A number of previous studies have shown that indigenous Australians seem to have higher rates of diabetic foot complications than non-indigenous Australians. Arguably the most famous was a Medical Journal of Australia paper authored by Professor Paul Norman and colleagues that reported indigenous people in certain age groups had up to a 38-fold increased rates of diabetes-related amputations. However, no study had reviewed all the literature in this critical area to confirm if an overall difference does exist between indigenous and non-indigenous Australians.
That was until a new systematic review was published in the Journal of Foot and Ankle Research by researchers from the University of Newcastle; led by Wiradjuri man Mr Matthew West, Professor Viv Chuter, Dr Fiona Hawke and colleagues.
This very nice and very timely review systematically searched all available diabetic foot literature that compared rates in indigenous and non-indigenous Australians. The authors identified 11 eligible articles after screening >1,200 papers. And what they found after reviewing these studies should be of significant interest to all of us in the Australian diabetic foot community.
First, they found that indigenous Australians had a 3-6 fold increased likelihood of having diabetic foot complications; 4 fold for peripheral neuropathy, 3-5 fold for foot ulcers and 6 fold for amputations. Second, in most populations studied there was only a small proportion of indigenous people, but this small proportion made up a large proportion of those with diabetic foot complications. Third, indigenous Australians developed diabetic foot complications on average ~14 years younger than non-indigenous Australians. Last, they could only find studies from populations in the Northern Territory, Western Australia and Queensland; none were found that reported on national populations.
While this study had many strengths – systematically screened all peer-reviewed studies, assessed the quality of all eligible studies, used two independent reviewers etc – it did have some limitations. These included the authors did not include government reports which may have shone more light on this critical area, and only included papers reporting indigenous rates with a non-indigenous comparator. Papers reporting overall numbers of diabetes-related foot complications in indigenous Australians without a non-Indigenous comparator were not included in the review.
The authors did however compare their findings with those found in other nations and in some Australian government reports in their discussion and concluded that indigenous populations across the world had much higher rates of diabetic foot complications than non-indigenous populations.
Sadly they also found very few studies investigating specific interventions to improve diabetic foot outcomes in indigenous populations anywhere in the world. This suggests there is an urgent need for much more research to monitor, intervene and reduce the high burden of diabetic foot complications experienced by our global indigenous populations. We are very excited to hear that Matthew and his team are doing just that so watch this space.
In conclusion, the authors state, “our review findings highlight an urgent need for culturally appropriate foot care intervention programs to be comprehensively evaluated, and for effective programs to be widely implemented to reduce rates of diabetes-related foot complications and associated morbidity and mortality in Aboriginal and Torres Strait Islander Australians”. And we could not agree more!
This means that the urgent recommendations to improve access to care and research for all Australians, made in the Australian diabetes-related foot disease strategy 2018-22, is even more urgent for our indigenous Australians if we are to truly close the gap on ending avoidable amputations in a generation.