Chair's foreword

Australia is a wealthy country and as such, we have seen gradual increases in life expectancy since European settlement.

Healthcare needs have changed and now, in the 21st century, we are faced with a number of challenges in dealing with chronic illness; the foremost of which is diabetes mellitus. We are now facing a situation where life expectancy may decline because of the diseases of affluence.

There are a number of classifications of diabetes mellitus but for the purposes of this review, we have used a broad classification of:

• Type 1 diabetes mellitus
• Type 2 diabetes mellitus (and associated obesity)
• Gestational diabetes
• Pre-diabetes and insulin resistance
• Rare forms of diabetes associated with pancreatic damage or removal such as cystic fibrosis, post-surgical or rare genetic disorders.

Type 1 diabetes mellitus

In the 103 years since Banting and Best discovered insulin and treated 14-year-old Leonard Thompson with bovine insulin, there has been many advances in Type 1 diabetes management, including the use of home blood glucose monitoring instead of urine testing, the development of bio engineered human insulin and new forms of insulin, the use of insulin pumps and the development of Continuous Glucose Monitoring (CGM technology) and feedback systems that attempt to mimic pancreatic islet cell function.

There is now increasing evidence that a hybrid closed loop system using an insulin pump, CGM technology and a feedback system leads to better blood glucose control, reduced hypoglycaemic episodes, reduced complications, and much better outcomes for those with Type 1 diabetes, yet these systems are only available for a limited number of patients and more must be done to increase the availability of this technology.

There is evidence that some people, particularly in outer metropolitan, rural and regional areas are having difficulty accessing support from diabetes educators, podiatrists, dietitians, general practitioners (GPs), endocrinologists, and community outreach services. These services should be strengthened to allow more equitable access to support and an integrated model of care instituted with State and Federal Government support be made available to all those with diabetes mellitus.

Subsidies for new technology, such as insulin pumps and closed loop systems, should be made available to as many people with Type 1 diabetes as soon as possible as this will lead to reduced hospitalisations, reduced complications, and larger health cost savings. There are also exciting advances in screening for risk of Type 1 diabetes, and genetic predisposition for Type 1 diabetes and prevention of Type 1 diabetes.

It is important that availability of new screening procedures, treatment and prevention possibilities be made available and horizon scanning for new advances be part of a long-term research and development pipeline.

There are also other forms of diabetes such as those associated with pancreatic removal or destruction (e.g. cystic fibrosis, post pancreatitis etc.) and this cohort although small in number, should be offered access to new treatments and technology, given that they have the same issues in management as Type 1 diabetes.

Type 2 diabetes mellitus

Increasingly, there is a huge burden being placed on health resources by people with Type 2 diabetes and this is across virtually the entire health spectrum of disease from obstetrics, paediatrics, neurology, cardiology, vascular surgery, ophthalmology, and geriatrics.

Access to technology, such as CGM devices, is also important in Type 2 diabetes, and broader access to those requiring insulin is vital if we are to delay the onset of complications.Screening for Type 2 diabetes at contact points with the health system, e.g. GPs and emergency departments, is also important for reduction of complications and early diagnosis. CGM technology should be made available to those with Type 2 diabetes requiring insulin and to others who have had glucose control difficulties.

We have been presented with evidence that children as young as nine have been diagnosed with Type 2 diabetes and multigenerational diagnoses of Type 2 diabetes is occurring. This is often related to the epigenetic effects of gestational diabetes.

Children are being exposed to the risks of obesity and Type 2 diabetes for many reasons, including a lack of access to a healthy diet, lack of exercise and poor availability of education about the risks of diabetes.

When diagnoses are made with Type 2 diabetes, there are huge barriers to appropriate management and support, particularly in outer metropolitan, rural and regional areas. Access to diabetes educators and dieticians is vital in these areas if equality of care is to be addressed.

Indigenous communities lack adequate resources, including diabetes educators, podiatrists, endocrinologists, and GPs. In remote areas there is a significant shortage of Indigenous health workers, and this impacts severely on diabetes management.

Early onset Type 2 diabetes seems to have a more rapid trajectory with early development of complications, such as visual impairment, renal failure, and cardiovascular disease and this is severely impacting the health needs of these communities.

It is very important that all levels of government work together to address associated issues such as access to potable water, healthy foods, education, and health supports. Once again, it is important that an integrated model of care across all levels of government is seen as the gold standard.

Type 2 diabetes clearly affects these high-risk communities disproportionately, but it is having a severely impact across the health spectrum in all communities and is responsible for enormous pressure on our primary care system and our hospital system.

There are many new treatments available such as the GLP-1 receptor agonists (e.g. semaglutide) and they are indeed game changes for some people and access to these lifesaving treatments should be a priority with continuity of supply for those in greatest need.

However, they are very expensive, require continuing treatment, have been in short supply and may have significant side effects.

Because of the short-term benefits for weight loss, there has been pressure for off label prescribing of these new medications and this has led to considerable prescribing and reformulation. It is my view that this should not be permitted because of the risks, and I support the governments recently implemented restrictions.

The primary aim must be prevention and it is very important that every strategy possible is used as part of a comprehensive preventative response. This will require an all of Government approach involving local, State and Federal Governments. Some of the policy recommendations will include improving access to healthy foods, using a reformulation levy to decrease consumption of sugar sweetened beverages, limiting advertising of high sugar and highly processed foods, particularly to children, better urban planning to encourage increased physical activity and improved educational resources for our children about the dangers of diabetes.

It is of concern that the marketing of highly processed food products for very young infants, e.g. pureed foods in sachets and toddler formulas, is rampant. Food labelling is opaque, unintelligible to most people without consideration of the long-term consequences.

Urgent reform is required in advertising, marketing and community awareness. Dietary guidelines need to change.

Self-regulation by the food industry and the ‘fast food’ industry has not and will not work, and our children are suffering the consequences.

Data shows that the highest rates of Type 2 diabetes are found in South Western Sydney, which includes my electorate of Macarthur, followed by Western Queensland, Country South Australia, Western NSW and other rural and remote areas. Some areas of the highest incidence include remote Indigenous communities.

The electorates of Chifley, Fowler and McMahon – all located in Western Sydney – have the highest rates of diabetes (of all types), with regional and rural electorates, such as Spence, Grey and Hunter, close behind too.

This demonstrates that communities that have a high incidence of disadvantage have the highest rates of Type 2 diabetes and gestational diabetes.

There was significant evidence revealed about the importance of low carbohydrate diets in all forms of diabetes and this needs to be further promoted and evaluated.

As can be seen, there are enormous improvements in diabetes management and support across the spectrum of disease.

These advances have occurred because of medical research and evidence-based policy.

It is important that we have a well-coordinated, funded and integrated diabetes research program that involves longer term funding to support a cohort of researchers to consolidate appropriate research facilities.

Many of our recommendations will require ongoing assessment and I recommend that this be overseen by the Australian Centre for Evaluation in the Department of Treasury. State and Federal Health Departments require more integration in management and in research capabilities.

Australia has enormous potential for diabetes research and clinical trials and peak bodies should help coordinate where the main priorities lie and be provided with the funding to increase evidence-based research programs.

Gestational diabetes

It is of concern that the incidence of gestational diabetes is increasing, and we know through the science of epigenetics that this very significantly increases the risks not only to the child in utero but also to the risk of multigenerational Type 2 diabetes.

Diagnosis and management of gestational diabetes should be a priority and access to technology, such as CGM technology and insulin pumps, should be increased. Early diagnosis is vital to prevent long term consequences.

Obesity

Obesity in Australia goes hand in hand with our diabetes epidemic and unfortunately, like diabetes, it is the most disadvantaged communities that are suffering the most, although it is an increasing problem around the country.

Look at any community photograph taken in the 50s or 60s and compare it to one taken now and the change in body habitus is obvious. Current health practices have not reversed the trend and will require a review of what we can do.

Clearly, this will involve a multipronged approach from all levels of government including:

• Education
• Better access to a healthy diet
• Prevention of promotion of unhealthy foods, particularly to young children
• A reformulation levy on sugar sweetened beverages
• More understandable labelling on everyday foods
• Better access to exercise and to sport, especially for children and adults of all ages
• A healthy food Commissioner in the Department of Health

The new GLP-1 receptor agonists and other medication certainly have a role and the pressure for increased access is intense, but the caveats previously discussed still apply, i.e. they are expensive, there may be yet unknown long term side effects and particularly in a time of short supply off label prescribing and compounding should be discouraged.

However, for people with very high BMI (e.g. > 35) they can be lifesaving and reduce the incidence of severe illness. Other treatment options such as bariatric surgery are also a treatment option and more equitable access is important.

Conclusion

The health costs of obesity and diabetes are very high and of significant concern in virtually every community across the country and in every age group. We know that some groups are at high risk, for example Indigenous communities, Pacific Islander communities and increasingly those from the Indian subcontinent, but in truth, we are all at risk.

Access to services is inequitable and requires cooperation by all agencies – State and Federal. This is particularly true for Indigenous and culturally and linguistically diverse communities. If we are to reduce the burden of diabetes on the health system, we will require a multipronged approach that focuses on prevention and public health policies across not just health services, but also education, agriculture, construction, social services, communications, transport, and manufacturing.

There are several recommendations that cross the boundaries of several modalities, and it is important that flexibility of management and integrated care is available across all areas of the country.

We hope that the recommendations are taken as a whole, and that early implementation is commenced as we are truly facing huge health consequences if no action is taken.

I would like to thank all the member of the Health Secretariat, including Kate Portus, Clare Anderson, Andrew Bray, Iva Glisic and Kate Morris, as well as the APH Broadcasting team, for all their hard work, particularly on our travels.

I am incredibly impressed by their knowledge, support and diligence and it has been a wonderful experience to work with them.

I would like to thank all Committee Members who have all contributed to the Committee. Our original Deputy Chair, Melissa McIntosh, has been a pleasure to work with and provided personal insights into diabetes. I thank the new Deputy Chair, Julian Leeser, for his support and I look forward to working with him.

Further, I thank Monique Ryan, Jenny Ware, Gordon Reid, Mark Coulton, Michelle Ananda-Rajah, Anne Stanley, Graham Perrett, Sophie Scamps, Kate Thwaites and Jodie Belyea for their contribution and presence as Members throughout the Inquiry.

Lastly, I wish to thank our dear friend and colleague, Peta Murphy, who was a Member of this Committee and who we sadly lost during this Inquiry after a hard fought and valiant battle with cancer. Peta had a strong focus on the social determinants of health and had significant input into our Inquiry, and our report, I hope, reflects her ideals.