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Diabetes is a group of disorders marked by high levels of glucose in the blood  and caused by either or both of the following:
There are several types of diabetes, of which the most frequently occurring are type 1, type 2 and gestational diabetes mellitus (GDM) . Type 1 diabetes is relatively uncommon in the Indigenous population . Type 2 diabetes, however, represents a serious health problem for many Indigenous people, who tend to develop it at earlier ages than other Australians, and often die from it at younger ages. GDM develops in some women during pregnancy  and is more common among Indigenous women than among non-Indigenous women .
Diabetes can lead to life-threatening health complications, some of which may develop within months of diagnosis while others may take years to develop . Complications of diabetes include diseases of the large blood vessels (macrovascular disease), which can lead to heart disease and stroke, and diseases of the small blood vessels (microvascular disease), which can lead to kidney failure, limb amputations, eye disease and blindness . For many Indigenous people diabetes is not diagnosed until after complications have developed .
Diabetes is known to have adverse effects on pregnant women and their babies . Outcomes that may occur for the mother include: pre-term birth; pre-term induced labour; caesarean section; hypertension; and increased length of stay in hospital. Outcomes that may occur for the infant include: higher rates of stillbirth, pre-term birth; high birthweight; low Apgar score; high-level resuscitation; admission to special care unit; and increased length of stay in hospital.
Statistics about diabetes for Indigenous people are often underestimated for several reasons, including under-identification of Indigenous status.1 Self-reported diabetes data may underestimate the prevalence of diabetes by up to 50% .
Around 8.6% of Aboriginal and Torres Strait Islander people (8.8% of Aboriginal people and 7.0% of Torres Strait Islander people) aged 2 years and over reported in the 2012-2013 AATSIHS that they had type 1 or type 2 diabetes and/or high sugar levels in their blood or urine . After age-adjustment, rates of diabetes and/or high sugar levels were 3.2 times higher among Indigenous people than among non-Indigenous people . Diabetes and/or high sugar levels were reported by a higher proportion of Indigenous females (9.6%) than Indigenous males (7.7%) 
The prevalence of diabetes and/or high sugar levels increased with age for all age-groups . The prevalence ranged from 5.3% for Indigenous people aged 25-34 years2 to 40% for those aged 55 years and over (Figure 3) . The age-specific levels from 25 years onwards were between three and five times higher than those for non-Indigenous people.
Figure 3. Proportions (%) of people reporting diabetes/high sugar levels as a long-term health condition, by Indigenous status, and age-group, Australia, 2012-2013
The prevalence of diabetes/high sugar levels was lower for Indigenous people living in non-remote areas (7.5%) than among those living in remote areas (12.8%) .
The self-reported results obtained from the AATSIHS were broadly consistent with biomedical results obtained for a subset of Indigenous adults (18 years and over) who provided blood and urine samples . In 2012-2013, results for fasting plasma glucose levels revealed that:
The most recent analysis of the incidence of insulin-treated diabetes in Australia uses data from the National (insulin-treated) Diabetes Register (NDR) . In 2011, Indigenous people accounted for 2.6% of new cases of type 1 diabetes, 1.8% of new cases of type 2 diabetes, and 1.9% of new cases of GDM among women aged 15-49. For 2006-2011, after age-adjustment, incidence rates of diabetes type 1 were lower for Indigenous people (7 per 100,000) than for non-Indigenous people (10 per 100,000). The incidence rate of insulin treated diabetes was almost 4 times higher for Indigenous people (134 per 100,000) than non-Indigenous people (36 per 100,000). After age-adjustment, incidence rates for insulin treated GDM were similar for Indigenous women (60 per 100,000) and non-Indigenous women (59 per 100,000).
In the period 2005-2007, almost 7% of Indigenous mothers in NSW, Vic, Qld, WA, SA and the NT had diabetes during pregnancy: 1.5% had pre-existing diabetes; 5.1% had GDM; and 93.4% did not have diabetes . Indigenous women who gave birth were 3.2 times more likely than their non-Indigenous counterparts to have pre-existing diabetes and 1.6 times more likely to have GDM.
Hospitalisation rates are not an accurate reflection of the burden of diabetes in the community because, as is the case for most chronic health conditions, the treatment of diabetes is well supported by primary health care from doctors, nurses, and allied health professionals. In the period April 2008 to March 2013, type 2 diabetes was managed at encounters with general practitioners (GPs) twice as frequently for Aboriginal and Torres Strait Islander patients as for other patients (8.2 per 100 encounters compared with 4.0 per 100 encounters) . More details are available for the earlier period April 2006 to March 2011, when diabetes problems were managed at a rate of 76 per 1,000 GP encounters with Indigenous patients . After adjusting for age, this was about three times the rate for other patients, due mainly to the higher management rate of type 2 diabetes. GP encounters for GDM for Indigenous females were managed at 1.5 times the rate of encounters for other females.
There were 6,391 hospital separations for ICD ‘Endocrine, nutritional and metabolic diseases’ (which includes diabetes) among Indigenous people in Australia in 2013-14, accounting for 1.6% of separations identified as Indigenous . In 2012-13, hospitalisation rates for diabetes as the principal and/or an additional diagnosis were 4 times higher for Indigenous people than for non-Indigenous people . Indigenous males (108 per 1,000) were 3 times more likely to be hospitalised for diabetes than non-Indigenous males (36 per 1,000) and Indigenous females (140 per 1,000) were 5 times more likely than non-Indigenous females (28 per 1,000) to be hospitalised for diabetes. Indigenous people were 1.7 times more likely than their non-Indigenous people to be hospitalised for type 1 diabetes as the principal and/or an additional diagnosis. Indigenous males (4.2 per 1,000) were almost twice as likely to be hospitalised for type 1 diabetes than non-Indigenous males (2.4 per 1,000) and Indigenous females (4.2 per 1,000) were almost twice as likely than non-Indigenous females (2.4 per 1,000) to be hospitalised for type 1 diabetes. Hospitalisation rates were 4 times higher for Indigenous people compared with non-Indigenous people for type 2 diabetes as the principal and/or an additional diagnosis. Indigenous males (107 per 1,000) were 3 times more likely to be hospitalised than non-Indigenous males (34 per 1,000) and Indigenous females (134 per 1,000) were almost 6 times more likely to be hospitalised for type 2 diabetes than non-Indigenous females (23 per 1,000).
For the two year period July 2008 to June 2010, diabetes (all types excluding GDM) accounted for almost 8,000 episodes of hospitalisation, and was the principal diagnosis for 1.4% of all hospital separations for Indigenous people living in NSW, Vic, Qld, WA, SA and the NT . Detailed analyses revealed:
GDM accounted for a further 1,171 hospitalisations of Indigenous females . After age-adjustment, Indigenous females were hospitalised for GDM at almost three times the rate of non-Indigenous females.
Complications from diabetes, particularly renal complications but also circulatory and ophthalmic conditions, are the cause of high rates of hospitalisations . Hospitalisation rates for renal complications of type 2 diabetes were 11.2 times higher for Indigenous people living in NSW, Vic, Qld, WA, SA and the NT in 2008-09 than those for non-Indigenous people. The hospitalisation rate for multiple complications of diabetes was 6.5 times higher for Indigenous people than for other Australians.
Diabetes was responsible for 8.1% (201 deaths) of deaths of Indigenous people living in NSW, Qld, SA, WA and the NT in 2012 . Diabetes was the second leading specific cause of death for Indigenous people, with an overall death rate 7.0 times higher than that for non-Indigenous people. (It should be noted that death data on diabetes are probably an underestimate as the condition tends to be under-reported on death certificates or is not recorded as the underlying cause of death .)