Diabetes in Canada

Diabetes is a serious and growing public health problem in Canada with significant financial and human costs. In 2000-01, 4.1% of Canadians aged 12 and over were diagnosed as having diabetes. Among the 65 and over, 12.7% were diagnosed with diabetes. Of all diabetics in Canada, an estimated 90% have type 2 diabetes. Because of the nature of the disease, for example its lack of specific symptoms, many older Canadians are unaware they have diabetes. The 12.7% figure underestimates the extent of the disease among older Canadians.

Introduction

Since diabetes most often appears in adults between the ages of 51 and 60 and since our baby boom population is aging, the number of older Canadians with diabetes is expected to increase by about 50% in the next decade.

Left untreated or poorly managed, diabetes leads to other serious health problems. Diabetic complications increase with age and this exacerbates the effects of diabetes for seniors. Diabetes ranks as the seventh leading cause of death in Canada. People with diabetes are:

• 25 times more likely to become blind;
• 17 times more likely to have kidney disease;
• 20 times more likely to get gangrene;
• 15 times more likely to need a limb amputated; and,
• twice as likely to have a heart attack or stroke as the average older Canadian.

These outcomes have serious implications for the health care system serving diabetics. Older Canadians with diabetes are hospitalized 70% more often than non-diabetic seniors. Not only are acute health services more affected by this disease, but diabetes also increases the need for other supportive services including in-hospital chronic care, home care, drug benefits, supportive housing and transportation. Financially, the treatment of all diabetes and its complications in Canada, consumes an estimated nine billion dollars annually.

Incidence and Prevalence

The frequency of a disease may be measured in two ways: incidence and prevalence. Incidence is the number of new cases detected in the population at risk for the disease during a specific period measured as the number of new cases per 1,000 population. The incidence rate for type 2 diabetes is increasing significantly among Canadian adults.

Studies reporting incidence for diabetes in Canadian seniors show a rate of 8.6 new cases of diabetes for every 1,000 senior Canadians. The incidence rate is highest for those 65-74 at 9.5 per 1000 and declines at older age: the incidence rate is 7.9 for those 75-84 and only 3.1 for those 85 and older.

Prevalence is the total number of persons known to have had the disease at any time during a specific period and gives an idea of the importance of a disease at a given time. The National Population Health Survey (NPHS) 2000-01, reported the prevalence of diabetes between men (4.4%) and women (3.9%) as not that different.

The important relationship with the prevalence of diabetes is age. In 2000-01, the NPHS reported a prevalence rate of 4.3% for those 45-54, 8.7% for those 55-64, and 12.7% for those 65 and over. Provincially, the prevalence of diabetes is observed to be highest in Newfoundland (5.8%), Nova Scotia (5.2%) and New Brunswick (5.1%), and lowest in Alberta (3.4%). Analysis of the NPHS data for the survey years 1994-95 to 2000-01, indicates a trend toward increased diabetes prevalence for those 65-74 rising from 11% in 1994-95 to 12.9% in 2000-01.

Other factors that affect the prevalence rate among seniors are increased survival after diagnosis and the increasing likelihood of diabetes being indicated as the cause of death on death certificates.

Risk Factors and Control

There are several risk factors for type 2 diabetes, some modifiable, some not. Nonmodifiable risk factors include age, genetic predisposition, race and ethnic background and gestational diabetes. Modifiable risk factors include being overweight, being physically inactive, having a poor diet, having elevated cholesterol and triglyceride levels, and having high fasting glucose levels. People with the latter risk factors can benefit from adopting healthy behaviours.

Healthy behaviours are, however, influenced by education and income levels and individuals with lower income and less formal education are more likely to be overweight and physically inactive. The risk of diabetes increases with the amount and the duration of being overweight especially if the weight is concentrated around the waist.

A worrisome trend is the increase in overweight Canadians of all ages. Based on estimations of body mass index, Statistics Canada reported in 2000-01 that of the 55- 64 group, 39.8% were overweight. Six years earlier, the 1994-95 survey reported 38.1% overweight for this age group.

While being overweight is a modifiable risk, weight loss for older adults may result in loss of muscle tissue (sarcopenia) rather than adipose tissue. Depending on the age of the older adult, and the relative state of health, it is probably better to focus on the prevention of weight gain, along with messages connected to healthy eating and regular physical activity.

Physical inactivity also leads to a higher risk for the development of type 2 diabetes. In this regard, the trend has been very positive. In 2000-01, Statistics Canada reported that 51.1% of seniors aged 65-74 were inactive compared with the 1994-95 level of 58.3%.

Managing Diabetes

There is no cure for diabetes but it can be managed. Managing diabetes requires a multi-disciplinary team approach with close involvement of the diabetic. Older Canadians who have type 2 diabetes can manage their diabetes through education, meal planning, physical activity, achieving or maintaining a healthy weight and stress control.

It is possible that over time, additional treatment, oral medication or even insulin may be required to manage and treat the disease. To avoid complications, diligent blood sugar monitoring and close involvement with health service providers to monitor progress and side effects are critical to the managing process. Since diabetes can affect many different organs, the services of several different health disciplines may be required to complete the management of the disease.

Canadian Diabetes Strategy

In November, 1999, the Government of Canada committed $115 million over five years to Health Canada for the Canadian Diabetes Strategy (CDS) to prevent and control diabetes.

The CDS is an effort to develop and establish effective diabetes prevention and control strategies by adopting a population health approach. This strategy is designed to help to reduce the risk of diabetes developing in individuals without the disease, and the risk of complications in those living with it.

Working in partnership with the provinces and territories, Health Canada seeks to inform Canadians about diabetes, prevent diabetes where feasible, and help Canadians better manage diabetes and its complications. The strategy is comprised of four elements:

• National Coordination;
• Aboriginal Diabetes Initiative;
• Prevention and Promotion; and,
• National Diabetes Surveillance System.

National Coordination initiatives develop a national action plan. Working with partners, Health Canada promotes prevention, care, education, surveillance and research as part of this plan.

The Aboriginal Diabetes Initiative addresses the high numbers of type 2 diabetes among the Aboriginal population through community-based, culturally appropriate programs.

A major focus of Prevention and Promotion is to reduce the incidence and prevalence of diabetes in such at risk populations as: seniors, the overweight, and the physically inactive. There are four major areas of focus: knowledge development, public awareness, innovative practices and community development.

To achieve these objectives some 102 national and regional contribution projects have been funded in whole or in part by the Prevention and Promotion Contribution Program. This portion of the CDS has also supported other information projects associated with type 2 diabetes in the senior population.

The National Diabetes Surveillance System (NDSS) is a multi sector initiative geared to developing a national surveillance system. There are serious gaps in the information available regarding type 2 diabetes. The surveillance program aims to correct the situation by providing information in three broad areas. The first is diabetes care, services and their quality and diabetes management practice by health professionals. The second is the incidence and prevalence of type 2 diabetes and its complications and disabilities. The third area concerns provision of diabetes education, the effectiveness of prevention and control programs and the economic costs of diabetes.

The primary focus will be to use existing administrative data to resolve these knowledge gaps. All provinces and territories are partners in this initiative along with the Canadian Diabetes Association, Association Diabète Québec, the Aboriginal community, private industry and other non-government representatives.

Learning from Manitoba

To have more information on the factors that protect seniors from developing diabetes over time as well as approaches to promote effective management of the disease among diabetic seniors, the Division of Aging and Seniors, Health Canada commissioned analysis of data from the Aging in Manitoba Study (AIM). Because AIM has been collecting comprehensive health information from Manitoba seniors since 1971, it was possible to compare "healthy diabetic" seniors with "less healthy" diabetic seniors using self-rated health as a measure of overall health.

The study demonstrated many differences between healthy diabetics and less healthy diabetics. Over time, consistently more healthy diabetics were satisfied with life, were functionally more capable, and participated in more physical activities than the less healthy diabetics. Less healthy diabetics suffered from more chronic illnesses, especially heart and circulation problems, foot and kidney problems. Over time, healthy diabetics suffered fewer negative health outcomes and survived longer.

In addition to the AIM study, the Division of Aging and Seniors (DAS), commissioned "Seniors and Diabetes: A Canadian Perspective." This study clearly outlined the situation of seniors in Canada affected by diabetes and developed a profile of seniors affected by diabetes. It also reviewed current diabetes-related health promotion initiatives and identified the critical needs of seniors and their families. In partnership with Canadian Pensioners Concerned (CPC), DAS identified significant gaps in the information and programs on the prevention and management of type 2 diabetes available to seniors.

National Diabetes Information Projects

To increase seniors' awareness and knowledge about type 2 diabetes, the Prevention and Promotion Contribution Program of the CDS is working to improve diabetes prevention and control in Canada. This program makes people more aware of diabetes, its risk factors and complications, and how to delay or to prevent the onset of type 2 diabetes.

This strategy has placed a specific focus on the needs of seniors with diabetes or those who have a chance of developing type 2 diabetes. To develop the tools to fill the gaps in knowledge and practice, Health Canada supports projects across Canada. Of the 21 nationally funded projects, five focus on later adult life.

The Active Living Coalition for Older Adults (ALCOA) promotes a project called "Active Living and Diabetes: A prescription for change among older Canadians." This national coalition of groups involved in active living for older adults is developing an information kit and a speakers' bureau diabetes presentation that taps into their network for cross- Canada delivery by trained peer presenters.

The Canadian Centre for Activity and Aging (CCAA) is working on a project called "Evaluation and Dissemination of the First Step Program." The purpose of this project is to pilot and evaluate the First Step Program from a national perspective. The First Step Program gives front-line diabetes educators an effective, specific physical activity template (using pedometers) to use with individuals who have type 2 diabetes, to help them make a positive lifestyle change through increased physical activity.

The Canadian Ethnocultural Council (CEC) is working on two projects. The first is called "Diabetes in Older Adults from Hispanic, Black and Asian Populations: A communitybased prevention model." This project assesses the needs of older adults in specific populations to develop a community-based prevention model related to their preferred foods, menus and physical activities. The tools are developed in 13 different languages. The second CEC project is to develop best practice models for the prevention and management of type 2 diabetes among seven ethnic populations at risk.

Finally, the group Canadian Pensioners Concerned (CPC) has a project entitled "What Does It Take? The Development and Pilot Testing of a Diabetes Tool Kit for Older Canadians." This project will develop, evaluate and disseminate a diabetes tool kit and training material that includes senior-specific information. The information is developed and delivered by older adults and attempts to address issues related to those seniors who may not be reached by the usual channels of communication.

Conclusion

Type 2 diabetes is a major problem in Canada today. There is no quick fix. Although the picture of this disease is incomplete due to limited data, it is clear that for the near future, type 2 diabetes will impose an increasing health burden on older Canadians. Prevention and control will require the combined efforts of individual seniors and their families, health care providers, and health care institutions. Most promising though, is that through healthy living practices and good health care management, seniors with type 2 diabetes can manage their disease and enhance their opportunity to participate actively in life.

Additional information concerning diabetes is available on the Health Canada Web site: www.hc-sc.gc.ca.