Diabesity & Associated
Disorders in Australia - 2000
The Accelerating Epidemic
The Australian Diabetes, Obesity and
Lifestyle Study (AusDiab)

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AusDiab Report
Authors
Dr D Dunstan, Professor P Zimmet, Professor T Welborn, Dr R Sicree, Dr T Armstrong,
Professor R Atkins, Mr A Cameron, Dr J Shaw, and Dr S Chadban on behalf of the
AusDiab Steering Committee
Contributors
Dr S Bennett
Dr M de Courten
Ms G Hodgson
Mr A Meehan
Ms S Murray
Ms N Watson
Dr J Williams
List of sponsors
The Federal Government Commonwealth Dept of Health and Aged Care
(Minister: The Hon Dr Michael Wooldridge, Federal Minister for Health and Aged Care)
Eli Lilly (Aust) Pty Ltd
Janssen - Cilag (Aust) Pty Ltd
Knoll Australia Pty Ltd
Merck Lipha s.a. Alphapharm Pty Ltd
Merck Sharp & Dohme (Aust) Pty Ltd
Pharmacia and Upjohn Pty Ltd
Roche Diagnostics
Servier Laboratories (Aust) Pty Ltd
SmithKline Beecham International
BioRad Laboratories Pty Ltd
HITECH Pathology Pty Ltd
Qantas Airways Ltd
State Governments of: Queensland, South Australia, Tasmania, Western Australia and Victoria
Territory Health Services
Australian Kidney Foundation
Diabetes Australia - Northern Territory
The International Diabetes Institute
Copyright © 2001 by the International Diabetes Institute
ISBN 0957831021
Published by the International Diabetes Institute, Melbourne 2001
Cover Design by S.O.D.A. Graphic Design.
Publication graphics and design by A Meehan.
Printed by RB Print Imaging.
ii
Authors and sponsors

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AusDiab Report
What is Diabetes?
Diabetes mellitus is a metabolic disease characterised by high
blood glucose levels (hyperglycaemia) resulting from defects in
insulin secretion, insulin action or both.
The chronic hyperglycaemia of diabetes is associated with long-
term damage, dysfunction and failure of virtually every body
organ, especially the eyes, kidneys, nerves, heart and blood
vessels.
!
Type 1 diabetes results from autoimmune destruction of the
pancreatic beta cells, the cells which produce insulin. In this
form of diabetes, insulin is required for survival. It accounts for
10% of all persons with diabetes in Australia. It can appear at
any age, although usually before 40 years.
!
Type 2 diabetes is characterised by resistance to insulin's
action and impaired insulin production by the pancreas,
either of which may predominate. It is the most common form
of diabetes accounting for more than 85% of persons with
diabetes in Australia. It has a strong genetic (familial)
propensity which is unmasked by lifestyle factors such as
obesity (hence the term “diabesity”) and lack of exercise. In
most instances, the molecular or metabolic causation is not
yet known.
What is Diabetes?
iii

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AusDiab Report
Ministerial foreword
iv
Ministerial foreword

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AusDiab Report
Foreword
International Diabetes Federation
Professor Sir K George MM Alberti
Message from the IDF
This work represents a landmark in the history of diabetes in Australia. Amongst the earliest hints
of the emerging diabetes pandemic were the studies by Australians of diabetes in the Pacific
Islands and subsequent work with the indigenous populations. Both of these pointed to
Westernisation of lifestyle as a crucial factor.
Studies from Western Australia at that time suggested that there was less of a problem in those of
European origin. However, no Australia-wide data have been available. This has finally been
rectified.
The results should focus attention on the incontrovertible truth: that diabetes is now one of the
biggest health problems assailing Australia.
The prevalence rates match or exceed those in most Western countries and are similar to those in
the USA. This, together with the presumptive much higher rates in the Indigenous population,
should be taken by all as a call to action on two fronts: first, prevention of Type 2 diabetes by
tackling the horrendous twin problems of obesity and lack of physical activity; and second,
improved treatment facilities to hold at bay the deadly complications.
Australia led the way by early identification of the world pandemic. Now the IDF challenges
Australia to lead the way by implementing the first successful nationwide preventive strategy.
Professor Sir K George MM Alberti
President, International Diabetes Federation
Foreword
v

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AusDiab Report
Table of contents
Authors and sponsors
ii
What is Diabetes?
iii
Ministerial foreword
iv
Foreword - International Diabetes Federation
v
Executive summary
1
Chapter 1:
Background
4
Chapter 2:
Diabetes mellitus
7
Chapter 3:
Overweight and obesity
13
Chapter 4:
Dyslipidaemia
18
Chapter 5:
Hypertension
22
Chapter 6:
Smoking
26
Chapter 7:
Physical activity
29
Chapter 8:
Cardiovascular disease risk factors
31
Chapter 9:
Indicators of renal disease
33
Chapter 10: Survey methodology
35
Appendix 1: Summary table with confidence intervals
40
Appendix 2: Survey sites
41
References
42
Steering committee
44
Acknowledgements
45
Australian Diabetes Declaration
46
vi
Contents

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AusDiab Report
Executive summary
In both human and economic terms, diabetes
Diabetes mellitus
mellitus is already one of Australia's most costly
The prevalence of diabetes in the Australian
diseases with the number of new cases and its
population aged 25 years and older was 7.5%:
impact accelerating. It is a major risk factor for
8.0% for males and 7.0% for females. The
heart disease, kidney failure, blindness,
prevalence of diabetes rose from 2.5% in people
amputations and birth defects. Diabetes shortens
35 to 44 years to 23.6% in those 75 years and over.
life expectancy by up to 15 years and its annual cost
to the nation exceeds $1.2 billion. Already in the
!
For every known case of diabetes, there was
United States, diabetes related costs account for
one undiagnosed case.
12% of the national health budget. The
proliferation of studies describing the epidemiology
!
There are about 940,000 people over the
and impact of diabetes over the last 20 years in
age of 25 years with diabetes in Australia.
many countries has been extraordinary. Surprisingly
however, there has never been a national study
!
The number of adults in Australia with
performed in Australia.
diabetes has trebled since 1981.
Against this background, the National Diabetes
!
The prevalence of impaired glucose
Strategy (NDS), launched in 1998 and
metabolism (being either impaired glucose
spearheaded by Dr Michael Wooldridge, the
tolerance or impaired fasting glycaemia) in
Federal Minister for Health and Aged Care, was a
the population was 16.3%: 17.3% for males
visionary and innovative public health initiative.
and 15.3% for females.
Arising from the NDS, the Australian Diabetes,
Obesity and Lifestyle Study (AusDiab) was
Almost 1 in 4 Australians 25 years and over
conducted to determine the prevalence of diabetes,
has either diabetes or a condition of impaired
obesity and other cardiovascular disease risk
glucose metabolism. This condition is
factors including hypertension and abnormal
associated with substantially increased
serum lipid profiles (dyslipidaemia).
immediate risk of heart disease as well as
increased risk of diabetes in the future.
Until recent years, our governments and public
health planners in Australia were largely unaware
In comparison to people with normal glucose
of the magnitude of diabetes and its costs and,
tolerance, those with diabetes were more likely to
more importantly, the predicted escalation of the
have hypertension (69.3% vs. 21.1%), to be obese
number of persons with diabetes and its serious
(44.4% vs. 15.9%), to have elevated triglycerides
complications. For this reason, diabetes was not
(42.9% vs. 16.0%), and to have a depressed HDL-
prioritised as a major public health challenge
cholesterol (23.1% vs. 10.6%).
before 1996. However, in recognition of the impact
of diabetes on the Australian community, Australian
Overweight and obesity
Health Ministers agreed in 1996 that diabetes
would become one of the National Health Priorities
!
The prevalence of being mildly overweight
2
and a commitment was made to address diabetes
(BMI 25-29.9 kg/m ) was 39.1%: 48.2% for
in its major forms: Type 1, Type 2 and gestational
males and 30.2% for females.
diabetes. In 1999, the Health Ministers endorsed
2
the National Diabetes Strategy 2000-2004 with the
!
The prevalence of obesity (BMI 30 kg/m
³
)
signing of the Australian Diabetes Declaration.
was 20.5%: 19.1% for males and 21.8% for
females. This is more than double the rate
Thus AusDiab was commissioned as the first
observed in 1980.
accurate national study of diabetes prevalence. The
findings will provide the baseline data for the
!
Thus 59.6% of the participants were mildly
evaluation of the success of any intervention
overweight or obese. The rate for males was
programs introduced as part of the NDS.
67.4%, and for females, 52.0%.
Executive summary
1

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AusDiab Report
Dyslipidaemia (abnormal cholesterol and
or clustering with diabetes of other risk factors such
other blood fats)
as abdominal (central) obesity, dyslipidaemia and
hypertension i.e. the Metabolic Syndrome or what is
!
The prevalence of elevated total cholesterol
sometimes called the “Deadly Quartet”.
(³5.5 mmol/l) was 51.2%: 51.1% for males
and 51.2% for females.
Over 50% of Australian adults have at least one
component of the “Deadly Quartet” and the
!
The prevalence of elevated triglycerides (³2.0
consequent risk of cardiovascular disease. This
mmol/l) was 20.5%: 24.5% for males and
percentage does not take into account other
16.6% for females.
cardiovascular disease risk factors such as cigarette
smoking, sedentary behaviour and family history of
!
Lipid lowering agents were being taken by only
heart disease.
7.3% of the population.
Renal disease
Hypertension
!
Renal disease is a major health burden, and
!
The prevalence of hypertension was 28.8%:
currently consumes 5.7% of the Australian
30.6% for males and 27.1% for females.
health care budget.
!
Anti-hypertensive medication was being taken
!
Proteinuria was detected in 2.5% of the
by 13.4% of the population: 11.5% of males,
survey population, haematuria in 6.4% and
and 15.3% of females.
1.1% had an elevated serum creatinine.
!
Of those with hypertension, only 37.6% of
!
Together with diabetes and hypertension, this
males and 56.5% of females were on
indicates over one third of Australian adults
medication for hypertension. Thus, for every
are at increased risk of renal disease.
known case of hypertension, there was at least
one untreated case.
A later report will examine the problem of renal
disease in greater detail including information on
!
There is a trend to a lowering of prevalence of
renal disease in people with and without diabetes.
hypertension over the last two decades.
Conclusions
Smoking
The prevalence of diabetes and its co-morbidities in
!
The rate for current smoking was 15.6%:
Australia is very high by world standards for a
18.2% of males and 13.1% of females.
Western nation. The number of people with
diabetes has trebled since 1981.
!
Of those who had ever smoked, 63.3% had
ceased smoking: the same for both males and
Apart from the escalating rate of diabetes, there is a
females.
high prevalence of impaired glucose metabolism, a
condition associated with increased risk of heart
Physical activity
disease and future diabetes. The high rates of
!
Only half (49.8%) of the Australian adults
diabetes and impaired glucose metabolism,
aged 25 years and above were undertaking
coupled with those of obesity, dyslipidaemia and
'sufficient' physical activity to maintain good
hypertension, constitute a significant threat in terms
health.
of the future socio-economic burden of
cardiovascular disease and diabetes complications
!
Approximately 1 in 6 people (15.6%) reported
for Australia.
no participation in physical activity at all.
Diabetes and its complications are associated with
Cardiovascular disease risk factors - the
very high social and economic costs for both the
“Deadly Quartet”
person with diabetes, and State and Federal
governments. The high rates of diabetes and
A major reason for the high rates of cardiovascular
cardiovascular disease risk factors represent a
disease in persons with diabetes is the co-existence
2
Executive summary

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AusDiab Report
significant public health burden that requires urgent
Finally, we propose:
measures both for prevention of diabetes and its
!
A 5 year follow-up study be undertaken to
associated complications.
monitor outcomes in the people who
participated in the AusDiab survey to examine
The magnitude of the diabetes epidemic in
the natural history of diabetes, its
Australia, coupled with the significant premature
complications, impaired glucose metabolism
morbidity and mortality due to the enormous
as well as cardiovascular disease and stroke.
burden associated with diabetic complications,
including heart and kidney disease, heralds the
!
A comparable study is urgently needed to
need for increased attention and resources. The
assess the magnitude of the challenge at a
fact that potent environmental risk factors for Type 2
national level in Australia's Indigenous
diabetes such as obesity and exercise are
community given the epidemic rates and huge
modifiable, points to lifestyle intervention. This
health burden of diabetes. Such a study will
involves the incorporation of a healthy diet with an
provide the first accurate assessment of the
increase in physical activity, as a means of curbing
burden of diabetes, diabetes complications
the impact of this epidemic.
and associated chronic diseases in the
Indigenous population.
Executive summary
3

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AusDiab Report
1
Background
Diabetes mellitus is now recognised as a serious
importantly, the future potential for increases in
global health problem often resulting in substantial
diabetes and its serious complications in Australia.
morbidity and mortality, primarily from
cardiovascular complications, eye and kidney
Australia is a nation that by world standards
diseases and limb amputations. It will undoubtedly
provides a high proportion of its population with the
be one of the major health problems facing
opportunities for good health. Life expectancy is
1
Australia in the 21st century .
high, but, increasingly an ageing population and
some susceptible groups in the community are
World-wide, diabetes is becoming epidemic.
suffering from lifestyle diseases. This is the result of
Recently, in collaboration with the World Health
the public health triumphs of the 20th century with
Organization (WHO) in Geneva, the International
the near elimination of the infectious diseases that
Diabetes Institute produced new global predictions
were the major causes of death in the 19th century,
of the number of people with diabetes for various
and the unfavourable effects on lifestyle that have
countries for the year 2025 (unpublished, April,
come with modernization and industrialization of
2001). It was estimated that in the year 2000 there
our society. For example, exercise is being
were approximately 160 million people with
engineered out of our lives with the mechanisation
diabetes in the world. This will climb to over 280
and computerization of our society.
million people by the year 2025, the majority of
them with Type 2 diabetes. It was estimated that for
The major causes of death in Australia are currently
9
Australia there will be 1.23 million persons with
coronary heart disease, cancer and stroke . Much
diabetes in the year 2010. From Figure 1.1, the
of this mortality is the result of life-style changes that
predicted number at the time of this survey is nearly
have led to lower levels of physical activity and
950,000. This figure illustrates the dramatic rise in
unfavourable changes in our diet with consequent
3
diabetes cases over the last two decades and shows
increase in obesity and detrimental changes to
the estimated number of persons with diabetes in
lipid profiles. Indications that diabetes rates were
Australia
also on the rise led to the AusDiab initiative.

The number of studies describing the epidemiology
The above factors and the ageing of the Australian
of diabetes over the last twenty years in many
population have led to high levels of morbidity from
countries has been extraordinary, yet there has not
a number of chronic diseases which contribute
been a national study in Australia. For this reason,
greatly to the national health costs. Diabetes
governments and public health planners in this
mellitus and cardiovascular disease (CVD) are two
country had not prioritised diabetes. They remained
1,3
of these conditions . As a result they have been
largely unaware of the current magnitude, or, more
included by the Federal, State and Territory
Figure 1.1: Estimated diabetes cases in Australia:: number of persons
1400
e
1200
1000
d
s
d
n 800
c
s
a
u
o 600
b
h
T 400 a
200
0
1982
1986
1990
1994
1998
2002
2006
2010
Year
For the questionnaire based studies (1983, 1989-90, 1995), the total number of people with diabetes is calculated on
1-3
the basis of there being one undiagnosed case for every diagnosed case .
4
5,6
7
8
a. Busselton, 1981 ; b. NHF, 1983 ; c. ABS, 1989-90 ; d. ABS, 1995 ; e. (Estimate).
4
Background

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