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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
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
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
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
3
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
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
4
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.
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
5
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
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
6
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
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
7
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.
10
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.
20
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.
10
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
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
8
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
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
9
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
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
10
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.
10
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.
10
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
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
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
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
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,
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
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-
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
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
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
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.
DIABETES: AN EPIDEMIC IN MANITOBA AND CANADA
16
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