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DIABETES

An Epidemic of the New


Millennium
Program & Policy
Implications
for Canada
Dr. Stewart Harris
University of Western Ontario

Canadian Diabetes Strategy: Time For Action


Overview of Today’s Talk

• The Epidemiology
• Current Healthcare Delivery &
Innovative Models
• Future Policy & Program Direction

Canadian Diabetes Strategy: Time For Action,


May 2003
The World Wide Epidemic:
Prevalence of Diabetes

5%

8%
3%
14%

4%

Canadian Diabetes Strategy: Time For Action,


May 2003
The Worldwide Epidemic:
Diabetes Trends
400 370
350
300
Millions with Diabetes

300
250 221
200 177
135
150
100
30
50
0
1985 1995 2000 2010 2025 2030

Sources: www.who.int
www.idf
Zimmet P. et al Nature: 414, 13 Dec 2001
Canadian Diabetes Strategy: Time For Action,
May 2003
The World Wide Epidemic:
Millions with Diabetes 2000 & 2030
2000
People with
Diabetes
(millions)
< 30
31 - 35
36 - 40
41 - 45
46 - 50
>50
2030

Canadian Diabetes Strategy: Time For Action,


May 2003
The World Wide Epidemic:
Millions by Degree of Development
250 1995
2025
200
Millions with Diabetes

150

100

50

0
Developed Countries Developing Countries

REF: www.who.int Sept 2002 Fact Sheet#236


Canadian Diabetes Strategy: Time For Action,
May 2003
The Diabetes Epidemic
in Canada
Prevalence, Risk Factors,
and
Current Cost Implications

Canadian Diabetes Strategy: Time For Action


The Canadian Epidemic:
Prevalence of Diabetes in Canada,
1996
14%
12.6%
12%
10.2% 10.2%
10% Overall self-reported 9.6%

prevalence (15+):
Prevalence (%)

8.2%
8%
3.4% (n=786,000)
5.9%
6%
4.4%
4%
2.7%
1.9%
2%
0.6% 0.5% 0.5% 0.7% 0.7%

0%
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+
Age Group

Source: Statistics Canada, National Population Health Survey, Public Use Microdata,
1996/97 Canadian Diabetes Strategy: Time For Action,
May 2003
The Canadian Epidemic:
Prevalence in Canada, 1994/95 to 2000/01, by
Province
1994 - 1996 - Prevalence (%)
1995 1997 1.30 to
2.90
3.00 to
3.40
3.50 to 3.90
4.00 to
4.60 4.40
5.00 to
2.7 3.9

2.8 3.2
0 3.
2.5
3.40
3.2
5.40
5.50 to
3.1 1 3.20
3.1 3.5 3.2
3.0 3.20 5.90
No
2.80 3.2
4.6
3.6
data

1998 - 1999 2000 -


2001

3.2
1.3
5.8
5.2
3.4 3.9
3.1 4.0 4.0
3.1 3.1 3.4 4.1
3.10 3.1 4. 5.0
3.6 4.2
3.3 4.4 0 5.1 5.2

Source: Statistics Canada: CANSIM II Canadian Diabetes Strategy: Time For Action,
May 2003
These numbers are an
under-representation
of the true burden of
diabetes….

Canadian Diabetes Strategy: Time For Action


The Canadian Epidemic:
Undiagnosed DM and ‘PreDiabetes’

In international population based diabetes


prevalence studies
• American study found:
– 33% of all cases of diabetes were undiagnosed
• Australian study found:
– 50% of all cases of diabetes were undiagnosed
• For a total prevalence of 7.4%

REF: The Australian Diabetes, Obesity and Lifestyle Study, Diabetes Care, V25 5, May 2002
Harris MI, Eastman RC, Diabetes Metab Res Rev 2000 Jul-Aug;16(4):230-6
Canadian Diabetes Strategy: Time For Action,
May 2003
The Canadian Epidemic:
Age Distribution of Canadians with Diabetes in 2000
& 2016

400,000

350,000
2000 (n=1.4 million)
300,000
Persons with Diabetes

2016 (n=2.5 million)


250,000

200,000

150,000

100,000

50,000

0
<5 5-9 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80+
14 19 24 29 34 39 44 49 54 59 64 69 74 79
Age Group

* Source: Statistics Canada Canadian Diabetes Strategy: Time For Action,


May 2003
The Canadian Epidemic:
Alberta Prevalence

First Nations

Social Services

Subsidy

No-Subsidy

Canadian Diabetes Strategy: Time For Action,


May 2003
Diabetes Risk Factors

Modifiable Risk Factors


•Physical Activity
• Obesity
•Diet

&
Non-Modifiable Risk
Factors
•Ethnicity
•Family History
Canadian Diabetes Strategy: Time For Action
Diabetes Risk Factors:
Modifiable
Physical Activity:
Relative Risk For Developing Diabetes
2
Relative Risk

0
>7 4 to 7 2 to 4 .5 to 2 <0.5
Hours per week

Source: Choi B, Shi F. Diabetologia 2001, 44:1221-


Canadian Diabetes Strategy: Time For Action,
1231.
May 2003
Diabetes Risk Factors:
Modifiable

Healthy Diet:
Relative Risk for Developing DM

1.5
relative risk

0.5

0
5 4 3 2 1
quintiles based on fat/fibre content

Source: Choi B, Shi F. Diabetologia 2001, 44:1221-


Canadian Diabetes Strategy: Time For Action,
1231.
May 2003
Diabetes Risk Factors:
Modifiable

Obesity:
Relative Risk For Developing DM
40
Relative Risk

30

20

10

0
<23 23-25 25-30 30-35 <35
2
BMI = wt/ (ht)

Source: Choi B, Shi F. Diabetologia 2001, 44:1221-


1231. Canadian Diabetes Strategy: Time For Action,
May 2003
Diabetes Risk Factors:
Modifiable
• Relative risk for developing type 2 is cumulative.
– A physically inactive individual (less than 30 min/wk of
exercise)
– who consumes an unhealthy diet
– and is modestly overweight (BMI 25-30)
– would have a 30-fold increased (1.8*2*8) risk of
developing type 2 DM compared to the general
population,
• which would translate to a lifetime risk of nearly
100%
REF: Atlas of Diabetes 2nd Ed, Part 2, JS Sklyer, Editor

Canadian Diabetes Strategy: Time For Action,


May 2003
Diabetes Risk Factors: Modifiable
Physical Inactivity in Adults by Province,
1998-2001
1998 1999

51 47
4
7 55
60
67
67
56 57
58 63 63 68 65
69 62 72 68
6 60 61
63 65 65
3
70 73

40 to 49
2000 50 to 59
2001
60 to 69
70 to 79
58
65 49
6
65 7
61
56
66 62 47
6 69 65 61 59
50 59 62
3 5
9 64 62 55
63 57
ource: www.cflri.ca
anadian Fitness & Lifestyle Research Institute
Canadian Diabetes Strategy: Time For Action,
May 2003
Diabetes Risk Factors: Modifiable
Obesity by Province: BMI ≥ 30

198 1990 1994


5

< 10%
1996 1998
< 10% - 14.9%
> 15%
No data

ource: Katzmarzyk PT, CMAJ Apr. 16, 2002; 166 (8)


Canadian Diabetes Strategy: Time For Action,
May 2003
Diabetes Risk Factors: Modifiable
Obesity
• The proportion of children and
adolescents who are overweight has
tripled in the past 3 decades.
• Fat kids become fat adults
• More fat kids means more fat adults
down the road

Canadian Diabetes Strategy: Time For Action,


May 2003
The Canadian Epidemic:
Future Implications
Two major demographics are at play
in Canada:
• ‘Boomer’ and ‘Echo’ Generation
• Immigration and Ethnicity
– High percentage of Canadian
immigrants are from ethnic groups that
are at high risk for the development of
DM

Canadian Diabetes Strategy: Time For Action,


May 2003
The Epidemic:
Non-Modifiable Risk
Factors
Ethnicity
Age
Family History / Genetics

Canadian Diabetes Strategy: Time For Action


The Epidemic:
Ethnic Groups at High Risk for
DM
Aboriginal
Latino
South East Asian
Asian
African Descent

Canadian Diabetes Strategy: Time For Action


Diabetes Risk Factors: Non-
Modifiable
Aboriginal Peoples in Canada & the World

Canadian Diabetes Strategy: Time For Action,


May 2003
Type 2 Diabetes Prevalence Rates:
NPHS, Sandy Lake to the Canadian Population,
age adjusted prevalence (%) by sex

30 28

25 24.2

20 19.8
16.9
15
Canadian

Sandy Lake (IGT)


Sandy Lake (DM)
Sandy Lake (DM)

11
NPHS
10
7.1 Sandy Lake (DM)
NPHS (DM)

NPHS (DM)
Sandy Lake (I GT)
5
3.3 3.2
0
Male Female

REF: Harris SB et al Diabetes Care 1997;20:185-187 & NPHS


Canadian Diabetes Strategy: Time For Action,
May 2003
Age-Standardized Prevalence of Obesity by Glucose
Tolerance Status (BMI>27): Canada and Sandy Lake

80
77.5
70 73.1 75.1
60 63.9 64.6 •Both measures of obesity
50 (BMI and WHR) were
50.9 associated with
40 increasing glucose
30 35 intolerance for both sexes
20 27
10
0
Men Women

Canada Sandy Lake (Norm) Sandy Lake (I GT) Sandy Lake (DM)

REF: Hanley AJG, Harris SB et al Diabetes Care 1997;20:185-187.


Canadian Diabetes Strategy: Time For Action,
May 2003
Prevalence of Abdominal Obesity (WHR) by Glucose
Tolerance Status: Canada and Sandy Lake (Age-
Standardized)

100
99.1
93.4 98.7
80 93.6
91.9
81.8
60

50
40
34
20
•WHR was shown
0
to be a
Men Women significant
predictor for
Canada Sandy Lake (Norm) diabetes
Sandy Lake (I GT) Sandy Lake (DM)

REF: Harris SB et al Diabetes Care 1997;20:185-187.


Canadian Diabetes Strategy: Time For Action,
May 2003
Pediatric Obesity Study:
Sandy Lake and NHANES III Males, age 2-19

Canadian Diabetes Strategy: Time For Action,


May 2003
Diabetes Risk Factors: Non-
Modifiable
Other High-risk Groups in Canada
• 77.1% of Canada’s immigrant
population are coming from
populations which from high risk
ethnic groups
• 7.3% Latinos
– Central and South America, 7.3%
• 57.0% Asian
• 12.8% African Decent
– Caribbean and Bermuda, 5.5%
– Africa, 7.3%

REF: Statistics Canada, 1996 Census

Canadian Diabetes Strategy: Time For Action,


May 2003
Diabetes Complications

Macrovascular
Heart Disease and Stroke

Microvascular
Kidneys
Eyes
Feet

Canadian Diabetes Strategy: Time For Action


Macrovascular
Complications
The management of macrovascular
disease is estimated to be the
largest component of diabetes-
related complications costs,
accounting for 52% of the costs
REF: Caro JJ, Diabetes Care 2002 Mar;25(3):476-81

Canadian Diabetes Strategy: Time For Action


Diabetes Complications:
Macrovascular
• DM is a major risk factor for cardiac
disease
• Acute MI occurs 15-20 years earlier
in those with DM
• Heart disease accounts for
approximately 50% of all deaths
among people with diabetes in
industrialized countries
REF: Diabetes in Ontario, An ICES Practice Atlas,
2002
Canadian Diabetes Strategy: Time For Action,
May 2003
Diabetes Complications:
Macrovascular
• Several large epidemiological studies
have found a strong relationship
between
– glucose level and subsequent coronary
events, even at ‘pre-diabetes’ levels (IGT
and IFG)
– glucose levels that are only modestly
elevated place patients at risk.

REF: Coutiho M. et al Diabetes Care 1999;22:233-240.


& DECODE Study Group. Arch Intern Med 2001;161:397-404.
Canadian Diabetes Strategy: Time For Action,
May 2003
Diabetes Complications:
Macrovascular
Relationship between FPG and CHD
Metaregression - 20 prospective studies
n = 95,783 - follow-up 12.4 yrs
2.5 FPG > 6 mmol/L: RR 1.38 (1.06-1.67)
Relative Risk

1.5

1
4 5 6 7 8 9
Fasting glucose (mmol/L)
REF: Coutinho et al. Diabetes Care 1999;22:233-40.

Canadian Diabetes Strategy: Time For Action,


May 2003
Diabetes Complications:
Macrovascular

Men with DM
Male No DM
Women with DM
Women No DM

Canadian Diabetes Strategy: Time For Action,


May 2003
Increasing Morbidity from Ischaemic
Heart Disease in Sandy Lake, Ontario

120
100
I HD 80
admissions 60
per 10,000
persons 40
20
0
1983-1987 1988-1992 1993-1997

REF: Hanley AJG, Harris SB et al Diabetes Care 1997;20:185-187.


Canadian Diabetes Strategy: Time For Action,
May 2003
Rates of Acute MI Admissions: 1980-
1996
Native Communities, Northern Ontario, All of Ontario

60
Acute MI s per 10,000 population

50

40

30

20

10

0
1980 1982 1984 1986 1988 1990 1992 1994 1996
Native Communities Northern Ontario All Ontario

REF: Baiju R. Shah, Arch Intern Med V160, 2000


Canadian Diabetes Strategy: Time For Action,
May 2003
Diabetes Complications:
Macrovascular
Projected Number of Cardiovascular Disease (CVD)
Hospitalizations Among Persons with Diabetes, Canada

250,000 228,214

200,000
158,056
CVD Hospitalizations

150,000

98,925
100,000

50,000

0
1996 2006 2016

REF: Blanchard J. Unpublished


Canadian Diabetes Strategy: Time For Action,
May 2003
Microvascular
Complications
Neuropathy accounts for 17%,
retinopathy for 10%, and
nephrology 21% of the costs of DM
complications

REF: Caro JJ, Diabetes Care 2002 Mar;25(3):476-81

Canadian Diabetes Strategy: Time For Action


Diabetes Complications:
Microvascular – Amputation
• Diabetes….
– Is the leading cause of non traumatic
amputation
– Increases the risk of amputation by 20
fold
• those living in the north or in low income
neighborhoods and those with poor access
to physician services are at particular risk
for amputation.

REF: Diabetes in Ontario, An ICES Practice Atlas, 2002

Canadian Diabetes Strategy: Time For Action,


May 2003
Diabetes Complications:
Microvascular – Amputation

First Nations

General Population

Canadian Diabetes Strategy: Time For Action,


May 2003
Diabetes Complications:
Microvascular - Amputation
Projected Number of Lower Limb Amputations Among
Persons with Diabetes, Canada
15,275
16,000

14,000

12,000 10,573
Amputations

10,000

8,000 6,602
6,000

4,000

2,000

0
1996 2006 2016

REF: Blanchard J, Unpublished Canadian Diabetes Strategy: Time For Action,


May 2003
Diabetes Complications:
Microvascular – Retinopathy
Diabetes
• Is a leading cause of adult-onset
blindness
• Prevalence of diabetic retinopathy is ~ 70% in
persons with type 1 and 40% with person with
type 2 diabetes.

REF: Diabetes in Ontario, An ICES Practice Atlas, 2002

Canadian Diabetes Strategy: Time For Action,


May 2003
Diabetes Complications:
Microvascular - Nephropathy
• Diabetes
– Is the leading cause of ESRD
– Increases the risk of developing ESRD
by up to 13-fold

Refs: Meltzer S, et al CMAJ 1998; 159 (8 suppl):S1-S29, &


Parchman ML, et al Medical Care 2002; 40(2):137-144.
Canadian Diabetes Strategy: Time For Action,
May 2003
Diabetes Complications:
Microvascular - Nephropathy

Social Services First Nations

Subsidy

No-Subsidy

Canadian Diabetes Strategy: Time For Action,


May 2003
Diabetes Complications:
Microvascular - Nephropathy
New Persons with Diabetes on Dialysis

4000
Projected Number of New Persons 3,533
with
3500 Diabetes on Dialysis, Canada
3000
2,494
2500

2000 1,574

1500

1000

500

0
1996 2006 2016

REF: Blanchard J,
Unpublished.
Canadian Diabetes Strategy: Time For Action,
May 2003
Current Canadian Costs

The Financial Impact of


Diabetes

Canadian Diabetes Strategy: Time For Action


Cost of Diabetes:
Impact of Diabetes on Health Care
Costs
Estimated Selected Direct Health
Care Costs, Manitoba 1995/96
General Population Status Population
Diabetes No Diabetes No
Diabetes Diabetes

Hospital $1196 $479 $2362 $893


PCH $340 $251 $195 $156
Professional $519 $271 $606 $267
Dialysis $114 $10 $493 $43
Total $2169 $1011 $3656 $1359
REF: Blanchard J, Unpublished, 2001
Canadian Diabetes Strategy: Time For Action,
May 2003
Cost of Diabetes:
The Cost in Canada, 1998
• The total economic burden (in US dollars) of diabetes and
its chronic complications in Canada for 1998 was likely to
be between $4.76 and $5.73 billion.

• In those people just with diagnosed diabetes, the direct


medical costs associated with diabetes care, before
considering complications, were $573 million.

• Of the costs associated with the complications of


diabetes, cardiovascular disease was by far the greatest
at $673 million.

REF: Dawson KG et al. Diabetes Care 2002 Aug;25(8):1303-7


Canadian Diabetes Strategy: Time For Action,
May 2003
Cost of Diabetes:
The Cost in United States, 2002
• In 2002, the direct and indirect expenditures attributable
to diabetes were estimated at $132 billion
– up from 1998 estimate of $92 billion

• The estimated $132 billion cost likely underestimates the


true burden because it omits intangibles,
– such as pain and suffering,
– care provided by non-paid caregivers,
– and several areas of health care spending where people with diabetes
probably use services at higher rates than people without diabetes (eg.
dental care, optometry care, and the use of licensed dieticians).

• Likely underestimating the growth of high risk populations

REF: ADA, Diabetes Care, V26, 3 March


2003
Canadian Diabetes Strategy: Time For Action,
May 2003
Cost of Diabetes:
The Cost in United States, 2002

Total Cost
$23.2* billion
$132 billion Diabetes Care
$40.1 billion
Indirect

$44.1* billion *Direct


General Costs
$24.6* billion Medical
Chronic Conditions
Complications

REF: Diabetes Care Vol. 26, No. 3 March


2003 Canadian Diabetes Strategy: Time For Action,
May 2003
Cost of Diabetes:
The Cost in United States & Canada,
2002
• Cost projections for the United States
– Annual cost, in 2002 dollars,
$132 billion, 2002
$156 billion by 2010
$192 billion by 2020
• Cost projections for Canada
– Cost estimates based 10% of population base
– Annual cost, in 2002 dollars,
$13.2 billion, 2002
$15.6 billion by 2010
$19.2 billion by 2020

REF: Diabetes Care Vol. 26, No. 3 March


2003 Canadian Diabetes Strategy: Time For Action,
May 2003
Cost of Diabetes:
Pay Now or…. Pay Later
• Health care system can choose to invest
now to help manage it properly
OR
• the alternative is to wait,
• AND spend….
– $50,000/yr for kidney dialysis
– $74,000 for the cost of a leg amputation
– Etc.

REF: CDA, 2003 www.diabetes.ca

Canadian Diabetes Strategy: Time For Action,


May 2003
Current Diabetes Models

Status, Gaps, Barriers,


Innovations

Canadian Diabetes Strategy: Time For Action


Provisions in CDS Blueprint

• Primary Prevention
– Prevent diabetes through reduction of modifiable
risk factors in general population
• Secondary Prevention
– Screening those at high-risk for diabetes
• Tertiary Prevention
– Upon diagnosis of diabetes, prevention of
complications morbidity, and mortality

REF: Diabetes Blueprint


Canadian Diabetes Strategy: Time For Action,
May 2003
Primary Prevention

Population Health Model

Canadian Diabetes Strategy: Time For Action


Primary Prevention Model

• Goal
– Reducing modifiable risk factors for diabetes
• Target
– General population & high-risk groups
• Messages
– Healthy lifestyle choices
• Current Delivery Models of Primary
Prevention
– Population Health
– Primary Care

Canadian Diabetes Strategy: Time For Action,


May 2003
Primary Prevention Model:
Population Health – National

CDS

Health Canada

NADA
REF: Health
Canada Canadian Diabetes Strategy: Time For Action,
May 2003
Primary Prevention Model:
Population Health
• Despite population health initiatives
• Obesity is increasing
• Diabetes is increasing
– Are these models and strategies under-
funded and maximally coordinated?
– Are the models and strategies effective?
– Are the models and strategies evaluated?
– Are these models well suited for many high-
risk groups
• Specific innovative models are needed

Canadian Diabetes Strategy: Time For Action,


May 2003
Primary Prevention

Primary Care Model

Canadian Diabetes Strategy: Time For Action


Primary Prevention: Primary Care
Model
Role of Primary Care Physician
• First contact of patients with health
care system is with family doctors
• Role is…
– to promote healthy lifestyle
• Healthy diet
• Physical activity
• Healthy body weight

Canadian Diabetes Strategy: Time For Action,


May 2003
Primary Prevention: Primary Care
Model
Current Status
• Large national sample of family
physicians on lifestyle management
– 96% of FPs believe that lifestyle
interventions have a role in preventing
and managing type 2 diabetes
– 86% believe that FPs should assess
lifestyle
– But….96% think lifestyle
counseling and programs
should be provided by others
REF: Harris SB, Petrella RJ et al submitted Canadian Family Physician, 2003

Canadian Diabetes Strategy: Time For Action,


May 2003
Secondary Prevention

Screening Those at High


Risk

Canadian Diabetes Strategy: Time For Action


Secondary Prevention

• Goal
– Early identification of those with
dysglycemia
• Target
– High-risk individuals and groups
• Messages
– Diabetes awareness
• Current delivery model of secondary
prevention relies on primary care

Canadian Diabetes Strategy: Time For Action,


May 2003
Secondary Prevention:
Is It Effective?
• Yes….
– Patients diagnosed with IGT can be
prevented from progressing to type 2
diabetes
• 58% reduction with lifestyle changes (DPP,
DPS)
• 30% reduction with medication (DPP, Stop
NIDDM)

Canadian Diabetes Strategy: Time For Action,


May 2003
Secondary Prevention:
Challenges
Health care system focuses on
acute care
• Preventive measures difficult to achieve
with this model
• Screening measures difficult to achieve
with this model
• No systems to track and facilitate
preventative practices
• Physician shortages

Canadian Diabetes Strategy: Time For Action,


May 2003
Secondary Prevention:
Challenges

REF: Chan, CIHI, 2002


Canadian Diabetes Strategy: Time For Action,
May 2003
Secondary Prevention: Strategies
Clinical Practice Guidelines
• Our strategy has
been to develop
clinical practice
guidelines to assist
providers on how
to screen patients
for diabetes

Canadian Diabetes Strategy: Time For Action,


May 2003
Tertiary Prevention

Diabetes Management

Canadian Diabetes Strategy: Time For Action


Tertiary Prevention

• Goals
– Glucose, blood pressure, and lipid
control to reduce the development of
complications
– Complication screening for early
identification and management

Canadian Diabetes Strategy: Time For Action,


May 2003
Tertiary Prevention:
Is it Effective?
• Yes…
– Strong evidence for tertiary prevention
particularly for microvascular disease
• DCCT, UKPDS
– How to translate this evidence into
practice?

Canadian Diabetes Strategy: Time For Action,


May 2003
Tertiary Prevention: Current Status
Conclusions From a National Study
(GPDM)
• Patients are seen frequently by their
family physicians
• Acceptable performance for
macrovascular disease complication
screening (BP, lipids)
• Major deficiencies were identified in
microvascular disease complication
screening (retinopathy,
nephropathy, neuropathy, foot)
REF: Harris SB, et al Diabetes 2001
Canadian Diabetes Strategy: Time For Action,
May 2003
Tertiary Prevention: Challenges
The Canadian Health Care System
• Structure of system designed for
acute care not chronic disease
• Healthcare under-funding is a
barrier to diabetes care
• Challenges to keep up with
complications management
– growing need for dialysis, costs for
medications, hospital restructuring and
physician remuneration

Canadian Diabetes Strategy: Time For Action,


May 2003
Tertiary Prevention: Challenges
Hospital Based Model (DECs)
• Reduced funding and increased
demand
• Funding mechanism is problematic
• No formal evaluation on
effectiveness
• Limited flexibility in adapting to new
cultural and linguistic realities in
Canada

Canadian Diabetes Strategy: Time For Action,


May 2003
Primary, Secondary, Tertiary
Prevention: Status
In Summary
• The models and funding have not
kept pace with the burden of disease
– Prevalence of diabetes increasing
– Recognition of new disease in IGT/IFG
– Models are not adequately designed to
prevent and care for people with
diabetes

Canadian Diabetes Strategy: Time For Action,


May 2003
Future Policy & Program
Directions
Recommendations

Canadian Diabetes Strategy: Time For Action


Future Directions:
Wake Up Call!
• We know that diabetes is a world-
wide epidemic…

• Are we, in Canada, going to


be proactive and meet the
challenge?
– or be passive and pay the
cost?
Canadian Diabetes Strategy: Time For Action,
May 2003
Future Directions:
Take Action!
• We CAN act on modifiable risk factors
– Aging population
– Immigration from high-risk populations
– Growth in aboriginal population
• We CAN effectively target high-risk
populations
– Obesity
– Physical inactivity
– Calorie-dense/high-fat diet

Canadian Diabetes Strategy: Time For Action,


May 2003
Future Directions: Cost to Act
Pay Now…Pay Later
• Cost of diabetes in Canada
– 2002 $13.2 billion
– 2010 $15.2 billion
– 2020 $19.2 billion
• We CAN have an impact on the cost
by effective implementation and
utilization at all three levels of
prevention

Canadian Diabetes Strategy: Time For Action,


May 2003
Future Directions:
Provisions of a Diabetes Model
• Public education and prevention
• Screening/Diagnosis of diabetes
• Education for those diagnosed
• Screening and treatment of
associated complications
• Treatment of diabetes/insulin
management
• Program evaluation

Canadian Diabetes Strategy: Time For Action,


May 2003
Future Directions:
Complexity of the Model

Canadian Diabetes Strategy: Time For Action,


May 2003
So…
What should a Canadian
Diabetes Strategy address?

What should the priorities be?

Canadian Diabetes Strategy: Time For Action


Future Directions:
1. National Diabetes Surveillance
Strategy
• One of the gems of CDS to date has
been the establishment of National
Diabetes Surveillance System

• We need to continue and expand


data collection in other jurisdictions,
and generate quality data including
cost on an ongoing basis

Canadian Diabetes Strategy: Time For Action,


May 2003
Future Directions: Primary Prevention
2. National Strategies for Prevention &
Promotion
• Need increased effort on a national level
targeting the general populations and
high risk groups
– Boomers
– Aboriginals
– Other high risk immigrant groups

for modifiable risk factors


– Obesity
– Physical inactivity
– Unhealthy diets

Canadian Diabetes Strategy: Time For Action,


May 2003
Future Directions:
3. CDS National Coordination
• Continued and enhanced effort to
ensure effective coordination with
existing federal and provincial
health promotion
Nutrition
Obesity prevention
prevention programs

Canadian Diabetes Strategy: Time For Action,


May 2003
Future Directions: Tertiary
Prevention
4. Diabetes Education Centres
• Existing Diabetes Care Models need to
be formally evaluated
• We need to know….
– who they are serving?
– how long are the waiting lists?
– are they effective in addressing needs of
patients with diabetes and ‘pre-
diabetes’?
– are they cost effective?
– are the funding schemes appropriate?

Canadian Diabetes Strategy: Time For Action,


May 2003
Future Directions:
5. Innovative Program Fund
• We need a a program to fund and evaluate
new, innovative diabetes care models
– Current care models are stale and in need of
innovation

• Best practice model


– Target primary and secondary prevention
according to regional needs (i.e. Latinos in ON, Asians in
BC, lower SES geographic areas)
– Should support 50-100 innovative programs

Canadian Diabetes Strategy: Time For Action,


May 2003
Future Directions:
6. Translation of Evidence into
Practice
• CDS should be supporting efforts to
implement the evidence-based
clinical practice guidelines
• Work to reduce the barriers to
chronic care management.
• Facilitate improved data collection
at primary and tertiary care level
• Implement prospective, regional
registry for diabetes
Canadian Diabetes Strategy: Time For Action,
May 2003
Future Directions:
7. Aboriginal Diabetes Initiative
Need to fund two corollary programs, both
on and off reserve
1) Primary Prevention
– MAJOR expansion of community-based
diabetes prevention programs needed
2) Secondary & Tertiary Prevention
– Establishment of a basic clinical diabetes and
complications prevention programs

Canadian Diabetes Strategy: Time For Action,


May 2003
Research
Canada has always been a
world-wide leader in
diabetes research
innovations
From the discovery of
insulin…
to the Edmonton protocol
for islet transplants
Canadian Diabetes Strategy: Time For Action
Future Directions:
8. Enhanced Research
• The establishment of Nutrition,
Metabolism, and Diabetes and the
Aboriginal People’s Health Institutes
with increased funding was a major
improvement in diabetes research.

• We need to continue to expand this


funding base

Canadian Diabetes Strategy: Time For Action,


May 2003
Future Directions:
Research Priorities should include:
• Pathophysiology of diabetes
• Translation of evidence to practice
• Health services
• Prevention
• Populations at risk (i.e. Aboriginal)

Canadian Diabetes Strategy: Time For Action,


May 2003
Canadian Diabetes Strategy 2005-
2010
New Component Costs for CDS ($
millions)
National Diabetes Surveillance System $12 (up from $10.8)

Prevention and Promotion-National $50 (up from $41.8)


National Coordination $25 (up from $4.4)
Evaluation of Current Models $10
Innovation Funds $100
Translation $25
Aboriginal Diabetes Initiative
–Primary Prevention $75 (up from $58)
–Clinical $250
Research $50
TOTAL $597 million
(Up from $115
Canadian Diabetes Strategy: Time For Action,
May 2003million)
Is this a worthwhile
investment ?
… remember the cost of
diabetes in Canada now
and over the next 20
years….
• 2002 $13.2 billion
• 2010 $15.6 billion
• 2020 $19.2 billion
Canadian Diabetes Strategy: Time For Action
$600 million for the
Canadian Diabetes
Strategy…

… less than 4% of what


this disease will cost us
by 2010

Canadian Diabetes Strategy: Time For Action