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Globally, rates of hyperglycaemia in pregnancy are highest among Indigenous women. The highest prevalence has been documented among Aboriginal women in the Northern Territory of Australia. Despite knowledge of this for over two decades, there has been very limited examination of the specific needs and experiences of Aboriginal women regarding this condition. How do Aboriginal women with hyperglycaemia in pregnancy understand and experience this condition, and how can their care be improved? A phenomenological methodology underpinned semi-structured in-depth interviews with 35 Aboriginal women and seven health professionals across the Northern Territory. Data were inductively analysed. The findings revealed that in general, participants in this study could recite simple health messaging regarding diabetes (e.g. 'no sugar'), but many lacked in-depth knowledge and this affected the management of their condition. Nevertheless, many identified pregnancy as a powerful motivator for change, signalling scope to improve health messaging. Women consistently expressed the need for diabetes education that was culturally appropriate, a clear desire for maternity care that was family-centred, based on respectful relationships with the same care provider, and respected Aboriginal ways of knowing and being. Existing health messaging around hyperglycaemia in pregnancy has limited reach with Aboriginal women in the Northern Territory. Reducing the burden of hyperglycaemia in pregnancy among these women requires a sustained commitment to redesign of maternity and diabetes care to incorporate the cultural and social context of women's lives. [ABSTRACT FROM AUTHOR]

Background: Australian Aboriginal and Torres Strait Islander women have high rates of gestational and pre-existing type 2 diabetes in pregnancy. The Northern Territory (NT) Diabetes in Pregnancy Partnership was established to enhance systems and services to improve health outcomes. It has three arms: a clinical register, developing models of care and a longitudinal birth cohort. This study used a process evaluation to report on health professional's perceptions of models of care and related quality improvement activities since the implementation of the Partnership.Methods: Changes to models of care were documented according to goals and aims of the Partnership and reviewed annually by the Partnership Steering group. A 'systems assessment tool' was used to guide six focus groups (49 healthcare professionals). Transcripts were coded and analysed according to pre-identified themes of orientation and guidelines, education, communication, logistics and access, and information technology.Results: Key improvements since implementation of the Partnership include: health professional relationships, communication and education; and integration of quality improvement activities. Focus groups with 49 health professionals provided in depth information about how these activities have impacted their practice and models of care for diabetes in pregnancy. Co-ordination of care was reported to have improved, however it was also identified as an opportunity for further development. Recommendations included a central care coordinator, better integration of information technology systems and ongoing comprehensive quality improvement processes.Conclusions: The Partnership has facilitated quality improvement through supporting the development of improved systems that enhance models of care. Persisting challenges exist for delivering care to a high risk population however improvements in formal processes and structures, as demonstrated in this work thus far, play an important role in work towards improving health outcomes. [ABSTRACT FROM AUTHOR]

Aim To assess the relationships of diabetes and albuminuria with all-cause mortality and cardiovascular disease outcomes in a population without prior cardiovascular disease using data from the Darwin Region Urban Indigenous Diabetes (DRUID) study. Methods We conducted a prospective cohort study of 706 participants (aged 15-81 years, 68% women) without prior cardiovascular disease who underwent a 75-g oral glucose tolerance test. Deaths and fatal or non-fatal cardiovascular disease were determined over 7 years, and hazard ratios with 95% CIs and population attributable risks were estimated for baseline glycaemia and albuminuria. Results Compared with normoglycaemia and after adjustment for age, sex, hypertension, dyslipidaemia and smoking, known diabetes was associated with an adjusted hazard ratio of 4.8 (95% CI 1.5-14.7) for all-cause mortality and 5.6 (95% CI 2.1-15.2) for cardiovascular disease. Compared with normoalbuminuria, the respective adjusted risks for macroalbuminuria were 10.9 (95% CI 3.7-32.1) and 3.9 (95% CI 1.4-10.8). The Adjusted all-cause mortality and cardiovascular disease estimated population attributable risks for diabetes were 27% and 32%, and for albuminuria they were 32% and 21%, respectively. Conclusions In our study population, the burden of mortality and cardiovascular disease was largely driven by diabetes and albuminuria. This finding on the influence of diabetes and albuminuria is consistent with reports in other high-risk Indigenous populations and should be better reflected in risk scores and intervention programmes. [ABSTRACT FROM AUTHOR]

Aims In the Diabetes Control and Complications Trial, mean updated HbA1c accounted for most of the differential risk of microvascular complications between intensive and conventional insulin therapy. We hypothesized, however, that a more precise measure of chronic hyperglycaemic exposure may be the incremental area-under-the-HbA1c-curve above the Diabetes Control and Complications Trial-standardized normal range for HbA1c (iAUCHbA1c>norm). Methods Using the Principal Diabetes Control and Complications Trial data set, we compared the following three measures of chronic glycaemic exposure for their capacity to predict retinopathy, nephropathy and neuropathy during the Diabetes Control and Complications Trial: mean updated HbA1c, iAUCHbA1c>norm, and total area-under-the-HbA1c-curve (tAUCHbA1c). For each outcome, models using each of these three glycaemic measures were compared in the following three ways: hazard or odds ratio, χ2 statistic, and Akaike information criterion. Results The three glycaemic measures did not differ in their prediction of neuropathy. iAUCHbA1c>norm was modestly superior to mean updated HbA1c for predicting nephropathy (χ2 P = 0.017, Akaike P = 0.032). In contrast, for predicting retinopathy, both iAUCHbA1c>norm (χ2 P = 0.0005, Akaike P = 0.0005) and tAUCHbA1c (χ2 P = 0.004, Akaike P = 0.004) were significantly better than mean updated HbA1c. Varying its HbA1c threshold incrementally between 37 and 53 mmol/mol (5.5-7.0%), inclusive, did not improve the prediction of retinopathy by iAUCHbA1c>threshold beyond that of tAUCHbA1c,consistent with the concept of a continuous relationship between glycaemia and retinopathy, with no glycaemic threshold. Conclusions Both iAUCHbA1c>norm and tAUCHbA1c were superior to mean updated HbA1c for predicting retinopathy. Optimal assessment of chronic glycaemic exposure as a determinant of retinopathic risk may require consideration of both the degree of hyperglycaemia and its duration. [ABSTRACT FROM AUTHOR]

Background: Aboriginal and Torres Strait Islander women experience high rates of diabetes in pregnancy (DIP), contributing to health risks for mother and infant, and the intergenerational cycle of diabetes. By enhancing diabetes management during pregnancy, postpartum and the interval between pregnancies, the DIP Partnership aims to improve health outcomes and reduce risks early in the life-course. We describe a mixed methods formative study of health professional's perspectives of antenatal and post-partum diabetes screening and management, including enablers and barriers to care.Methods: Health professionals involved in providing diabetes care in pregnancy, from a range of health services across the Northern Territory, completed the survey (n = 82) and/or took part in interviews and/or focus groups (n = 62).Results: Qualitative findings highlighted factors influencing the delivery of care as reported by health professionals, including: whose responsibility it is, access to care, the baby is the focus and pre-conception care. The main challenges were related to: disjointed systems and confusion around whose role it is to provide follow-up care beyond six weeks post-partum. Quantitative findings indicated that the majority of health professionals reported confidence in their own skills to manage women in the antenatal period (62%, 40/79) and slightly lower rates of confidence in the postpartum interval (57%, 33/58).Conclusion: These findings regarding whose role it is to provide postpartum care, along with opportunities to improve communication pathways and follow up care have informed the design of a complex health intervention to improve health systems and the provision of DIP related care. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective To describe the detailed associations of albuminuria among a contemporary cohort of Aboriginal and Torres Strait Islander people to inform strategies for chronic kidney disease prevention and management. Methods A cross-sectional analysis of Indigenous participants of the eGFR Study. Measures Clinical, biochemical and anthropometric measures were collected (including body-circumferences, blood pressure (BP); triglycerides, HbA1c, liver function tests, creatinine; urine- microscopic-haem, albumin: creatinine ratio (ACR), prescriptions- angiotensin converting enzyme inhibitor or angiotensin receptor II antagonist (ACEI/ARB). Albuminuria and diabetes were defined by an ACR>3.0 mg/mmol, and HbA1c≥48 mmol/mol or prior history respectively. Waist: hip ratio (WHR), and estimated glomerular filtration rate (eGFR) were calculated. ACR was non-normally distributed; a logarithmic transformation was applied (in base 2), with each unit increase in log2-albuminuria representing a doubling of ACR. Results 591 participants were assessed (71% Aboriginal, 61.6% female, mean age 45.1 years, BMI 30.2 kg/m2, WHR 0.94, eGFR 99.2 ml/min/1.73m2). The overall prevalence of albuminuria, diabetes, microscopic-haem and ACEI/ARB use was 41.5%, 41.5%, 17.8% and 34.7% respectively; 69.3% of adults with albuminuria and diabetes received an ACEI/ARB. Using multivariable linear regression modelling, the potentially modifiable factors independently associated with log2-albuminuria were microscopic-haem, diabetes, WHR, systolic BP, alkaline phosphatase (all positive) and eGFR (inverse). Conclusion Albuminuria is associated with diabetes, central obesity and haematuria. High ACEI/ARB prescribing for adults with diabetes and albuminuria was observed. Further understanding of the links between fat deposition, haematuria and albuminuria is required. [ABSTRACT FROM AUTHOR]

Type 2 diabetes mellitus and other chronic cardio-metabolic conditions are significant contributors to the large disparities in life expectancy between Indigenous and non-Indigenous Australians. Type 2 diabetes is more prevalent from a young age among Indigenous Australians and is often preceded by a cluster of risk factors, including central obesity, dyslipidaemia, albuminuria and socio-economic disadvantage. Management of type 2 diabetes in Australian Indigenous peoples can be challenging in the setting of limited resources and socio-economic disadvantage. Key strategies to address these challenges include working in partnership with patients, communities and primary healthcare services ( PHC, Aboriginal community controlled and government services) and working in a multidisciplinary team. Population prevention measures are required within and beyond the health system, commencing as early as possible in the life course. [ABSTRACT FROM AUTHOR]

Issues Addressed: In Australia, Aboriginal and Torres Strait Islander young people in remote settings are most-affected by young onset type 2 diabetes (T2D). It is necessary to understand young people's experiences, including factors impacting on self-management, to improve models of care., Methods: A phenomenological methodology underpinned this qualitative study in Western Australia's Kimberley region. Two Aboriginal Community Controlled Health Services supported recruitment of seven Aboriginal young people aged 12-24 with T2D, who participated in interviews. A carer and health professional of one young person in each site were also interviewed and relevant medical record data reviewed to assist with triangulation of data. De-identified transcripts were inductively coded and a coding structure developed with oversight by a Kimberley Aboriginal researcher., Results: Young people reported varied experiences and emotions relating to a T2D diagnosis. Most recounted this was upsetting and some reported current negative impact on emotional wellbeing. Challenges with understanding and managing diabetes were highlighted, particularly regarding healthy eating, physical activity and medication. Family are a prominent source of self-management support, with the intergenerational impact of diabetes being evident for each participant. Positive relationships with health professionals, entailing continuity of care, were valued., Conclusions: There are significant emotional and medical challenges for young people with T2D and their families. Recommendations from this work will contribute to the development of local resources and initiatives to improve diabetes-related support. SO WHAT?: Alongside broader efforts to support good health at the societal level, enhanced health education and family-oriented support structures including Aboriginal clinical staff for young people with T2D are needed., (© 2024 The Author(s). Health Promotion Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of Australian Health Promotion Association.)

This review outlines some of the extraordinary recent advances in diabetes technology, which are transforming the management of type 1 diabetes before, during and after pregnancy. It highlights recent improvements associated with use of continuous glucose monitoring (CGM) but acknowledges that neither CGM nor insulin pump therapy are adequate for achieving the pregnancy glucose targets. Furthermore, even hybrid closed-loop (HCL) systems that are clinically effective outside of pregnancy may not confer additional benefits throughout pregnancy. To date, there is only one HCL system, the CamAPS FX, with a strong evidence base for use during pregnancy, suggesting that the pregnancy benefits are HCL system specific. This is in stark contrast to HCL system use outside of pregnancy, where benefits are HCL category specific. The CamAPS FX HCL system has a rapidly adaptive algorithm and lower glucose targets with benefits across all maternal glucose categories, meaning that it is applicable for all women with type 1 diabetes, before and during pregnancy. For women of reproductive years living with type 2 diabetes, the relative merits of using non-insulin pharmacotherapies vs diabetes technology (dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors) are unknown. Despite the urgent unmet need and potential benefits, studies of pharmacotherapy and technology use are extremely limited in pregnant women with type 2 diabetes., (© 2024. The Author(s).)

Background: Aboriginal and Torres Strait Islander communities in remote Australia have initiated bold policies for health-enabling stores. Benchmarking, a data-driven and facilitated 'audit and feedback' with action planning process, provides a potential strategy to strengthen and scale health-enabling best-practice adoption by remote community store directors/owners. We aim to co-design a benchmarking model with five partner organisations and test its effectiveness with Aboriginal and Torres Strait Islander community stores in remote Australia., Methods: Study design is a pragmatic randomised controlled trial with consenting eligible stores (located in very remote Northern Territory (NT) of Australia, primary grocery store for an Aboriginal community, and serviced by a Nutrition Practitioner with a study partner organisation). The Benchmarking model is informed by research evidence, purpose-built best-practice audit and feedback tools, and co-designed with partner organisation and community representatives. The intervention comprises two full benchmarking cycles (one per year, 2022/23 and 2023/24) of assessment, feedback, action planning and action implementation. Assessment of stores includes i adoption status of 21 evidence-and industry-informed health-enabling policies for remote stores, ii implementation of health-enabling best-practice using a purpose-built Store Scout App, iii price of a standardised healthy diet using the Aboriginal and Torres Strait Islander Healthy Diets ASAP protocol; and, iv healthiness of food purchasing using sales data indicators. Partner organisations feedback reports and co-design action plans with stores. Control stores receive assessments and continue with usual retail practice. All stores provide weekly electronic sales data to assess the primary outcome, change in free sugars (g) to energy (MJ) from all food and drinks purchased, baseline (July-December 2021) vs July-December 2023., Discussion: We hypothesise that the benchmarking intervention can improve the adoption of health-enabling store policy and practice and reduce sales of unhealthy foods and drinks in remote community stores of Australia. This innovative research with remote Aboriginal and Torres Strait Islander communities can inform effective implementation strategies for healthy food retail more broadly., Trial Registration: ACTRN12622000596707, Protocol version 1., (© 2024. The Author(s).)

Background: The burden of chronic conditions is growing in Australia with people in remote areas experiencing high rates of disease, especially kidney disease. Health care in remote areas of the Northern Territory (NT) is complicated by a mobile population, high staff turnover, poor communication between health services and complex comorbid health conditions requiring multidisciplinary care., Aim: This paper aims to describe the collaborative process between research, government and non-government health services to develop an integrated clinical decision support system to improve patient care., Methods: Building on established partnerships in the government and Aboriginal Community-Controlled Health Service (ACCHS) sectors, we developed a novel digital clinical decision support system for people at risk of developing kidney disease (due to hypertension, diabetes, cardiovascular disease) or with kidney disease. A cross-organisational and multidisciplinary Steering Committee has overseen the design, development and implementation stages. Further, the system's design and functionality were strongly informed by experts (Clinical Reference Group and Technical Working Group), health service providers, and end-user feedback through a formative evaluation., Results: We established data sharing agreements with 11 ACCHS to link patient level data with 56 government primary health services and six hospitals. Electronic Health Record (EHR) data, based on agreed criteria, is automatically and securely transferred from 15 existing EHR platforms. Through clinician-determined algorithms, the system assists clinicians to diagnose, monitor and provide guideline-based care for individuals, as well as service-level risk stratification and alerts for clinically significant events., Conclusion: Disconnected health services and separate EHRs result in information gaps and a health and safety risk, particularly for patients who access multiple health services. However, barriers to clinical data sharing between health services still exist. In this first phase, we report how robust partnerships and effective governance processes can overcome these barriers to support clinical decision making and contribute to holistic care., (© 2024. The Author(s).)

Introduction: Premature onset of type 2 diabetes and excess mortality are critical issues internationally, particularly in Indigenous populations. There is an urgent need for developmentally appropriate and culturally safe models of care. We describe the methods for the codesign, implementation and evaluation of enhanced models of care with Aboriginal and Torres Strait Islander youth living with type 2 diabetes across Northern Australia., Methods and Analysis: Our mixed-methods approach is informed by the principles of codesign. Across eight sites in four regions, the project brings together the lived experience of Aboriginal and Torres Strait Islander young people (aged 10-25) with type 2 diabetes, their families and communities, and health professionals providing diabetes care through a structured yet flexible codesign process. Participants will help identify and collaborate in the development of a range of multifaceted improvements to current models of care. These may include addressing needs identified in our formative work such as the development of screening and management guidelines, referral pathways, peer support networks, diabetes information resources and training for health professionals in youth type 2 diabetes management. The codesign process will adopt a range of methods including qualitative interviews, focus group discussions, art-based methods and healthcare systems assessments. A developmental evaluation approach will be used to create and refine the components and principles of enhanced models of care. We anticipate that this codesign study will produce new theoretical insights and practice frameworks, resources and approaches for age-appropriate, culturally safe models of care., Ethics and Dissemination: The study design was developed in collaboration with Aboriginal and Torres Strait Islander and non-Indigenous researchers, health professionals and health service managers and has received ethical approval across all sites. A range of outputs will be produced to disseminate findings to participants, other stakeholders and the scholarly community using creative and traditional formats., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe glucose metrics in a high-risk population of women with type 2 diabetes (T2DM) in pregnancy and to explore the associations with neonatal outcomes. Research Design and Methods: Prospective observational study of 57 women. Continuous glucose monitoring (CGM) trajectories were determined from metrics collected in early and late gestation using the first and last two (mean 16 and 35) weeks of Freestyle Libre data. Logistic regression was used to examine associations of CGM metrics with neonatal hypoglycemia (glucose <2.6 mmol/L requiring intravenous dextrose) and large for gestational age (LGA) (>90th percentile for gestational age and sex). Pregnancy-specific target glucose range was 3.5-7.8 mmol/L (63-140 mg/dL). Results: Forty-one women used CGM for 15 weeks (mean age 33 years, 73% Aboriginal or Torres Strait Islander, 32% living remotely). There was limited change in average metrics from early to late pregnancy. For the subgroup with sensor use >50% ( n  = 29), mean time in range (TIR) increased by 9%, time above range reduced by 12%, average glucose reduced by 1 mmol/L, and time below range increased by 3%. Neonatal hypoglycemia was associated with most CGM metrics, HbA1c and CGM targets, particularly those from late pregnancy. LGA was associated with hyperglycemic metrics from early pregnancy. Each 1% increase TIR was associated with a 4%-5% reduction in risk of neonatal complications. Conclusion: In this high-risk group of women with T2DM, CGM metrics only improved during pregnancy in those with greater sensor use and were associated with LGA in early pregnancy and neonatal hypoglycemia throughout. Culturally appropriate health care strategies are critical for successful use of CGM technology.

Aims: To investigate epigenomic indices of diabetic kidney disease (DKD) susceptibility among high-risk populations with type 2 diabetes mellitus., Methods: KDIGO (Kidney Disease: Improving Global Outcomes) clinical guidelines were used to classify people living with or without DKD. Differential gene methylation of DKD was then assessed in a discovery Aboriginal Diabetes Study cohort (PROPHECY, 89 people) and an external independent study from Thailand (THEPTARIN, 128 people). Corresponding mRNA levels were also measured and linked to levels of albuminuria and eGFR., Results: Increased DKD risk was associated with reduced methylation and elevated gene expression in the PROPHECY discovery cohort of Aboriginal Australians and these findings were externally validated in the THEPTARIN diabetes registry of Thai people living with type 2 diabetes mellitus., Conclusions: Novel epigenomic scores can improve diagnostic performance over clinical modelling using albuminuria and GFR alone and can distinguish DKD susceptibility., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Diabetes is a serious chronic disease with high associated burden and disproportionate costs to communities based on socioeconomic, gender, racial, and ethnic status. Addressing the complex challenges of global inequity in diabetes will require intentional efforts to focus on broader social contexts and systems that supersede individual-level interventions. We codify and highlight best practice approaches to achieve equity in diabetes care and outcomes on a global scale. We outline action plans to target diabetes equity on the basis of the recommendations established by The Lancet Commission on Diabetes, organising interventions by their effect on changing the ecosystem, building capacity, or improving the clinical practice environment. We present international examples of how to address diabetes inequity in the real world to show that approaches addressing the individual within a larger social context, in addition to addressing structural inequity, hold the greatest promise for creating sustainable and equitable change that curbs the global diabetes crisis., Competing Interests: Declaration of interests AFW is supported by The Leona M and Harry B Helmsley Charitable Trust (2005-03934) and the National Institutes of Health-National Institute of Diabetes and Digestive Kidney Disease (5P30DK111024-07). LM-B is supported by an Australian National Health and Medical Research Council (NHMRC) investigator grant (1194698), and leads projects that are funded by NHMRC, the Australian Department of Health, and the Australian Medical Research Future Fund. LEE and JAC are supported by the National Institutes of Health-National Institute of Diabetes and Digestive Kidney Disease (R01DK118038 and R01DK120861, awarded to LEE; K01DK131319, awarded to JAC). LEE and RJW are supported by the National Institute on Minority Health and Health Disparities (R01MD013826, awarded to LEE and RJW; R01MD017574, awarded to LEE). RJW is supported by the American Diabetes Association (1-19-JDF-075). ANW is supported by the National Institutes of Health-Fogarty International Centre (K43TW010698). ANW declares an honorarium received from Sanofi for serving as a panel member at an educational event on thyroid cancer. JCM receives honorarium from Servier Laboratories for serving on the advisory committee at educational events. OE is a health-care disparities adviser (on a temporary advisory board role) for Medtronic. OE has received research support through his organisation T1D Exchange from Medtronic, Vertex, Dexcom, and Eli Lilly. Medtronic supports components of T1DX-QI health equity work. The T1DX-QI is funded by The Leona M and Harry B Helmsley Charitable Trust. LAD has received research support to her institution from Dompé, Lilly, MannKind, Medtronic, Provention, and Zealand Pharma; and served as a consultant for Abata Therapeutics and Vertex. SA is supported by the National Institutes of Health-National Institute of Diabetes and Digestive Kidney Disease (R01DK132302, K23115896, and P30DK111022-07), JDRF, and The Leona M and Harry B Helmsley Charitable Trust. SA receives research devices, but not salary support from Dexcom and Abbott, and is a health-care disparities adviser (on a temporary advisory board role) for Medtronic and Beta Bionics. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Diabetes is pervasive, exponentially growing in prevalence, and outpacing most diseases globally. In this Series paper, we use new theoretical frameworks and a narrative review of existing literature to show how structural inequity (structural racism and geographical inequity) has accelerated rates of diabetes disease, morbidity, and mortality globally. We discuss how structural inequity leads to large, fixed differences in key, upstream social determinants of health, which influence downstream social determinants of health and resultant diabetes outcomes in a cascade of widening inequity. We review categories of social determinants of health with known effects on diabetes outcomes, including public awareness and policy, economic development, access to high-quality care, innovations in diabetes management, and sociocultural norms. We also provide regional perspectives, grounded in our theoretical framework, to highlight prominent, real-world challenges., Competing Interests: Declaration of interests SA is supported by the National Institutes of Health-National Institute of Diabetes and Digestive Kidney Disease (R01DK132302, K23115896, and P30DK111022-07), JDRF, and The Leona M and Harry B Helmsley Charitable Trust. SA receives research devices, but not salary support from Dexcom and Abbott, and is a health-care disparities adviser (on a temporary advisory board role) for Medtronic and Beta Bionics. ANW is supported by the National Institutes of Health-Fogarty International Centre (K43TW010698). ANW declares an honorarium received from Sanofi for serving as a panel member at an educational event on thyroid cancer. JCM receives honorarium from Servier Laboratories for serving on the advisory committee at educational events. LEE and JAC are supported by the National Institutes of Health-National Institute of Diabetes and Digestive Kidney Disease (R01DK118038 and R01DK120861, awarded to LEE; K01DK131319, awarded to JAC). LEE and RJW are supported by the National Institute on Minority Health and Health Disparities (R01MD013826, awarded to LEE and RJW; R01MD017574, awarded to LEE). RJW is supported by the American Diabetes Association (1-19-JDF-075). LM-B is supported by an Australian National Health and Medical Research Council (NHMRC) investigator grant (1194698), and leads projects that are funded by NHMRC, the Australian Department of Health, and the Australian Medical Research Future Fund. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objectives: In Australia, Aboriginal children experience disproportionate rates of type 2 diabetes (T2D) compared with non-Aboriginal children. The aim of this qualitative study was to explore the experiences of Aboriginal adolescents with T2D and their family members to better understand the influences of T2D on self-management, with findings used to inform an enhanced service model of care., Methods: Semistructured interviews were conducted with purposively selected Western Australian Aboriginal adolescents with T2D and their parents and guardians. Interviews were transcribed verbatim and analyzed with NVivo software using interpretative thematic analysis; overarching themes were generated., Results: Interviews with 24 participants, including 8 adolescents aged 11 to 16 years, were conducted across 4 regions of Western Australia. A high proportion of these adolescents were diagnosed with T2D during an unrelated hospitalization or medical appointment. Most did not fully understand or were unaware of the long-term impact of T2D. Discussions about diabetes within families did not typically occur, and shame and concealment of the diagnosis was a common finding. The parents of the adolescents described the diagnosis of T2D as compounding an already challenging set of circumstances for the family; this impacted their capacity to promote self-management activities and attend hospital and outpatient appointments., Conclusions: This study privileges the voices of Aboriginal adolescents and family members and offers insight into their personal narrative of living with T2D. Building family and community capacity to normalize preventive activities and manage T2D postdiagnosis is recommended to improve health outcomes., (Copyright © 2023 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Background: An epidemic of type 2 diabetes in remote Aboriginal people in Central Australia, contributes to high rates of morbidity and mortality. Remote non-Aboriginal Health Care Workers (HCW) and the Aboriginal people they serve inhabit a complex cultural interface. This study aimed to recognise racial microaggressions in the everyday discourse of HCWs. It proposes a model of interculturality for remote HCWs that avoids racialisation and essentialising of Aboriginal people's identities and cultures., Methods: Semi-structured in-depth interviews were undertaken with HCWs from two Primary Health Care services in very remote Central Australia. Fourteen interviews were analysed from seven Remote Area Nurse, five Remote Medical Practitioners and two Aboriginal Health Practitioners. Discourse analysis was employed to explore racial microaggressions and power relations. NVivo software assisted in the thematic organisation of microaggressions according to a predefined taxonomy., Results: Seven microaggression themes were identified - racial categorization and sameness, assumptions about intelligence and competence, false colour blindness, criminality and dangerousness, reverse racism and hostility, treatment as second-class citizens and pathologizing culture. A model of interculturality for remote HCWs was based on concepts of the third space, deCentred hybrid identities and small culture formation on-the-go combined with a duty-conscious ethic, cultural safety and humility., Conclusions: Racial microaggressions are common in the discourse of remote HCWs. The model of interculturality proposed could improve intercultural communication and relationships between HCWs and Aboriginal people. This improved engagement is required to address the current diabetes epidemic in Central Australia., (© 2023. The Author(s).)

Background: Pancreatitis and diabetes are common among Aboriginal people of Central Australia. The contribution of pancreatitis to the development of post-pancreatitis diabetes mellitus (PPDM) is not known., Aims: To describe among Aboriginal and non-Aboriginal people living in Central Australia, (i) the prevalence and aetiology of acute (AP) and chronic pancreatitis (CP), and (ii) diagnosis of new onset diabetes after pancreatitis., Methods: Retrospective medical record review of patients ≥15 years admitted to hospitals in the Central Australia Health Service between 2009 and 2018 with pancreatitis. Prevalence as a proportion of the resident population and aetiology of AP and CP were determined. Diagnosis of new onset diabetes after admission with pancreatitis was assessed., Results: Of the 638 patients assessed, 73% were Aboriginal and 48% female. The annual prevalence in 2009 and 2018 for AP was 171 and 203 per 100 000 persons, and for CP was 206 and 114 per 100 000 persons respectively. Rates were high in Aboriginal people. Alcohol aetiology was most common in Aboriginal people (66%) and biliary aetiology in non-Aboriginal people (37%). A diagnosis of diabetes after pancreatitis was detected in 125 (29%) of 438 patients who did not have a diabetes diagnosis previously recorded, and 20 of the 22 tested for diabetes-associated antibodies were negative, fitting criteria for PPDM., Conclusion: Prevalence of AP and CP in Central Australia was higher in Aboriginal than non-Aboriginal people. Few patients with diabetes recorded after pancreatitis had appropriate PPDM diagnostic testing. Interdisciplinary education on the diagnosis of PPDM is required., (© 2021 Royal Australasian College of Physicians.)

Competing Interests: DPM is supported as a fellow of the Wingara Mura Leadership Program, University of Sydney and received a grant from The University of Sydney, Charles Perkins Centre Aboriginal and Torres Strait Islander Wingara Mura Leadership Academy Early to Mid-Career Research Seeding Grant; associated manuscript processing charges will be costed to these funds. LM-B received a NHMRC Australia grant to their university for salary and research projects, including Global Alliance for Chronic Diseases (GACD), and was a board member for the Australian Diabetes Society 2014–2021. GSG received consulting fees from the Australian Department of Health and NSW Health for their role on a national advisory panel review about medications for smoking cessation and clinical work in refugee health; had unpaid leadership roles for the Global Alliance for Chronic Disease and Global Implementation Society; and received grants to their institution for research into Indigenous smoking cessation from the Australian Department of Health, NHMRC, GACD and Cancer Australia and Cure Cancer Australia. AGT received grants from NHMRC Australia (grant numbers 1143155, 1171966, and 1182071) and a Medical Research Future Fund (Australian Government; grant number 2015976) while writing the grant; funds were made to their institution. JAA received a NHMRC Australia, GACD grant for the Breathe Easy, Walk Easy, Lungs for Life (BE WELL) project and grant funds used to attend annual GACD scientific meetings. KSL received NHMRC Centre of Research Excellence (application number 1117198) and Ideas grant (application number 1183744). MC received a GACD/Canadian Institute of Health Research (CIHR) grant to their institution. MA received a CIHR grant for a research programme with Indigenous communities (commercial tobacco harm reduction) and is a Pallium Canada board member. FGo-Sm received Global Alliance for Chronic Diseases-Health Research Council funding to their institution in 2017 (reference: 17/705). DM received a postgraduate scholarship from the National Health and Medical Research Council (NHMRC), Australia while preparing this manuscript; was an unpaid member of Australian Diabetes Association's Clinical Advisory Sub-Committee and the Northern Territory Maternal and Neonatal Network. These institutions had no role or influence on the content of the manuscript. All other authors declare no competing interests. We acknowledge all members of the GACD Indigenous Population Working Group for their advice, guidance and support preparing this statement. This statement reflects the perspectives of the contributing authors of the GACD Indigenous Populations Working Group, but it does not necessarily reflect the perspective of GACD and the funding agencies.

Introduction: Cardiovascular disease (CVD) is the leading cause of death in women around the world. Aboriginal and Torres Strait Islander women (Australian Indigenous women) have a high burden of CVD, occurring on average 10-20 years earlier than non-Indigenous women. Traditional risk prediction tools (eg, Framingham) underpredict CVD risk in women and Indigenous people and do not consider female-specific 'risk-enhancers' such as hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM) and premature menopause. A CT coronary artery calcium score ('CT-calcium score') can detect calcified atherosclerotic plaque well before the onset of symptoms, being the single best predictor for future cardiac events. A CT-calcium score may therefore help physicians intensify medical therapy in women with risk-enhancing factors., Methods and Analysis: This multisite, single-blind randomised (1:1) controlled trial of 700 women will assess the effectiveness of a CT-calcium score-guided approach on cardiovascular risk factor control and healthy lifestyle adherence, compared with standard care. Women without CVD aged 40-65 (35-65 for Aboriginal and Torres Strait Islander women) at low-intermediate risk on standard risk calculators and with at least one risk-enhancing factor (eg, HDP, GDM, premature menopause) will be recruited. Aboriginal and Torres Strait Islander women will be actively recruited, aiming for ~10% of the sample size. The 6-month coprimary outcomes will be low-density lipoprotein cholesterol and systolic blood pressure. Barriers and enablers will be assessed, and a health economic analysis performed., Ethics and Dissemination: Western Sydney Local Health District Research Ethics Committee (HREC 2021/ETH11250) provided ethics approval. Written informed consent will be obtained before randomisation. Consent will be sought for access to individual participant Medicare Benefits Schedule, Pharmaceutical Benefits Scheme claims usage through Medicare Australia and linked Admitted Patient Data Collection. Study results will be disseminated via peer-reviewed publications and presentations at national and international conferences., Trial Registration Number: ACTRN12621001738819p., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Our aim in this study was to gain an understanding of the experiences of Aboriginal and Torres Strait Islander young people aged 10 to 25 years with type 2 diabetes (T2D) living in Northern and Central Australia., Methods: In this qualitative study we explored participants' experiences of T2D using a social constructionist epistemology and a phenomenologic methodology. Twenty-seven young people participated in semistructured in-depth interviews from 4 primary health-care sites., Results: Three major constructs emerged. Young people experienced a normalisation-shame paradox in response to their diagnosis (partly related to that "everyone has diabetes," as well as the fear that friends "might judge [me]"), had suboptimal levels of understanding of T2D ("I don't really know what diabetes is. I just need somebody to explain to me a bit more") and experienced multiple barriers inhibiting their T2D management. These included complex lives ("I have a rheumatic heart disease […] then they told me that I have diabetes…I have two things") and the availability of support ("[I] talk to my mum…I talk to my aunty too…I don't talk to anyone else"). Successful management requires support from health professionals and family and includes strengthening social networks and educational opportunities., Conclusions: Our findings reinforce the need for alternative support systems tailored to the specific needs of young Aboriginal and Torres Strait Islander people with T2D. Enhanced models of care must be codesigned with young people and their communities and include a focus on shifting norms and expectations about youth T2D to reduce diabetes stigma and broaden social support and consider the delivery of health information in youth-friendly environments., (Copyright © 2022 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Objectives: Aboriginal and Torres Strait Islander Australians have a substantially greater fracture risk, where men are 50% and women are 26% more likely to experience a hip fracture compared with non-Indigenous Australians. Fall-related injuries in this population have also increased by 10%/year compared with 4.3%/year in non-Indigenous Australians. This study aims to determine why falls and fracture risk are higher in Aboriginal and Torres Strait Islander Australians., Setting: All clinical assessments will be performed at one centre in Melbourne, Australia. At baseline, participants will have clinical assessments, including questionnaires, anthropometry, bone structure, body composition and physical performance tests. These assessments will be repeated at follow-up 1 and follow-up 2, with an interval of 12 months between each clinical visit., Participants: This codesigned prospective observational study aims to recruit a total of 298 adults who identify as Aboriginal and Torres Strait Islander and reside within Victoria, Australia. Stratified sampling by age and sex will be used to ensure equitable distribution of men and women across four age-bands (35-44, 45-54, 55-64 and 65+ years)., Primary and Secondary Outcome Measures: The primary outcome is within-individual yearly change in areal bone mineral density at the total hip, femoral neck and lumbar spine assessed by dual energy X-ray absorptiometry. Within-individual change in cortical and trabecular volumetric bone mineral density at the radius and tibia using high-resolution peripheral quantitative computed tomography will be determined. Secondary outcomes include yearly differences in physical performance and body composition., Ethical Approval: Ethics approval for this study has been granted by the Monash Health Human Research Ethics Committee (project number: RES-19-0000374A)., Trial Registration Number: ACTRN12620000161921., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The effectiveness of erythropoiesis-stimulating agents, which are the main stay of managing anaemia of chronic kidney disease (CKD), is largely dependent on adequate body iron stores. The iron stores are determined by the levels of serum ferritin concentration and transferrin saturation. These two surrogate markers of iron stores are used to guide iron replacement therapy. Most Aboriginal and/or Torres Islander Australians of the Northern Territory (herein respectfully referred to as First Nations Australians) with end-stage kidney disease have ferritin levels higher than current guideline recommendations for iron therapy. There is no clear evidence to guide safe and effective treatment with iron in these patients. We aim to assess the impact of intravenous iron treatment on all-cause death and hospitalisation with a principal diagnosis of all-cause infection in First Nations patients on haemodialysis with anaemia, high ferritin levels and low transferrin saturation METHODS: In a prospective open-label blinded endpoint randomised controlled trial, a total of 576 participants on maintenance haemodialysis with high ferritin (> 700 μg/L and ≤ 2000 μg/L) and low transferrin saturation (< 40%) from all the 7 renal units across the Northern Territory of Australia will be randomised 1:1 to receive intravenous iron polymaltose 400 mg once monthly (200 mg during 2 consecutive haemodialysis sessions) (Arm A) or no IV iron treatment (standard treatment) (Arm B). Rescue therapy will be administered when the ferritin levels fall below 700 μg/L or when clinically indicated. The primary outcome will be the differences between the two study arms in the risk of hospitalisation with all-cause infection or death. An economic analysis and several secondary and tertiary outcomes analyses will also be performed., Discussion: The INFERR clinical trial will address significant uncertainty on the safety and efficacy of iron therapy in First Nations Australians with CKD with hyperferritinaemia and evidence of iron deficiency. This will hopefully lead to the development of evidence-based guidelines. It will also provide the opportunity to explore the causes of hyperferritinaemia in First Nations Australians from the Northern Territory., Trial Registration: This trial is registered with The Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12620000705987 . Registered 29 June 2020., (© 2021. The Author(s).)

Objectives: To determine demographic and clinical characteristics of youth diagnosed with type 1 (T1D) or type 2 (T2D) diabetes aged ≤15 years from 1999 to 2019 in Western Australia, and examine time to first diagnosis of diabetes complications., Methods: A retrospective cohort study was conducted of patients identified from the population-based, prospective Western Australian Children's Diabetes Database and longitudinal data extracted for available demographic and clinical variables. Patients were followed from diagnosis to transition to adult services, death, or December 31, 2019. Cox proportional hazards regression models were used to analyse time to first diagnosis of hypertension, high cholesterol or microalbuminuria, after adjusting for sex, age at diagnosis, time period of diagnosis, hemoglobin A1 c , and body max index Z-score., Results: 2438 eligible patients were identified (2209 [91%] T1D: 229 [9%] T2D). The mean age at diagnosis was lower in patients with T1D (8.5 [±4.0] vs. 12.7 [±2.0] years). A higher proportion of patients with T2D were female (58% vs. 47%) and of Aboriginal ethnicity (59% vs. 2%). The median HbA1c (interquartile range) at diagnosis was lower 8.9% [6.7, 11.5] (74 mmol/mol [50, 102]) versus 11.6% [10.1, 13.3] (103 mmol/mol [87, 122]) and mean body max index Z-score higher (2.05 [±0.66] vs. 0.37 [±0.95]), in patients with T2D compared to T1D. Patients with T2D had a higher risk of hypertension, high cholesterol, and microalbuminuria (aHR 3.39 [95%CI:2.04, 5.63], 2.69 [95%CI:1.21, 5.98], and 19.79 [95%CI:10.99, 35.64] respectively)., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: To assess associations of hyperglycemia in pregnancy with the risk of postpartum hemorrhage (PPH) in a prospective cohort of Indigenous and non-Indigenous women, compared with normoglycemia., Methods: Data were from 1102 (48% Indigenous) women of the Pregnancy And Neonatal Diabetes Outcomes in Remote Australia (PANDORA) Study. Age-adjusted associations of gestational diabetes mellitus (GDM) or pre-existing type 2 diabetes mellitus (T2DM), obstetric and demographic covariables with PPH (blood loss ≥500 ml) were assessed using logistic regression. Multivariable-adjusted models included Indigenous ethnicity, diabetes type and their interaction., Results: A higher proportion of Indigenous women developed PPH than non-Indigenous women (32% versus 22%; P < 0.001). Compared with non-Indigenous women with normoglycemia, risks of PPH for Indigenous women with GDM or T2DM were higher (odds ratio [OR] 1.83, 95% confidence intervals [CI] 1.11-3.02, and OR 1.72, 95% CI 0.99-3.00 after age adjustment, OR 1.84, 95% CI 1.06-3.19, and OR 1.33, 95% CI 0.70-2.54 after adjustment for school education and delivery mode, and OR 1.62, 95% CI 0.95-2.77, and OR 0.99, 95% CI 0.53-1.86 after adjustment for birth weight). Importantly, Indigenous women without hyperglycemia in pregnancy were not at increased risk of PPH., Conclusion: The significantly higher rates of PPH experienced by Indigenous women compared with non-Indigenous women may be explained by a greater effect of GDM among Indigenous women that was only partly accounted for by birth weight., (© 2021 International Federation of Gynecology and Obstetrics.)

Objective: To identify successes to date and opportunities for improvement in the implementation of a complex health systems intervention aiming to improve prenatal and postpartum care and health outcomes for women with hyperglycemia in pregnancy in regional and remote Australia., Methods: A qualitative evaluation, underpinned by the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), was conducted mid-intervention. Semi-structured interviews were conducted with the participants, who included clinicians, regional policymakers and managers, and study implementation staff., Results: Interviewees (n = 45) reported that the early phase of the intervention had resulted in the establishment of a clinician network, increased clinician awareness of hyperglycemia in pregnancy, and improvements in management, including earlier referral for specialist care and a focus on improving communication with women. Enablers of implementation included existing relationships with stakeholders and alignment of the intervention with health service priorities. Challenges included engaging remote clinicians and the labor-intensive nature of maintaining a clinical register of women with hyperglycemia in pregnancy., Conclusion: The early phase of this health systems intervention has had a positive perceived impact on systems of care for women with hyperglycemia in pregnancy. Findings have informed modifications to the intervention, including the development of a communication and engagement strategy., (© 2021 International Federation of Gynecology and Obstetrics.)