can help individuals make
the necessary adjustments towards improving a
patient’s health and quality of life.
Diabetes is a chronic condition requiring the
use of a variety of health services for its control
and for the early diagnosis and treatment of
associated complications. People with diabetes
use a range of health services to control blood
sugar, blood pressure and blood lipid levels to
reduce symptoms and the risk of complications,
and to enhance their quality of life. Having
complications as well as diabetes greatly
increases the use of health services. People
without diabetes who have a number of diabetes
risk factors are also likely to use more health
resources (Burke et al. 2007).
How is diabetes managed?
Diabetes management involves a combination of
medical and non-medical approaches. The overall
goal is for the patient to have a life that is as
healthy, and as normal, as possible. This can be a
demanding task because the condition requires
careful attention and monitoring by the patient,
their doctor and other health professionals.
The medical aims of diabetes management are:
to remove the symptoms and short-term risks
of high blood glucose
to prevent longer term complications
to detect and treat any complications early if
they do arise.
Symptom control and longer term prevention
can be achieved by maintaining normal blood
glucose levels and by attention to lifestyle and its
associated risk factors (such as diet and physical
activity). Research studies have shown the beneﬁts
of improved blood glucose control in reducing
the risk of complications in people with diabetes
(UKPDS Group 1998; Stratton et al. 2000).
For both Type 1 and Type 2 diabetes, together
with medication, a degree of blood glucose
control can be brought about through lifestyle
approaches, such as a healthy diet, regular
exercise and resulting weight control. Avoiding
smoking and maintaining good control of blood
pressure and blood cholesterol levels as well as
the lifestyle approaches help reduce the risk of
complications such as heart attack and stroke.
Diabetes management guidelines
The annual cycle of care for diabetes describes the
minimum level of care for people with diabetes.
This is aimed at monitoring blood glucose
control, and preventing or delaying the onset of
complications. Care will often be managed by a
general practitioner (GP); however, is also likely
to involve nurses, specialists and allied health
professionals as well as the patients themselves.
More information on diabetes management
guidelines based on Diabetes Management in
General Practice (13th edition 2007/8) (Diabetes
Australia 2007b) and Medicare Service Incentive
Payment items (DoHA 2007) for patients with
diabetes mellitus are given in Table 6.1.
In Australia available research has identiﬁed
the need for improved quality of diabetes care
(Georgiou et al. 2004; Kemp et al. 2005). For
example, in 1999 in divisions of general practice
providing data for the National Divisions
Diabetes Program (NDDP) fewer than 60% of
patients were receiving care consistent with best-practice
guidelines (Carter et al. 2000).
Medical and allied health services
GPs are usually the initial point of contact
for people with diabetes and play a key role
in coordinating the services that are needed
because the condition and its complications
aﬀect several parts of the body. Patients and
their carers also need information and support.
Thus, a range of other health professionals may
also be involved. GPs and other primary healthcare
professionals often manage diabetes in
collaborative arrangements with specialised
services. The Bettering the Evaluation and Care
of Health (BEACH) report (Britt et al. 2007)
established that diabetes was one of the main
chronic conditions managed by GPs.
Use of health services 71
Use of health services

Doctors use a blood test, called HbA1c or glycated
haemoglobin, to assess how well blood glucose
has been controlled over recent months; and
sometimes a fructosamine test is used to assess
the preceding three weeks. Doctors also advise and
monitor their patients on lifestyle measures and
other risk factor control, check regularly for any
early damage to the kidneys and feet, periodically
refer them for expert check-ups of their eyes
and periodically review any medicines they are
prescribing and how their patients are using them.
General practitioner visits
In 2005–06 GPs managed diabetes (excluding
gestational diabetes) at a rate of 3.5 per 100
encounters, representing 2.4% of all problems
managed. Diabetes was the third most frequently
managed chronic problem accounting for 6.9% of
all chronic problems managed (Britt et al. 2007).
GPs provided clinical treatment (advice and
counselling) for 23.3% of consultations for
diabetes problems. Diabetes was the problem
most frequently referred to specialists in 2005–
06, with 6.9% of diabetes encounters generating
a referral to specialists by GPs. During the same
period, 4.9% of all diabetes encounters with GPs
resulted in referral to allied health professionals,
including dieticians, diabetes educators, diabetes
clinics, and podiatrists (Britt et al. 2007).
Visits to medical specialists and
allied health professionals
Diabetes complications may aﬀect a number
of the body’s organs, necessitating treatment
by specialists in areas such as endocrinology,
cardiology, nephrology, obstetrics and
ophthalmology.
Table 6.1: Elements of the annual cycle of care for managing diabetes
Elements Diabetes Management in General Practice Medicare Service Incentive Payment
Measure HbA1c Measure HbA1c at least six monthly. Assess diabetes control by measuring HbA1c at least
once every year.
Review smoking
status, physical
activity and nutrition
Minimal interventions in general practice settings
can improve cessation rate of smoking. Encourage
people with diabetes at least 30 minute walking
(or equivalent) for 5 or more days a week. Nutrition
management involves optimising weight and the
introduction of a healthy eating plan.
Check smoking status; if applicable encourage
cessation of smoking. Review levels of physical
activity; reinforce information about appropriate levels
of physical activity. Review diet; reinforce information
about appropriate dietary choices.
Measure body mass
index (BMI)
Maintain a BMI ≤ 25kg/m2 where practicable. Measure weight and height and calculate BMI at least
once every six months.
Measure blood
pressure and lipids
Check blood pressure every three to four months;
ensure that blood pressure is maintained at a target
level of <130/80 mm Hg. Blood fats (cholesterol
and triglycerides) tested every 12 months; targets
are LDL cholesterol < 2.5 mmol/L, total cholesterol
4.0 mmol/L, HDL cholesterol > 1.0 mmol/L and
triglycerides < 1.5 mmol/L.
Measure blood pressure at least once every six months.
Measure total cholesterol, triglycerides and HDL
cholesterol at least once every year.
Review medication n.a. Medication can be reviewed at least once every year.
Eye examination Second yearly referral to an ophthalmologist/
optometrist if the patient has no retinopathy, more
frequently if abnormal.
Ensure that comprehensive eye examination is carried
out at least once every two years.
Foot examination Check for ulcers, infections or abnormalities at least
once every six months.
Examine feet, at least once every six months.
Tests for
microalbuminuria
Test for microalbuminuria at least once every year. Test for microalbuminuria at least once every year.
Note: The Diabetes Management in General Practice applies to the management of Type 2 diabetes only.
Sources: DoHA 2007; Diabetes Australia 2007b.
Diabetes: Australian facts 2008 72
Information from the 2004–05 NHS indicates
that people with diabetes were over 2.5 times
as likely as people without diabetes to have
visited a specialist. In the two weeks before the
survey, 13% of people with diabetes had visited
a specialist, compared with 6% of those without
diabetes (Figure 6.1).
Per cent
People with diabetes People without diabetes
0
5
10
15
20
25
Females
Males
Consulted other
health professional
Consulted
specialist
Consulted other
health professional
Consulted
specialist
Notes
1. Based on self-reported information.
2. Data are for all persons.
Source: AIHW analysis of ABS 2004–05 National Health Survey data.
Figure 6.1: Consultations with a specialist or other
health professional (excluding GPs), by diabetes status,
2004–05
In addition to the care provided by medical
specialists, people with diabetes may also seek
the advice of diabetes educators, nutritionists and
podiatrists. The services of other allied health
professionals and natural therapists may also be
used.
Results from the 2004–05 NHS indicate that
more people with diabetes (20.1%) sought advice
from other health professionals than people
without diabetes (15.1%).
Hospitalisations
Hospital services are required to treat the
advanced stages of diabetes complications,
which include heart disease, stroke, kidney
disease, and foot, eye and nerve problems. People
with diabetes may also be hospitalised when
blood glucose is particularly unstable. Thus,
hospitalisation data provide a picture of the more
severe aspects of the disease. Australian hospitals
data are a valuable source of information about
health service provision. In terms of diabetes,
this gives an indication of the impact of
diabetes and can help provide some background
information on people with diabetes who are
accessing services.
It is important to note that it is the condition
responsible for the hospitalisation that is
recorded as the principal diagnosis. Thus diabetes
may not be the principal diagnosis even when
the hospitalisation is for a complication of
diabetes. Diabetes is more frequently recorded as
an additional diagnosis, particularly when it is
associated with coronary heart disease, stroke or
kidney disease.
In 2004–05 there were a total of 74,490
hospitalisations with diabetes as a principal
diagnosis and 531,069 with diabetes as any
(principal or additional) diagnosis, accounting for
1% and 8% respectively of all hospitalisations for
that year.
Type of diabetes
There are a greater number of hospitalisations
for Type 2 diabetes than for Type 1. In 2004–05
Type 1 diabetes accounted for just over one-
ﬁfth (22%) of hospitalisations with a principal
diagnosis of diabetes and 10% of those with any
diagnosis of diabetes. Type 2 diabetes accounted
for just over two-thirds (69%) of hospitalisations
with a principal diagnosis of diabetes and 85% of
those with any diagnosis of diabetes (Figure 6.2).
Per cent
Diabetes type
0
20
40
60
80
100
Any diagnosis
Principal diagnosis
Other or
unspecified
Gestational Type 2 Type 1
Note: Hospitalisations with any diagnosis of diabetes include those with
a principal diagnosis of diabetes, classified according to ICD-10-AM
codes. See Appendix 1.
Source: AIHW National Hospital Morbidity Database.
Figure 6.2: Proportion of diabetes hospitalisations by
type of diabetes, 2004–05
Use of health services 73
Use of health services

Age and sex
Hospitalisations with any diagnosis of diabetes
increase with age for both males and females
(Figure 6.3). Among females in 2004–05, a small
peak was seen for those aged 25 to 44 years,
mainly due to gestational diabetes, however,
males had higher rates of hospitalisations at
ages between 45 to 74 years. A similar pattern
occurred for hospitalisations with a principal
diagnosis of diabetes.
As mentioned above, the peak in diabetes
hospitalisations among females aged 25 to 44
years in 2004–05 was due to gestational diabetes
(see Figure 6.4), with the greatest proportion
of hospitalisations for gestational diabetes
occurring among women aged 25–34 years. The
increase in diabetes hospitalisations among men
and women aged 55 years and over was attributed
to Type 2 diabetes. Hospitalisation rates for
Type 1 diabetes remained relatively constant
across all age groups for both males and females.
Length of stay in hospital
In 2004–05, the average length of stay in
hospital for hospitalisations with any diagnosis
of diabetes was 5.6 days, and this was slightly
longer than for those with a principal diagnosis
of diabetes (4.8 days). In contrast, the average
length of stay for all hospitalisations was
3.4 days. Males had a longer average length
of stay for hospitalisations with a principal
diagnosis of diabetes (5.3 days compared with
4.4 days for females). The average length of
stay for hospitalisations with any diagnosis of
diabetes was similar for males and females.
Trends
Over the period 2000–01 to 2004–05, both
the number of diabetes hospitalisations and
the rate steadily increased. Between 2000–01
and 2004–05, the rates of hospitalisation for
any diagnosis of diabetes increased by 35%,
from 1,932 hospitalisations per 100,000 people
to 2,608 per 100,000. Between the same two
years, a 32% increase was observed in the rate
of hospitalisations where diabetes was the
principal diagnosis (272 hospitalisations per
100,000 people in 2000–01 compared with 358
hospitalisations in 2004–05 (Figure 6.5). Part
of this increase may be the result of changes
Per cent Per cent
Age group (years)
Males
0
10
20
30
40
50
60
70
Other/unspecified
Type 2
Type 1
75+ 65–74 55–64 45–54 35–44 25–34 <25
Age group (years)
Females
0
10
20
30
40
50
60
70
Other/unspecified
Gestational
Type 2
Type 1
75+ 65–74 55–64 45–54 35–44 25–34 <25
Note: Includes principal and additional diagnoses of diabetes, classified according to ICD-10-AM codes. See Appendix 1.
Source: AIHW National Hospital Morbidity Database.
Figure 6.4: Proportion of diabetes hospitalisations, by type of diabetes, age group and sex, 2004–05
Hospitalisations per 100,000 population
Age group (years)
0
2,500
5,000
7,500
10,000
12,500
15,000
17,500
20,000
Females
Males
75+ 65–74 55–64 45–54 35–44 25–34 <25
Note: Includes principal and additional diagnosis of diabetes, classified
according to ICD-10-AM codes. See Appendix 1.
Source: AIHW National Hospital Morbidity Database.
Figure 6.3: Diabetes hospitalisations by age group and sex,
2004–05
Diabetes: Australian facts 2008 74
made to the way complications are coded in
hospitalisations data (see Appendix 1).
Males had higher hospitalisation rates than
females over the ﬁve-year period.
Hospitalisations per 100,000 population
Year
0
500
1,000
1,500
2,000
2,500
3,000
Females, any diagnosis
Females, principal diagnosis
Males, any diagnosis
Males, principal diagnosis
2004–05 2003–04 2002–03 2001–02 2000–01
Notes
1. Directly age-standardised to the 2001 Australian population.
2. Hospitalisations with any diagnosis of diabetes include those with
a principal diagnosis of diabetes, classified according to ICD-10-AM
codes. See Appendix 1.
Source: AIHW National Hospital Morbidity Database.
Figure 6.5: Trends in diabetes hospitalisations, 2000–01
to 2004–05
Medicines use
People with diabetes often require medication
regimes to control high blood glucose levels.
Further, people with the condition frequently
have associated health problems such as high
blood pressure and high blood lipids (cholesterol
and related substances) that may necessitate
taking multiple medicines. Clinical trials have
shown that good control of blood glucose,
blood lipids and blood pressure in patients
with diabetes delays the onset and slows the
progression of complications (DCCT Research
Group 1993; HPS Collaborative Group 2003;
UKPDS Group 1998b).
Medicines for diabetes
Self-reported data on medicine use from the
2004–05 NHS indicates that one-ﬁfth (21%) of
people with diabetes were using insulin, 68% were
using other pharmaceutical medicines and only
4% were using vitamin or mineral supplement or
herbal or natural medicines (ABS 2006a).
Oral medicines used by people with diabetes
include: 40% were using metformin, 20% were
using gliclazide and 6% were using other oral
blood glucose lowering agents. Over 90% of these
medicines were reported to be for the treatment
of Type 2 diabetes. Metformin and gliclazide
were also the most common medicines prescribed
for diabetes in general practice (28.3 and 14.7
per 100 problems managed respectively) in the
2003–04 BEACH study (Britt et al. 2004).
During the 1990s the use of insulins and oral
glucose-lowering medicines in Australia increased
and the trend has continued over the past few
years (Figure 6.6) reﬂecting the increase in the
number of people being diagnosed with diabetes
and changing treatment practices. These results
refer to the use of prescription medicines in
the community (excluding public hospitals).
Medicines use is expressed in the World Health
Organization standard measurement unit—
deﬁned daily doses (DDDs) per 1,000 population
per day (DDD/1,000/day). This is based on the
assumed average dose per day of a medicine
used for its main indication in adults. The DDD
enables valid comparisons between medicines
independent of diﬀerences in price, formulation
and quantity per prescription.
In 2006, 15 DDD/1,000/day of insulin were
dispensed while oral hypoglycaemics were
dispensed at a rate of 30 DDD/1,000/day
(Figure 6.6).
Insulins
All people with Type 1 diabetes and some people
with Type 2 diabetes need insulin to control
their blood glucose levels. Insulin helps the body
use or store the glucose it gets from food. People
whose pancreas does not make insulin (Type 1
diabetes) need insulin injections to survive.
Some people with Type 2 diabetes also require
insulin injections to improve diabetes control.
Giving suitable doses of insulin to people with
diabetes temporarily restores their ability to
process carbohydrates, fats and proteins, to store
glycogen in the liver, and to convert glucose to fat.
There are several types of insulin that diﬀer in
how soon the insulin starts working (onset),
when it works most (peak time) and how long it
lasts in the body (duration). Fast-acting insulin
reaches the blood within 15 minutes of injection,
peaks 30–90 minutes later and may last for up to
5 hours. In 2006, fast-acting human insulin was
dispensed at a rate of 3.2 DDD/1,000/day.
Human intermediate-acting insulin reaches
the blood 2–6 hours after injection, peaks 4–14
hours later and stays in the blood for about 14–20
hours. This type was dispensed at a rate of 3.4
DDD/1,000/day in 2006.
Long-acting insulin takes 6–14 hours to start
working. It has no peak or a very small peak
10–16 hours after injection and stays in the blood
between 20 and 24 hours. Long-acting insulin was
dispensed less frequently and no recent data are
available on the daily dispense rate of this type.
Some types of insulin come mixed together to
make it easier to inject two kinds of insulin at
the same time. Human intermediate-acting
combined with fast acting insulin is the most
common insulin of this kind and was the most
common insulin dispensed overall in 2006
(5.8 DDD/1,000/day).
Oral blood glucose–lowering medicines
Biguanides lower blood glucose by suppressing
glucose production in the liver and also promote
the action of insulin by increasing the uptake
of glucose in the tissues (especially muscle).
Metformin belongs to this class of medicines.
It’s use has increased since the 1990s and in
2006 it was the most frequently dispensed
oral hypoglycaemic medicine overall (15.3
DDD/1,000/day) (Figure 6.7).
Metformin is among the top 20 most commonly
prescribed medicines in general practice; in
2003–04 it accounted for 1.2% of all prescriptions
issued by general practitioners (Britt et al. 2004).
Sulfonylurea medicines stimulate the beta
cells in the pancreas to release more insulin.
Chlorpropamide, glipizide, glibenclamide,
gliclazide and tolbutamide are members of
this class. Gliclazide was the most commonly
dispensed sulfonylurea in 2004 (7.0 DDD/1,000/
day), followed by glimepiride (3.5 DDD/1,000/
day) (Figure 6.7). While the use of metformin has
continued to increase since 1990, gliclazide use
peaked in 2000 and has since decreased slightly.
This coincided with the inclusion of glimepiride
in the Pharmaceutical Beneﬁts Scheme (PBS) and
Repatriation Pharmaceutical Beneﬁts Scheme
during 2000.
Alpha glucosidase inhibitors help the body lower
blood glucose by blocking the gut enzymes that
DDD/1,000 population/day
Year
0
5
10
15
20
25
30
35
Oral hypoglycaemics
Insulins
2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990
Note: Data relate to products dispensed through community pharmacies only; medicines provided in public hospitals and highly specialised medicines
available to outpatients through public hospital pharmacies are not included.
Source: DoHA Drug Utilisation Sub-Committee Database.
Figure 6.6: Community use of insulins and oral blood glucose-lowering medicines, 1990–2005
Diabetes: Australian facts 2008 76
break down starches (such as bread, potatoes
and pasta) and certain sugars into glucose.
Their action slows the rise in blood glucose levels
after a meal. Acarbose is a member of this class
and was dispensed at a rate of 0.2 DDD/1,000/day
in 2006 (Figure 6.7).
Thiazolidinedione agents (including glitazones
such as rosiglitazone and pioglitazone) have been
listed on the PBS only since 2003. In general,
thiazolidinediones are recommended when either
metformin or a sulfonylurea is contra-indicated
or not tolerated, when combination therapy with
metformin and a sulfonylurea fails, or when
insulin (with or without oral medicines) no longer
maintains blood glucose control (NPS 2004). In
2006 thiazolidinediones were dispensed at a rate
of 2.3 DDD/1,000/day (Figure 6.7).
Medicines for associated
conditions
The 2004–05 NHS showed that people with
diabetes used medicines for cardiovascular
conditions or its risk factors such as high blood
pressure or high blood cholesterol at higher rates
than those without diabetes. Blood pressure
lowering medicines were used as follows: agents
acting on renin-angiotensin system —includes
ACE inhibitors and angiotensin II receptor
antagonists (36%), beta-blocking agents (11%)
and other antihypertensive medicines (7%).
Cardiac therapy medicines were used by 6% of
people with diabetes and 27% used serum lipid
reducing agents.
In the 1999–2000 AusDiab study 35% of people
with diabetes took blood pressure–lowering
medicines, almost three times the proportion of
people without diabetes (13%). More than twice
the proportion of people with diabetes took
blood cholesterol–lowering medicines than those
without diabetes (15% and 7% respectively).
According to 2006 ANDIAB results, 55% of
people with diabetes who were attending
specialist diabetes services were on bloodpressure
lowering treatments and 89% were on
cholesterol lowering medicines (NADC 2007).
DDD/1,000 population/day
Year
0
2
4
6
8
10
12
14
16
18
Thiazolidinediones
Acarbose
Glimepiride
Tolbutamide
Glipizide
Glibenclamide
Gliclazide
Metformin
2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990
Note: Data relate to products dispensed through community pharmacies only; medicines provided in public hospitals, and highly specialised medicines
available to outpatients through public hospital pharmacies are not included.
Source: DoHA Drug Utilisation Sub-Committee Database.
Figure 6.7: Community use of oral blood glucose-lowering medicines, 1990 to 2006
Use of health services 77
Use of health services

Pathology and other tests
There are a variety of pathology tests used in the
diagnosis and management of diabetes. The more
common tests include:
oral glucose tolerance test (OGTT) which is a
diagnostic test to assess absorption of glucose
after a dose is given
glycosylated haemoglobin (HbA1c) and
fructosamine, which monitor glucose control
microalbuminuria, which tests for amounts of
protein (albumin) in the urine
blood lipids tests, which include total
cholesterol, triglycerides and HDL cholesterol.
Pathology tests processed by
Medicare
Pathology tests billed to Medicare are subject
to ‘coning’, that is, pathology companies
charge Medicare for the three most expensive
tests undertaken even where more tests were
undertaken. Where a patient with diabetes is
likely to receive multiple tests for monitoring the
disease and its complications, the less expensive
test may not be recorded in the Medicare data, i.e.
it may ‘drop’ oﬀ the billing process due to coning
(Britt et al. 2003).
According to Medicare items processed in 2006,
943,532 were for glycosylated haemoglobin
(HbA1c). Over 99% of these were for persons with
established diabetes (Medicare Online Health
Statistics 2007).
Pathology tests ordered by GPs
A survey of general practice activity (BEACH)
found that in 2005–06, GPs ordered pathology
tests for diabetes problems relatively frequently:
30% of diabetes contacts resulted in pathology
orders, with 263 tests ordered per 100 diabetes
contacts where at least one pathology test was
ordered. The speciﬁc pathology tests requested
by GPs in the management of diabetes have not
been published. However, pathology tests for
electrolytes/urea/creatinine were requested at
a rate of 2.8 per 100 GP encounters. Tests for
glycosylated haemoglobin (HbA1c) which are
mainly for people with diabetes were requested
at a rate of 1.0 per 100 encounters. Note that the
BEACH data do not capture whether the patients
sent for pathology test ordered by the GP actually
presents for the test, and therefore whether the
test is performed (Britt et al. 2007).
Pathology tests at diabetes clinics
According to the ANDIAB data collection
conducted in 2006, 93% of patients visiting
specialist diabetes clinics had an HbA1c
measurement in that year. Nearly 70% of patients
attending specialist diabetes clinics had a
microalbumin (or urinary protein level) recorded,
and 79% had a cholesterol level recorded (66%
had an HDL cholesterol level recorded, 76% had
a triglyceride level recorded and 54% had an LDL
cholesterol level recorded) (NADC 2007).
Programs and services
There are a number of programs and services
available to people with diabetes providing
information and support to help people in
the self-management of their diabetes. Some
programs also provide diabetes-related products
at a subsidised cost, while others provide clinical
consultations, counselling services, information
and support services.
Organisations in Australia that provide services
and support to people with diabetes and
coordinating diabetes management include
consumer, professional, research and education
organisations. A number of agencies or programs
central to the provision of services for diabetes
management are described below. In addition to
these organisations there are numerous others
that are crucial to the provision of support and
care for people with diabetes in Australia.
National Diabetes Services
Scheme
The National Diabetes Services Scheme (NDSS)
provides important support for many people with
diabetes. The NDSS is an Australian Government
program that provides products for the self-management
of diabetes, such as blood and urine
testing strips, syringes and needles for special
injection systems, at subsidised prices. It also
provides a range of information and education
Diabetes: Australian facts 2008 78
services to people with diabetes and a variety
of electronic and interpersonal communication
strategies are used to deliver programs to
communities and individuals throughout
Australia. Diabetes Australia has administered
the NDSS since it was introduced in 1987. As
at 30 June 2006, 788,214 people with diabetes
were registered for NDSS beneﬁts and 228,774
(29%) of these were people requiring insulin. The
NDSS distributed more than 3.2 million packets
of blood glucose test strips during 2005–06
and 616,336 boxes of syringes and pen needles
(Diabetes Australia 2007a).
Diabetes centres and educators
Diabetes centres, often referred to as Diabetes
Ambulatory Care Centres, provide services such
as diabetes education, nutrition advice and
complications assessment to adults and children.
As well as clinical management of the disease,
centres generally aim to improve personal
management of diabetes to minimise the eﬀect of
diabetes on daily living. Most patients attending
diabetes centres are referred by GPs to receive
specialist assessment and treatment, generally
these are people whose diabetes is not managed
as well as in other patients.
Staﬀ of diabetes centres include an
endocrinologist, diabetes nurse educators,
dieticians and podiatrists. Many centres also
provide training in diabetes care to other health
professionals, and may conduct research into
medical or social aspects of diabetes.
There were over 60 diabetes centres that were
members of the National Association of Diabetes
Centres (NADC) in 2006 (NADC 2007). The
NADC promotes effective health care practice
for people with diabetes. Over the past few
years a number of the centres in the collective
have participated in data collection through the
ANDIAB project, enabling assessment and review
of diabetes management. Some of these data have
been reported in other sections of this report.
National Divisions Diabetes Program
The National Divisions Diabetes Program (NDDP)
is a coordinated national approach to diabetes
care in Australian General Practice.
As part of the NDDP Data Collation Project, 38
Divisions of General Practice reported having a
diabetes program in 1999–00. At least 27% of
GPs nationally participated in some aspect of a
diabetes program.
In the 2004–05 annual survey of divisions,
98% of divisions conducted diabetes programs
or activity (Hordacre et al. 2006). Approaches
used to conduct these programs included:
practice education (92%); GP education (89%);
recall systems (80%); collaboration with other
agencies (82%); community awareness (61%); and
patient services (46%). Divisions also reported
on services in their area, program highlights and
barriers, advice to other divisions and future
plans.

7 Impact
Introduction ...................................................................... 80
Quality of life..................................................................... 80
Burden of disease............................................................. 83
Costs .................................................................................. 84
Diabetes: Australian facts 2008 80
Introduction
Diabetes is associated with substantial morbidity
and mortality and has a signiﬁcant impact
on affected individuals and their families. In
particular, the onset of macrovascular and
microvascular complications reduces quality of
life through increased burden of illness and the
costs of managing the complications of diabetes
over time.
A number of studies have shown that the long-term
complications of diabetes may lower the
quality of life of people with diabetes (Bates
& Jerums 2003; Maddigan et al. 2006; Mehta
et al. 1999; Redekop et al. 2002). People with
diabetes and peripheral neuropathy experience
chronic, painful symptoms that diminish their
quality of life and disrupt sleep, which can lead
to depression (Argoﬀ et al. 2006). They also
experience social isolation due to impaired
mobility and consequent physical and emotional
ill health (Nabuurs-Franssen et al. 2005). There
is evidence suggesting that depression is often
diagnosed in people with diabetes because of
its association with poor metabolic control,
poor diet, adherence to the medication regimen
and decreased quality of life (Egede et al. 2002;
Hanninen et al. 1999). Depression is found to
be highly prevalent among people with Type 2
diabetes and chronic comorbidities than among
those with Type 2 diabetes only (Pouwer et al.
2003). People with diabetes complications are
also likely to experience physical disability which
will limit their ability to perform daily activities
(Clarke et al. 2006; Egede 2004).
Diabetes is associated with substantial costs to
the health system and to affected individuals and
their families. These costs can be direct, indirect
or intangible (Milton et al. 2006; Parsons et al. 2000).
Intangible costs are usually quantiﬁed using
health ‘gap’ measures that indicate the difference
between a population’s actual health status
and some ‘ideal’ or reference status. The most
widely known example of such a measure is the
disability-adjusted life year (DALY). Another
measure commonly used in economic evaluations,
but not in health status assessments, is the
Quality Adjusted Life Year (QALY) (AIHW: Begg
et al. 2007).
Quality of life
Measurement of the quality of life of people
with diabetes assists in understanding the effect
diabetes has on the individual. In addition,
an individual’s view of their quality of life is
important for evaluating and understanding
treatment effects from the person’s perspective
and for improving future care (Higginson & Carr
2001).
In the 2003 DiabCost Australia study, people with Type 2 diabetes in the 36–65 year age group reported poor quality of life compared with other Australians of the same age. Most frequently reported problems affecting quality of life for people with diabetes were pain/discomfort, impeded mobility and anxiety/depression. Having
complications decreased quality of life compared
with people without complications, but there
was little variation in quality of life between
different types of complications. When compared
by treatment type, people whose diabetes was
controlled by diet alone reported the highest
quality of life, whereas those on insulin reported
the lowest (Colagiuri et al. 2003).
Little information is available on the quality of
life of people with Type 1 diabetes in Australia.
A study of children and young people with Type
1 diabetes in Melbourne found that their general
health and quality of life were poorer than those
of children and young people in the general
population. Lower quality of life was found to be
related to poor blood glucose control in children
(5–11 years), but not in 12–18 year-olds, while
the presence of diabetes-related symptoms and
concerns was associated with poorer psychosocial
functioning for both age groups (Wake et al.
2000). Children with diabetes living in regional
areas of Victoria have also been found to have
lower quality of life than those from urban areas,
despite similar diabetes knowledge and similar
levels of glycosylated haemoglobin (HbA1c)
(Cameron et al. 2002).
Self-assessed health
The ABS NHS collects information on ‘selfassessed
health status’, which is the respondent’s
perception of their general health measured
against a ﬁve-point scale: excellent, very good,
good, fair and poor.
Impact 81
According to 2004–05 NHS self-reports, an agestandardised
rate of 20% of people with diabetes
assessed their health as very good or excellent,
compared with 58% of those without diabetes.
People with diabetes in all age groups (48%)
were 3 times as likely to rate their own health as
fair or poor than people without diabetes (15%)
(Figure 7.1).
Per cent
Self-assessed health status
0
5
10
15
20
25
30
35
40
People without diabetes
People with diabetes
Poor Fair Good Very Good Excellent
Notes
1. People aged 15 years and over are included.
2. Directly age-standardised to the 2001 Australian population.
Source: AIHW analysis of ABS 2004–05 National Health Survey data.
Figure 7.1: Self-assessed health status of people with
and without diabetes, 2004–05
More females than males (51% and 45%,
respectively) with diabetes rated their health as
fair or poor (Table 7.1). The corresponding ﬁgures
for those without diabetes were 14% for females
and 15% for males.
Table 7.1: Self-assessed health status of people with and
without diabetes, by sex, 2004–05 (per cent)
Self-assessed
health
status
People with
diabetes
People without
diabetes
Males Females Males Females
Excellent 4.9 4.6 21.3 22.0
Very Good 15.0 15.2 35.4 37.1
Good 34.9 29.6 28.3 26.9
Fair 26.3 33.6 11.0 10.2
Poor 19.0 17.0 3.9 3.8
Notes
1. People aged 15 years and over are included.
2. Directly age-standardised to the 2001 Australian population.
Source: AIHW analysis of ABS 2004–05 National Health Survey data.
People with diabetes and other long-term health
conditions were more than twice as likely as
people with other long-term health conditions
to rate their own health to be fair or poor. The
2004–05 NHS results showed that 60% of
people with diabetes and other long-term heath
conditions rated their health as fair or poor
compared with 27% of people with other longterm
conditions.
Mental health
Depression and depressive symptoms have been
shown to be highly prevalent in people with
diabetes compared with those without diabetes
(Anderson et al. 2001) and there is emerging
evidence suggesting that depression itself is
a risk factor for Type 2 diabetes (Arroyo et al.
2004; Brown et al. 2005b; Golden et al. 2004). A
Canadian population-based study conducted from
1992 to 2000, showed that people with a history
of depression were at a greater risk of developing
diabetes (Brown et al. 2005b). Possible reasons for
this relationship are that people with depression
are less likely to be engaged in physical activities,
and more likely to experience changes in body
weight, which increases the risk of developing
diabetes. In addition, some medications used to
treat depression are known to cause weight gain
and sedation, which, again, could contribute to
the development of diabetes (Brown et al. 2005b).
In the Fremantle Diabetes Study (1993–1996),
32% of people with Type 2 diabetes self-reported
depression and it was associated with a greater
prevalence of diabetic complications (Bruce et al.
2005). Having a number of comorbidities places
an additional burden on people with diabetes as
these conditions are associated with an increased
number of functional limitations. Subsequently,
functional limitations can reduce the patients’
quality of life and thus contribute to the
development of depression (Pouwer et al. 2003).
According to the 2004–05 NHS, 18% of people
with diabetes had high or very high levels of
psychological distress compared with 12% of
people without diabetes, as measured by the
Kesslar-10 scale (see Box 7.1). More females (22%)
than males (15%) with diabetes had high or very
high levels of psychological distress (Table 7.2).
Diabetes: Australian facts 2008 82
Disability and activity limitation
Diabetes has been shown to be associated with
an increased risk of disability in adults (Gregg
et al. 2002; Ryerson et al. 2003). This is mainly
because diabetes is related to numerous vascular
and neuropathic complications that could aﬀect
functional status. A study by Gregg et al. (2002)
found that after controlling for a number of
comorbidities (including coronary heart disease
(CHD), stroke, depression, cognitive and visual
impairment and arthritis) diabetes was still
related to a 42% increased risk of disability.
In a nationally representative sample of U.S.
adults, 66% with diabetes had diﬃculty doing
at least one of the physical tasks that were
assessed. The tasks involving mobility or lower
extremity function, such as stooping, standing,
walking, pushing, and climbing, tended to be
the most problematic for people with diabetes
and had the highest prevalence of any limitation
(Ryerson et al. 2003).
Based on 2003 Survey of Disability Ageing
and Carers (SDAC) self-reports, there were
approximately 634,600 people with diabetes and,
of them, 56% had a disability. Disability among
people with diabetes was higher at older ages:
46% of people with diabetes aged less than 65
years compared with 67% of people with diabetes
aged 65 years and over had a disability. This
pattern was similar for both males and females
(Figure 7.2).
Of the people with diabetes and a disability, 42%
had a profound or severe core activity limitation,
indicating that they were unable to do, or always/
sometimes needed help with, a core activity task
such as self-care, mobility and communication.
Again, the proportion reporting profound or
severe core activity limitation among people
with diabetes and a disability increased with age.
Among people with diabetes and a disability, 31%
aged less than 65 years and 49% aged 65 years
Box 7.1: Psychological distress according to Kessler-10 scale
Psychological distress refers to an individual’s overall level of psychological strain or pain, evidenced
by psychological states such as depression, anxiety and anger. Psychological distress may be fairly
transient—for example, experiencing high anxiety over an upcoming event, or sadness because of
the break-up of a relationship—but may also be a continuing problem, particularly among those
experiencing mental health problems and clinical disorders.
Psychological distress can be measured using the Kessler-10 (K-10) distress scale, which is a 10-item
questionnaire asking about feelings such as nervousness, hopelessness, restlessness, depression and
worthlessness. For each item, the respondents are asked how often they experienced these feelings
in the past 4 weeks, with responses ranging from ‘none of the time’ to ‘all of the time’ (scoring 1 to 5).
The maximum score is 50 (indicating severe distress) and the minimum score is 10 (no distress).
Andrews & Slade (2001) showed a strong association between the K-10 scale and current diagnoses
of anxiety and affective disorders. They also showed a lesser, but significant, association with other
mental disorder categories.
Table 7.2: Level of psychological distress experienced by people with or without diabetes
Level of psychological distress
(K-10 scale(a))
People with diabetes People without diabetes
Males Females Males Females
Low (0–15) 62.5 53.7 68.9 61.7
Moderate (16–21) 22.6 23.9 21.1 24.3
High (22–29) 9.9 13.2 6.9 10.1
Very high (30–50) 5.0 9.2 3.1 3.9
(a) Based on the Kessler-10 scale of psychological distress.
Source: AIHW analysis of ABS 2004–05 National Health Survey data.
Impact 83

and over had a profound or severe core activity limitation.
Twenty-four per cent of people with diabetes
and a disability considered diabetes as the main
condition causing their disability in 2003.
Burden of disease
The impact of diabetes on the health of the
population can be shown using a number of
summary measures of health that combine
information on mortality and non-fatal health
outcomes into a single number. The disability adjusted
life year or DALY is one such measure
that summarises the burden of disease and injury
in a population. The DALY combines information
on the impact of premature death as well as
non-fatal health outcomes. Premature death is
measured by the years of life lost (YLL) due to
disease or injury and non-fatal health outcomes
are measured by years of ‘healthy’ life lost (YLD)
due to disease, disability or injury. To combine
these two health measures into a summary
health measure, the DALY uses time as a common
‘currency’. It is a measure of the years of healthy
life lost due to illness or injury—one DALY is one
lost year of ‘healthy’ life (AIHW: Begg et al. 2007).
Diabetes was the eighth leading cause of
burden of disease and injury in 2003 and it
was responsible for 5.5% of the total burden
(Table 7.3), with Type 2 diabetes accounting for
92% of this burden (AIHW: Begg et al. 2007).
Table 7.3: Diabetes burden of disease by specific cause, 2003
Cause YLD
Per cent of
total YLL
Per cent of
total DALYs
Per cent of
total
Diabetes per se 89,252 6.6 32,295 2.5 121,547 4.6
Neuropathy 6,500 0.5 — 0.0 6,500 0.2
Peripheral vascular disease 5,917 0.4 — 0.0 5,917 0.2
Diabetic foot 3,672 0.3 — 0.0 3,672 0.1
Amputation 2,455 0.2 — 0.0 2,455 0.1
Retinopathy 1,258 0.1 — 0.0 1,258 0.0
Other(a) 2,483 0.2 — 0.0 2,483 0.1
Total diabetes burden 111,536 8.2 32,295 2.5 143,831 5.5
Ischaemic heart disease attributable
to diabetes 8,494 0.6 45,948 3.6 54,442 2.1
Stroke attributable to diabetes 3,985 0.3 16,260 1.3 20,245 0.8
Total burden attributable to
diabetes 124,015 9.2 94,503 7.4 218,518 8.3
(a) Includes renal failure.
Notes
1. YLD = Healthy years lost due to disability.
2. YLL = Years of life lost due to premature mortality.
3. DALY = Disability adjusted life years.
Source: AIHW: Begg et al. 2007.
People with diabetes and a disability
Per cent
0
10
20
30
40
50
60
70
80
65 years and over
Under 65 years
Females Males
Source: AIHW analysis of ABS 2003 Survey of Disability, Ageing and
Carers data.
Figure 7.2: Disability among people with diabetes, 2003
Diabetes: Australian facts 2008 84
Eighty-ﬁve per cent of the total diabetes burden
was due to diabetes per se (that is, the experience
of having diabetes regardless of complications),
with the remainder being due to complications
such as neuropathy (5%), peripheral vascular
disease (PVD) (4%), and diabetic foot (3%). The
majority (78%) of the diabetes burden was due to
years of health life lost, and the remainder was
due to premature death.
Diabetes was responsible for a loss of just over
111,500 years or 8% of ‘healthy’ life due to
disability in 2003. More males—9% compared
with 7% females—with diabetes experienced loss
of healthy life due to disability (AIHW: Begg et al.
2007).
Diabetes also carries with it an increased risk
of ischaemic heart disease and stroke and the
associated burden has not been included in the
above ﬁgures. When this risk was accounted for,
the burden attributable to diabetes increased to
8.3% of total burden (Table 7.3).
The burden from diabetes in both sexes
increased linearly until age 80 then declined. The
contribution from diabetes per se dominated at
all ages.
Type 2 diabetes was ranked sixth among the
20 leading speciﬁc causes of burden (DALY) for
both males and females in 1993. By 2003, it was
ranked second for males and fourth for females.
Type 2 diabetes is projected to be the leading
speciﬁc cause for males and second for females by
2023 (AIHW: Begg et al. 2007).
Costs
Diabetes places a large burden on healthcare systems in terms of expenditure on hospitalisations, aged c8 are, medications,
diagnostic services, and other out-of-hospital medical care, including general practice and community health services. Non-health care and indirect costs borne by governments, private health insurers, and people with diabetes can also be substantial (AIHW: Dixon 2005). People with diabetes, particularly those with complications, are more likely to use health services than people without diabetes, and to use them more often and for longer periods of time (Ramsey et al. 2002).
Disease-related costs fall into four broad categories:
1. direct health-care costs, which include hospital treatment, medications, GP visits, allied health and specialist care, use of diagnostic services and medical research (see Appendix 1 for a description of these categories)
2. direct non-health-care costs, including transport to and from medical services, child care, and home care
indirect costs, such as lost productivity, lost income, disability, and lost years of life intangible costs, such as impact on quality of life (Colagiuri et al. 1998; Parsons et al. 2000).
This section mainly focuses on direct healthcare expenditure for diabetes—that is, money spent by governments, private health insurers,
companies, households and individuals to prevent, diagnose and treat diabetes. Very little information is available in Australia on the other
types of costs associated with diabetes.
Two sources of data on direct health expenditure for diabetes are used:
*    AIHW Disease Expenditure Database
*    National Diabetes Services Scheme.

Direct health expenditure
Data on allocatable recurrent health expenditure from the AIHW Disease Expenditure Database
showed that direct health-care expenditure on diabetes in 2004–05 was $907 million. Diabetes accounted for 1.7% of the year’s total allocatable recurrent health expenditure (see Appendix 1 for discussion of exclusions).
It is estimated that expenditure on -
*   Type 1 diabetes accounted for 17% of the diabetes expenditure, at $158 million, and
*   Type 2 diabetes accounted for 81% at $733 million.
The remaining $17 million related to diabetes prevention services.
Much of the expenditure on diabetes was on hospital services, $379 million (41.8%) followed by diabetes-related pharmaceuticals, $273 million (30.1%), out-of-hospital medical services, $200 million (22.1%), and research, $55 million (6.1%) (Figure 7.3).

The National Diabetes Services Scheme (NDSS)
The NDSS provides access to products and
services—such as syringes, insulin infusion
pump consumables and blood and urine glucose
testing reagents—that are needed for self-management
of diabetes at prices subsidised by
the Australian Government. It is administered
by Diabetes Australia on behalf of the DoHA.
The state and territory governments contribute
co-payments for needles and syringes, which
effectively makes them effectively free to NDSS registrants.
Australian Government expenditure on the
NDSS is presented here, but no information on
the total value of patient contributions to NDSS subsidised
products is available.
In 2006–07, there were 844,062 people registered with the NDSS (Diabetes Australia 2008) and the Australian government expenditure on the NDSS in that ﬁnancial year was nearly $114 million
(Personal communication with Special Access
Programs Section, DoHA). This expenditure is in
addition to the direct health expenditure shown
in Figure 7.3, as expenditure on the NDSS, which
is grouped under ‘health aids and appliances’, has
not been allocated by disease group and therefore
not included in the AIHW Disease Expenditure Database.
Direct non-health care costs
Results from the DiabCost study estimated that average annual direct non-health-care costs for
people with Type 2 diabetes were $1,065 per person (Colagiuri et al. 2003). Home support and
special foods accounted for around two-thirds
of these costs (40% and 28%, respectively), with
transport accounting for a further 12%. There
is no information available on the direct non health-
care costs for people with Type 1 diabetes in Australia.
Indirect costs
The estimated average income lost by patients
and carers unable to attend work was low in
the DiabCost study: an average of only $35 per
person per year, but the study sample had a mean
age of 65 years and therefore few participants
were employed (Colagiuri et al. 2003). The average
income lost per person, particularly for carers,
increased if complications were present. The
impact of diabetes in terms of lost income is likely
to be higher if people with Type 1 diabetes are
included, because this type of diabetes generally
develops at a much younger age and therefore
affects parents of children with the disease as
well as employed people who themselves have
Type 1 diabetes. There are currently no Australian
data available on the indirect costs associated
with Type 1 diabetes.
Intangible costs
The impact of diabetes on quality of life was
discussed earlier in this chapter. However,
intangible costs of diabetes are diffcult to quantify
and there is no information currently available.
Sector
Expenditure ($ million)
0 50 100 150 200 250 300 350 400
Admitted patient hospital services
Prescription pharmaceuticals
Out-of-hospital medical services
Research
Source: AIHW Disease Expenditure Database.
Figure 7.3: Direct health expenditure on diabetes by sector, 2004–05

8 Mortality
Diabetes as the underlying cause of death ................. 88
Diabetes as an underlying or associated cause
of death .............................................................................. 90
Diabetes-related deaths ................................................. 91
Causes of death commonly listed with diabetes ........ 91
Deaths of people on the National Diabetes
Register ............................................................................. 92
Diabetes: Australian facts 2008 88
Mortality rates are a vital measure of population
health that can be used to assess the nature and
progress of diseases such as diabetes (AIHW
2005d). In Australia, more than one cause of
death can be listed on the death certiﬁcate. This
means that for each death, both underlying and
associated causes of death can be listed and have
been available for analysis of deaths data since
1997. The underlying cause of death is the disease
or injury initiating the sequence of events leading to death.
Diabetes is recognised as having a substantial impact on mortality in Australia; however, it may not be diabetes itself which directly leads to death, but one of its many complications. As
a result, it is commonly the complication that
is listed as the underlying cause of death on the
death certiﬁcate. A more complete picture of the
mortality burden of diabetes can be obtained by
examining both diabetes as the underlying cause,
which is the primary disease or injury causing
the deaths, and diabetes as an associated cause of
death (diseases or injuries that are considered to
have contributed to the death).
The method of examining deaths where diabetes
is listed as the underlying or associated cause of
death may overestimate the true contribution
of diabetes to mortality in Australia as it often
includes deaths for a wide range of conditions,
some of which are unlikely to be complications
of diabetes (AIHW: Dixon & Webbie 2005).
This may be overcome, at least to some extent,
by examining diabetes-related deaths—that
is, deaths where diabetes was listed as the
underlying cause of death, or where diabetes was
listed as the associated cause of death and the
underlying cause of death was one of a speciﬁc
list (see Box 8.1) commonly associated with
diabetes complications.
Diabetes as the underlying cause of death
Diabetes is among the top ten leading causes of
death among Australians. In 2005, diabetes was
the underlying cause of death in 3,529 deaths
registered (2.7% of all deaths). Of these, about
10% were due to Type 1 diabetes, 42% were due
to Type 2 diabetes and the remaining deaths were
due to unknown or unspeciﬁed type of diabetes.
Sex and age
More males than females die from diabetes. In
2005, Australian males were nearly one and a half
times as likely to die from diabetes as Australian
females (a death rate of 19 per 100,000 compared
with 13 per 100,000, respectively). Diabetes
mortality increases dramatically with age, with
over 86% of deaths occurring in those aged 65
years and over in 2005 (Figure 8.1).
Box 8.1: Diabetes-related deaths
For the purposes of this report, diabetes-related
deaths refer to deaths where:
diabetes was listed as the underlying cause of death
OR
diabetes was listed as an associated cause of
death, where the underlying cause of death was
one of:
myocardial infarction (heart attack)
ischaemic heart disease*
stroke or sequelae of stroke*
heart failure*
sudden death (cardiac arrest)
peripheral vascular disease
kidney disease
hyperglycaemia
hypoglycaemia.
Note: ‘Diabetes-related deaths’ is based on the
definition of ‘deaths related to diabetes’ used in
the United Kingdom Prospective Diabetes Study
(UKPDS 1998). The UKPDS definition has been
modified by diabetes specialists on the National
Diabetes Data Working Group to include ischaemic
heart disease, sequelae of stroke and heart failure,
and other commonly recognised complications of
diabetes.
*Not included in the UKPDS definition of deaths
related to diabetes.

Trends
Over the 26-year period between 1980 and 2005,
there were a total of 65,221 deaths (an average
of 2,508 deaths per year) registered where
diabetes was recorded as the underlying cause;
this represents 2% of all deaths registered over
that time. Trend analysis indicates that the death
rate for diabetes as an underlying cause of death
increased for males over the last 25 years, with
an average annual increase of 0.7% between 1980
and 2005. However, for females the death rate for
diabetes decreased over the same period, by 0.5%
per year on average (Figure 8.2).
Deaths per 100,000 population
Year
0
5
10
15
20
25
Females
Males
2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980
Notes
1. Directly age-standardised to the Australian population as at 30 June 2001.
2. For 1980 to 1996 the disease grouping is classified according to the ICD-9 code: 250 for diabetes.
3. For 1997 to 2005 the disease grouping is classified according to the ICD-10 codes: E10–E14 for diabetes.
Source: AIHW National Mortality Database.
Figure 8.2: Deaths with diabetes as the underlying cause of death, 1980 to 2005
Deaths per 100,000 population
Age group (years)
0
50
100
150
200
250
Females
Males
75+ 65–74 55–64 45–54 35–44 25–34 <25
Note: Deaths classified according to the ICD-10 codes. See appendix 1.
Source: AIHW National Mortality Database.
Figure 8.1: Deaths with diabetes as the underlying cause of death, by age and sex, 2005
Diabetes: Australian facts 2008 90
Diabetes as an
underlying or associated
cause of death
Diabetes is more often listed as an associated
cause of death than as the underlying cause. In
2005, the total number of deaths for diabetes
increased from 3,529 when diabetes was the
underlying cause to 11,864 when diabetes was
also listed as an associated cause of death—this
represents 9% of all deaths recorded in 2005.
Sex and age
The sex and age distribution of deaths with
diabetes as the underlying or associated cause
is similar to that of deaths with diabetes listed
as just an underlying cause. In 2005, the total
number of deaths was higher for men than for
women (6,325 deaths compared with 5,540
deaths, respectively). The majority of deaths, with
diabetes as the underlying or associated cause
(87%), occurred in those aged 65 years and over
(Figure 8.3).
Trends
As previously noted, data for associated causes of
death ﬁrst became available in 1997. Therefore,
trends for deaths with diabetes as an underlying
or associated cause are presented for the years
1997 to 2005.
Over the 9-year period, there were a total of
95,478 deaths registered where diabetes was
listed as an underlying or associated cause of
death (an average of 10,609 deaths per year); this
represents 8% of all deaths registered in that
period. The death rates for both men and women
remained fairly stable between 1997 and 2005,
however, males experienced higher death rates
than females across all years (Figure 8.4).
Deaths per 100,000 population
Age group (years)
0
100
200
300
400
500
600
700
800
Females
Males
75+ 65–74 55–64 45–54 35–44 25–34 <25
Note: Includes deaths where diabetes was the underlying or an associated cause of death.
Source: AIHW National Mortality Database.
Figure 8.3: Death with diabetes as the underlying or associated cause of death, by sex and age, 2005

Diabetes-related deaths
Diabetes-related death are deaths where diabetes
was listed as the underlying cause of death, or
where diabetes was listed as the associated cause
of death and the underlying cause of death was
one of a speciﬁc list (see Box 8.1) commonly
associated with diabetes complications.
In 2005, there were 7,012 diabetes-related deaths,
which constituted 5% of all deaths recorded.
More males died from diabetes-related deaths
than females (3,629 deaths compared with 3,383
deaths, respectively). The majority of diabetes related
deaths occurred in those aged 65 years and over.
Over the 9-year period 1997 to 2005, there were
a total of 61,255 deaths registered where diabetes
was a related cause of death. This represents an
average of 6,780 deaths each year. The trend for
the underlying or associated cause of death was
similar—the death rates for diabetes-related
deaths remained relatively stable for both males
and females, but males had higher rates than
females in all years.
Causes of death commonly listed with diabetes
As noted above, diabetes is rarely listed as the
only cause of death on death certiﬁcates. In
2005, diabetes was recorded as the only cause of
death in 31 (0.9%) deaths where diabetes was the
underlying cause of death. Where diabetes was
listed as the underlying cause of death, conditions
most commonly listed as associated causes of
death included coronary heart disease (in 67% of
deaths), kidney-related diseases (30%), and stroke
and heart failure (20%).
Of the deaths in 2005 where diabetes was listed
as an associated cause of death, coronary heart
disease was recorded as the underlying cause of
death in 28% of deaths. Cancer (25%) and stroke
(8%) were the other main underlying causes listed
with diabetes deaths.
Deaths per 100,000 population
Year
0
10
20
30
40
50
60
70
80
Females
Males
2005 2004 2003 2002 2001 2000 1999 1998 1997
Notes
1. Directly age-standardised to the Australian population as at 30 June 2001.
2. For 1997 to 2005 the disease grouping is classified according to the ICD-10 codes: E10–E14 for diabetes.
3. Note that there have only been two cases in which gestational diabetes mellitus has been recorded as a cause of death; these deaths occurred in the
years 2000 and 2005.
4. In 2005, two deaths with missing age or sex have been included in the total.
Source: AIHW National Mortality Database
Figure 8.4: Deaths with diabetes as the underlying or associated cause of death, 1997 to 2005
Diabetes: Australian facts 2008 92
Deaths of people on
the National Diabetes
Register
There were over 7,500 deaths of NDR registrants
during the period 1999–2005. Diabetes was the
underlying cause of death in just over 14% of
deaths. At broad disease group level, neoplasms
were the most common underlying cause of
death, accounting for just over a third (36%) of all
deaths of NDR registrants, followed by diseases
of the circulatory system, which accounted for
29% of deaths.
Coronary heart disease (CHD) was the most
common speciﬁc underlying cause of death of
NDR registrants—accounting for 19% of deaths.
Cerebrovascular diseases accounted for nearly 5%
of total deaths.
Diabetes is often under-reported on death
certiﬁcates (Whittall et al. 1990) mainly because
diabetes indirectly causes death being a strong
risk factor for common cause of death such as
heart and other circulatory diseases (AIHW:
Dixon & Webbie 2005). Furthermore, many
people have other chronic disease in addition to
diabetes and selecting a single underlying cause
of death in these people may be diﬃcult (AIHW:
Mathur et al. 2000).
Of all deaths to NDR registrants—people known
to have diabetes—in 1999–2005 just under 50%
had diabetes listed as a cause on their death
certiﬁcates.

93
Appendixes
Appendix 1:
Methods, definitions and main data sources ...................... 94
Appendix 2:
Diabetes indicator data reference table ............................. 101
Diabetes: Australian facts 2008 94
Appendix 1: Methods, definitions and main
data sources
Methods and definitions
Also see Glossary for deﬁnitions used in this
report.
Prevalence
Prevalence refers to the number or proportion
(of cases, instances, and so on) present in a
population at a given time.
Prevalence rate in this report is calculated by
dividing the number of people with the disease
by the average population in the same reference
period. The resulting number is expressed as a
percentage, or as x cases per a given population
base (for example, 1,000, 10,000 or 100,000).
Incidence
Incidence refers to the number of new cases (of
a disease, condition or event) occurring during a
given period.
Incidence rate is calculated by dividing the
number of new cases in a given period by the
population at risk in the same period, expressed
as x cases per a given population base (for
example, 10,000 or 100,000). Although the
individuals who have already developed the
condition under study should be excluded from
the denominator, it is often not possible to
determine the individuals with the disease in the
general population. Therefore, the denominator
population used in calculating incidence rates
is the average population—often the mid-year
population, in the reference period.
Crude rates
A crude rate is deﬁned as the number of events
over a speciﬁed period (for example, a year)
divided by the total mid-year population (30
June of the reference year for mortality and 31
December for hospital separations).
Age-specific rates
An age-speciﬁc rate is deﬁned as the number of
events for a speciﬁed age group over a speciﬁed
period (for example, a year) divided by the
total population at risk of the event in that age
group. Age-speciﬁc rates in this report were
calculated by dividing, for example, the number
of hospitalisations or deaths in each speciﬁed age
group by the mid-year population in the same age
group.
Age-standardised rates
Age-standardisation is a technique used to
eliminate the effect of differences in population
age structures when comparing rates for different
periods of time, and/or different geographic areas
and/or different population groups. Deﬁnitions
are included in the National health data dictionary
(HDSC 2006).
There are two methods of age-standardisation,
direct and indirect. The direct method was used
in all chapters except in Chapter 5 where the
indirect method was used.
Direct age-standardisation
Direct age-standardisation applies the age speciﬁc rates to a ‘standard population’ in order
to determine the rate that would have occurred
in the standard population. This allows direct
comparison of different rates applied to the
same standard population. The 2001 Australian
population was used as the standard population
in calculating age-standardised rates, as
described below:
The method used for the calculation of age standardised
rates consists of three steps:
Step 1: Calculate the age-speciﬁc rate for each
age group.

Appendixes

Step 2: Calculate the expected number of cases
in each age group by multiplying the age-speciﬁc proportion by the corresponding
standard population to get the expected
number of cases.
Step 3: Sum the expected number of cases in
each age group, divide by the total of the
standard population and multiply by
100,000. This gives the age-standardised
rate.
Indirect age-standardisation
The indirect method is recommended for use
when calculating rates for small populations
where ﬂuctuations in age-speciﬁc rates can affect
the reliability of rates calculated using the direct
method (HDSC 2006).
Standardised mortality or hospitalisation ratios
Comparisons between mortality or hospitalisations
rates for speciﬁc population groups were made
with the other Australian population or another
standard population using standardised mortality
or hospitalisation ratios, which use indirect
standardisation to account for any differences in
the age structure between the two populations.
These rates were calculated using the following steps:
1. The ‘observed’ number (that is, the actual
number) of events for the population of
interest (that is, the Indigenous population)
was derived by age and sex.
2. Calculate age-speciﬁc proportions for the
standard population of choice.
4. Multiply the observed cases in each age and
sex group by the corresponding age-speciﬁc
proportions in the standard population to get
expected numbers in each age and sex group.
5. The total expected number was calculated by
summing the age-speciﬁc expected numbers
for each sex (from Step 4).
7. The standardised mortality or hospitalisation
ratio was then calculated by dividing the
total observed deaths by the total expected
deaths (from Step 5). A ratio of 1.0 indicates
that there is no difference between the rate
of death or hospitalisations experienced
by the study population and the standard
population.
8. The conﬁdence intervals were calculated using
the method outlined below.
Significance testing
The observed value of a rate may vary due to
chance even where there is no variation in the
underlying value of the rate. Therefore, where
indicators include a comparison between time
periods, geographical locations, socioeconomic
groups or Indigenous and non-Indigenous status,
a 95% conﬁdence interval has been calculated
for administrative data (including data from the
AIHW National Hospital Morbidity Database and
the AIHW National Mortality Database).
The 95% conﬁdence intervals for this report
were calculated using a method for obtaining
approximate conﬁdence intervals for a weighted
sum of Poisson parameters developed by Dobson
et al. (1991). This method calculates approximate
conﬁdence intervals for a weighted sum of
Poisson parameters.
The conﬁdence intervals are used to provide
an approximate indication of the differences
between rates. Where the conﬁdence intervals of
two rates do not overlap, the corresponding rates
are statistically signiﬁcantly different from each
other; that is, there is at least 95% conﬁdence
that the change in a rate is greater than that
which could be explained by chance.
As with all statistical comparisons, care should
be exercised in interpreting the results of
the comparison. If two rates are statistically
signiﬁcantly different from each other, this
means that the difference is unlikely to have
arisen by chance. Judgement should, however,
be exercised in deciding whether or not the
difference is of any practical signiﬁcance.
In this report, differences have been reported
based on 95% conﬁdence intervals. These
conﬁdence intervals are available on request.
For survey data, signiﬁcance testing was
undertaken where possible, using information
about sampling variability.
Diabetes: Australian facts 2008 96
Classifications
Cause of death and hospital diagnosis
Table A1.1: ICD-10-AM codes used to define diagnosis groups for diabetes hospitalisations
Diagnosis ICD-10-AM
Diabetes
Type 1 diabetes E10
Type 2 diabetes E11
Gestational diabetes O24.4
Other/Unspecified diabetes E12–E14
Complications
CHD I20–I25
Stroke I60–I64
PVD I70–I79
Kidney
Kidney complications of diabetes E102, E112, E122,E132, E142
Chronic kidney failure N18
Eye complications of diabetes E103, E113, E123, E133, E143
Nervous system complications of diabetes E104, E114, E124, E134, E144
Oral complications of diabetes E1063, E1163, E1263, E1363, E1463
Lower limb ulcers L97
Table A1.2 ICD-10 codes used to define cause of death groups for diabetes mortality
Cause of Death ICD-10
Diabetes
Type 1 diabetes E10
Type 2 diabetes E11
Other/Unspecified diabetes E12–E14
Complications
CHD I20–I25
Stroke I60–I64
PVD I70–I79
Kidney
Kidney complications of diabetes E102, E112, E122, E132, E142
Chronic kidney failure N18
Eye complications of diabetes E103, E113, E123,E133, E143
Nervous system complications of diabetes E104, E114, E124, E134, E144
Lower limb ulcers E105, E115, E125, E135, E145

Defining exercise levels
High exercise level is deﬁned as more than 3,200
mins and 2 hours or more of vigorous exercise,
over a two-week period.
Moderate exercise level is deﬁned as 1,600–3,200
mins or more than 3,200 mins but less than
2 hours of vigorous exercise, over a two-week
period.
Low exercise level is deﬁned as 100 mins to less
than 1,600 mins of exercise over a two-week
period.
Sedentary exercise level is deﬁned as less than
100 mins (includes no exercise) over a two-week
period.
Defining lipid levels
High blood pressure is deﬁned as systolic blood
pressure of 140mmHg or more; or diastolic
blood pressure of 90mmHg or more; or receiving
medication for high blood pressure.
High total cholesterol is deﬁned as total cholesterol
greater than or equal to 5.5mmol/L.
High LDL-cholesterol is deﬁned as LDL greater
than or equal to 3.5mmol/L.
Low HDL-cholesterol is deﬁned as HDL less than
1.0mmol/L.
High triglyceride is deﬁned as greater than or
equal to 2.0mmol/L.
Methods used in the analyses specific to
population groups
Aboriginal and Torres Strait Islander peoples
Hospitalisations
Analysis of hospitalisations for Aboriginal and
Torres Strait Islander peoples was restricted to
hospitals in Queensland, Western Australia,
South Australia and public hospitals in the
Northern Territory only, due to data quality
issues related to Indigenous identiﬁcation.
Hospitalisations where Indigenous status was
missing or unknown were amalgamated with
those for non-Indigenous Australians as ‘other’
Australians (AIHW 2005c).
Deaths
Analysis of deaths among Aboriginal and Torres
Strait Islander peoples was restricted to deaths
registered in Queensland, Western Australia,
South Australia and the Northern Territory.
Death records with a missing/not stated
Indigenous status were excluded (ABS 1997).
Care should be exercised when interpreting
both hospitalisation and deaths statistics by
Indigenous status, as these data may not be
representative of other states and territories or
for Australia as a whole.
Prevalence
Self-reported diabetes and risk factor prevalence
data was sourced from the 2004–05 NATSIHS.
This survey presented ﬁndings on the number
of Aboriginal and Torres Strait Islander people
in the community who reported having ever
been told by a doctor or nurse that they had
diabetes. The type of diabetes a person had was
not asked. These data may underestimate the true
prevalence of diabetes as those undetected cases
of diabetes (that is, where the individual does not
know they have diabetes) are not identiﬁed by the
survey. The survey design similarly aﬀects the
self-reported prevalence of heart conditions and
kidney disease as well as risk behaviours.
Socioeconomic status
Hospitalisations
Analysis of diabetes hospitalisations by
socioeconomic status are based on the Index of
Disadvantage from the Socioeconomic Index for
Areas (SEIFA 2001) (ABS 2001), and were grouped
into quintiles: the ﬁrst representing the most
disadvantaged areas, with the ﬁfth representing
the least disadvantaged areas. Hospitalisations
for which no SEIFA is available have not been
included in the analysis.
Deaths
Analyses of diabetes deaths by socioeconomic
status are based on the Index of Disadvantage
from the Socio-economic Index for Areas
(SEIFA 2001) (ABS 2001), and were grouped
into quintiles: the ﬁrst representing the most
disadvantaged areas, with the ﬁfth representing
the least disadvantaged areas. Death records
Diabetes: Australian facts 2008 98
for which no SEIFA is available have not been
included in the analysis.
Due to small numbers of deaths from diabetes
each year, data from the years 2002–2004 have
been combined (2003 to 2005 for complications),
and year of registration of death has been used for
all years. Trend data is only available from 2001.
Prevalence
Self-reported diabetes and risk factor prevalence
data was sourced from the 2004–05 NHS
conducted by the ABS. This survey presented
ﬁndings on the number of Australians in the
most disadvantaged and the least disadvantaged
socioeconomic quintiles who reported having
ever been told by a doctor or nurse that they
had diabetes. These data may underestimate the
true prevalence of diabetes in the Australian
community, as those undetected cases of diabetes
(that is, where the individual does not know they
have diabetes) are not identiﬁed in the survey.
Geographic region
Hospitalisations
Analysis of diabetes hospitalisations by
geographical location was based on the Australian
Standard Geographical Classiﬁcation Remoteness
Structure (ASGC), categorised as ‘Major Cities’,
‘Inner Regional’, ‘Outer Regional’, ‘Remote’
and ‘Very Remote’. Hospitalisations for which
geographical area was not stated, classed as
migratory or oﬀshore, have not been included in
the analyses.
Deaths
Analysis of diabetes deaths by geographical
location was based on the Australian Standard
Geographical Classiﬁcation Remoteness Structure
(ASGC), categorised as ‘Major Cities’, ‘Inner
Regional’, ‘Outer Regional’, ‘Remote’ and ‘Very
Remote’. Deaths for which region is not stated,
migratory or oﬀshore have not been included in
the analyses. Due to small numbers of diabetes
deaths each year, data for the years 2003–2005
have been combined, and year of registration of
death used throughout.
Prevalence
Self-reported diabetes and risk factor prevalence
data was sourced from the 2004–05 NHS
conducted by the ABS. This survey presented
ﬁndings on the number of Australians in non-remote
areas who reported having ever been told
by a doctor or nurse that they had diabetes. These
data may underestimate the true prevalence of
diabetes in the Australian community, as those
undetected cases of diabetes (that is, where the
individual does not know they have diabetes) are
not identiﬁed in the survey.
Overseas-born population
Hospitalisations
Analyses of diabetes hospitalisations by country
of birth are based on the Standard Australian
Classiﬁcation of Countries (SACC) (ABS 1998),
and were grouped by seven major regions:
Australia, Oceania, North-West Europe, South-
East Europe, Africa and the Middle East, Asia and
The Americas. Due to small numbers, for some
analyses only two groups are used: Australian-born
and overseas-born. Hospitalisations for
which country of birth is unknown have not been
included in the analysis.
Deaths
Analysis of diabetes deaths by country of birth
are based on the SACC (ABS 1998), and were
grouped by seven major regions: Australia,
Oceania, North-West Europe, South-East
Europe, Africa and the Middle East, Asia and
The Americas. Due to small numbers, for some
analyses only two groups are used: Australian-born
and overseas-born. Deaths for which
country of birth is unknown have not been
included in the analysis. Due to small numbers
of deaths from diabetes each year, data from the
years 2003–2005 have been combined, and year
of registration of death has been used for all years.
Prevalence
Self-reported diabetes and risk factor prevalence
data was sources from the 2004–05 NHS
conducted by the ABS. This survey presented
ﬁndings on the number of Australians born
Australia, Other Oceania, UK, Other North-West
Europe, Southern and Eastern Europe, North
Africa and the Middle East, South-East Asia,
and All other Countries, who reported having
ever been told by a doctor or nurse that they
had diabetes. These data may underestimate the
true prevalence of diabetes in the Australian
community, as those undetected cases of diabetes
(that is, where the individual does not know they
have diabetes) are not identiﬁed in the survey.
Main data sources
AIHW disease expenditure database is a
comprehensive database that allows expenditure
estimates to be produced by source of funds (that
is, Commonwealth, state or private) for each area
of expenditure. Utilisation measures such as bed
days, separations, number of medical encounters
and services and pharmaceutical scripts can
also be estimated (AIHW 2005c). There are
some key exclusions in the 2004–05 health
expenditure data, compared with that presented
in previous reports. High level residential aged
care expenditure (which was $5,807 million in
2004–05) has now been reclassiﬁed out of health
expenditure to welfare expenditure. Also note
that expenditure by disease for non-admitted
hospital services, other health practitioner
services (excluding optometry) and over-the-counter
pharmaceuticals was unable to be
allocated in 2004–05. This means that these data
are not comparable with data reported in Costs of
Diabetes in Australia, 2000–01 and Health system
expenditure on disease and injury in Australia,
2000–01.
This report provides direct health expenditure on
diabetes under four categories:
Admitted patient hospital services covering the
expenditure on services provided to an admitted
patient including expenditure on medical services
delivered to private admitted patients in hospitals
Prescription pharmaceuticals including
prescriptions subsidised under government
schemes (e.g. Pharmaceutical Beneﬁts Scheme)
and private prescriptions
Out of hospital medical services comprising medical
services funded under the Medical Beneﬁts
Scheme, such as primary health visits, pathology
and specialist services. Practice Incentive
Payments are also included in this category
Research including health socioeconomic research
funded by tertiary institutions, private non-proﬁt
organisations and government. Commercial
research funded by private business is not
included.
AIHW National Hospital Morbidity Database
contains demographic, diagnostic, procedural
and duration-of-stay information on episodes
of care for patients admitted to hospital. The
data collection is maintained by the AIHW
using data supplied by state and territory health
authorities. The database is episode-based and it
is not possible to count patients individually. In
this report, disease data relate to the principal
diagnosis reported for hospitalisations unless
otherwise speciﬁed. Data presented in this report
are for the period July 2004 to June 2005, except
in the case of trends. It is important to note
that new coding standards introduced in 2000
(changed the meaning of diabetes complication
codes in hospital data from one of causality to the
complication appearing with the diabetes) and in
may have had an eﬀect (AIHW: Phillips 2003) on
trends.
AIHW National Mortality Database contains
information on the cause of death supplied by
the medical practitioner certifying the death
or by a coroner. Registration of deaths is the
responsibility of the state and territory registrars
of Births, Deaths and Marriages. Registrars
provide the information to the ABS for coding
of cause of death and then provided to AIHW.
In this report, unless otherwise speciﬁed, death
data relate only to the underlying cause of death.
Data presented in this report are for the period
January to December 2005, as year of death/year
of registration.
Australia and New Zealand Dialysis and
Transplant Registry (ANZDATA) collects
information to monitor dialysis and transplant
treatments from all renal units in Australia and
New Zealand on all patients receiving kidney
replacement therapy where the intention to treat
is long term. Cases of acute kidney failure are
excluded. The Registry is coordinated within the
Queen Elizabeth Hospital in Adelaide.
The Australian Diabetes, Obesity and
Lifestyle Study (AusDiab) (1999–2000)
conducted by the International Diabetes
Institute, was designed to provide national
estimates of the prevalence of diagnosed and
undiagnosed diabetes. It also provided national
measurements of blood pressure, blood lipids,
blood glucose, body fat, height and weight, and
waist and hip circumference, as well as self-
Diabetes: Australian facts 2008 100
reported information on cardiovascular disease,
anti-hypertensive and lipid lowering medication
use, diet, smoking, alcohol consumption, physical
activity, and general health and wellbeing.
The study collected information in urban and
non-urban areas in all states and the Northern
Territory for more than 11,000 people aged
25 years and over who underwent a physical
examination. This represents a response rate of
37% (Dunstan et al. 2002b).
Analysis of this data by the AIHW included only
those people for whom all relevant data were
available.
In this report, measured prevalence data on
high blood pressure, high blood cholesterol and
overweight was obtained from this source.
Australian National Diabetes Information
Audit and Benchmarking (ANDIAB), a
collection by the National Association of Diabetes
Centres (NADC) based on an audit of patients
attending a selection of specialist diabetes
centres and specialist endocrinologists in private
practice. In 2004, ANDIAB reported on 3,108
persons with diabetes requiring specialist clinical
management, in particular those who have had
poor control of their diabetes. The ANDIAB
surveys have been conducted over one month
periods since 1998. A limitation of the sample is
that it does not accurately reﬂect the conditions
prevailing in the general diabetes population, as
people attending diabetes centres are likely to be
more severe cases.
Bettering the Evaluation and Care of Health
(BEACH) Survey of General Practice—an
ongoing national survey looking at aspects of
general practice in Australia, is conducted by
the General Practice Statistics and Classiﬁcation
Unit (an AIHW collaborating unit within the
Family Medicine Research Centre, University of
Sydney). BEACH began in April 1998 and involves
a random sample of approximately 1,000 GPs per
year, each of whom records details regarding 100
consecutive patient encounters.
Drug Utilisation Sub-Committee Database
(DUSC)—held at the DoHA, monitors the
community (that is, non-public hospital) use
of prescription medicines in Australia. This
database combines information on prescriptions
subsidised by the PBS and the RPBS and an
estimate from the Pharmacy Guild Survey of
those prescriptions that are not subsided (that
is, private prescriptions and PBS prescriptions
priced under the general patient co-payment).
The Pharmacy Guild Survey collects dispensing
information each month from a random
sample of about 150 pharmacies throughout
Australia. Information on drugs prescribed in
public hospitals and on highly specialised drugs
available to outpatients through public hospital
pharmacies under section 100 of the National
Health Act 1953 is not included in the DUSC
database.
National Aboriginal and Torres Strait
Islander Health Survey 2004–05, collected
information relating to Indigenous health—
including health status, health action taken,
and lifestyle factors—that may inﬂuence health.
Information was collected from 10,439 Indigenous
persons living in both remote and non-remote
areas of Australia. This survey covered information
similar to the NHS, including health status, health
risk factors, long-term conditions, health service
use, social and emotional wellbeing and basic
demographic information.
Information from this survey is mainly presented
in the chapter on population groups (Aboriginal
and Torres Strait Islander peoples section).
National Diabetes Register (NDR) is a database
that collects information about people who use
insulin as part of their treatment of diabetes. It
includes data for persons who began to use insulin
from 1 January 1999. Data for the register are
obtained from two main sources: the National
Diabetes Services Scheme, administered by
Diabetes Australia, and the APEG state-based
registers. APEG registers collect information about
children with diabetes aged less than 15 years.
National Drug Strategy Household Survey
(2004) includes data on 29,445 Australians aged
12 years and older. This was the eighth survey
in a series that began in 1985. The survey is
conducted by the AIHW. Respondents were asked
about their use of licit and illicit drugs, their
attitudes towards drugs and drug taking and
their perception of drugs and related behaviours.
In this report, self-reported prevalence of tobacco
smoking was obtained from this source.

National Health Survey 2004–05, a series of
surveys conducted by the ABS, were designed
to obtain national information on the health
status of Australians, their use of health services
and facilities, and health-related aspects of
their lifestyle. The 2004–05 survey included
25,906 persons and the 2001 survey collected
information from a sample of 26,900 people from
February to November 2001. The 1995 survey
was considerably larger and collected information
from a sample of 57,600 people over a 12-month
period from January 1995 to January 1996.
Northwest Adelaide Health Study (NWAHS)
conducted during 2000–2003 has been designed
to segment a large representative population
sample according to stage of disease in order
to identify each segment’s characteristics and
determine how they change over time.
Diabetes: Australian facts 2008 102
Appendix 2: Diabetes indicator data reference table
Indicator Chapter Reference
1. Prevalence of Type 2 modifiable diabetes risk factors over time.
1.1 Prevalence of overweight and obesity over time
1.1.1 Prevalence of overweight, but not obese
1.1.2 Prevalence of overweight
1.1.3 Prevalence of obesity.
3. Risk factors for diabetes
and its complications—
Overweight.
How many Australians are overweight?
Body Mass index—Prevalence/Trend:
1999–2000 AusDiab (Table 3.2);
1995, 2001, 2004–05 NHS (Fig 3.5).
Waist circumference: 1999–2000 AusDiab
(Fig 3.6).
1.2 Proportion of people not following guidelines for physical
activity over time.
3. Risk factors for diabetes
and its complications—
Physical inactivity
How many Australians are physically
inactive?
Prevalence/Trends: 1995, 2004–05 NHS
(Fig 3.3).
1.3 Proportion of people not following Australian dietary
recommendations over time.
3. Risk factors for diabetes
and its complications—
Unhealthy diet
Dietary risk factors for diabetes and its
complications—
Dietary fat intake (whole milk): 2004–05
NHS (Fig 3.4).
Dietary fibre intake (fruit and vegetables):
2004–05 NHS (Fig 3.4).
7. The proportion of people with diabetes mellitus (Type 1,
Type 2 and gestational) who have had an annual cycle of care).
6. Health service use Pathology tests at diabetes clinics:
2004, 2006 ANDIAB (HbA1c; lipids-total
cholesterol, HDL, LDL, triglycerides; eye
examination; microalbumin).
9. The diabetes-related death rate (includes Type 1, Type 2 and
gestational) among:
The general population
8. Mortality Diabetes-related deaths: 1997 to 2005
NMD (Fig 8.4, trend).
Aboriginal and Torres Strait Islander peoples
People of different socioeconomic status
People from different geographic areas
People of culturally and linguistically diverse backgrounds
5. Population Groups Aboriginal and Torres Strait Islander
peoples—Diabetes mortality: 2003–2005
NMD (Fig 5.4).
Socioeconomic disadvantage—Diabetes
mortality: 2003–2005 NMD (Fig 5.7), 2001
to 2005 NMD (Fig 5.8, trend).
Geographical location—Diabetes
mortality: 2003–2005 NMD (Table 5.7,
5.8); 2000 to 2005 NMD (Fig 5.12, trend).
Overseas-born—Diabetes mortality:
2003–2005 NMD (Fig 5.17, Table 5.11),
2000 to 2005 NMD (Fig 5.18, trend).
(continued)

Indicator Chapter Reference
11. Prevalence and incidence of diabetes (Type 1, Type 2 and
gestational), its complications and comorbidities among:
The general population
Aboriginal and Torres Strait Islander peoples
People of culturally and linguistically diverse backgrounds
People of different socioeconomic status
People from different geographic areas.
11.1 Prevalence of diabetes (Type 1, Type 2 and gestational) over time.
2: Diabetes incidence and
prevalence
Prevalence of diabetes:
Measurement data: 1999–2000 AusDiab
(Fig 2.1, 2.2); 2000–2003 NWAHS
Self-reported data: 2004–05 NHS (Fig 2.3,
2.4 (trend))
International comparison: IDF 2006 (Fig.
2.5).
Type 1 diabetes—Prevalence: 2004–05
NHS; 2006 NDSS; 2005 NDR; 1999–2000
AusDiab.
Type 2 diabetes—Prevalence: 1995,
2004–05 NHS (Fig 2.7, 2.8 (trend));
1999–2000 AusDiab.
Gestational diabetes mellitus: 2004–05
NHS.
5: Population groups Aboriginal and Torres Strait Islander
peoples—Self-reported prevalence:
2004–05 NATSIHS (Fig 5.1).
Overseas-born—Self-reported
prevalence: 2004–05 NHS.
Socioeconomic disadvantage—Selfreported
prevalence: 2004–05 NHS.
Geographical location—Self-reported
prevalence: 2004–05 NHS.
11.2 Incidence of diabetes (Type 1, Type 2 and gestational) over time
2: Diabetes incidence and
prevalence
Incidence of diabetes:
Estimates from disease register and
administrative data: 2003–2005 NDR;
2003 NDSS; 2003–04 to 2004–05 NHMD
(Table 2.1)
Estimates from cohort study: 2005
AusDiab.
Type 1 diabetes—Incidence: 2005 NDR
(Table 2.2); IDF 2006 (Fig 2.6).
Type 2 diabetes—Incidence: 2005 NDR;
2005 AusDiab.
Gestational diabetes mellitus: 2000–01 to
2004–05 NHMD (Fig 2.9).
5: Population groups Aboriginal and Torres Strait Islander
people—Incidence: population-based study.
(continued)
Diabetes: Australian facts 2008 104
Indicator Chapter Reference
11.3 Prevalence of cardiovascular disease among people with
diabetes over time.
4: Complications
of diabetes—
Cardiovascular disease
How many Australians with diabetes also
have cardiovascular disease?
Coronary heart disease: 2004–05 NHS;
1999–2000 AusDiab
Stroke: 2003 SDAC; 1999–2000 AusDiab
Peripheral vascular disease: 2004 ANDIAB.
5: Population groups Aboriginal and Torres Strait Islander
peoples—Complications, self-reported
prevalence: 2004–05 NATSIHS (heart &
circulatory problems or disease).
11.4 Incidence of cardiovascular disease among people with
diabetes over time.
11.5 Prevalence of visual loss among people with diabetes over
time.
4: Complications of diabetes—Eye disease
How many Australians with diabetes also
have eye disease?
Diabetic retinopathy: 1999–2000
AusDiab; 2000, 2001, 2002 NDDP; 2004
ANDIAB.
Cataracts and Glaucoma: 2004–05 NHS.
Blindness: 2004–05 NHS; 2006 ANDIAB.
11.6 Incidence of visual loss among people with diabetes over time.
11.7 Prevalence of end-stage renal disease among people with diabetes over time.
11.8 Incidence of end-stage renal disease among people with diabetes over time.
4: Complications of diabetes—Kidney disease
How many Australians with diabetes also
have kidney disease?
ESRD: 2004 ANZDATA.
5: Population groups Aboriginal and Torres Strait Islander
peoples—Complications, self-reported
prevalence: 2004–05 NATSIHS (kidney disease).
11.9 Prevalence of non-traumatic amputation among people
with diabetes over time.
11.10 Incidence of non-traumatic amputation among people
with diabetes over time.
4: Complications of diabetes—Foot complications
How many Australians with diabetes also
have foot complications?
Lower limb amputation: 2004 ANDIAB.
Glossary
additional diagnosis: A diagnosis established
after study to be a contributing factor to or
impacting on the patient’s episode of care
in hospital (or attendance at the health-care
facility). Compare with principal diagnosis.
albuminuria: More than normal amounts of a
protein called albumin in the urine.
angina: Temporary chest pain or discomfort
when the heart’s own blood supply is inadequate
to meet extra needs, as in exercise.
associated cause(s) of death: Any conditions,
diseases and injuries—other than the underlying
cause of death—considered to contribute to the
death. Compare with underlying cause of death. See
also cause of death.
atherosclerosis: A process in which fatty and
ﬁbre-like deposits build up on the inner walls
of the arteries, often forming plaques that can
then cause blockages. It is the main underlying
condition in heart attack, angina, stroke and
peripheral vascular disease.
Australian Standard Geographical
Classiﬁcation (ASGC): the ASGC uses the
Accessibility/Remoteness Index of Australia
(ARIA), which is based on how distant a place is
by road from urban centres of diﬀerent sizes, and
therefore provides a relative indication of how
diﬃcult it might be for residents to access certain
services such as health care and education. Five
categories are used in this publication: ‘Major
cities of Australia’, ‘Inner regional Australia’,
‘Outer regional Australia’, ‘Remote Australia’ and
‘Very remote Australia’.
blood cholesterol: Fatty substance produced by
the liver and carried by the blood to supply the
rest of the body. Its natural function is to supply
material for cell walls and for steroid hormones,
but if levels in the blood are too high it can lead to
atherosclerosis and heart disease.
blood pressure: It is the force exerted by blood
against the walls of the arteries. The force is
created by the pumping action of the heart, at
contraction (systolic) and at relaxation (diastolic).
body mass index (BMI): The most commonly
used method of assessing whether a person is
healthy weight, underweight, overweight or
obese. It is calculated by dividing the person’s
weight (in kilograms) by their height (in metres)
squared, that is, kg/m2. For both men and
women, underweight is a BMI of less than 18.5,
healthy weight is from 18.5 to less than 25,
overweight is 25 or more (includes obese), and
obese is 30 or more.
cardiovascular disease: Any disease of the heart
or blood vessels, including heart attack, angina,
stroke and peripheral vascular disease.
cataract: A cloudy or opaque area in the lens of
the eye.
cause of death: The disease or factor contributing
to the death. When used technically, this term is
usually applied to the ‘underlying cause’ listed on
the medical certiﬁcate issued at death according
to rules and conventions of the 10th revision
of the International classiﬁcation of diseases.
The underlying cause of death is deﬁned as the
main disease that initiated the train of events
leading directly to death, distinct from associated
causes of death which are conditions, diseases or
injuries that contributed to the death, directly or
indirectly. See also underlying cause of death and
associated cause(s) of death.
cerebrovascular: Of or relating to blood vessels
and the supply of blood to the brain. See also
stroke.
chronic disease: A disease persisting for a long
period (at least 3 to 6 months).
complications: Secondary conditions and illness
resulting directly or indirectly from another
disease or condition.
coronary heart disease (CHD): Heart attack
and angina (chest pain). Also known as ischaemic
heart disease.
Diabetes: Australian facts 2008 106
creatinine: A chemical found in the blood and
passed in the urine. A test of the amount of
creatinine in blood or in blood and urine indicates
functioning of the kidneys.
dental caries: Tooth decay.
diabetes (diabetes mellitus): A chronic
condition in which the body cannot properly
use its main energy source, the sugar glucose.
This is due to either the pancreas not producing
enough of the hormone insulin or the body being
unable to effectively use the insulin produced.
Insulin helps glucose enter the body’s cells from
the bloodstream and then be processed by them.
Diabetes is marked by an abnormal build-up
of glucose in the blood and it can have serious
short-term and long-term effects on many of the
body’s systems, especially the blood vessels and
nerves. For the different types of diabetes, see
Type 1 diabetes, Type 2 diabetes, gestational diabetes
mellitus (GDM) and other types of diabetes.
dialysis: A method of removing excess waste
substances from the blood when the kidneys are
unable to work effectively.
disability: When used technically, disability
refers to the presence of one or more of a deﬁned
set of limitations, restrictions or impairments.
disability-adjusted life year (DALY): A
summary statistic to describe years of healthy
life lost through disability and/or premature mortality.
encounter (general practitioner): Any
professional interchange between a patient and a
general practitioner.
endocrinologist: A doctor who treats people
who have problems with their endocrine glands.
Diabetes is an endocrine disorder.
gestational diabetes mellitus (GDM): A form of
diabetes that is deﬁned as glucose intolerance in
pregnant women not previously diagnosed with
diabetes. GDM is a temporary form of diabetes
that usually disappears after the baby is born.
Women who have had GDM are at increased risk
of developing Type 2 diabetes and GDM increases
the risk of perinatal morbidity and mortality.
Compare with Type 1 diabetes, Type 2 diabetes and
other types of diabetes.
glaucoma: An eye disease associated with
increased pressure within the eye.
glomeruli: The primary ﬁltration units of the
kidney.
glucose: The main sugar that the body uses for
energy. Glucose is a simple sugar that comes
from the breakdown of carbohydrates in the diet
as well as from the breakdown of glycogen (the
storage form of glucose) in the liver. The body
requires the hormone insulin to use glucose
properly.
HDL cholesterol: Cholesterol packaged in high-density
lipoprotein particles. The HDLs are good
acceptors of membrane-free cholesterol and
transport it back from tissues to the liver.
heart attack: Life threatening emergency that
occurs when a vessel supplying blood to the
heart muscle is suddenly blocked completely. The
event may lead to the death of a part of the heart
muscle. The medical term commonly used for a
heart attack is myocardial infarction.
heart failure: When the heart cannot pump
strongly enough to keep the blood circulating
around the body at an adequate rate.
hospital separation: The formal process by
which a hospital records the completion of
treatment and/or care for an admitted patient.
The episode of care may be completed by an
admitted patient’s discharge, death, transfer to
another hospital, or change in the type of care.
hyperglycaemia: High blood glucose levels.
hypertensive: High blood pressure.
hypertriglyceridemia: High levels of
triglycerides; a marker of lipid abnormalities.
hypoglycaemia: A low blood glucose level.
impaired glucose tolerance: Slower metabolism
of glucose due to insulin deﬁciency or resistance.
Classiﬁed as fasting plasma glucose less than
7.0 mmol/L and 2-hour plasma glucose 7.8–11.0
mmol/L after oral glucose tolerance testing
(OGTT).
incidence: The number of new cases (of a disease,
condition or event) occurring during a given
period. Compare with prevalence.

insulin: A hormone produced in the pancreas
that helps glucose to enter body cells for energy
metabolism.
insulin resistance: A condition in which insulin
works inefficiently and the body compensates by
producing an excess supply.
insulin-treated diabetes: All types of diabetes
treated with insulin, includes Type 1, Type 2,
gestational and other types of diabetes. It is a
term used to describe those on the NDR and
is not a standard classiﬁcation used in clinical
practice.
International Classiﬁcation of Diseases (ICD):
The World Health Organization’s internationally
accepted statistical classiﬁcation of disease and
injury.
ischaemic heart disease: See coronary heart disease.
LDL cholesterol: Cholesterol packaged in
low-density lipoprotein particles. LDLs carry
cholesterol to the various tissues for use.
metabolic syndrome: Also called Syndrome X,
is a symptom cluster associated with a high risk
of coronary heart disease and stroke. Central
to metabolic syndrome is insulin resistance.
Other common signs include: impaired glucose
tolerance, excessively high blood insulin levels,
high blood pressure and abnormal blood
cholesterol levels (speciﬁcally high levels of
triglycerides and low levels of HDL cholesterol).
morbidity: Refers to ill health in an individual
and to levels of ill health in a population or group.
myocardial infarction: See heart attack.
nephropathy: A disease of the kidneys.
neuropathy: A disease of the system that results
in damage to nerves.
obesity: Increased adiposity or fat mass,
associated with several chronic diseases and their
risk factors. Technically deﬁned as body mass
index ≥ 30, or waist circumference ≥ 102 cm for
males or ≥ 88 cm for females.
ophthalmologist: A doctor who sees and treats
people with eye problems or diseases.
other types of diabetes: Other types of diabetes
include certain conditions or syndromes, such as:
genetic defects of beta-cell function (formerly
referred to as maturity-onset diabetes of the
young (MODY)
genetic defects in insulin action
diseases of the exocrine pancreas (including
cystic ﬁbrosis and cancer of the pancreas)
endocrinopathies (for example, acromegaly and
Cushing’s Syndrome)
drug- or chemical-induced diabetes (for
example, steroid-induced diabetes)
infections (for example, congenital rubella)
uncommon but speciﬁc forms of immune mediated
diabetes mellitus
other genetic syndromes sometimes associated
with diabetes (WHO 1999).
These types of diabetes are relatively uncommon.
Only persons being treated with insulin for these
types of diabetes are included on the National
Diabetes Register. Compare with Type 1 diabetes,
Type 2 diabetes and gestational diabetes mellitus (GDM).
pancreas: An organ that is located behind the
lower part of the stomach and produces digestive
substances and hormones, including insulin.
periodontal: Refers to the supporting structures
of the teeth; including the gums, connective
tissue and bone.
peripheral vascular disease: Pain in the legs due
to an inadequate blood supply to them.
prevalence: The number or proportion (of cases,
instances, and so on) present in a population at a
given time. Compare with incidence.
principal diagnosis: The diagnosis established
after study to be chieﬂy responsible for
occasioning the patient’s episode of care in
hospital (or attendance at the health-care
facility).
retinopathy: A disease of the small blood vessels in the retina of the eye.

Diabetes: Australian facts 2008 108
risk factor: Any factor that represents a greater
risk of a health disorder or other unwanted
condition or event. Some risk factors are regarded
as causes of disease, others are not necessarily
so. Along with their opposites, protective factors,
risk factors are known as determinants.
saturated fats: Fats that are solid and are found
in the diet mostly from animal sources. In excess,
they tend to raise blood cholesterol.
separation: See hospital separation.
Socioeconomic Index for Areas (SEIFA):
An area-based measure of socioeconomic
disadvantage derived from the social and
economic characteristics of a statistical local
area (SLA) including income, education and
employment. In this report, quintiles of
socioeconomic disadvantage are presented: the
ﬁrst quintile represents the most disadvantaged
areas; the ﬁfth quintile represents the least
disadvantaged areas.
stroke: When an artery supplying blood to the
brain suddenly becomes blocked or bleeds. Often
causes paralysis of parts of the body normally
controlled by that area of the brain, or speech
problems and other symptoms.
triglycerides: The more common form in which
fats exist in the body in which three lipid (fat)
molecules are packaged with proteins and
cholesterol and are found in both the blood
plasma and adipose (fatty) tissue.
Type 1 diabetes: A form of diabetes marked by
a complete lack of insulin and needing insulin
replacement for survival. This form of diabetes
mostly arises in childhood or in young adults,
though it can occur at any age. Adults may
develop a slowly progressive form of Type 1
diabetes called Latent Autoimmune Diabetes in
Adults (LADA), which can be treated initially
without insulin injections. See also Type 2
diabetes, gestational diabetes mellitus (GDM) and
other types of diabetes.
Type 2 diabetes: The most common form of
diabetes, which is marked by reduced or less
effective insulin. Some cases may be managed
with changes to diet along with increased exercise
and weight loss. Many require drugs as well—
namely oral glucose-lowering drugs that work
on the pancreas. Many others require insulin
in addition to other treatments. See also Type 1
diabetes, gestational diabetes mellitus (GDM) and
other types of diabetes.
underlying cause of death: The condition,
disease or injury initiating the sequence of events
leading directly to death; that is, the primary,
chief, main or principal cause. Compare with
associated cause(s) of death. See also cause of death.
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List of tables
Table 2.1: New cases of diagnosed diabetes recorded in disease register and administrative data
by year of diagnosis, 2003–2005 .................................................................................................12
Table 2.2: Incidence of Type 1 diabetes among those aged 0–39 years at their ﬁrst insulin use,
by age and sex, 2005 .....................................................................................................................14
Table 2.3: Risk factors for Type 2 diabetes ...................................................................................................15
Table 3.1: Prevalence of impaired glucose regulation among adults aged 25 years and over,
1999–2000 ....22
Table 3.2: Prevalence of overweight (measured) based on body mass index, people aged 25 years
and over, 1999–2000 (per cent) ...................................................................................................28
Table 4.1: Hospitalisations with diabetes and CHD, stroke or PVD, 2004–05 .........................................37
Table 4.2: Diabetes deaths also involving CHD, stroke or PVD, 2005 .......................................................37
Table 4.3: Number of diabetes hospitalisations with periodontal complications, 2004–05 ....................47
Table 4.4: Pre-existing and gestational diabetes, 2004–05 ....................................................................... 48
Table 5.1: Hospitalisations for diabetes complications among Indigenous Australians, 2004–05 .........53
Table 5.2: Deaths from diabetes complications among Indigenous Australians, 2003–2005 .................53
Table 5.3: Prevalence of diabetes risk factors by socioeconomic position, 2004–05 (per cent) ...............54
Table 5.4: Risk factors by diabetes status and geographical location, 2004–05 (per cent) ......................59
Table 5.5: Diabetes hospitalisations by sex and geographical location, 2004–05 (per 10,000) ...............59
Table 5.6: Diabetes hospitalisations by geographical location and type of diabetes, 2004–05 ...............60
Table 5.7: Diabetes deaths by sex and geographical location, 2003–2005 (per 100,000) ........................61
Table 5.8: Diabetes deaths as any cause of death, by geographical location and type of diabetes,
2003–05 ........61
Table 5.9: Prevalence of diabetes risk factors by region of birth, 2004–05 (per cent) .............................63
Table 5.10: Hospitalisations by type of diabetes, Australian and overseas-born populations,
2004–05 ....... 64
Table 5.11: Diabetes deaths for overseas-born and Australian-born people by type of diabetes,
2003–2005 ....65
Table 6.1: Elements of the annual cycle of care for managing diabetes.....................................................71
Table 7.1: Self-assessed health status of people with and without diabetes, by sex, 2004–05
(per cent) .......81
Table 7.2: Level of psychological distress experienced by people with or without diabetes ....................82
Table 7.3: Diabetes burden of disease by speciﬁc cause, 2003 ...................................................................83
Table A1.1: ICD-10-AM codes used to deﬁne diagnosis groups for diabetes hospitalisations ...................96
Table A1.2 ICD-10 codes used to deﬁne cause of death groups for diabetes mortality ..............................96
Diabetes: Australian facts 2008 118
List of figures
Figure 2.1: Age-speciﬁc prevalence of diabetes, by sex, 1999–2000 ...........................................................9
Figure 2.2: Age-speciﬁc prevalence of diagnosed and undiagnosed diabetes, 1999–2000........................9
Figure 2.3: Age-speciﬁc prevalence of diagnosed diabetes, 2004–05 .......................................................10
Figure 2.4: Trends in the prevalence of diagnosed diabetes, 1989–90 to 2004–05 .................................10
Figure 2.5: Estimated diabetes prevalence, 20–79 year olds, 2007 ...........................................................11
Figure 2.6: Incidence of Type 1 diabetes in OECD countries, 0–14 year olds, late 1990s to
early 2000s ..14
Figure 2.7: Age-speciﬁc prevalence of diagnosed Type 2 diabetes 2004–05 ............................................15
Figure 2.8: Trends in the prevalence of diagnosed Type 2 diabetes, 1995 to 2004–05 ...........................16
Figure 2.9: Trends in hospitalisations with gestational diabetes, 2000–01 to 2004–05 ........................17
Figure 3.1: Age-speciﬁc prevalence of impaired fasting glucose (IFG) in adults, 1999–2000 .................22
Figure 3.2: Age-speciﬁc prevalence of impaired glucose tolerance (IGT) in adults, 1999–2000 .............22
Figure 3.3: Prevalence of physical activity among people aged 15 years and over, 2004–05 ..................24
Figure 3.4: Prevalence of whole milk consumption, and inadequate fruit and vegetable intake
among people aged 12 years and over, 2004–05 ......................................................................25
Figure 3.5: Prevalence of overweight (self-reported) based on body mass index, people aged
15 years and over, 2004–05 .......................................................................................................29
Figure 3.6: Prevalence of overweight (measured) based on waist circumference among people
aged 25 years and over, 1999–2000 ..........................................................................................29
Figure 3.7: Prevalence of smoking among people aged 18 years and over, 2004–05 ...............................30
Figure 3.8: Prevalence of high blood pressure among people aged 25 years and over, 1999–2000 ........31
Figure 3.9: Prevalence of blood lipid risk factors among adults, 1999–2000 ...........................................32
Figure 4.1: Number of hospitalisations for diabetes with ophthalmic complications, 2004–05 ........... 40
Figure 4.2: Number of hospitalisations for diabetes with kidney complications, 2004–05 ....................41
Figure 4.3: Number of hospitalisations for diabetes with neurological complications, 2004–05 ......... 44
Figure 4.4: Number of diabetes hospitalisations where a lower limb amputation was performed,
2004–05 ..... 46
Figure 5.1: Prevalence of diabetes by Indigenous status and sex, 2004–05 .............................................50
Figure 5.2: Diabetes hospitalisations by Indigenous status, 2004–05 .....................................................51
Figure 5.3: Diabetes hospitalisations by Indigenous status, 2000–01 to 2004–05 .................................52
Figure 5.4: Diabetes deaths by Indigenous status, 2003–2005 .................................................................52
Figure 5.5: Diabetes hospitalisations by socioeconomic position and sex, 2004–05 ...............................55
Figure 5.6: Diabetes hospitalisations by socioeconomic position, 2000–01 to 2004–05 ........................55
Figure 5.7: Diabetes deaths by socioeconomic position, 2003–2005 ........................................................56
Figure 5.8: Diabetes deaths by socioeconomic position, 2001 to 2005 .....................................................56
Figure 5.9: Hospitalisations for diabetes complications by socioeconomic position, 2004–05 ..............57
List of figures

Figure 5.10: Deaths from diabetes complications by socioeconomic position, 2003–2005 ......................57
Figure 5.11: Diabetes hospitalisations by geographical location, 2000–01 to 2004–05 ...........................60
Figure 5.12: Diabetes death rates by geographical location 2000 to 2005 ..................................................61
Figure 5.13: Hospitalisations for diabetes complications by geographic location, 2004–05 ....................62
Figure 5.14: Deaths from diabetes complications by geographic location, 2003–2005 .............................62
Figure 5.15: Diabetes hospitalisations by region of birth, 2004–05 .......................................................... 64
Figure 5.16: Diabetes hospitalisations, Australian-born and overseas-born people, 2000–01
to 2004–05 ..65
Figure 5.17: Diabetes deaths by region of birth, 2003–2005 .......................................................................65
Figure 5.18: Diabetes deaths as any cause of death, selected regions of birth, 2000 to 2005 ...................66
Figure 5.19: Diabetes hospitalisations among Australian-born and overseas-born people, by
type of diabetes-related complication, 2004–05 .....................................................................67
Figure 5.20: Diabetes deaths among Australian-born and overseas-born persons, by type of
diabetes-related complication, 2003–2005 ..............................................................................67
Figure 6.1: Consultations with a specialist or other health professional (excluding GPs), by
diabetes status, 2004–05 ...........................................................................................................72
Figure 6.2: Proportion of diabetes hospitalisations by type of diabetes, 2004–05 .................................72
Figure 6.3: Diabetes hospitalisations by age group and sex, 2004–05 ......................................................73
Figure 6.4: Proportion of diabetes hospitalisations, by type of diabetes, age group and sex,
2004–05 ......73
Figure 6.5: Trends in diabetes hospitalisations, 2000–01 to 2004–05 .....................................................74
Figure 6.6: Community use of insulins and oral blood glucose-lowering medicines, 1990–2005 ..........75
Figure 6.7: Community use of oral blood glucose-lowering medicines, 1990 to 2006 .............................76
Figure 7.1: Self-assessed health status of people with and without diabetes, 2004–05 ..........................81
Figure 7.2: Disability among people with diabetes, 2003 ..........................................................................83
Figure 7.3: Direct health expenditure on diabetes by sector, 2004–05 ....................................................85
Figure 8.1: Deaths with diabetes as the underlying cause of death, by age and sex, 2005 ......................89
Figure 8.2: Deaths with diabetes as the underlying cause of death, 1980 to 2005 ..................................89
Figure 8.3: Death with diabetes as the underlying or associated cause of death, by sex and age,
2005 .............90
Figure 8.4: Deaths with diabetes as the underlying or associated cause of death, 1997 to 2005 ...........91