Diabetes in the Cook Islands: a clinical audit
Machaela Tepai 1 , Vili Nosa![https://orcid.org/0000-0002-7144-2805](/media/client/orcid_16x16.png)
![https://orcid.org/0000-0002-0856-7381](/media/client/orcid_16x16.png)
![https://orcid.org/0000-0002-0011-5049](/media/client/orcid_16x16.png)
![https://orcid.org/0000-0002-9722-139X](/media/client/orcid_16x16.png)
1 Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand. Email: mttepai@gmail.com, aumeah@gmail.com, akia647@aucklanduni.ac.nz, j.sluyter@auckland.ac.nz
2 Ministry of Health, PO Box 109, Avarua, Rarotonga, Cook Islands. Email: yin.may@cookislands.gov.ck
Journal of Primary Health Care 15(2) 176-183 https://doi.org/10.1071/HC21138
Published: 1 June 2023
© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of The Royal New Zealand College of General Practitioners. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Introduction: The global burden of diabetes mellitus (diabetes) is significant and of increasing concern with more pregnant women being diagnosed with gestational diabetes mellitus (GDM). The Cook Islands face mounting pressures to address diabetes alongside competing population health needs and priorities. Cook Islands residents frequently travel to New Zealand to access health services. Inadequate information systems also make it difficult for countries to prioritise preventative measures for investment. In the absence of good data to inform effective diabetes preventative and treatment measures, people with diabetes are likely to progress to complications which will burden society and health systems in the Cook Islands and New Zealand.
Aim: To determine the prevalence of diabetes and prediabetes, and incidence of GDM, in the Cook Islands.
Methods: We analysed two Te Marae Ora Cook Islands Ministry of Health datasets, the Non‐Communicable Diseases (NCD) register examining demographic data for the period 1967 to December 2018 and same for the GDM register from January 2009 to December 2018.
Results: Of the 1270 diabetes cases, 53% were female and half were aged 45–64 years. There were 54 pre-diabetes cases and 146 GDM. Of the 20 GDM cases who developed type 2 diabetes, 80% were diagnosed before the age of 40 years. Data quality was poor.
Discussion: The Cook Islands diabetes registers provide important data to inform priorities for diabetes-related preventative and treatment measures. A data analyst has been employed to ensure quality, regularly audited data and information systems.
Keywords: Cook Islands, Cook Islands women, diabetes mellitus, gestational diabetes mellitus, non-communicable diseases, obesity, Pacific people, prediabetes.
WHAT GAP THIS FILLS |
What is already known: The burden of diabetes among Pacific populations in the Pacific region and in New Zealand is significant. Diabetes registers play a critical role to monitor trends, inform effective preventative and treatment measures, and improve health systems efficiencies and population health outcomes. |
What this study adds: New information quantifying the burden and demographic characteristics of diabetes in the Cook Islands and acknowledging the importance of ensuring the quality of diabetes data through regular data quality audits. |
Introduction
The global burden of diabetes mellitus (diabetes) is a significant public health threat with approximately 537 million adults living with diabetes.1 Diabetes is broadly categorised as type 1 diabetes, where an individual has a deficient level of insulin secretion or type 2 diabetes, the cause being a combination of resistance to insulin and/or inadequate levels of insulin secretion in response to glucose in the blood stream. Previous studies have shown an increase in the prevalence of people with prediabetes who are at risk of developing diabetes.2 Prediabetes is defined as having a higher level of blood sugar than normal, but lower than the diabetes threshold.3 There are three substitutable criteria for diagnostic screening of prediabetes that include fasting plasma glucose (FPG, 5.6–6.9 mmol/L), 2-h plasma glucose (2-h PG, 7.8–11.0 mmol/L), and haemoglobin A1c 5.7–6.4% (HbA1c, 39–47 mmol/mol).4 In New Zealand, one of the criteria of prediabetes diagnosis is a fasting glucose range of 6.1–6.9 mmol/L;5 therefore, diabetes is diagnosed if either the HbA1c is ≥50 mmol/mol, fasting glucose is ≥7 mmol/L or the random glucose is ≥11.1 mmol/L.6 The Cook Islands medical guidelines are similar to New Zealand guidelines in terms of diabetes diagnosis criterion.7
It is evident that there is an increase in the prevalence of gestational diabetes mellitus (GDM) observed in women when signs of glucose tolerance are shown.8 It is possible that the current obesity and diabetes epidemic has resulted in a higher proportion of women of childbearing age with type 2 diabetes, consequently resulting in an increase in the number of mothers with GDM.9 In a study conducted among pregnant women in their second trimester in Rarotonga, 646 women were reported to have glucose challenges in a 4 -year period (January 2009 to December 2012).10
The global burden of diabetes is a significant public health issue that impacts differentially on vulnerable populations, with three-quarters of adults living with diabetes residing in low- and middle-income countries.1 The global economic burden of diabetes and its related complications is substantial and projected to reach USD 2.1 trillion in 2030.11 The global direct health expenditure on diabetes is estimated to be USD 760 billion and is projected to increase to USD 845 billion by 2045.12 In Pacific Island countries and territories, non-communicable diseases (NCD; mostly cardiovascular disease, diabetes, cancer and chronic respiratory disease), account for more than 70% of deaths.13 In a World Health Organization (WHO) surveillance survey of NCD risk factors in some Pacific nations (2002–2011) almost half of the adult population in American Samoa had been diagnosed with diabetes compared to one-third in Niue and the Federated States of Micronesia, and one-quarter in the Cook Islands.13 Obesity as a risk factor for diabetes14,15 was reported by more than 75% of adults in American Samoa, 63% in Niue and Tokelau, and 61% in the Cook Islands.13
The Cook Islands National Strategy and Action Plan for NCDs was developed in 2009 and has led to the development of the Cook Islands NCD Strategy 2015–2019.16 The strategy is operationalised through eight components, including integrated NCD activities; alcohol harm reduction; tobacco control; mental health and disability; food and nutrition; physical activities; national health system approach and monitoring; evaluation; and surveillance.16 These components were established in collaboration with relevant stakeholders and are the basis of all NCD activities. Programmes include promotion of healthy living at church services and youth groups, free health risk assessments at one’s place of employment, and smoking cessation services on the main island of Rarotonga.16 In the recent strategic action plan to prevent and control NCD during 2021–2025,17 the Cook Islands ministry takes steps in four domains: enabling national multi-sectoral action to expedite whole-of-country NCD prevention and control (e.g. establish community NCD committees); promoting and educating NCD patients, families and communities to prevent and control NCDs (e.g. establishing a NCD communications strategy, identifying the target audience, key messages, media platforms); reinforcing NCD preventive and control legislation and policy for effective action (e.g. promoting healthy food and nutrition); and providing access to quality and equitable health services for NCD patients and people at risk of NCDs (e.g. maintaining currency of the NCD register). For instance, evidence-based profitable interventions for people with diabetes in this action plan includes offering glycaemic control, providing preventive foot care, as well as screening diabetes patients for retinopathy and providing laser photocoagulation to prevent blindness.17
Therefore, evidence-based studies could promote our knowledge of better screening and providing services for NCD patients and people at risk of NCDs (e.g. diagnosis and diabetes management). Furthermore, in a bigger picture, such documents could help direct policies and medical services to improve public health. Although global and regional information systems suggest that the burden of diabetes is high, inadequate surveillance systems in the Pacific region and the Cook Islands have hindered the ability for countries to quantify the burden of diabetes and subsequently mount an effective response. The aim of this audit is to examine the prevalence of diabetes and pre-diabetes and the incidence of GDM in the Cook Islands during 1967–2018.
Methods
The Cook Islands consists of 15 islands dispersed over 2 million km2 of the South Pacific Ocean and is geographically divided into the Southern and Northern group islands.16,18 According to the 2016 population census, the population was 17 434 with over three-quarters living on the main island of Rarotonga. The Cook Islands is part of the Realm of New Zealand and maintains a strong relationship with the New Zealand Government.19 Te Marae Ora Cook Islands Ministry of Health acts on behalf of the Cook Islands Government to deliver publicly funded health services.
We analysed the Cook Islands NCD register, which is maintained on the Ministry Patient Information System (MedTech) and holds all available data from 1967 to 1931 December 2018. We sought information regarding the demographic characteristics of registered patients with all types of and pre-diabetes. This included the date when diabetes or prediabetes was diagnosed. We also analysed the Cook Islands GDM register, which is a subset of the NCD register and is administered by the Obstetrics and Gynaecology service, for the period of 2009–2018.
As part of the data quality assessment process, we sought additional data from MedTech using the pre-determined Classification Read Code for Diabetes. Data sets were extracted to Microsoft Excel and two reviewers verified the data examining for completeness, accuracy and consistency, and correcting these on the Microsoft Excel sheet as necessary. Once validated as correct, revised information was updated directly to the patients’ clinical notes and classifications section on MedTech.
Patients were included in the study if they were alive, living in-country, and regularly receiving medical or nursing care for diabetes or pre-diabetes. All cases who were deceased or had moved overseas were excluded. Patients with pre-diabetes have been included, as the majority would have been registered with the diabetes clinic and therefore received dietary and lifestyle advice, with a few receiving metformin.
This study was conducted as part of a 6-week summer studentship provided through the Health Research Council of New Zealand Pacific scholarship. Data analysis was conducted using Microsoft Excel and STATA15 software (StataCorp, College Station, TX, USA). The data were properly anonymised and confidentiality of information was assured. Ethics approval was obtained from the University of Auckland Human Subjects Committee (Reference 020659) and the Cook Islands National Research Committee.
Results
For all recorded data over the period of 1967–2018, 1270 diabetes cases were registered on the Cook Islands Non-Communicable Diseases database. In addition, there were 54 pre-diabetes cases and 146 patients diagnosed with gestational diabetes from January 2009 to December 2018.
Prevalence and incidence rates of diabetes
The total population was needed to measure the prevalence rate and incidence rate of diabetes among people in the Cook Islands. Therefore, using a report about the total population (calculated for every 5 years) by the Ministry of Finance and Economic Management (2021),20 the average population during 1966–2021 was reported to be 18 000 people (min = 15 040, max = 21 322). Based on this ratio, the results in Table 1 indicate the annual prevalence and incidence rates of diabetes in the Cook Islands during 1967–2018. Based on Table 1, the prevalence rate of diabetes has been significantly increasing over the past decades; however, the incidence rate among the cases had more fluctuations, but has still increased over time. The highest incidence was seen in 2008 and 2016. Based on the dataset used for this study, the crude prevalence of diabetes for 814 cases during 2009–2018 was 452 per 10 000 and the incidence rate was 4.5 cases per 1000 people-year.
Years | Number of diabetes cases diagnosed per year | Prevalence rate of diabetes (%) | Incident rate of diabetes (%) |
---|---|---|---|
1967 | 2 | 0.01 | NA |
1968 | 0 | 0.00 | −0.01 |
1969 | 1 | 0.01 | 0.01 |
1970 | 0 | 0.00 | −0.01 |
1971 | 0 | 0.00 | 0.00 |
1972 | 0 | 0.00 | 0.00 |
1973 | 0 | 0.00 | 0.00 |
1974 | 0 | 0.00 | 0.00 |
1975 | 0 | 0.00 | 0.00 |
1976 | 0 | 0.00 | 0.00 |
1977 | 1 | 0.01 | 0.01 |
1978 | 0 | 0.00 | −0.01 |
1979 | 2 | 0.01 | 0.01 |
1980 | 6 | 0.03 | 0.02 |
1981 | 1 | 0.01 | −0.03 |
1982 | 0 | 0.00 | −0.01 |
1983 | 1 | 0.01 | 0.01 |
1984 | 3 | 0.02 | 0.01 |
1985 | 2 | 0.01 | −0.01 |
1986 | 0 | 0.00 | −0.01 |
1987 | 2 | 0.01 | 0.01 |
1988 | 4 | 0.02 | 0.01 |
1989 | 2 | 0.01 | −0.01 |
1990 | 9 | 0.05 | 0.04 |
1991 | 3 | 0.02 | −0.03 |
1992 | 5 | 0.03 | 0.01 |
1993 | 8 | 0.04 | 0.02 |
1994 | 4 | 0.02 | −0.02 |
1995 | 11 | 0.06 | 0.04 |
1996 | 7 | 0.04 | −0.02 |
1997 | 7 | 0.04 | 0.00 |
1998 | 8 | 0.04 | 0.01 |
1999 | 8 | 0.04 | 0.00 |
2000 | 17 | 0.09 | 0.05 |
2001 | 18 | 0.10 | 0.01 |
2002 | 20 | 0.11 | 0.01 |
2003 | 24 | 0.13 | 0.02 |
2004 | 33 | 0.18 | 0.05 |
2005 | 56 | 0.31 | 0.13 |
2006 | 34 | 0.19 | −0.12 |
2007 | 48 | 0.27 | 0.08 |
2008 | 109 | 0.61 | 0.34 |
2009 | 70 | 0.39 | −0.22 |
2010 | 63 | 0.35 | −0.04 |
2011 | 57 | 0.32 | −0.03 |
2012 | 72 | 0.40 | 0.08 |
2013 | 69 | 0.38 | −0.02 |
2014 | 65 | 0.36 | −0.02 |
2015 | 80 | 0.44 | 0.08 |
2016 | 141 | 0.78 | 0.34 |
2017 | 85 | 0.47 | −0.31 |
2018 | 112 | 0.62 | 0.15 |
NA, data were not available.
Frequency of diabetes and pre-diabetes cases by sex and age group
Of the 1270 diabetes cases, most were aged 45–64 years, with four aged <24 years; one of whom was a male aged 10 years diagnosed in 2018 (Table 2). Over half were female (53%) and the majority (80%) were aged between 45 and 64 years. Likewise, of the 54 pre-diabetes registered cases during 2009–2018, 52% were females and the majority (80%) were aged between 45 and 64 years (Table 2). It should be noted that deceased people and those who were not longer residing in the Cook Islands were excluded.
Age group (years) | Diabetes cases | Pre-diabetes cases | ||||
---|---|---|---|---|---|---|
Female | Male | Total | Female | Male | Total | |
<15 | 1 | 0 | 1 | NA | NA | NA |
15–24 | 1 | 2 | 3 | NA | NA | NA |
25–44 | 55 | 70 | 125 | 0 | 0 | 0 |
45–64 | 332 | 351 | 683 | 20 | 24 | 44 |
65–74 | 147 | 142 | 289 | 3 | 2 | 5 |
75–84 | 58 | 90 | 148 | 5 | 0 | 5 |
85+ | 5 | 16 | 21 | NA | NA | NA |
Total | 599 | 671 | 1270 | 28 | 26 | 54 |
NA, data were not available.
Frequency of diabetes cases diagnosed by year
The number of diabetes cases has increased over time, with a gradual increase in numbers observed in the early 1990s, followed by rapid acceleration after 2000 (Fig. 1). As the Fig. 1 shows, there were two major peaks in 2008 and 2016.
Frequency and age at diagnosis of diabetes cases diagnosed by year
Regarding age of the case at the time of diagnosis, an increasing number of diabetes cases was observed from the age of 25 years, which peaked around age 55 years, before declining (Fig. 2).
Frequency of births and GDM cases by year
Based on Fig. 3, for the years 2009–2018, 146 cases of gestational diabetes were diagnosed. Of these, 11 women had two pregnancies and were diagnosed with GDM, whereas four women had three pregnancies and were diagnosed during this period. Of these, three were diagnosed with diabetes within 2 years. Of all those diagnosed with GDM, 20 were eventually diagnosed with Type 2 diabetes. The average age at diagnosis was 37 years, with at least 80% diagnosed before the age of 40 years. On average, there are 260 births per year in the Cook Islands and about 14 GDM cases diagnosed. As Fig. 3 shows, GDM cases had two significant peaks in 2009 and 2012.
Discussion
The burden of diabetes in the Cook Islands is significant, with 1270 diabetes cases diagnosed over the past decades. The rates of diabetes and prediabetes are higher among women and people aged between 45 and 64 years. Women with gestational diabetes (mean age = 37 years) are significantly at risk of developing diabetes after pregnancy. The prevalence of diabetes is increasing in the Cook Islands, affecting those aged from 45 to 64 years, reflecting similar trends globally.1
Although there were a few pre-diabetes cases diagnosed, given the number of diabetes cases and GDM cases, this study suggests that it is likely that many pre-diabetes cases that have not been further diagnosed. In the Cook Islands, most antenatal women are screened for diabetes during pregnancy. There is no systematic diabetes screening undertaken for the general population. Inconsistent with some previous research in the Pacific,21–23 the current findings show a decrease in GDM prevalence among people in the Cook Islands. This inconsistency in results could possibly be linked to immigration of young people from the Cook Islands. In part, a decreasing population since 2006–2021 (19 342–15 040 people) might play a role in reducing the rate of GDM.20
With the large proportion of young women developing diabetes during pregnancy and progressing to type 2 diabetes, urgent attention is required to understand the drivers and factors that could be responsible for this. The study findings suggest that perhaps screening for diabetes in Cook Islands women may have to begin at a younger age, and that more effort should be placed on raising awareness about the risks to both mum and baby, including information about foetal abnormalities and complications during childbirth. These findings also relate to a qualitative research paper24 that examines prediabetes for the Tongan population in New Zealand in which the age of newly diagnosed women with prediabetes was reported at a younger age (20s and 30s).
Modernisation, migration, and urbanisation have impacted dietary intake and physical activity, thus driving the obesity epidemic, and the increase in NCDs in the Cook Islands.25 Imported foods such as rice, sugar, canned foods, and sugar drinks have replaced traditional foods such as taro, fish, fruits, and vegetables due to the increased affordability and accessibility.26 Consequently, more Cook Islanders are leading sedentary lifestyles, and fewer individuals are obtaining resources from the land due to the physically demanding activities associated with growing crops.27,28 This could explain the rapid acceleration of the number of diabetes cases from 2000 onwards. Reduced physical activity level could result in obesity, which contributes to diabetes development.14
The findings from this study have also noted that young adolescents are also being diagnosed with type 2 diabetes. Previous studies also support these findings and have shown an increase in the number of diabetes cases among young adolescents that could be a result of global increasing obesity, contextual factors and/or genetics, gender, race, or physical activity level and insulin sensitivity.29 In New Zealand, obesity and ethnicity (Māori and Pacific Island) were considered as factors of increasing prevalence of type 2 diabetes among adolescents.30 In a more recent study,31 the risk of type 2 diabetes among young people was found to be associated with gender (being females) and being from high-risk ethnic groups (Māori and Pacific Island), and increased deprivation.
Poor data quality and limited data fields, and the lack of regular quality audits was apparent. Due to the limited time period of the study, severe time constraints were due largely to the time required to verify the datasets. Additionally, missing data for patients who had been referred, or who were deceased, reduced the ability to monitor progress. The Te Marae Ora Cook Islands Ministry of Health had no access to patient records once they were referred overseas. Missing data and inaccuracies in the reporting of results reduced the quality of data and increased the time required to analyse data appropriately.
The Cook Islands NCD register contains almost 7000 cases. When extracting data from the diabetes register, there were just over 2200 cases. However, during the verification process, it became clear that regular data quality audits had not been undertaken for some time. Subsequently, the register included deceased persons and those who were no longer residing in the Cook Islands. Did they die outside the study period, and reside outside the study period?
Diabetes threatens to undermine and reverse the social and economic development of the Cook Islands. This calls for urgent attention to address the drivers of diabetes that must also consider the social and economic factors that hinder preventative measures.
Strategies for improving the quality of data collection processes
The prevalence rate of diabetes among Pacific people is reported to be higher in other countries such as New Zealand (11.1%, in 2019),32 the US (17.7%, in 2018),33 and Australia (8%, in 2018)34 in comparison with this study. In agreement with other research,35 data linked to the prevalence of diabetes among Pacific people are broadly deficient and underreported to provide an accurate picture. In line with this statement, the inconsistency of the data from the Cook Islands was reported as a prevalence of 25.4% in 2004 in one research13 whereas in this study, it was found to be 0.18% in the same year. Therefore, there is an urgent need to improve NCD clinic processes. As previously mentioned, the exclusion criteria reduced the number of diabetes cases on the register. Many were removed because they were deceased, had been referred overseas, or were no longer visiting the clinic. It is critical that the NCD clinic improves the monitoring of NCD patients, particularly the follow-up process for those who have missed appointments or have poor medical adherence. Revision of the NCD clinic services delivery model is recommended within primary healthcare services.
This study has highlighted serious concerns regarding the burden of diabetes in the Cook Islands. Lowering the diabetes screening age for young and vulnerable adults provides an opportunity to diagnose pre-diabetes and to establish preventive measures.36 There is a need for doctors to be aware of the early onset of diabetes and to provide preventive measures.
Promoting healthier living in homes, schools, churches, the workplace and in recreational spaces is important to help reduce the obesogenic environments. Limiting children’s access to high fat, high sugar drinks while promoting increased physical activity is important. Primary healthcare professionals and health services need to promote the dangers of diabetes.
The Te Marae Ora Cook Islands Ministry of Health should continue to pursue to work closely with the World Health Organization to conduct a cost burden analysis of diabetes. As a Pacific realm country of New Zealand, Cook Islands citizens regularly access New Zealand health services. Although this is beneficial for the population, given limited resources on the main island of Rarotonga, the rise in diabetes cases and other health challenges continues to increase the burden on the New Zealand health system.
One of the strengths for this study is the availability of quantitative data highlighting the burden of diabetes in the Cook Islands. These findings can be used by the Cook Islands Ministry of Health to inform the design and implementation of context-specific population and health service delivery initiatives to address NCDs.
Lessons and messages
The current finding of a decreasing number of GDM cases among young women might be a favourable finding; however, the need to introduce screening for diabetes at an earlier age should not be overlooked. This should include the review of prenatal and antenatal education and counselling for women with diabetes, as well as those at risk of developing diabetes, such as those with a family history. Regular data quality audits are also required, not only to improve surveillance and the evaluation of services, but also to inform policy and practice in the Cook Islands.
The lower rates of recorded data for diabetes cases before 1999 could be that the data were not regularly and properly recorded because there were no technology-based systems that were available like there are in the current era. As a result of this study, the Te Marae Ora Cook Islands Ministry of Health is preparing to undertake the following: recruit a data analyst to help interpret the data and to assist in data quality assessment; conduct a study to determine the economic cost of NCDs; a policy shift to move primary care services closer to community settings in order to focus on keeping people healthy and well; a focus on environmental measures to address the obesogenic environments; implement a tobacco-free island; and to continue to increase tax on tobacco, sugar and alcohol.
The Te Marae Ora Cook Islands Ministry of Health should continue to work closely with community groups including churches, local stores, and local sports teams, to promote healthy eating and healthy living. More emphasis needs to be placed on preventative care through appropriate health policies that will reduce NCDs such as diabetes.
Conclusion
The prevalence of diabetes and pre-diabetes in the Cook Islands has increased progressively. The risk is disproportionately linked with gender and age (being female and an age range of 45–64 years). Young people also are considerably at risk of diabetes. Although the findings showed a decrease in the number of gestational diabetes mellitus cases, it has been reported that gestational diabetes mellitus could lead to other types of diabetes later in life. Consistent data collection and improving medical records are highly recommended to provide precise evaluations of the non-communicable diseases register trends and to help facilitate effective services and interventions.
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