Health Omnibus Survey Research Articles

Influence of mammographic screening on breast cancer incidence trends in South Australia.

To examine breast cancer (BC) incidence trends in relation to mammographic screening and risk factor prevalence in South Australia (SA). Trends in annual BC incidence rates were calculated using direct standardisation and compared with projected incidence derived from Poisson regression analysis of pre-screening rates. Annual percentage change and change time points were estimated using Joinpoint software. Biennial mammography screening participation rates were calculated using data from BreastScreen SA. Trends in overweight/obesity, alcohol use and hormone replacement therapy (HRT) use were examined using 1991-2009 Health Omnibus Survey data. Trends in total fertility were examined using data from the Australian Bureau of Statistics. BC incidence increased around the time BreastScreen commenced and then stabilised in the mid-1990s. However rates have remained higher than projected, even though the proportion and age distribution of first time screening attendees stabilised around 1998. A decrease in BC incidence was observed among women aged 50-59yrs from the late-1990's but not among older women. Obesity and alcohol use have increased steadily in all age groups, while HRT use declined sharply from the late-1990s. BC incidence has remained higher than projected since mammography screening began. The sustained elevation is likely to be due to lead time effects, though over-diagnosis cannot be excluded. Declining HRT use has also impacted incidence trends. Studies using individual level data, which can account for changes in risk factor prevalence and lead time effects, are required to evaluate 'over-diagnosis' due to screening.

Caring at the end of life: do cancer caregivers differ from other caregivers?

Cancer is one of the most common health conditions in receipt of informal caregiving. This study compares key characteristics of caregivers who cared for someone with cancer until death with caregivers of people with other life-limiting illnesses and their care recipients irrespective of health service utilisation. Data were analysed from annual state-wide South Australian Health Omnibus Surveys (2000-2007) involving 14,624 respondents, regarding end of life care. Descriptive and comparative data are presented. Almost a third of respondents (32%; participation rate 72%) had someone close to them die from an 'expected' death in the preceding 5 years. One in 10 (10%) respondents reported providing hands-on care predominantly for someone with cancer. Compared with non-cancer caregivers, cancer caregivers cared for someone who was significantly younger (mean age 66 (95% CI 64 to 67) years vs 74 (95% CI 72 to 77) years; one-way analysis of variance p<0.0001) and were more likely to report having a hospice/palliative care service involved in the care of the deceased (65% (95% CI 63 to 67) compared with 39% (95% CI 37 to 42). In the Australian context, this may mean contact with inpatient, outpatient and community-based services.There were no differences between the needs which caregivers perceived to be unmet or the perceptions that no additional supports were required between the two groups. Informal caregivers perform a critical social and economic role in care provision. Cancer caregivers are a proportionally larger cohort than non-cancer caregivers. With the increasing incidence of cancer, the sustainability of a voluntary cancer caregiving workforce will be reliant upon minimising the burden of care.

CURRENT ADVANCE DIRECTIVE USE IN SOUTH AUSTRALIA: RESULTS FROM THE 2012 SPRING SOUTH AUSTRALIAN HEALTH OMNIBUS SURVEY

BackgroundAdvance directives enable autonomous decision-making for future healthcare and welfare and are an integral part of many advance care planning programmes. Current evidence of use of these instruments in South...

Intertemporal discounting as a risk factor for high BMI: Evidence from Australia, 2008

This paper explores the relationship between intertemporal discounting and body weight, using stated preference measures of intertemporal discounting, and the body mass index (BMI) to represent relative body weight. The empirical analysis uses Australian data obtained in 2008 through the South Australian Health Omnibus Survey. A quantile regression analysis is used to allow the marginal effects of the explanatory variables on BMI to vary across the conditional BMI distribution. It is shown that an indicator of intertemporal discounting elicited from a hypothetical monetary trade-off has a significant positive relationship with BMI. This relationship appears to be stronger in the upper quantiles, but there is insufficient statistical evidence for this difference. Evidence is presented that intertemporal discounting is a risk factor for increased BMI with a magnitude of effect comparable to more commonly recognized risk factors such as income and education. However there is no significant relationship found between BMI and an alternative indicator of intertemporal discounting elicited from trade-offs in health status.

Observed Agreement Problems between Sub-Scales and Summary Components of the SF-36 Version 2 - An Alternative Scoring Method Can Correct the Problem

PurposeA number of previous studies have shown inconsistencies between sub-scale scores and component summary scores using traditional scoring methods of the SF-36 version 1. This study addresses the issue in Version 2 and asks if the previous problems of disagreement between the eight SF-36 Version 1 sub-scale scores and the Physical and Mental Component Summary persist in version 2. A second study objective is to review the recommended scoring methods for the creation of factor scoring weights and the effect on producing summary scale scoresMethodsThe 2004 South Australian Health Omnibus Survey dataset was used for the production of coefficients. There were 3,014 observations with full data for the SF-36. Data were analysed in LISREL V8.71. Confirmatory factor analysis models were fit to the data producing diagonally weighted least squares estimates. Scoring coefficients were validated on an independent dataset, the 2008 South Australian Health Omnibus Survey.ResultsProblems of agreement were observed with the recommended orthogonal scoring methods which were corrected using confirmatory factor analysis.ConclusionsConfirmatory factor analysis is the preferred method to analyse SF-36 data, allowing for the correlation between physical and mental health.

E-Mental health in South Australia: impact of age, gender and region of residence

Respondents to the 2008 South Australian Health Omnibus survey (n=2996) indicated whether, in the previous 12 months, they had searched for information on the Internet relating to emotional issues such as depression, anxiety or relationship problems. Logistic regression was used to examine the penetration of e-mental health in rural and metropolitan areas (region of residence), and determine if other demographic variables (age group, gender) also impacted on the likelihood of an individual reporting that they had used the Internet to obtain such information. Overall, 9% of respondents reported that they had used the Internet for this purpose. The multivariate model was significant, F(11, 2985)=4.82, P<0.0001, with middle-aged rural females most likely to report doing so (18.1%), whereas older rural males were least likely to report doing so (2.2.%). These findings have important implications for the design of e-mental health promotional programs that provide information and interventions to improve mental health.

An assessment of the relationship between informal caring and quality of life in older community-dwelling adults - more positives than negatives?

The main objective of the study was to apply the recently developed Index of Capability (ICECAP-O) instrument to measure and value the quality of life of a representative sample of the older South Australian population (aged ≥ 65 years) according to carer status. A Health Omnibus survey including the ICECAP-O instrument, carer status (informal carer vs. non-carer) and several socio-demographic questions was administered in 2009 as a face-to-face interview to 789 individuals aged 65 years or older in their own homes. A total of 671 individuals (85%) characterised themselves as a non-carer and 115 individuals (15%) characterised themselves as an informal carer. In general, carers exhibited relatively high quality of life as measured by the ICECAP-O, with carers having comparable mean ICECAP-O scores to non-carers in the general population [carers: mean (SD) 0.848 (0.123), non-carers: mean (SD) 0.838 (0.147)]. The results of the multivariate regression model for the total sample indicated statistically significant variations in overall ICECAP-O scores according to age (with younger participants tending to have slightly higher scores on average), country of birth (with those participants who were born in Australia having higher scores on average than those who were born elsewhere) and household income (with participants with higher income levels having higher scores on average). The results of the multivariate regression model differentiated by carer status also indicated some important differences. Specifically, average ICECAP-O scores were noticeably lower for carers who are separated or divorced and for carers who lived alone and these differences were statistically significant. The study findings provide support for the existence of process utility in informal care-giving. The provision of informal care may be associated with a positive impact upon quality of life for many caregivers, which may mediate the negative aspects arising from the burden associated with informal care-giving.

Sicca Symptoms and their Association with Chronic Rhinosinusitis in a Community Sample

Objective:To determine associations between sicca symptoms, chronic rhinosinusitis (CRS) symptoms and asthma in a community survey.Methods:Data was obtained from the Spring 2009 South Australian Health Omnibus Survey which sampled, via interviewer administered questionnaire, 3007 individuals aged 15 years and over whose socio-demographic distribution corresponded to South Australian population estimates. Respondents were asked a range of questions relating to the presence of persistent dry eyes or dry mouth, CRS and medically diagnosed nasal polyps and asthma. Relationships between symptoms were explored using maximum likelihood dependency tree analysis.Results:The respective population prevalences were: dry mouth (5.9%), dry eyes (8.6%), nasal polyps (3.8%), CRS (13.2%) and asthma (12.0%). The overall prevalence of sicca symptoms (dry eyes or dry mouth) was 12.4%. Dependency tree analysis revealed the expected symptom clustering between (1) sicca symptoms and their association with female gender and increasing age and (2) CRS, nasal polyps and asthma (one airway hypothesis). However there was also an association between dry eyes and CRS (OR 2.5, 95% CI 1.9, 3.4), which was in fact stronger than the association between CRS and asthma (OR 1.9, 95% CI 1.4, 2.5).Conclusions:Sicca symptoms are common in the community. Our novel finding of a strong association between dry eyes and CRS suggests that further research into the relationship between airway inflammation and sicca symptoms is required. These findings may have particular relevance to Sjögren’s syndrome (SS) in both its primary and secondary forms.

Investigating obstructive sleep apnoea: will the health system have the capacity to cope? A population study

To obtain prevalence estimates of clinical features of obstructive sleep apnoea (OSA) and identify the dimensions of the public health problem requiring further investigation for an Australian population. The South Australian Health Omnibus Survey is an annual representative population survey of South Australians aged≥15 years, conducted via interviewer-administered questionnaire. In 2009, 3007 participants were asked the STOP-BANG instrument measure of obstructive sleep apnoea risk, which includes symptoms of loud snoring, frequent tiredness during daytime, observed apnoea, and high blood pressure (STOP), and measured body mass index, age, neck circumference and gender (BANG). Three or more positive response categorises a person at high risk for OSA. Snoring was reported by 49.7% of adults. Tiredness after sleep more than 3 - 4 times per week was reported by 24.8%, and during wake-time by 27.7% of adults, with 8.8% reporting having fallen asleep while driving. Over half of the surveyed men (57.1%, n=566) and 19.3% (n=269) of the women were classified at high-risk of OSA with the STOP-BANG measure. In multivariable models, high risk was associated with less education, lower income, and residence in a regional rather than metropolitan area. The high prevalence of adults at risk for OSA suggests that the capacity currently available within the healthcare system to investigate and diagnose OSA is likely to be inadequate, particularly outside urban areas. This highlights an important public health problem that requires further detailed study and trials of new models of care.

Changes in the Prevalence of Major Depression in an Australian Community Sample Between 1998 and 2008

To identify changes in the prevalence of major depression between 1998, 2004 and 2008 in South Australia. Face-to-face Health Omnibus surveys were conducted in 1998, 2004 and 2008 with approximately 3000 participants aged 15 years and over, who were random and representative samples of the South Australian population. Each survey used the same methodology. Outcome measures were: major depression as detected by the Mood module of the Primary Care Evaluation of Mental Disorders instrument; mental health literacy by recognition and exposure to classical symptoms of depression; and health status using the SF-36 Physical and Mental Component summaries. There was a significant increase in the prevalence of major depression from 6.8% (95%CI: 5.9%-7.7%) to 10.3% (95%CI: 9.2%-11.4%; χ² 24.59, p < 0.001) between 1998 and 2008. Significant increases were observed in males aged 15-29 and females aged 30-49 years. There was no significant increase in any other sub-group. The strongest predictor of major depression was health status. Participants with poor/fair mental health literacy were 37% less likely to be classified with major depression. The prevalence of major depression increased significantly in South Australia over the last decade and there was a reduction in mental health status and an increase in persons reporting poor health. Unexpectedly, having poor or fair mental health literacy was significantly protective for major depression. Ideally, public health initiatives should result in an improvement in health, but this did not appear to have occurred here.

Quantifying the impact of transient joint symptoms, chronic joint symptoms, and arthritis: A population‐based approach

To estimate the prevalence and co-occurrence of self-reported doctor-diagnosed arthritis, chronic joint symptoms (pain, aching, stiffness, or swelling on most days for a month), and transient joint symptoms (pain, aching, stiffness, or swelling but not on most days for a month), and to compare the sociodemographic characteristics, activity limitations, and health-related quality of life (HRQOL) of people with joint conditions with those who have no self-reported doctor-diagnosed arthritis and no joint symptoms. Data from the 2004 population-based South Australian Health Omnibus Survey (n = 2,840, ages 18-96 years) were used in the study. Activity limitations were assessed using 10 activity limitations questions from the Short Form 36 health survey. HRQOL was assessed using the Assessment of Quality of Life scale. Half of all respondents reported having joint problems, with 26%, 11%, and 13% reporting self-reported doctor-diagnosed arthritis, chronic joint symptoms, and transient joint symptoms, respectively. Chronic joint conditions (self-reported doctor-diagnosed arthritis and chronic joint symptoms) accounted for 74% of all joint problems and were associated with higher odds of activity limitations and poorer HRQOL. The frequency of transient and chronic joint symptoms was highest among middle-aged participants (ages 45-54 years for transient and 45-64 years for chronic joint symptoms) and those who had a body mass index in the obese range. Prevalence of self-reported doctor-diagnosed arthritis increased with age and was higher among women and those who were overweight or obese. This study documented the high prevalence and impact of joint conditions in the community. Chronic joint conditions affect daily life and are substantial barriers for effective public health interventions aimed at reducing obesity and inactivity.

Assessing Utility Where Short Measures Are Required: Development of the Short Assessment of Quality of Life-8 (AQoL-8) Instrument

As researchers seek to include clinical outcomes, the health-related quality of life (HRQoL) of participants and meet economic evaluation demands, they are confronted with collecting disparate outcome data where parsimony is imperative. This study addressed this through construction of a short HRQoL measure, the Assessment of Quality of Life (AQoL)-8 from the original AQoL. Data from the AQoL validation database (N = 996) were reanalyzed using item response theory (IRT) to identify the least fitting items, which were removed. The standard AQoL scoring algorithm and weights were applied. Validity, reliability, and sensitivity tests were carried out using the 2004 South Australian Health Omnibus Survey (N = 3015), including direct comparisons with other short utility measures, the EQ5D and SF6D. The IRT analysis showed that the AQoL was a weak scale (Loevinger H = 0.36) but reliable (Mokken rho = 0.84). Removal of the four weakest items led to an 8-item instrument with two items per subscale, the AQoL-8. The AQoL-8 Loevinger H = 0.38 and Mokken rho = 0.80 suggested similar psychometric properties to the AQoL. It correlated (intraclass correlation coefficient) 0.95 (or 90% of shared variance) with the AQoL. The AQoL-8 was as sensitive to six common health conditions as the AQoL, EQ5D, and SF6D. The utility scores fall on the same life-death scale as those of the AQoL. Where parsimony is imperative, researchers may consider use of the AQoL-8 to collect participant self-report HRQoL data that is suitable for use either as reported outcomes or for the calculation of quality-adjusted life-years for cost-utility analysis.

Quantification and examination of depression‐related mental health literacy

The aim of the study was to create an algorithm to measure depression-related mental health literacy. Participants were those recruited for the 1998 and 2004 South Australian Health Omnibus Surveys. Two unprompted questions were selected from a mental health literacy questionnaire and responses were quantified through allocation of scores agreed by a focus group of mental health professionals. An application of the algorithm resulted in findings consistent with those of other research, providing face validity for the method developed. The application allowed for examination of overall levels of depression-related mental health literacy, with improvement found between 1998 and 2004. Similarly, differences in overall literacy according to demographics were also uncovered. Tracking mental health literacy within populations is important as it has been shown to be related to individual help-seeking as well as provision of support for those with a mental disorder. The method devised in this study allows for comparisons of literacy levels to be made across populations and time. It also offers increased capacity for statistical application.

Tracking Depression-Related Mental Health Literacy Across South Australia: A Decade of Change

The aim of the present study was to measure and compare levels of depression-related mental health literacy in South Australia across three points in time: 1998, 2004, and 2008. Participants were those recruited for the 1998, 2004, and 2008 South Australian Health Omnibus Surveys. Comparisons were made across overall levels of depression-related mental health literacy as well as between responses to independent questionnaire items. A significant improvement was found in the overall measure of depression-related mental health literacy between 1998 and 2004 and this was consolidated in 2008. Some discrete changes in literacy were found between 2004 and 2008, with improvements recorded across some demographic groups and in participants' ability to accurately classify symptoms. Participants in 2008, however, were significantly less likely to endorse providers or treatments as 'helpful' than in 2004. Although knowledge and understanding of depression have improved significantly and stabilized since 1998, patient confidence in both mental health therapists and treatment options fell between 2004 and 2008, although it is still greater than in 1998.

Defining distinct caregiver subpopulations by intensity of end-of-life care provided

Interventions designed to assist informal caregivers who serve individuals at or near the end of life have predominantly focused on caregiving spouses. Can we define other caregiver subpopulations – by intensity of care provided – so as to enable better a) identification of caregiver needs and b) targeting of support to caregivers? The Health Omnibus Survey, an annual face-to-face survey in South Australia, collects health-related data from a representative sample of 4400 households. Piloted questions included in the 2001–2005 Health Omnibus surveys addressed death of a loved one, caregiving provided, impact of caregiving and caregiver characteristics. Of 18,224 respondents, 5302 reported a loved one’s death due to terminal illness in the previous 5 years. In all, 502 (10%) provided daily care [5–7 days/week], 619 (12%) provided intermittent care [2–4 days/week] and 425 (8%) provided rare care. Active (daily plus intermittent) caregivers, compared with non-active (rare) caregivers, were more often women (63% vs 50%; P < 0.0001). Daily caregivers were distinguishable from intermittent; daily caregivers were more often widowed (95% vs 7%; P < 0.0001) and ≥60 years (80% vs 64%; P < 0.0001); intermittent caregivers were more commonly children/parents (35%), other relatives (33%), or friends (26%; P < 0.0001) and were better educated, more active in paid work and wealthier. Financial burden, experience at time of death, ability to move on after the death and need for grief support also differed by intensity of caregiving. Caregiver subpopulations can be defined according to intensity of caregiving with distinct demographic features helping to distinguish them.

Severe obesity: Investigating the socio-demographics within the extremes of body mass index

To examine the trends in the prevalence of classes I, II and III obesity between 1991 and 2006 among the South Australian adult population. In addition, to explore the association of severe (class II and III) obesity with a range of socio-demographics, chronic conditions and risk factor variables. Trends of self-reported obesity prevalence were examined using representative, annual, face-to-face South Australian Health Omnibus Surveys from 1991 to 2006 (n ≈ 3000 per year). Biomedical data, including measured height and weight, were collected in the North West Adelaide Health (cohort) Study (NWAHS), a representative random adult sample selected from the electronic white pages (EWP) (n = 4060). The age standardised prevalence of self-reported class II and III obesity among those aged 18 years and over increased from 2.4% in 1991 to 8.1% in 2006. The greatest relative percentage increase over this time was seen amongst those with class III obesity (452.3%). Using biomedical data, multivariate analysis results indicated that among those who were obese, women were more than two and a half times more likely than men to be of class II and III. Among those who were obese, those aged 20-54 years and living in the low/lowest quintiles of Socioeconomic Indexes for Areas, Index of Relative Socioeconomic Disadvantage (SEIFA IRSD) were statistically significantly more likely to be class II or III obese when compared to those in the highest categories. The prevalence of class II and III obesity increased significantly between 1991 and 2006. The socio-demographics of those who are class II and III obesity are different from those that are normally described for obesity as a whole especially in regard to the younger age cohort. The current prevalence of severe obesity within Australia is probably underestimated and these results highlight the need to address this sub-group of the population.

Depression Prevalence: Is it Really Increasing?

There is conflicting evidence as to whether depression prevalence is increasing or is stable. Although birth cohort analysis studies show increasing prevalence, longitudinal studies do not. To date there are no published Australian studies providing long-term estimates of depression prevalence. The aim of the present study was to examine the increasing depression prevalence hypothesis in an Australian context. Data from the 1998 and 2004 South Australian Health Omnibus Surveys were re-analysed. In each survey there were >3000 participants who were interviewed. The data were weighted to achieve representativeness prior to analysis. Depression status was classified by the Primary Care Evaluation of Mental Disorders scale (the PRIME-MD) into major, other and no depressions. Both univariate and multivariable analyses were used to examine depression trends over time and to adjust the data for significant background variables. There was no significant increase in the cases of patients classified with major depression between 1998 and 2004; there was, however, a significant decrease in other depression. The overall unadjusted prevalence of major depression was 7.4% (6.8% in 1998 and 8.0% in 2004) and for other depression it was 9.5% (10.6% in 1998 and 8.4% in 2004). The highest levels of depression, both major and other, were observed among females aged 15-29 years, and the lowest levels among those aged > or =50 years. The strongest predictor of depression was poor overall health status. It is time for the conventional wisdom that depression is increasing to be reconsidered, and for a more realistic perspective, developed from evidence-based analyses, to be accepted.

Specialized palliative care services are associated with improved short- and long-term caregiver outcomes.

Goals of workThe goal of this study was to evaluate, at a population level, the association between specialized palliative care services (SPCS) and short- and long-term caregiver outcomes.Patients and methodsThe Health Omnibus Survey, a face-to-face survey conducted annually in South Australia since 1991, collects health-related data from a rigorously derived, representative sample of 4,400 households. This study included piloted questions in the 2001, 2002, and 2003 Health Omnibus Survey on the impact of SPCS. Sample size was 9,088 individuals. “Unmet needs,” a short-term outcome relevant to the caregiving period during a life-limiting illness, were tallied. “Moving on,” a long-term caregiver-defined outcome reflecting the caregiver’s adaptation and return to a new equilibrium after the death, was assessed with and without SPCS.ResultsThirty-seven percent (3,341) indicated that someone close to them had died of a terminal illness in the preceding 5 years, of whom 949 (29%) reported that they provided care. SPCS were involved in caring for 60% of deceased patients. Day-to-day caregivers indicated fewer unmet needs when SPCS were involved (p = 0.0028). More caregivers were able to “move on” with their lives when SPCS were involved than when SPCS were not involved (86 vs 77%, p = 0.0016); this effect was greatest in the first 2 years after the loved one’s death.ConclusionAt a population level, SPCS were associated with meaningful improvements in short-term (“unmet needs”) and long-term (”moving on”) caregiver-defined outcomes.

Have Education and Publicity about Depression Made a Difference? Comparison of Prevalence, Service use and Excess Costs in South Australia: 1998 and 2004

To identify changes in depression, its management and associated excess costs, between 1998 and 2004 in South Australia. A face-to-face Health Omnibus Survey was conducted in 2004 among 3015 randomly selected participants aged 15 years and over, who were a random and representative sample of the South Australian population, and this was compared with a survey conducted in 1998 that used the same methodology. The main outcome measures were prevalence of depression detected by the Mood Module of the Primary Care Evaluation of Mental Disorders (PRIME-MD); use of health services; health-related quality of life assessed by the Assessment of Quality of Life; estimates of excess costs and demographic data. There was no significant change in the overall prevalence of depression, although there was a significant decrease in respondents with other depressions, and a non-significant increase in those with major depression. No significant differences in the mean number of PRIME-MD depression symptoms were reported. Greater use of predominantly non-medical treatment services and antidepressants were reported by both those with depression and those without depression. There was a marked increase in the associated excess costs of depression. There has been no significant improvement in the prevalence of depression and its associated morbidity and financial burden in the South Australian community between 1998 and 2004, despite a number of professional and community education programmes. It is possible that without these efforts and the increased treatment reported on in this survey, there may have been an increase in the prevalence of depression and an even greater financial burden. However, it is also possible that community services for the provision of treatment for depression have not been able to implement research strategies that have been demonstrated to be effective.

The increasing prevalence of diabetes in South Australia: The relationship with population ageing and obesity

To use representative population surveillance data to monitor and project changes in the prevalence of diabetes for different age and body mass index (BMI) groups. Representative, annual, face-to-face South Australian Health Omnibus Surveys, 1991-2003 (n=3000 per year). Trends in self-reported diabetes prevalence by age group and BMI were examined. Separate projections were made on the basis of predicted changes in population demography and diabetes prevalence. The age-sex standardized absolute prevalence of self-reported diabetes among people aged 15 years and over increased from 3.5% in 1991 to 6.7% in 2003. If this current trend continues, the prevalence is expected to increase to 10.5% by 2016. The prevalence of diabetes was significantly higher among those classified as obese (6.5% in 1991 to 12.2% in 2003) than those with normal BMI. The greatest relative percentage increase in prevalence between 1991 and 2003 (169%) was seen among people aged 15-39 years. Taking both age group and BMI classification into account, the greatest relative percentage increases over this time were seen among those with normal BMI aged 60 years or older (148%), and those who were obese and aged less than 60 years (139%). The prevalence of diabetes and obesity increased significantly between 1991 and 2003. Population ageing and an increase in diabetes prevalence in the future will further increase the burden of diabetes. Future increases in diabetes prevalence are not inevitable, however, if investments are made in public health prevention programmes, particularly those addressing obesity.