Canada’s Silent Epi­demic: One Cana­dian in Three is Threat­ened by Di­a­betes

Policy - - In This Issue - Kimberley Han­son

One of the great ironies of pub­lic health trends in the 21st cen­tury is that, de­spite the height­ened aware­ness of—and glob­al­iza­tion of in­for­ma­tion avail­abil­ity on— chronic dis­ease pre­ven­tion, di­a­betes rates are sky­rock­et­ing. The good news is that life­style changes can pre­vent many peo­ple from de­vel­op­ing the dis­ease or its com­pli­ca­tions. But Canada needs an ac­tion plan.

You’re at a din­ner party or at work. Look to your left. Look to your right. Wher­ever you may be, if you’re in Canada, the chances are that ei­ther you or one of the peo­ple next to you has di­a­betes.

Today, four mil­lion Cana­di­ans have been di­ag­nosed with di­a­betes, of whom ap­prox­i­mately 300,000 have Type 1, while the rest have Type 2. An ad­di­tional one mil­lion Cana­di­ans are es­ti­mated to be liv­ing with un­di­ag­nosed Type 2 di­a­betes. Six mil­lion more Cana­di­ans are es­ti­mated to be liv­ing with pre­di­a­betes. Al­to­gether, 11 mil­lion Cana­di­ans—nearly one Cana­dian in three—are liv­ing with or threat­ened by di­a­betes. Glob­ally, di­a­betes cases world­wide more than dou­bled dur­ing the past 20 years.

By any def­i­ni­tion, di­a­betes, which af­fects over 400 mil­lion peo­ple world­wide, is a pan­demic.

Yet it’s not a health cri­sis Cana­di­ans on the whole seem pro­por­tion­ally con­cerned about. The last na­tional di­a­betes strat­egy fiz­zled away in 2014 fol­low­ing a scathing re­port on its un­der­per­for­mance by the Au­di­tor Gen­eral. All that re­mains of our pre­vi­ous na­tional strat­egy is the Abo­rig­i­nal Di­a­betes Ini­tia­tive. The 2018 fed­eral bud­get con­tained only one men­tion of the word di­a­betes in its 367 pages. Clearly, im­prov­ing the pre­ven­tion and man­age­ment of di­a­betes is not a top pri­or­ity for our coun­try.

But should it be? It should come as no sur­prise that as a rep­re­sen­ta­tive of Di­a­betes Canada—the na­tional pa­tient ad­vo­cacy or­ga­ni­za­tion on the dis­ease—and as a per­son with nearly a quar­ter cen­tury’s ex­pe­ri­ence liv­ing with Type 1 di­a­betes, I am ar­gu­ing that it should.

First, a re­fresher on the dis­ease: Di­a­betes is a meta­bolic dis­or­der in which the body ei­ther can­not pro­duce in­sulin or can­not prop­erly use the in­sulin it pro­duces. In­sulin is a hor­mone that con­trols the amount of glu­cose (sugar) in the blood. The body needs in­sulin to use sugar as an en­ergy source. Di­a­betes leads to high blood sugar lev­els, which can dam­age or­gans, blood ves­sels and nerves.

There are three types of di­a­betes:

• Type 1 di­a­betes, which is an au­toim­mune con­di­tion that gen­er­ally de­vel­ops in child­hood or ado­les­cence, and oc­curs when the body does not pro­duce in­sulin (or pro­duces very lit­tle) and re­quires the daily ad­min­is­tra­tion of in­sulin.

• Type 2 di­a­betes re­sults from the body’s in­ef­fec­tive use of in­sulin; when the body does not make enough in­sulin or can­not prop­erly use the in­sulin it pro­duces. This used to be a type of di­a­betes ex­clu­sively ex­pe­ri­enced by adults, but in­creas­ingly (and alarm­ingly) it is de­vel­op­ing in chil­dren. “Type 2 di­a­betes com­prises the ma­jor­ity of peo­ple with di­a­betes around the world, and is largely the re­sult of ex­cess body weight and phys­i­cal in­ac­tiv­ity,” ac­cord­ing to the World Health Or­ga­ni­za­tion (WHO).

• Ges­ta­tional di­a­betes is a tem­po­rary con­di­tion that de­vel­ops dur­ing preg­nancy and leads to in­creased risk of de­vel­op­ing Type 2 di­a­betes for both mother and child.

In ad­di­tion to these types of di­a­betes, there’s a pre­cur­sor con­di­tion known as pre­di­a­betes. Pre­di­a­betes refers to blood glu­cose lev­els that are higher than nor­mal, but not yet high enough to be di­ag­nosed as Type 2 di­a­betes. Nearly 50 per cent of those with pre­di­a­betes will go on to de­velop Type 2 di­a­betes.

Glob­ally, the num­ber of adults liv­ing with di­a­betes has quadru­pled since 1980, from just over 100 mil­lion to more than 400 mil­lion ac­cord­ing to the World Health Or­ga­ni­za­tion 2016 Global Re­port on Di­a­betes. In 2012, the dis­ease di­rectly caused 1.5 mil­lion deaths and el­e­vated blood glu­cose lev­els linked to di­a­betes were re­spon­si­ble for an ad­di­tional 2.2 mil­lion deaths that year.

The In­ter­na­tional Di­a­betes Fed­er­a­tion lists Canada in the bot­tom third of OECD (Or­ga­ni­za­tion for Eco­nomic Co-op­er­a­tion and De­vel­op­ment) coun­tries for di­a­betes preva­lence. More than twice as many Cana­di­ans live with di­a­betes today as did in 2000. Both preva­lence and di­rect costs of treat­ing the dis­ease in Canada have been ris­ing at a rate of four per cent per year and show no signs of slow­ing down. Di­a­betes costs our health care sys­tem $3.6 bil­lion per year in di­rect costs today, and that num­ber will soar to nearly $5 bil­lion within a decade.

And the best es­ti­mates sug­gest that the in­di­rect costs of di­a­betes in lost pro­duc­tiv­ity might add up to triple that amount. The per­sonal toll on in­di­vid­u­als and their fam­i­lies is in­cal­cu­la­ble.

Peo­ple of­ten ex­press to me that they don’t think di­a­betes is a par­tic­u­larly se­ri­ous dis­ease, which il­lus­trates how much is truly un­known. Di­a­betes-re­lated com­pli­ca­tions can be se­ri­ous and life-threat­en­ing. Peo­ple with di­a­betes ac­count for 30 per cent of the strokes, 40 per cent of heart at­tacks, 50 per cent of kid­ney fail­ure re­quir­ing dial­y­sis and 70 per cent of am­pu­ta­tions in Canada each year. The life ex­pectancy of a per­son with di­a­betes is short­ened by an av­er­age of 13 years.

Statis­tics Canada lists di­a­betes as the sev­enth lead­ing cause of death in Canada, and a key con­trib­u­tor to peo­ple de­vel­op­ing the top three causes (can­cer, heart dis­ease and stroke). Be­tween 2004 and 2008, when rates of di­a­betes in Canada were much lower, di­a­betes con­trib­uted to an ad­di­tional 10.6 per cent of all deaths. It is rea­son­able to as­sume that that rate has

Glob­ally, the num­ber of adults liv­ing with di­a­betes has quadru­pled since 1980, from just over 100 mil­lion to more than 400 mil­lion ac­cord­ing to the World Health Or­ga­ni­za­tion 2016 Global Re­port on Di­a­betes. In 2012, the dis­ease di­rectly caused 1.5 mil­lion deaths.

been main­tained if not in­creased in the in­ter­ven­ing years, which could mean that nearly 30,000 Cana­di­ans died of di­a­betes in 2015 (the last year for which data is avail­able).

With statis­tics like these, it’s easy to won­der why we’re not all pan­ick­ing about this epi­demic. And yet, like the prover­bial frog in the pot, we seem un­aware of the boil­ing wa­ter that sur­rounds us. It’s time for ur­gent change.

This is not a prob­lem that will be ad­dressed by per­sonal willpower and shame. To blame and stig­ma­tize those liv­ing with Type 2 di­a­betes for their dis­ease is not only un­help­ful, it is a vast over­sim­pli­fi­ca­tion. Type 2 di­a­betes is caused by a com­plex ar­ray of fac­tors in­clud­ing ge­net­ics, life­style and en­vi­ron­men­tal fac­tors such as poverty, re­duced ac­cess to clean drink­ing wa­ter, food in­se­cu­rity, and a dis­ease-pro­mot­ing food and phys­i­cal en­vi­ron­ment.

To re­ally turn the tide of the di­a­betes tsunami, we need a na­tion­wide ap­proach that helps all Cana­di­ans know the risks of di­a­betes, re­duces in­di­vid­ual risk fac­tors, pro­motes health­ier en­vi­ron­ments and cre­ates mea­sur­able health out­comes for pa­tients.

In 2018, Di­a­betes Canada is de­vel­op­ing just such an ap­proach. We’re build­ing on a suc­cess­ful ‘90-90-90’ model im­ple­mented in the HIV/AIDS com­mu­nity and adapt­ing it to tackle di­a­betes in Canada.

A ‘90-90-90’ ap­proach was pi­o­neered by Dr. Julio Mon­taner from the Univer­sity of Bri­tish Columbia and adopted glob­ally to com­bat HIV/AIDS. Canada will be the first coun­try to ap­ply such a model to re­duce the im-

pact of di­a­betes and it has the po­ten­tial to change the tra­jec­tory of this dis­ease in our coun­try.

Im­ple­ment­ing a 90-90-90 ap­proach would mean that, in time, 90 per cent of Cana­di­ans who are at risk for or liv­ing with di­a­betes would know their sta­tus, 90 per cent of those di­ag­nosed with di­a­betes or pre­di­a­betes would be ben­e­fit­ting from health­ier en­vi­ron­ments and ap­pro­pri­ate in­ter­ven­tions, and 90 per cent of them would be ex­pe­ri­enc­ing im­proved health out­comes.

This trans­lates into mil­lions of Cana­di­ans who are cur­rently on track to de­velop di­a­betes avoid­ing that fate. Mil­lions of Cana­di­ans with di­a­betes who are at risk of de­vel­op­ing se­ri­ous com­pli­ca­tions like blind­ness, kid­ney fail­ure or am­pu­ta­tion would see their risk re­duced. And sig­nif­i­cant time and money would be saved by our health care sys­tem.

While it’s early in the process to iden­tify the specifics of the 90-90-90 ap­proach, there are some tan­ta­liz­ing pos­si­bil­i­ties. For ex­am­ple, we know from re­search that when some­one who is at risk of de­vel­op­ing Type 2 di­a­betes makes mi­nor life­style ad­just­ments (los­ing 5-10 per cent of their body weight, for ex­am­ple), they are 60 per cent less likely to de­velop the dis­ease. That could mean that if we in­crease risk aware­ness, and then pro­vide ad­e­quate sup­port, we could help 3.5 mil­lion Cana­di­ans make mean­ing­ful changes to avoid or sig­nif­i­cantly de­lay de­vel­op­ing di­a­betes.

To de­velop the best ap­proach pos­si­ble to tack­ling this prob­lem, Di­a­betes Canada is work­ing with ex­pert stake­hold­ers rep­re­sent­ing more than 80 or­ga­ni­za­tions from coast to coast to coast to de­velop a rec­om­men­da­tion for how Canada can im­ple­ment a new ap­proach that will bring real re­sults.

Canada has a proud his­tory of be­ing on the fore­front of di­a­betes treat­ment, in­clud­ing 1923 No­bel co-lau­re­ate Dr. Fred­er­ick Bant­ing’s role in the dis­cov­ery of in­sulin in Toronto. A de­ci­sion by the fed­eral gov­ern­ment to sup­port a 90-90-90 ap­proach to di­a­betes could put Canada in a po­si­tion of global lead­er­ship in the treat­ment of di­a­betes in time for the 100th an­niver­sary of the dis­cov­ery of in­sulin in 2021. That is some­thing we could all be proud of.

Archbishop Des­mond Tutu once said, “There comes a point where we need to stop just pulling peo­ple out of the river. We need to go up­stream and find out why they’re fall­ing in.”

When it comes to the mil­lions upon mil­lions of Cana­di­ans who al­ready have or are well on their way to de­vel­op­ing di­a­betes and its many com­pli­ca­tions, the time to move up­stream and fix the prob­lem is now. With ex­pert guid­ance and in­put from hun­dreds of knowl­edge­able Cana­di­ans, Di­a­betes Canada plans to chart a path to do­ing just that.

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