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Cardiovascular disease and type II diabetes are major health issues for Māori because:
- They are major causes of mortality and hospitalisations, affecting individuals, whānau and community.
- Inequalities in rates and outcomes between Māori and non-Māori persist and in some cases appear to be increasing.
Risks can be reduced and these conditions respond well to being managed with appropriate care.
What can health professionals do?
Set realistic practice goals
Start screening programmes ten years earlier in Māori
Māori develop diabetes and cardiovascular disease earlier than non-Māori. Screening programmes should be started
earlier to identify and diagnose disease and reduce the development of more serious disease. Ideally, cardiovascular risk
assessment should be started ten years earlier in Māori (35 years for Māori men and 45 years for Māori
women). A recent study in patients receiving cardiovascular risk assessment showed that Māori were receiving a risk
assessment three years earlier than non-Māori but the average age of first assessment was 53 years.1
Ko te pipi te tuatahi, ko te kaunuku te tuarua.
A small wedge is used first followed by a larger one
(Whakatauk? (Proverb)�In reference to tree felling: an initial small effort may lead to a significant
Although a full cardiovascular risk assessment is ideal, a partial cardiovascular risk assessment may be better than
none at all. For a patient who does not attend general practice regularly, an achievable goal might be to record blood
pressure and take a random blood glucose. Note details about smoking status, family history, blood pressure, height, weight
and abdominal circumference. There is evidence that the recording of these details in primary care is incomplete.2
Decision support and practice management programmes may be helpful in reducing barriers to care by providing alerts
to identify patients eligible for screening and tools to assess risk.1 See Ten Minute
Tutorial for details on how to set up patient alerts for screening.
Build a trusting therapeutic relationship
Effective communication, establishing links and building a rapport with the patient and whānau is critical. Provide
information that aligns with Māori beliefs, values and understandings. Many organisations in New Zealand provide
specific Māori resources.
Engage patients in their health issues
The following organisations have Māori resources available on their websites
Have a high index of suspicion for early symptoms of disease
Take every opportunity to enquire about symptoms such as exertional chest pain or breathlessness. If necessary, refer
patients for exercise testing to help with early diagnosis of cardiovascular disease. Early symptoms of diabetes might
include polyuria, thirst or fatigue.
Ask if any whānau have heart disease, diabetes or have had a stroke and how it has affected their lives. Discuss
how there are many things that can be done to prevent and treat these conditions.
Opportunistic testing can help engage Māori in healthy lifestyle programmes:
- Take any opportunity to measure glucose. Although a fasting glucose is the best option, a random blood glucose over
11 mmol/L suggests diabetes and below 5.5 mmol/L is likely to be normal. Discussion of results between these levels can
lead the way to further investigation.
- Give patients a form for a fasting lipid test, discuss when and where they can get it done and make a follow up appointment
for them to discuss the results or arrange for them to be phoned with the results. Create an expectation that the test
will be done.
- Consider cardiovascular risk in all people who present with gout as there is increasing recognition that asymptomatic
hyperuricaemia is an independent risk factor for development of cardiovascular disease (see BPJ
Agree on realistic patient-centred health goals
Promote prevention and early management of diabetes and cardiovascular disease by setting achievable
and measurable goals.
Smoking, high blood pressure and obesity are important targets for modification of cardiovascular risk, prevention of
type II diabetes and reduction in complications.
Don�t miss �golden opportunities�
One Heart Many Lives is a social marketing programme aimed at those at high risk of cardiovascular disease, such
as Māori and Pacific men over 35 years. The key messages are:
- Get your heart checked
- Get more active
- Eat better
- Stop smoking
The programme has been rolled out in Hawke�s Bay and Northland and recently launched in the Lakes DHB region.
As a result more Māori and Pacific peoples should be presenting for cardiac risk assessment, including a number
who may not have otherwise come in to see a doctor or nurse. Ensure that you maximise this opportunity as it is a positive
experience for all involved.
High blood pressure
In one New Zealand study, the age standardised prevalence of self reported high blood pressure was 23.7% in Māori
males compared to 17.6% in European males and 23.9% in Māori females compared to 19.2% in European females. Another
study found that Māori also have higher rates of undiagnosed high blood pressure than European New Zealanders.3
Smoking is the leading modifiable risk factor causing disease. In New Zealand 40% of Māori males compared to 21%
of European males are smokers. One half (50%) of Māori females are smokers, compared with around one fifth (20%)
of European females.4
Smoking is a significant contributor to ethnic and socioeconomic health inequalities. All Māori who smoke should
be encouraged and supported to stop. Māori are equally as motivated and just as likely as non-Māori to have
made a quit attempt in the past year. Māori can be encouraged to quit smoking using nicotine replacement therapy
(NRT) and programmes such as Aukati Kai Paipa, a smoking cessation support programme delivered by Māori for Māori,
that takes a whānau based approach to smoking cessation. The programme reports that quit rates are significantly
better for Aukati Kai Paipa than conventional programmes.5
A first step to engaging Māori in reducing or stopping smoking may be to encourage a smoke-free house and car.
The age standardised prevalence of obesity (BMI ≥30kg/m2 in non-Māori and ≥32kg/m2 in Māori) is higher in Māori
than European New Zealanders. In 2002, 26.5% of Māori males were obese compared to 16.9% of European males. 26.1%
of Māori females were obese compared to 19.1% of European females.3
A diet rich in fruit and vegetables and low in fat is beneficial for preventing and managing cardiovascular disease
and diabetes. Diabetes services, including the provision of dietary advice, specifically developed for Māori are
ideal to encourage Māori to implement and benefit from them.6
�Ngāti and Healthy Prevent Diabetes Project�
�Ngāti and Healthy� is a community-based diabetes prevention programme set up in 2004 in the rural Māori
community of Te Tairawhiti where approximately half of the adults in the Ngāti Porou community have a glucose
metabolism disorder. The programme�s main aim is to reduce the prevalence of insulin resistance in the short term and
therefore reduce type II diabetes and associated complications in the long term.
The population based intervention has three key messages:
- Increase consumption of fruit and vegetables
- Increase consumption of wholegrain foods
- Increase exercise levels
Education to encourage behavioural change is directed at all community levels such as health promotion (e.g. radio
advertisements, posters featuring local personalities); structural changes (e.g. working with schools and employers
to encourage healthy food choices, retailer promotion of healthy options); community based education programmes (e.g.
exercise classes, weigh-ins and menu swaps).
An initial goal may be to agree on a number of days that healthy food is consumed.
Physical activity or �Green Prescriptions�
General advice to increase physical activity is often given by primary care providers. One study showed that
Māori and Pacific peoples received more physical activity advice and Green Prescriptions than other New Zealanders
although numbers were very small�the same study showed that only 13% of all people reported receiving advice about physical
activity and 3% reported receiving a Green Prescription.7
An initial goal may be a small but agreed and measurable increase in exercise, for example to walk to school, work or
shops at least three times per week.
Enrol Māori patients in management programmes and refer to Māori providers where suitable and/or available
Where possible, enrol Māori patients in disease-specific and/or Māori-based disease management programmes. A
sound knowledge of Māori services available within your region and referral processes is essential to ensure patients
and whānau are fully informed.
The Get Checked programme provides a free annual check-up for people with diabetes focusing on physical
health, lifestyle, and disease management.
Māori enrolment in the Get Checked programme in 2006 was lower than non-Māori.3 However, there
is encouraging evidence that once Māori are involved in these programmes, they receive similar access to recommended
care. For example, Māori in the Get Checked programme were prescribed statins at equivalent levels to others in the
programme. Māori also received similar access to the recommended tests including blood tests, retinal screening,
and blood pressure measurement.3 Strategies to increase access to these services, by ensuring Māori patients
are enrolled and actively followed up, will help to reduce inequalities.
Improve coordination with secondary care
There are a number of reasons why Māori do not make it to secondary care appointments, ranging from simple administration
issues such as recall or appointment letters sent to a wrong address to more complex issues such as cultural barriers.
Primary care services may need to co-ordinate secondary care appointments on behalf of their patients and work with
hospitals to ensure timing for their patient is suitable, transport is organised, and whānau or other support are
There is some evidence that having specialist clinics in a practice � a diabetes specialist or cardiologist visiting
once a month for patient follow up � can be used to reduce non-attendance to specialist appointments and improve patient
Although in recent years coronary revascularisation rates for Māori have increased, there are still disparities
with less Māori referred for these procedures even though they have a higher burden of cardiovascular disease.3
Increasing access to exercise testing and diagnostic tests may also be needed.9
It is not too hard!
There are many opportunities in primary care to improve the health of Māori and reduce disparities at an individual
and whānau level. The first step is to get involved and get your patients involved. Use every opportunity to engage
Māori in health care, promote prevention, screen earlier and recognise early symptoms of chronic disease. Enrolling
Māori in management programmes and referring them where appropriate to Māori providers and secondary care will
help to reduce disparities.
- Riddell T, Jackson R, Wells S, et al. Assessing Māori/non-Māori differences in cardiovascular disease risk
and risk management in routine primary care practice using web-based clinical decision support: (PREDICT CVD-2). N Z
Med J 2007; 120(1250). Available from:
- Rafter N, Wells S, Stewart A et al. Gaps in primary care documentation of cardiovascular risk factors. N Z Med J
- Robson B, Harris R. (eds). Hauora: Māori Standards of Health IV. A study of the years 2000-2005. Wellington:
Te R?p? Rangahau Hauora a Eru P?mare 2007.
- Bramley D, Riddell T, Crengle S, et al. A call to action on Māori cardiovascular health. N Z Med J 2004; 117(1197).
Available from: http://www.nzma.org.nz/journal/117-1197/957/
- Aukati Kai Paipa history. Available from:
- New Zealand Guidelines Group (NZGG). Management of type 2 diabetes. Wellington: New Zealand Guidelines Group. 2003.
- Croteau K, Schofield G, Mclean G. Physical activity advice in the primary care setting: results from a population
study in New Zealand. Aust N Z J Public Health 2006; 30(3): 262-267.
- Gruen RL, Weeramanthri TS, Knight SE, Bailie RS. Specialist outreach clinics in primary care and rural hospital settings.
Cochrane Database Syst Rev 2003; 4.
- Penney L, McCreanor T, Moewaka Barnes H. 2006. New perspectives of heart disease in Te Tai Tokerau: Māori and
health practitioners talk. Final report. Te R?p? Whariki, Massey University, Auckland.