diabetes: an epidemic in manitoba and canada · diabetes, but type 2 diabetes may be prevented or...

DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA

By: Melissa Bulloch

Home for the Summer Program – May to August, 2016

Stonewall, Manitoba

Supervisor: Dr. Greg Pinniger


2

INTRODUCTION:

The town of Stonewall, Manitoba is located 25 km north of Winnipeg, and is home to

approximately 4 536 people (as of the 2011 Census).1 The Stonewall & District Health Centre

has a total of 18 beds, and the Stonewall Medical Group provides day clinic as well as walk-in

clinic services in a workspace adjacent to the hospital. Most of the health services in Stonewall

are regulated by the Interlake-Eastern Regional Health Authority (IERHA), which covers an area

of 61 000 square km.2

Within one week of working in Stonewall, it quickly became apparent that the most

prevalent disease affecting the patient population—seemingly more common than the

‘common cold’—was diabetes. Every day there were multiple encounters. Some patients with

diabetes were elderly, others were relatively young, and all came from various ethnic

backgrounds. Given the numerous health risks and complications that often accompany

diabetes, it was concerning to see such high prevalence rates of the disease in the region.

The diabetes prevalence rate in the IERHA as of 2013 was 10.7%, and the prevalence in

the South Zone of the IERHA which contains Stonewall was 8%.3 Though the number of patients

with diabetes encountered in Stonewall seemed high, it is far less than the number of patients

with diabetes that would be met in the Northern Remote Zone of the IERHA, where the

diabetes prevalence was last found to be 40%.3 The current estimated diabetes prevalence in

Manitoba as of 2016 is 9.1% of the population, or 121 000 people.4,5 However, the prevalence

of diabetes in Manitoba has been forecast to increase by 37% in the next decade, reaching

11.3% (165 000 people) by 2026.4 The prevalence of prediabetes increased from an estimated

198 000 Manitobans in 2015 to 252 000 in 2016, and the prediabetes and diabetes prevalence


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is expected to reach 31.3% (458 000 people) in 2026.4,5,6 Given the projected rise in diabetes, it

is important to examine why the prevalence rate of diabetes in Manitoba is increasing, what

impact it is having on the health of Manitobans, what economic and financial strains it is placing

on patients and the health care system, and what treatments and prevention strategies are

being developed to address these issues.

A BRIEF OVERVIEW OF DIABETES:

Diabetes is a group of metabolic diseases that present as hyperglycemia (high blood

glucose, or ‘blood sugar’) as a result of the body being unable to produce insulin, or unable to

respond to the insulin produced.7 Insulin is required by the body in order to allow glucose to

enter the body’s cells so that it may be used as an energy source. Chronically elevated glucose

levels in the bloodstream can lead to many health problems such as organ, blood vessel, and

nerve damage.8

Complex interactions between genetic and environmental factors may lead to several

different causes of diabetes, which has resulted in the classification of diabetes into various

types. The two major types of diabetes are: Type 1, which results from insufficient insulin

production by beta cells in the pancreas due autoimmune beta cell destruction, and Type 2,

which primarily results from failure of the body’s cells to respond to insulin (insulin resistance)

which eventually leads to impaired insulin secretion. Today, approximately 90% of all diabetes

patients in Canada have type 2 diabetes.8 Currently, there is no way of preventing type 1

diabetes, but type 2 diabetes may be prevented or delayed by healthy eating, increased


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physical activity, and maintaining a healthy weight. This report will focus primarily on type 2

diabetes, given its high prevalence.

Diabetes can be diagnosed by a number of different blood tests that measure a patient’s

blood glucose values. Four major blood tests are used (see Table 1). Although all of the tests in

Table 1 are a valid means for diagnosing diabetes, today’s diagnosing criteria emphasize the

hemoglobin A1C or the fasting plasma glucose as the most reliable and convenient tests for

identifying diabetes in asymptomatic patients (although some individuals may meet diabetes

criteria for one test but not the other).7

Table 1. Diagnosis of Prediabetes and Diabetesa

Test

Test Result

Abnormal Blood Glucose Category

Fasting Plasma Glucose (mmol/L)b

≥7.0 Diabetes

2-h Plasma Glucose in a 75 g Oral Glucose Tolerance Test (mmol/L)c

≥11.1 Diabetes

Hemoglobin A1C (%)d 6.0 – 6.4 Prediabetes

≥6.5 Diabetes

Random Plasma Glucose (mmol/L)e

≥11.1 Diabetes

aAdapted from Canadian Diabetes Association: Clinical Practice Guidelines Quick Reference Guide,

2016.9

bFasting is defined as no caloric intake for at least 8 h.

cOral glucose tolerance test should be done using a glucose load containing the equivalent of 75 g

anhydrous glucose dissolved in water, with blood glucose levels measured at regular intervals (usually 1 h and 2 h after drink consumption) to measures the body’s ability to break down and use carbohydrate.

10 Not recommended for routine clinical use.

dHemoglobin A1C provides an assessment of blood glucose control for past 60-90 days. Glucose

binds irreversibly to hemoglobin in red blood cells, forming a stable glycated hemoglobin complex. The amount of glucose bound is directly related to the blood glucose concentration. eRandom is defined as having no regard to time since the patient’s last meal.

Note: If the patient is asymptomatic, a repeat test must be done to confirm. If the patient is symptomatic, the diagnosis is made.


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These tests also allow us to identify patients who are prediabetic. Prediabetes refers to

higher than normal blood glucose levels, but not yet high enough to be diagnosed with type 2

diabetes. It is estimated that between 5.7 and 6 million Canadians have prediabetes, and that

nearly 50% of people with prediabetes will develop type 2 diabetes.8,11 Research has shown

that certain long-term complications associated with diabetes may begin during prediabetes,

such as heart disease and nerve damage.12 It is also important to note that there are many

undiagnosed people with diabetes. It has been estimated that 52 000 Manitobans4 and nearly 1

million Canadians have undiagnosed diabetes.13 Globally, the Centers for Disease Control and

Prevention and the International Diabetes Federation’s Diabetes Atlas estimate that nearly 50%

of adults with diabetes are undiagnosed.7,14

Although neither type 1 nor type 2 diabetes is curable, both are treatable.8 Type 1 is

treated by administering lifelong insulin injections while closely monitoring diet and exercise.10

Type 2 is treated by closely monitoring diet and exercise, and often includes additional

medications (oral antihyperglycemic agents) and/or insulin to help control blood glucose

levels.10 Type 1 diabetes usually develops before patients reach the age of 30, while type 2

diabetes typically develops with increasing age.7,8 However, type 2 diabetes is now being

diagnosed more often in children, adolescents, and young adults, especially those that are

obese.7,12,15


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RISK FACTORS FOR DEVELOPING TYPE 2 DIABETES:

There is no single cause for type 2 diabetes. The dramatic increase in the number of

people developing type 2 diabetes is due to several risk factors (see Table 2). Some of these risk

factors are genetic, while others are modifiable.

Table 2. Risk Factors for Type 2 Diabetes in Canada7,13,16,17,18

First degree relative with type 2 diabetes (i.e., parent, sibling)

Age ≥40 yearsa

Member of high-risk population (e.g., Indigenous, African, Hispanic, South or Southeast Asian)b

History of prediabetes*

History of gestational diabetesc

History of delivery of a baby > 4 kg (9 lb)

Low socioeconomic status (SES) gauged by level of income, education, and employment statusd

Sedentary lifestyle/physical inactivity

Poor diet (e.g., too much high-calorie processed foods)

Presence of vascular risk factors:

Hypertension (blood pressure ≥140/90 mmHg)*e

Overweight and/or abdominal obesity*f

Triglycerides ≥1.7 mmol/L*g

High-density lipoprotein (HDL) cholesterol level < 1.0 mmol/L in males, < 1.3 mmol/L in females*h

Presence of associated diseases:

Polycystic ovary syndrome*i

Acanthosis nigricans*j

Human immunodeficiency virus-1 (HIV) infectionⱡ

Obstructive sleep apnea

Psychiatric disorders (bipolar disorder, depression, schizophrenia)

Use of drugs associated with diabetes:

Glucocorticoids

Atypical antipsychotics

Highly active antiretroviral therapy (HAART)ⱡ

Presence of end organ damage associated with diabetes:

Microvascular: retinopathy, nephropathy, neuropathy

Macrovascular: cerebrovascular, coronary, peripheral *Associated with insulin resistance. ⱡHIV and HAART increase the risk of prediabetes and type 2 diabetes 1.5 to 4-fold compared to the general population.

16


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aLikelihood of developing diabetes increases with age as the body’s ability to produce and use

insulin deteriorates.17

Guidelines recommend screening people ≥40 years for diabetes every 3 years, and screening earlier and/or more frequently in those with additional risk factors.

9,17

bSouth and Southeast Asian, Indigenous, African, and Hispanic have higher rates of prediabetes,

obesity, childhood type 2 diabetes, and type 2 diabetes occurring at younger ages.16

cGestational diabetes refers to diabetes first diagnosed or developed during pregnancy.

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dPhysical inactivity, inadequate consumption of vegetables and fruit, and daily smoking are more

common among Canadians with lower incomes compared to higher incomes.17,19

eBlood pressure is the pressure exerted by blood flow on artery walls. Hypertension increases the

risk of diabetic nephropathy, retinopathy, and cardiovascular disesase.10

fPeople with higher levels of fat around their abdomen and waist are at higher risk for diabetes. The number of overweight and obese Canadians is a major risk factor in increasing diabetes prevalence.

13 Approximately 37% of Canadian adults are overweight and 24% are obese.

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gTriglycerides are the main component in animal fats and vegetable oil. High levels raise the risk

of stroke and heart disease.10

hHDL cholesterol helps to transport cholesterol and other fats from the body. High levels can

reduce risk of cardiovascular disease.10

iPolycystic ovary syndrome is a leading cause of infertility. It is characterized by obesity, menstrual problems, enlarged ovaries, and insulin resistance.

10

jAcanthosis nigricans is a skin disorder characterized by dark patches of skin and thickening of the skin (often in the neck, groin, or underarms). It is common in children with type 2 diabetes and may indicate insulin resistance.

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WHY IS THE DIABETES PREVALENCE IN MANITOBA INCREASING?

An understanding of the many risk factors outlined in Table 2 helps illustrate why the

number of people with type 2 diabetes is increasing so dramatically in Manitoba. An aging

population, overall increase in population growth, higher diabetes incidence rates and lower

mortality rates are, in part, responsible for the projected 44 000 net increase in people

diagnosed with diabetes in Manitoba in the next decade.4,15 However, Manitoba’s population

has several other risk factors for diabetes, such as a lower median family income, and higher

rates of overweight and obesity (due in part to increasingly sedentary lifestyles) compared to

other provinces.13,21

Additionally, 16.7% of Manitoba’s population is comprised of Indigenous peoples, the

highest concentration of Indigenous people in Canada.22 People of Indigenous descent are

three to five times more likely to develop type 2 diabetes compared to the general


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population.12,16 Assuming the current diabetes prevalence in Manitoba is 9.1% of the

population,4 this would mean that the prevalence rates among Indigenous populations is

greater than 27%. Indigenous peoples in Canada are among the highest risk populations for

developing diabetes and diabetes-related complications. In fact, compared to the general

population: prediabetes is more common in Indigenous communities,16 obesity rates are higher

in Indigenous communities,23 and the age of diagnosis of type 2 diabetes is much younger

among Indigenous peoples.16 Although genetic factors are important when examining the

epidemic of type 2 diabetes among Indigenous peoples, it is the inequities in the social

determinants of health resulting from colonization that contribute to the main risk factors for

type 2 diabetes in Indigenous peoples. Decreased physical activity, increased obesity, food

insecurity, stress, unhealthy diet, unsafe water, and overcrowding issues are just some of the

socioeconomic factors contributing to the high prevalence of diabetes among Indigenous

peoples.8,16

Finally, it is important to note that although the likelihood of developing type 2 diabetes

increases as we age, especially after age 40, the number of children in Manitoba developing

type 2 diabetes has increased dramatically in the last decade. The first cases of type 2 diabetes

in pediatric populations in Canada were first identified in the 1980s in northern Manitoba. At

that time, children were only tested for type 1 diabetes, as type 2 was thought to be a condition

only adults were susceptible to. Now, Type 2 diabetes in children has increased in frequency

around the globe, and it is children from ethnic groups at high risk for type 2 diabetes in adult

populations (i.e., Indigenous populations in Manitoba) that are disproportionately affected.16 A

Canadian national surveillance study found Manitoba had the highest minimum incidence of


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type 2 diabetes in persons less than eighteen years in Canada of 12.45 per 100 000 children per

year.24 In contrast, the national minimum incidence of type 2 diabetes in persons less than

eighteen years was found to be 1.54 per 100 000 children per year. 44% of the children in the

study with new onset type 2 diabetes were of Indigenous heritage.24

DIABETES-RELATED COMPLICATIONS AND MORTALITY:

The increase in the prevalence of type 2 diabetes in Manitoba has major health

implications for Manitobans. It is incredibly important for people to avoid the hyperglycemic

state caused by diabetes, as the direct and indirect effects to the vascular system can affect

multiple organ systems and are a major source of morbidity and mortality.25 People with type 2

diabetes often have a long asymptomatic period of hyperglycemia prior to seeking care and

being diagnosed. As a result, many people with type 2 diabetes already have health

complications at the time of diagnosis.

The complications for type 1 and type 2 diabetes are similar, and are most easily divided

into vascular and non-vascular complications (see Table 3).26 Vascular diabetes complications

can be further subdivided into microvascular (damage to small blood vessels) and

macrovascular (damage to large blood vessels). The microvascular complications of diabetes

result directly from chronic hyperglycemia, whereas the macrovascular complications are

similar to those found in individuals without diabetes, but occur more frequently in individuals

with diabetes.26


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Table 3. Type 2 Diabetes-Related Complications26

Microvascular:

Retinopathya

Macular edemab

Sensory and motor neuropathyc

Autonomic neuropathyd

Nephropathye

Macrovascular:

Coronary artery disease (i.e., heart disease)

Peripheral arterial disease (e.g., insufficient blood flow to limbs)

Cerebrovascular disease (i.e., stroke)

Non-vascular:

Gastrointestinal (e.g., gastroparesisf, diarrhea)

Genitourinary (e.g., uropathyg, erectile dysfunction)

Dermatologic

Frequent or recurring infectious

Cataracts

Glaucoma

Periodontal disease

Hearing loss

Cheiroarthropathyh aCapillaries in the retina bleed or form new vessels.

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bSwelling in the macula (area near the centre of the retina responsible for high visual acuity).

cDisease of the peripheral nerves causing numbness, weakness, and/or pain (often in the hands

and feet).10

dDisease of the autonomic nervous system that affects one or several organ systems (e.g.,

genitourinary, cardiovascular, digestive). eDisease of the kidney.

fNerve damage to the stomach and/or intestines, delaying the emptying of their contents.

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gDisease or disorder of the urinary tract.

hThickened skin and limited joint mobility of the hands and fingers.

26

Note: In addition to the complications listed above, other comorbid conditions associated with diabetes include: obstructive sleep apnea, fatty liver disease, hip fractures, cognitive impairment or dementia, low testosterone in males,

26 and 30% of people with diabetes experience clinically

relevant depressive symptoms.16,27

The increased risk of complications associated with diabetes cannot be overemphasized.

Diabetes is the leading cause of blindness, non-traumatic limb amputations and end-stage renal

disease in Canadian adults.16,28 The majority of Canadians with diabetes (~80%) die from a heart

attack or stroke.8,16 According to Canadian Chronic Disease Surveillance System Conditions data


11

from 2009/09, at least one of every ten deaths among Canadian adults was attributable to

diabetes.17 Annually, diabetes contributes to the deaths of approximately 41 500 Canadians.12

Canadian adults with diabetes are twice as likely to die prematurely compared to those

without, as the life expectancy for individuals with type 2 diabetes may be shortened by 5 to 10

years.12 Fortunately, many diabetes-related complications can be delayed or even prevented

with early detection, diligent blood sugar control, and active behaviour and lifestyle changes to

lower the risks of complications as much as possible.26 Such interventions lead to improved

health outcomes for individuals with diabetes, but changing human behaviour and lifestyle can

be challenging. However, the financial costs of diabetes are rising, which is leading to the

development of more primary prevention programs targeting at-risk populations for early

screening and health education.

THE COST OF DIABETES IN MANITOBA:

Individuals managing chronic illnesses with numerous complications such as diabetes

face many challenges. One such challenge is the financial burden that diabetes and its

complications imposes on individuals. Diabetic patients require access to medications, devices,

diabetes education, and quality care to effectively manage their illness. People with diabetes

incur health care costs two to three times greater than people without diabetes. In fact, an

individual with diabetes can face direct costs for medication and supplies ranging form $1000 to

$15 000 per year.12 The annual out-of-pocket cost for Manitobans with type 2 diabetes is

approximately $1930, or 2-5% of their annual income.17 Between 25-57% of Canadians with

diabetes do not comply with their prescribed treatments because they cannot afford their


12

medications, supplies and devices, increasing their risk of costly and life-threatening

complications.17,29 The Canadian Diabetes Association has suggested that the federal

government implement a system of increased tax credits or medical expense deductions so that

people living with diabetes can afford to manage their disease.8

The increase in diabetes-related complications resulting from patients lacking sufficient

funds to access treatments only places further strain on our provincial, as well as federal,

healthcare systems. In 2010, the economic burden of diabetes in Manitoba was estimated to be

$498 million (measured in 2009 dollars), but the cost is expected to increase to $639 million by

2020.15 Unsurprisingly, it is the indirect costs of diabetes, such as mortality and long-term

disability, that account for the 83% of the total cost of diabetes in Manitoba, while direct costs

such as hospitalizations, physician visits and medications account for 17%.5,15 Thus, it is

imperative that people with diabetes have access to affordable medications, supplies,

education and care in order to manage their condition and avert the immense costs associated

with diabetes-related deaths and complications.

PREVENTION AND ACTION AGAINST DIABETES:

The epidemic of diabetes in Manitoba and Canada is well-documented and has been

discussed for the better part of a decade. Despite the growing awareness of diabetes and its

complications, the number of people with the disease continues to rise, along with the number

of people living unhealthy lifestyles placing them at risk of developing type 2 diabetes. At this

time, more than one in four Canadians lives with diabetes or prediabetes, and it is predicted

that this will increase to more than one in three by 2020 based on current trends.13 Currently,


13

diabetes costs the Canadian healthcare system and economy $11.7 billion, and will cost nearly

$16 billion annually by 2020 if these trends persist.13 Put simply, diabetes is a crisis. It is a

personal crisis for individuals living with the disease and for their families. It is a crisis for

healthcare professionals working to manage and treat the ever-growing number of people with

diabetes and diabetes-related complications. It is a crisis for the regional health authorities and

provinces working to develop new policies and programs, and it is financial crisis for our

healthcare system in Canada.

Diabetes is a highly complex disease influenced by several genetic and lifestyle factors

(see Table 2). For patients with type 2 diabetes, reaching optimal blood glucose, cholesterol and

blood pressure targets recommended by the Canadian Diabetes Association’s 2013 Clinical

Practice Guidelines16 helps to prevent or delay diabetes complications. Healthy blood pressure,

cholesterol and blood glucose levels can reduce adverse cardiovascular events by 60%, and

mortality by 56%.30 For this reason, patients with diabetes need regular laboratory tests with

timely healthcare provider follow-up to evaluate their blood glucose and cholesterol levels, and

risks of complications. For instance, it is recommended that people with type 2 diabetes have: a

hemoglobin A1C test every three months to monitor blood glucose, a cholesterol test every one

to three years and an eye exam every one to two years to check for retinopathy. Additionally,

patients with type 2 diabetes should receive regular assessments of blood pressure and feet, as

well as screening for signs or symptoms of early kidney disease.31 Unfortunately, less than half

of all people with type 2 diabetes are regularly tested for hemoglobin A1C, blood pressure,

cholesterol levels, or kidney function.31 Also, less than half of Canadians with type 2 diabetes

are at their recommended hemoglobin A1C target (usually less than 7%, normal in adults is 4-


14

6%), and more than half are unaware of their recommended hemoglobin A1C target level.8 It is

critical that patients with type 2 diabetes have adequate education and support from

healthcare professionals to effectively manage their health.

However, the truth of the matter is that there is no single quick solution to reduce the

prevalence of diabetes. For those that already have diabetes, several comprehensive multi-

factorial interventions are being utilized throughout Manitoba to reduce mortality and

complications. Several policies, systems and prevention programs have already been created to

promote healthy living, screen and address risk factors, establish effective treatment, and

improve quality of life, and many more are being developed.21,32 As an example, the

Community Wellness and Chronic Disease Prevention program in the IERHA offers several

diabetes education classes across its region, including: diabetes self-management, diabetes and

heart health, diabetes solutions with a nurse educator, dietary education classes, insulin

education classes, and healthy eating classes. Registered dieticians, chronic disease nurses,

wellness facilitators and diabetes nurse educators are available for one-on-one consults with

IERHA residents. The program seeks to promote healthy living for all residents of the IERHA,

and the staff frequently travel to smaller communities to provide better access to care.33

Ultimately, reducing the number of Manitobans and Canadians with type 2 diabetes

requires long-term planning and action. It will need to involve primary prevention initiatives

ranging from individual approaches, such as identifying risk factors and promoting lifestyle

change, to societal changes that reduce the risk factors of populations as a whole, such as

addressing the social determinants of health and creating supportive environments that

empower people to maintain active lifestyles and healthy eating habits. It is estimated that


15

more than 50% of type 2 diabetes cases could be prevented or delayed with healthier eating

and increased physical activity.13,16,17 Reversing the trend of increasing obesity rates would

lower the risk of developing type 2 diabetes, in addition to many other chronic diseases. Several

fields of research, such as those examining barriers to physical activity among Canadians,34 have

been crucial to developing interventions to encourage regular activity among different

populations (see Diabetes in Manitoba: A Call to Action p. 9-1132 for examples of existing

programs and programs being developed in Manitoba). However, there is still much room to

improve. The development of standardized diabetes education may help to improve self-

management while simultaneously raising awareness about diabetes.

Although much progress has been made to prevent and mitigate type 2 diabetes and its

complications in the past several years, the prevalence and costs of the disease are continuing

to rise, with more children and young adults being diagnosed. Improvements in the prevalence

of type 2 diabetes will not be realized in the short-term, but the Canadian Diabetes Cost Model

estimates that even a 2% reduction in diabetes prevalence would have a 9% reduction in direct

healthcare costs.5,8 Continuing to improve primary prevention efforts and the care and

management of individuals with type 2 diabetes is essential for improving the health of

Manitobans, and preventing the costs and prevalence of diabetes from rising. Ultimately,

widespread societal change aided by substantial government involvement is needed to reverse

the trends of modifiable risk factors and meet the specific needs of populations at high risk of

developing type 2 diabetes. Quality, research-driven public policies promoting healthy eating

and environments promoting physical activity need to be established to change our current

trajectory, and eventually solve the diabetes epidemic.


16

REFERENCES:

1. Town of Stonewall. Community Profile. http://www.stonewall.ca. Published 2012.

Accessed July 25, 2016.

2. Interlake-Eastern Regional Health Authority. About Us. http://www.ierha.ca. Published

2016. Accessed July 25, 2016.

3. Fransoo R, Martens P, The Need To Know Team, Prior H, Burchill C, Koseva I, Bailly A,

Allegro E. The 2013 RHA Indicators Atlas. Winnipeg, MB; 2013. http://mchp-

appserv.cpe.umanitoba.ca/reference/RHA_2013_web_version.pdf.

4. Diabetes Charter for Canada. Diabetes in Manitoba.; 2016.

https://www.diabetes.ca/getmedia/4f2e47fe-df8d-4e1d-9404-c5c56ac15fc7/diabetes-

charter-backgrounder-mb-2016-05.docx.aspx.

5. Informetrica Limited. Economic Cost of Diabetes in Canada: An Overview. Toronto, ON;

2009.

6. Diabetes Charter for Canada. Diabetes in Manitoba.; 2015.

https://www.diabetes.ca/getmedia/cdbdf426-fd2f-4e90-8794-4b79db7f3b40/diabetes-

charter-backgrounder-mb-2015-11.pdf.aspx.

7. Powers AC. Diabetes Mellitus: Diagnosis, Classification, and Pathophysiology. In: Kasper

DL, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of

Internal Medicine. 19th ed. New York, NY: McGraw-Hill; 2015.

http://accessmedicine.mhmedical.com.


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8. Canadian Diabetes Association. An Economic Tsunami: The Cost of Diabetes in Canada.;

2009. doi:10.1016/j.diabres.2005.03.024.

9. Canadian Diabetes Association. Clinical Practice Guidelines Quick Reference Guide. 2016.

http://guidelines.diabetes.ca/cdacpg_resources/CPG_Quick_Reference_Guide_WEB.pdf.

10. Canadian Diabetes Association. Diabetes Dictionary. http://www.diabetes.ca/about-

diabetes/diabetes-dictionary. Published 2016. Accessed July 29, 2016.

11. Canadian Diabetes Association. Prediabetes. http://www.diabetes.ca/about-

diabetes/prediabetes. Published 2016. Accessed August 2, 2016.

12. Canadian Diabetes Association. The Prevalence and Costs of Diabetes.; 2008.

http://archive.diabetes.ca/files/prevalence-and-costs.pdf.

13. Canadian Diabetic Association, Diabète Québec. Diabetes: Canada at the Tipping Point -

Charting a New Path.; 2011.

http://www.diabetes.ca/CDA/media/documents/publications-and-

newsletters/advocacy-reports/canada-at-the-tipping-point-english.pdf.

14. National Diabetes Services Scheme. Diabetes Globally.

https://www.diabetesaustralia.com.au/diabetes-globally. Published 2015. Accessed

August 2, 2016.

15. Canadian Diabetes Association. The Cost of Diabetes in Manitoba.; 2010.


newsletters/advocacy-reports/cost-of-diabetes-in-manitoba.pdf.

16. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian

Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and


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Management of Diabetes in Canada. Can J Diabetes. 2013;37(suppl 1):S1-S212.

http://guidelines.diabetes.ca/app_themes/cdacpg/resources/cpg_2013_full_en.pdf.

17. Public Health Agency of Canada. Diabetes in Canada: Facts and Figures from a Public

Health Perspective. Ottawa; 2011. doi:HP35-25/2011E-PDF.

18. Canadian Diabetes Association. Are You at Risk? http://www.diabetes.ca/about-

diabetes/risk-factors/are-you-at-risk. Published 2016. Accessed August 4, 2016.

19. Rabi DM, Edwards AL, Southern D a, et al. Association of socio-economic status with

diabetes prevalence and utilization of diabetes care services. BMC Health Serv Res.

2006;6:124. doi:10.1186/1472-6963-6-124.

20. Statistics Canada. Canadian Health Measures Survey, 2007-2009. The Daily.

http://www.statcan.gc.ca/daily-quotidien/100113/dq100113a-eng.htm. Published 2010.

Accessed August 4, 2016.

21. Canadian Diabetes Association. At the Tipping Point: Diabetes in Manitoba.; 2011.


newsletters/advocacy-reports/canada-at-the-tipping-point-manitoba-english.pdf.

22. Statistics Canada. Number and distribution of the population reporting an Aboriginal

identity and percentage of Aboriginal people in the population, Canada, provinces and

territories, 2011. https://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-011-

x/2011001/tbl/tbl02-eng.cfm. Published 2011. Accessed August 4, 2016.

23. Katzmarzyk PT. Obesity and physical activity among Aboriginal Canadians. Obesity.

2008;16(1):184-190. doi:10.1038/oby.2007.51.

24. Shazhan Amed, Heather J. Dean, Constadina Panagiotopoulos, Elizabeth A.C. Sellers,


19

Stasia Hadjiyannakis, Tessa A. Laubscher, David Dannenbaum, Baiju R. Shah, Gillian L.

Booth JKH. Type 2 Diabetes , Medication-Induced Diabetes , and Monogenic Diabetes in

Canadian Children: A prospective national surveillance study. Diabetes Care.

2010;33(4):786-791. doi:10.2337/dc09-1013.All.

25. Fowler MJ. Microvascular and Macrovascular Complications of Diabetes. Clin Diabetes.

2008;26(2):77-82. doi:10.2337/diaclin.26.2.77.

26. Powers AC. Diabetes Mellitus: Complications. In: Kasper DL, Fauci AS, Hauser SL, Longo

DL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 19th ed. New

York, NY; 2015. http://accessmedicine.mhmedical.com.

27. Canadian Diabetes Association. Diabetes and Mental Health.; 2013.

http://guidelines.diabetes.ca/CDACPG/media/documents/patient-resources/diabetes-

and-mental-health-2014.pdf.

28. Canadian National Institute for the Blind. About Diabetic Retinopathy.

http://www.cnib.ca/en/your-eyes/eye-conditions/eye-

connect/dr/about/Pages/default.aspx. Published 2015. Accessed August 5, 2016.

29. PSL Research. Report on Survey of Canadians with Type 2 Diabetes.; 2007.

30. Gaede P, Lund-Andersen H, Parving H-H, Pedersen O. Effect of a Multifactorial

Intervention on Mortality in Type 2 Diabetes. N Engl J Med. 2008;358:580-591.

doi:10.1056/NEJMoa0706245.

31. Diabetes Task Force. Diabetes Task Force Report to the Ministry of Health and Long-Term

Care. Toronto, ON; 2004.

32. Government of Manitoba. Diabetes in Manitoba: A Call to Action.; 2009.


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http://www.gov.mb.ca/health/primarycare/diabetes/docs/calltoaction.pdf.

33. Interlake-Eastern Regional Health Authority. Diabetes and Heart Health Education

Diabetes and Heart Health Education.

http://www.ierha.ca/default.aspx?cid=6387&lang=1. Published 2015. Accessed August

10, 2016.

34. Canadian Fitness and Lifestyle Research. Results of the Physical Activity Monitor 2007.;

2009.

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