diabetes patient education

8/9/2019 Diabetes Patient Education

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Canadian Diabetes Strategy: Time For Action

DIABETESAn Epidemic of the New

Millennium

Program & Policy

Implicationsfor Canada

Dr. Stewart HarrisUniversity of Western Ontario


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Canadian Diabetes Strategy: Time For Action,May 2003

Overview of Todays Talk

The Epidemiology

Current Healthcare Delivery &

Innovative Models Future Policy & Program Direction


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The World Wide Epidemic:Prevalence of Diabetes

5%

8%

14%

4%

3%


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The Worldwide Epidemic:Diabetes Trends

30

135177

221

300

370

0

50

100

150

200

250

300

350

400

MillionswithDiabetes

1985 1995 2000 2010 2025 2030

Sources: www.who.int

www.idf

Zimmet P. et al Nature: 414, 13 Dec 2001
http://www.who.int/http://www.idf/http://www.idf/http://www.who.int/


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The World Wide Epidemic:Millions with Diabetes 2000 & 2030

< 30

36 - 40

31 - 35

41 - 45

46 - 50

>50

People withDiabetes(millions)

2030

2000


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The World Wide Epidemic:Millions by Degree of Development

0

50

100

150

200

250

MillionswithDiabetes

Developed Countries Developing Countries

1995

2025

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


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The Diabetes Epidemic

in Canada

Prevalence, Risk Factors,

andCurrent Cost Implications


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The Canadian Epidemic:Prevalence of Diabetes in Canada,1996

0.6% 0.5% 0.5%0.7% 0.7%

1.9%

2.7%

4.4%

5.9%

8.2%

9.6%

10.2%

12.6%

10.2%

0%

2%

4%

6%

8%

10%

12%

14%

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

Preva

lence

(%)

Overall self-reportedprevalence (15+):3.4% (n=786,000)

Source: Statistics Canada, National Population Health Survey, Public Use Microdata,

1996/97


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The Canadian Epidemic:Prevalence in Canada, 1994/95 to 2000/01, by

Province

1996 -1997

2.53.1

3.23.20

3.203.2

3.2

3.40

4.60

4.6

Prevalence (%)

1.30 to2.903.00 to3.403.50 to 3.90

4.00 to4.405.00 to

5.405.50 to5.90Nodata

3.10

1998 - 1999

3.4

4.4

3.13.13.1

3.33.6

4.0

5.2

3.1

2000 -2001

1.3

3.43.9

4.0

4.0

4.1

4.25.0

5.1 5.2

5.8

3.2

1994 -1995

2.7

2.8

2.83.0

3.13.1

3.2

3.50

3.6

3.9

0

Source: Statistics Canada: CANSIM II


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These numbers are anunder-representationof the true burden of

diabetes.


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In international population based diabetesprevalence 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%

The Canadian Epidemic:

Undiagnosed DM and PreDiabetes

REF: The Australian Diabetes, Obesity and Lifestyle Study, Diabetes Care, V25 5, May 200

Harris MI, Eastman RC, Diabetes Metab Res Rev 2000 Jul-Aug;16(4):230-6


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The Canadian Epidemic:Age Distribution of Canadians with Diabetes in 2000& 2016

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000


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The Canadian Epidemic:Alberta Prevalence

First Nations

Social Services

Subsidy

No-Subsidy


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Diabetes Risk Factors

Modifiable Risk FactorsPhysical Activity

Obesity

Diet

&

Non-Modifiable RiskFactorsEthnicity

Family History


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Diabetes Risk Factors:Modifiable

0

1

2

RelativeRisk

>7 4 to 7 2 to 4 .5 to 2


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0

0.5

1

1.5

2

relativeris

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

Healthy Diet:

Relative Risk for Developing DM

Source: Choi B, Shi F. Diabetologia 2001, 44:1221-1231.



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0

10

20

30

40

RelativeRis


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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 generalpopulation,

which would translate to a lifetime risk of nearly

100%REF: Atlas of Diabetes 2nd Ed, Part 2, JS Sklyer, Editor



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2000

56

58

62

6263

64

65

65

6566

59

69

40 to 49

50 to 59

60 to 69

70 to 79

2001

47

55

61

61

67

50

57

62

63

49

5959

60

47

1999

57

65

67

6162

65 65

6872

55

47

urce: www.cflri.canadian Fitness & Lifestyle Research Institute

63

69

1998

51

56

58

60

63

67

7363

63

70

68

Diabetes Risk Factors: ModifiablePhysical Inactivity in Adults by Province,1998-2001
http://www.cflri.ca/http://www.cflri.ca/


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19901985

1994

< 10%

< 10% - 14.9%

> 15%No data

1996 1998

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

Diabetes Risk Factors: ModifiableObesity by Province: BMI 30


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The proportion of children andadolescents who are overweight hastripled in the past 3 decades.

Fat kids become fat adults

More fat kids means more fat adultsdown the road

Diabetes Risk Factors: ModifiableObesity


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The Canadian Epidemic:Future Implications

Two major demographics are at playin Canada:

Boomer and Echo Generation

Immigration and Ethnicity

High percentage of Canadianimmigrants are from ethnic groups that

are at high risk for the development ofDM


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The Epidemic:Non-Modifiable Risk

Factors

Ethnicity

AgeFamily History / Genetics


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The Epidemic:Ethnic Groups at High Risk for

DM

AboriginalLatino

South East Asian

Asian

African Descent


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


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

3.3

11

24.2

7.1

3.2

16.9

28

19.8

0

5

10

15

20

25

30

Male Female

Canadian

NPHS

Sandy Lake (DM)

Sandy Lake (IGT)

S a n

d y

L a

k e

( D M

)

Sandy

Lake(DM)

Sandy

Lake(IGT)

NPHS

(DM)

NPHS

(DM)

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


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Age-Standardized Prevalence of Obesity by GlucoseTolerance Status (BMI>27): Canada and Sandy Lake

35

50.9

63.9

73.1

27

64.6

77.575.1

0

10

20

30

40

50

60

70

80

Men Women

Canada Sandy Lake (Norm) Sandy Lake (IGT) Sandy Lake (DM

Both measures of obesity(BMI and WHR) wereassociated withincreasing glucoseintolerance for both sexes

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


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Prevalence of Abdominal Obesity (WHR) by GlucoseTolerance Status: Canada and Sandy Lake (Age-Standardized)

50

81.8

93.693.4

34

91.9

98.799.1

0

20

40

60

80

100

Men Women

Canada Sandy Lake (Norm)Sandy Lake (IGT) Sandy Lake (DM)

WHR was shownto be asignificantpredictor for

diabetes

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


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Pediatric Obesity Study:Sandy Lake and NHANES III Males, age 2-19

Di b t Ri k F t N


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77.1% of Canadas immigrantpopulation are coming frompopulations 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%

Diabetes Risk Factors:Non-ModifiableOther High-risk Groups in Canada

REF: Statistics Canada, 1996 Census


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Diabetes Complications

Macrovascular

Heart Disease and Stroke

Microvascular

KidneysEyes

Feet


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Macrovascular

ComplicationsThe 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


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Diabetes Complications:Macrovascular

DM is a major risk factor for cardiacdisease

Acute MI occurs 15-20 years earlierin those with DM

Heart disease accounts forapproximately 50% of all deaths

among people with diabetes inindustrialized countries

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


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Several large epidemiological studieshave found a strong relationshipbetween

glucose level and subsequent coronaryevents, even at pre-diabetes levels (IGTand IFG)

glucose levels that are only modestlyelevated 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.



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Relationship between FPG and CHD

REF: Coutinho et al. Diabetes Care 1999;22:233-40.

Metaregression - 20 prospective studies

n = 95,783 - follow-up 12.4 yrs

FPG > 6 mmol/L: RR 1.38 (1.06-1.67)

Fasting glucose (mmol/L)

Relative

Risk

2.5

2

1.5

1

4 5 6 7 8 9


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Men with DM

Male No DMWomen with DM

Women No DM



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Increasing Morbidity from IschaemicHeart Disease in Sandy Lake, Ontario

0

20

40

6080

100

120

IHDadmissions

per 10,000

persons

1983-1987 1988-1992 1993-1997

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


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Rates of Acute MI Admissions: 1980-1996Native Communities, Northern Ontario, All of Ontario

0

10

20

30

40

50

60

1980 1982 1984 1986 1988 1990 1992 1994 1996

AcuteMIsper10,0

00population

Native Communities Northern Ontario All Ontario

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


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98,925

158,056

228,214

0

50,000

100,000

150,000

200,000

250,000

CVDHospitalizations

1996 2006 2016

REF: Blanchard J. Unpublished

Projected Number of Cardiovascular Disease (CVD)Hospitalizations Among Persons with Diabetes, Canada



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Microvascular

ComplicationsNeuropathy accounts for 17%,

retinopathy for 10%, and

nephrology 21% of the costs of DMcomplications

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


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Diabetes.

Is the leading cause of non traumaticamputation

Increases the risk of amputation by 20fold

those living in the north or in low incomeneighborhoods and those with poor accessto physician services are at particular riskfor amputation.

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

Diabetes Complications:Microvascular Amputation


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First Nations

General Population

Diabetes Complications:Microvascular Amputation


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6,602

10,573

15,275

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

Amputation

1996 2006 2016

Projected Number of Lower Limb Amputations Among

Persons with Diabetes, Canada

REF: Blanchard J, Unpublished

Diabetes Complications:Microvascular - Amputation


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Diabetes

Is a leading cause of adult-onsetblindness

Prevalence of diabetic retinopathy is ~ 70% inpersons with type 1 and 40% with person withtype 2 diabetes.

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

Diabetes Complications:Microvascular Retinopathy


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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.

Diabetes Complications:Microvascular - Nephropathy


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First NationsSocial Services

Subsidy

No-Subsidy



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REF: Blanchard J,

Unpublished.

1,574

2,494

3,533

0

500

1000

1500

2000

2500

3000

3500

4000

New

Personsw

ithDiabe

teson

Dial

1996 2006 2016

Projected Number of New Persons withDiabetes on Dialysis, Canada



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Current Canadian Costs

The Financial Impact of

Diabetes

Cost of Diabetes:


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Cost of Diabetes:Impact of Diabetes on Health CareCosts

General Population Status Population

Diabetes No

Diabetes

Diabetes No

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

Estimated Selected Direct HealthCare Costs, Manitoba 1995/96


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The total economic burden (in US dollars) of diabetes andits chronic complications in Canada for 1998 was likely tobe between $4.76 and $5.73 billion.

In those people just with diagnosed diabetes, the directmedical costs associated with diabetes care, beforeconsidering complications, were $573 million.

Of the costs associated with the complications of

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

Cost of Diabetes:The Cost in Canada, 1998

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


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In 2002, the direct and indirect expenditures attributableto 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 diabetesprobably 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

Cost of Diabetes:The Cost in United States, 2002

REF: ADA, Diabetes Care, V26, 3 March

2003


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$24.6* billion

ChronicComplications

$44.1* billionGeneralMedical

Conditions

$23.2* billionDiabetes Care

$40.1 billion

Indirect

*DirectCosts

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

2003

Total Cost$132 billion

Cost of Diabetes:The Cost in United States, 2002

Cost of Diabetes:


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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

C t f Di b t


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Health care system can choose to investnow 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

Cost of Diabetes:Pay Now or. Pay Later


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Provisions in CDS Blueprint

Primary Prevention

Prevent diabetes through reduction of modifiablerisk factors in general population

Secondary Prevention

Screening those at high-risk for diabetes

Tertiary Prevention

Upon diagnosis of diabetes, prevention ofcomplications morbidity, and mortality

REF: Diabetes Blueprint


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Primary Prevention

Population Health Model


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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

P i P ti M d l


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REF: Health

Canada

Primary Prevention Model:Population Health National

CDS

Health Canada

NADA

P i P ti M d l


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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

Primary Prevention Model:Population Health


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Primary Prevention

Primary Care Model

Primary Prevention: Primary Care


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Primary Prevention:Primary CareModelRole of Primary Care Physician

First contact of patients with healthcare system is with family doctors

Role is

to promote healthy lifestyle

Healthy diet

Physical activity

Healthy body weight

Primary Prevention: Primary Care


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Large national sample of familyphysicians on lifestyle management 96% of FPs believe that lifestyle

interventions have a role in preventingand managing type 2 diabetes

86% believe that FPs should assesslifestyle

But.96% think lifestylecounseling and programsshould be provided by others

Primary Prevention:Primary CareModelCurrent Status

REF: Harris SB, Petrella RJ et al submitted Canadian Family Physician, 2003


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Screening Those at HighRisk


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Goal

Early identification of those withdysglycemia

Target High-risk individuals and groups

Messages

Diabetes awareness Current delivery model of secondary

prevention relies on primary care



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Secondary Prevention:


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Secondary Prevention:Challenges

Health care system focuses onacute 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

Secondary Prevention:


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REF: Chan, CIHI, 2002

Secondary Prevention:Challenges

Secondary Prevention: Strategies


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Secondary Prevention: StrategiesClinical Practice Guidelines

Our strategy hasbeen to developclinical practice

guidelines to assistproviders on howto screen patientsfor diabetes


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Tertiary Prevention

Diabetes Management


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Tertiary Prevention

Goals

Glucose, blood pressure, and lipidcontrol to reduce the development of

complications Complication screening for early

identification and management

Tertiary Prevention:


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Tertiary Prevention:Is it Effective?

Yes

Strong evidence for tertiary preventionparticularly for microvascular disease

DCCT, UKPDS How to translate this evidence into

practice?

Tertiary Prevention: Current Status


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Conclusions From a National Study(GPDM)

Patients are seen frequently by theirfamily physicians

Acceptable performance for

macrovascular disease complicationscreening (BP, lipids)

Major deficiencies were identified inmicrovascular disease complicationscreening (retinopathy,nephropathy, neuropathy, foot)

REF: Harris SB, et al Diabetes 2001

Tertiary Prevention: Challenges


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Tertiary Prevention: ChallengesThe Canadian Health Care System

Structure of system designed foracute care not chronic disease

Healthcare under-funding is a

barrier to diabetes care

Challenges to keep up withcomplications management

growing need for dialysis, costs formedications, hospital restructuring andphysician remuneration

Tertiary Prevention: Challenges


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Reduced funding and increaseddemand

Funding mechanism is problematic

No formal evaluation oneffectiveness

Limited flexibility in adapting to newcultural and linguistic realities inCanada

Tertiary Prevention: ChallengesHospital Based Model (DECs)

Primary Secondary Tertiary


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Primary, Secondary, TertiaryPrevention: Status

In Summary

The models and funding have notkept 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 withdiabetes


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Future Policy & Program

DirectionsRecommendations

Future Directions:


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Future Directions:Wake Up Call!

We know that diabetes is a world-wide epidemic

Are we, in Canada, going tobe proactive and meet thechallenge?

or be passive and pay thecost?

Future Directions:


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We CAN act on modifiable risk factors Aging population

Immigration from high-risk populations

Growth in aboriginal population

We CAN effectively target high-riskpopulations

Obesity

Physical inactivity Calorie-dense/high-fat diet

Future Directions:Take Action!

Future Directions: Cost to Act


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Cost of diabetes in Canada 2002 $13.2 billion

2010 $15.2 billion

2020 $19.2 billion

We CAN have an impact on the costby effective implementation and

utilization at all three levels ofprevention

Future Directions: Cost to ActPay NowPay Later


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Future Directions:


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Future Directions:Complexity of the Model


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So

What should a CanadianDiabetes Strategy address?

What should the priorities be?

Future Directions:i l i b S ill


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1. National Diabetes SurveillanceStrategy

One of the gems of CDS to date hasbeen the establishment of NationalDiabetes Surveillance System

We need to continue and expanddata collection in other jurisdictions,

and generate quality data includingcost on an ongoing basis

Future Directions: Primary Prevention


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2. National Strategies for Prevention &Promotion

Need increased effort on a national leveltargeting the general populations and

high risk groups Boomers

Aboriginals

Other high risk immigrant groups

for modifiable risk factors Obesity

Physical inactivity

Unhealthy diets

Future Directions:


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Future Directions:3. CDS National Coordination

Continued and enhanced effort toensure effective coordination withexisting federal and provincial

health promotionNutrition

Obesity prevention

prevention programs

Future Directions:TertiaryP ti


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Prevention4. Diabetes Education Centres

Existing Diabetes Care Models need tobe formally evaluated

We need to know.

who they are serving? how long are the waiting lists?

are they effective in addressing needs ofpatients with diabetes and pre-

diabetes? are they cost effective?

are the funding schemes appropriate?

Future Directions:


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Future Directions:5. Innovative Program Fund

We need a a program to fund and evaluatenew, innovative diabetes care models

Current care models are stale and in need ofinnovation

Best practice model

Target primary and secondary preventionaccording to regional needs (i.e. Latinos in ON, Asians inBC, lower SES geographic areas)

Should support 50-100 innovative programs

Future Directions:6 T l ti f E id i t


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6. Translation of Evidence intoPractice

CDS should be supporting efforts toimplement the evidence-basedclinical practice guidelines

Work to reduce the barriers tochronic care management.

Facilitate improved data collectionat primary and tertiary care level

Implement prospective, regionalregistry for diabetes

Future Directions:


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Future Directions:7. Aboriginal Diabetes Initiative

Need to fund two corollary programs, bothon and off reserve

1) Primary Prevention

MAJOR expansion of community-baseddiabetes prevention programs needed

2) Secondary & Tertiary Prevention

Establishment of a basic clinical diabetes and

complications prevention programs


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ResearchCanada has always been a

world-wide leader in

diabetes researchinnovations

From the discovery of

insulinto the Edmonton protocol

for islet transplants

Future Directions:


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8. Enhanced Research

The establishment ofNutrition,Metabolism, and Diabetes and the

Aboriginal Peoples Health Institutes

with increased funding was a majorimprovement in diabetes research.

We need to continue to expand thisfunding base

Future Directions:


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Research Priorities should include:

Pathophysiology of diabetes

Translation of evidence to practice

Health services

Prevention

Populations at risk (i.e. Aboriginal)

Canadian Diabetes Strategy 2005-2010


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2010New 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

Clinical

$75 (up from $58)

$250

Research $50

TOTAL $597 million(Up from $115

million)


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Is this a worthwhile

investment ? remember the cost of

diabetes in Canada nowand over the next 20

years.

2002 $13.2 billion

2010 $15.6 billion

2020 $19.2 billion


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$600 million for the

Canadian DiabetesStrategy

less than 4% of whatthis disease will cost us

by 2010

diabetes patient education

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