1. Introduction
   1. In Australia, approximately 1.5 million people – some five per cent of the population – are known to live with diabetes. Moreover, there is overwhelming evidence that the number of Australians diagnosed with the condition will continue to rise. The nation faces what has throughout the inquiry been referred to as a diabetes epidemic.
   2. In this inquiry, the term ‘diabetes’ is used to denote diabetes mellitus.[1] Diabetes mellitus is a condition of chronically elevated blood glucose (sugar) levels, caused by a deficiency of the hormone insulin, which is produced in the pancreas, or resistance to the physiological actions of insulin. While there are a number of different types of diabetes, this report primarily focuses on the most prevalent forms, including Type 1 diabetes, Type 2 diabetes, and gestational diabetes. Some rare forms of diabetes – such as, for example, those collectively termed Type 3c (or pancreatogenic) diabetes – are also covered in this report.
   3. Type 1 diabetes occurs when cells of the pancreas are destroyed by the body’s own immune system, leaving the body unable to produce insulin at all. By contrast, Type 2 diabetes occurs when the pancreas is either not producing enough insulin, or when the insulin that is produced is not effective. Gestational diabetes is similar to Type 2 diabetes, but occurs during pregnancy, and is recognised as a risk factor for the subsequent development of Type 2 diabetes in both the mother and the child.
   4. Type 2 diabetes is the most common form of the condition. Some 1.3 million Australians live with Type 2 diabetes, representing about 87 per cent of all diabetes cases. Type 2 diabetes is often associated with certain risk factors, with obesity being acknowledged as a major risk factor. Accordingly, efforts to combat diabetes by reducing the cases of obesity are a prominent feature of this report.
   5. Often described as a ‘disease of affluence,’ Type 2 diabetes is particularly prevalent in wealthy societies that have greater access to a ‘rich’ diet that is high in protein and fat. Within these societies, however, it is members of communities with lower socio-economic status that are at higher risk of developing Type 2 diabetes due to restricted access to affordable fresh food, a lack of time and space for regular physical activity, and an inability to access quality health care.
   6. Indeed, diabetes does not impact all Australian communities equally, and the current rates are especially alarming among Indigenous and Torres Strait Islander communities. These communities experience not only higher levels of diabetes, but the disease often develops at a younger age, and is more severe. It is also important to note that electorates with the highest rates of Type 2 diabetes have huge levels of disadvantage. Devising and implementing diabetes prevention strategies across a range of areas will therefore be vital for managing the impact of the disease now and into the future.
   7. Equally, certain forms (such as Type 1 diabetes) are determined by genetics, and the modification of external factors cannot prevent or delay the onset of disease. As such, while prevention is vital for tackling the diabetes epidemic, the cultivation of a sophisticated research ecosystem and deep expertise in diabetes pharmacotherapy and technology remains just as important. This specialist knowledge is essential for ensuring that Australians have access to the best diagnosis and treatment options, and – ideally in the near future – a cure for Type 1 diabetes.
   8. In undertaking this inquiry into diabetes in Australia, the Committee was conscious of recent government initiatives in this area, including the National Diabetes Strategy 2021–2030 and the National Obesity Strategy 2022–2032. This inquiry does not seek to review or assess these initiatives, but instead aims to expand our understanding of diabetes, while raising the visibility of the disease, considering its impact, and identifying steps for tackling diabetes as a matter of medical, social, and economic urgency.

About the inquiry

Objectives and scope

1.9On 24 May 2023, the House of Representatives Standing Committee on Health, Aged Care and Sport adopted an inquiry into diabetes referred by the Minister for Health and Aged Care, the Hon Mark Butler MP.

1.10The inquiry primarily focused on the causes of diabetes, as well as advances in prevention, diagnosis and management of the condition. The Committee also considered the broader impacts of diabetes on Australia’s health system and economy, and the effectiveness of the Australian Government’s current diabetes related policies and programs. Where relevant, the Committee explored the interrelated health issues between diabetes and obesity.

Conduct of the inquiry

1.11On 30 May 2023, the Committee issued a media release announcing the inquiry and calling for submissions. The Committee invited submissions from a range of individuals and organisations with an interest in public health, all forms of diabetes and chronic diseases. This included federal and state government departments and agencies, industry groups and peak bodies, think tanks, academics, health practitioners, medical research organisations, pharmaceutical and health tech companies, and the general public.

1.12The Committee received 473 submissions in support of this inquiry, and an additional 22 supplementary submissions. The Committee also received three video submissions and a video exhibit. The full list of submissions is at Appendix A.

1.13The inquiry received a further 54 additional documents, including answers to questions taken on notice at public hearings, letters clarifying evidence, and other additional information. The full list of additional documents presented to the inquiry is at Appendix B.

1.14The Committee held 15 days of public hearings:

• 20 June 2023 – Canberra, ACT
• 15 September 2023 – Canberra ACT
• 18 September 2023 – Campbelltown NSW
• 17 November 2023 – Canberra ACT
• 20 November 2023 – Brisbane Qld
• 21 November 2023 – Yarrabah Qld
• 22 November 2023 – Cairns Qld
• 23 November 2023 – Melbourne Vic
• 16 February 2024 – Canberra ACT
• 1 March 2024 – Canberra ACT
• 6 March 2024 – Alice Springs NT
• 7 March 2024 – Darwin NT
• 8 March 2024 – Darwin NT
• 20 March 2024 – Canberra ACT
• 22 March 2024 – Canberra ACT
  15. A list of witnesses who attended these public hearings is at Appendix C. Transcripts of all public hearings are available on the Committee’s website.
  16. The Committee consulted widely throughout the inquiry and received submissions from individuals and organisations from every state and territory across Australia, including from many people living in regional, rural and remote areas. In recognition of the high level of community interest in this inquiry, the Committee continued to consider contributions received after the submission deadline of 31 August 2023 on a case-by-case basis.
  17. The Committee travelled across Australia to hear from 206 witnesses at public hearings. In seeking to hear first-hand from communities impacted by diabetes, the Committee also engaged an Indigenous Language Interpreter for witnesses giving evidence at a public hearing in Darwin. Witnesses from across the nation – from Adelaide to Norfolk Island – and overseas took the opportunity to contribute to the inquiry.
  18. On 21 November 2023, the Committee also attended a site visit to the Gurriny Yealamucka Health Service in Yarrabah in Far North Queensland.
  19. The Parliamentary Budget Office (PBO) prepared four costings to assist with the inquiry. The costings include:
• 20 per cent tax on sugar sweetened beverages
• Limit marketing of unhealthy foods on radio television, print and social media, especially for children
• Subsidise insulin pumps for all Australian living with Type 1 diabetes
• Subsidising glucagon-like peptide 1 receptor agonist drugs (GLP-1 RAs) on the Pharmaceutical Benefits Scheme for obesity and individuals with Type 2 diabetes requiring intensive insulin therapy.
  20. The key information contained within the PBO documents is available in appendices D, E, F and G respectively. The full costings have been published on the PBO website.

Acknowledgements

1.21The Committee would like to thank everyone who provided written submissions and gave evidence at public hearings.

1.22In particular, the Committee would like to thank all those individuals who, despite being personally impacted by diabetes, have gone to considerable effort to contribute to this inquiry.

1.23The Committee would also like to express its thanks to the Gurriny Yealamucka Health Services Aboriginal Corporation for facilitating a site visit. This site visit provided the Committee with valuable first-hand insights into the health and societal challenges affecting the Yarrabah community.

Report structure

1.24This report is structured into eight chapters, including this introduction.

1.25Chapter 2 sets out the definition of diabetes, and outlines the most prevalent types of the disease. Focus is placed on Type 1, Type 2, and gestational diabetes, as well as rare forms of the condition classified as Type 3c diabetes. In discussing the current state of knowledge regarding the causes and major risk factors for different diabetes types, the chapter reflects on obesity and its relation to diabetes. The chapter also offers insight into the current and projected levels of diabetes and obesity, and outlines the impact of the disease on Australia’s health sector and economy.

1.26Chapter 3 examines efforts to prevent diabetes and obesity, placing an emphasis on population-wide strategies. In acknowledging that diet has a significant impact on prevention and management of all types of diabetes, the discussion considers methods for supporting healthy eating habits, as well as strategies for managing the consumption and marketing of unhealthy foods and beverages. Initiatives designed to raise the level of physical activity in society are also considered.

1.27Chapter 4 focuses on current early detection and diagnosis practices for diabetes, while also examining available diabetes management strategies. In demonstrating that diabetes is a complex disease with various serious health complications, the chapter considers some of the current challenges that patients and health care specialists face in attempting to manage and treat diabetes and its complications. The extent to which Australia’s health care system and heath care workforce is prepared for dealing with the burden of this disease is also examined.

1.28The pace of innovation in the field of diabetes-related technology has been described as nothing short of remarkable throughout the course of this inquiry. Accordingly, Chapter 5 examines the latest innovations in the field of glucose monitoring and insulin administration, and the current clinical contexts in which these technologies are most frequently used. Questions around access to diabetes technology and the process of its assessment and reimbursement in Australia are also considered.

1.29Chapter 6 examines the current state of diabetes pharmacotherapy – the use of medication to treat the condition. In noting the ongoing importance of insulin and other common medications used in the treatment of different types of diabetes, emphasis is placed on the new generation of medications called Glucagon-like Peptide-1 (GLP-1) receptor agonists. GLP-1 receptor agonists have been described as a game-changer in the treatment of diabetes and obesity; as such, the chapter examines their function, current use, and availability in Australia. Other forms of treatment for diabetes and obesity, such as bariatric surgery, are also covered.

1.30Research is fundamental in the development of innovative diabetes treatments. Chapter 7 therefore examines current funding sources for and investment in research into diabetes and obesity. This chapter also offers an outline of the diabetes research ecosystem in Australia, and discusses the availability and quality of data on diabetes, as well as future research initiatives in this area.

1.31In recognising that the impact of diabetes and obesity is not expressed evenly across Australian communities, Chapter 8 places focus on at-risk cohorts. The impact of diabetes in Aboriginal and Terres Strait Islander communities is examined, with specific consideration of health care access, common complications, and the availability of fresh food. This discussion also reflects on challenges faced by members of culturally and linguistically diverse communities, people living with disability, as well as those living in rural and remote communities. As Australia is an aging society, issues faced by older Australians with diabetes are also noted. In terms of impact on the health system and costs to the economy, it is absolutely clear that prevention of diabetes should be the primary aim of management wherever possible.

Footnotes

[1]Diabetes insipidus – a rare condition that is caused by a deficiency of or a resistance to the hormone arginine vasopressin (or antidiuretic hormone) – is, however, beyond the scope of this inquiry.