Indigenous Australians and clinicians join forces to target diabetes remission

16 Feb 2023 --- Indigenous Australian leaders are joining forces with clinicians trained in Eurocentric-based medicine to tackle diabetes remission and metabolic syndrome in their community in a new project led by Flinders University. Diabetes disproportionately affects Australian Indigenous communities in terms of detection and management. 

The Coorong Diabetes Collaborative is described in an article in Nature Medicine journal. It aims to reduce the disease burden on the Ngarrindjeri community by helping to co-design a program that focuses on remission. 

“It is the first co-designed targeted and scalable diabetes remission program for Indigenous peoples in Ngarrindjeri country,” says Courtney Ryder, associate professor at Flinders University’s College of Medicine and Public Health. 

“The project aims to explore how Australian Indigenous people are advantaged by adopting a ketogenic diet.” Using ketogenic eating plans is one of three strategies for diabetes remission recommended by Diabetes Australia. 

Diabetes in indigenous communitiesDiabetes affects Australian Indigenous communities at a higher rate than non-indigenous people. 
Rates of diabetes in Australian Indigenous communities are rising, which suggests that current approaches for detection, care and management are failing, notes Ryder. 

“This leaves many Indigenous communities feeling that a diagnosis of diabetes or metabolic syndrome is an unavoidable death sentence, creating a ripple effect beyond the individual, affecting the whole family and community.”

Currently, diabetes contributes to 11% of all deaths in Australia. Annually, this costs the healthcare system AU$2.7 million (US$1.87 million). 

Indigenous people are five times more likely to die due to complications of diabetes than non-indigenous Australians, according to the research. Prevalence rates are also three times higher and hospitalization rates are four times higher. Moreover, the detection of diabetes in indigenous communities is limited. 

Metabolic syndrome is responsible for earlier and more severe complications of people diagnosed with diabetes, according to the authors. This syndrome includes hypertension, dyslipidemia, abdominal obesity and insulin resistance. 

Community co-design 
The Coorong Diabetes Collaborative project was created after intensive engagement between clinicians trained in Eurocentric-based medicine and the Ngarrindjeri community during the COVID-19 outbreaks. 

Clinicians and Ngarrindjeri leaders recognized that diabetes and metabolic syndrome levels in the community were a critical, ongoing vulnerability. Ngarrindjeri leaders called for a community-designed program to center on health’s cultural determinants: ownership, control and reciprocity. 

The created project connects Ngarrindjeri knowledge holders, Australian indigenous researchers and clinicians and health professionals with Eurocentric knowledge and research methods. 

The group will co-design a targeted and scalable remission and ketogenic eating program. This program will include cultural and contextual factors identified by the community and educational and motivational strategies to stick to the ketogenic diet. 

The program will monitor physiological, social and economic outcomes. 

Leveraging indigenous knowledge 
“A critical aspect to targeting diabetes and metabolic syndrome remission within Australian Indigenous communities is through centralizing indigenous knowledge and methodologies which have passed through generations and continue to evolve,” explains Ryder. 

The project uses a knowledge interface methodology, an indigenous research methodology, to integrate the different knowledge systems. This ensures that these come together through mutual respect, shared benefits, human dignity and discovering new knowledge formation.In the project, clinicians and Ngarrindjeri leaders co-design a model to target diabetes. 

Indigenous knowledge is central to research questions, conceptualization, co-design, data collection, analyses and translation of outcomes. As a result, power differentials are redressed, which helps to build an understanding of Australian indigenous communities. The project also recognizes and actively addresses the impacts of ongoing colonization. 

Ketogenic diet 
The authors identified ketogenic eating plans as the most suitable strategy for diabetes remission. These plans work by restricting the intake of carbohydrates to a level low enough that the body uses fat as the principal energy source instead of carbohydrates. 

“A low-carbohydrate ketogenic eating plan appears similar to pre-colonization eating patterns for Australian Indigenous people,” says Ryder. Therefore, it aligns the uptake and maintenance of a ketogenic diet with Indigenous knowledge.

Ketogenic eating plans are one of three evidence-based remission strategies recommended by Diabetes Australia. The other two are less suitable for indigenous communities. Bariatric surgery is not easily accessible for indigenous people and participant adherence to long-term, very low-calorie diets is poor, according to the authors. 

By Jolanda van Hal