The Not-So-Sweet Story of Diabetes in Canada

Jan Hux, MD SM FRCPC

CIFST Technical Meeting

October 20, 2017

Overview

1. The trajectory of the diabetes epidemic in Canada

2. What is driving the growth?

3. What approaches can turn the tide?

The Burden of Diabetes

• 3.5 M Canadians have been diagnosed with

diabetes – the number has doubled in the last 12

years

• Nearly 1M live with undiagnosed Type 2

• More than 6M meet criteria for prediabetes

• Another Canadian is diagnosed every 3

minutes

The Evolving Epidemic in Canada

3

4

5

6

7

8

9

10

11

12

13

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.02

00

0

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

20

14

20

15

20

16

20

17

20

18

20

19

20

20

20

21

20

22

20

23

20

24

20

25

Pre

vale

nce

(%

)

Nu

mb

er o

f p

reva

len

t ca

ses

(mil

lion

s)

Diabetes prevalence in Canada, 2000–2025

T1DM Prevalence T2DM Prevalence Prevalence Rate (right axis)

2015 Report on Diabetes: Driving Change. CDA

The Burden of Diabetes

At a time when people with diabetes made up 6% of the population, they accounted for:

• 30% of the strokes

• 40% of the heart attacks

• 50% of kidney failure requiring dialysis

• 70% of amputations

Life expectancy may be shortened by 5-15 years.

3

Beyond Chronic Complications

• The relentless “dailiness” of diabetes

•Misunderstanding and stigma

• Lost opportunities

• Isolation

What is the cause of this growth?

Look to the causes of type 2 diabetes!

•Genetics

• Lifestyle

• Environment

What is the cause of this growth?

Look to the causes of type 2 diabetes!

• Genetics• Canada is undergoing a demographic shift

• More than 20% of us are foreign born (highest in G8)

• Asia is now the largest source• Before 1970, 8.5% from Asia

• Since 2000, nearly 60% from Asia

• Increasing immigration from Caribbean and South/Central America

What is the cause of this growth?

Look to the causes of type 2 diabetes!

• Genetics

• Lifestyle• Sedentary behaviour

• Unhealthy foods; excessive portion sizes

Prevalence of Obesity, Ages 18+

Obesity in Canada, 2011, PHAC/CIHI

What is the cause of this growth?

Look to the causes of type 2 diabetes!

• Genetics

• Lifestyle

• Environment• Food availability and affordability

• Opportunities for physical activity

• Poverty

• Psychosocial stress

• Pollution

But that’s only part of the growth story…

•All of these factors contribute to growing incidence of diabetes (newly diagnosed cases)

• Increasing incidence only accounts for half of the growth in prevalence (total number of cases)

Overcrowding in the diabetes pool

Victims of Our Own Success?

Lipscombe, Lancet 2007; 369: 750–56

Mortality Rates for People with Diabetes

To summarize:

Diabetes rates are rising because:

• Demographics are changing (immigration)

• Sedentary lifestyle, overconsumption of unhealthy foods

• Unhealthy environments

• Improved survival

What is the role of food in fueling the epidemic?

• Food is part of the problem

What is the role of food in fueling the epidemic?

• Food is part of the problem

BUT

•Demonizing individual foods/food groups not helpful

Any food consumption pattern that leads to obesity increases the risk of type 2 diabetes

Does sugar consumption itself cause type 2 diabetes?

•Many studies!

• Inconclusive results

•No clear evidence that sugar is a problem apart from its impact on weight gain

HEALTH

Soft drinks, hard decisions: What Canada is doing amid the global sugar tax debateAs childhood obesity rates rise, the country is being drawn into the mix on the issue. Proponents say a tax is necessary to curb consumption while opponents argue that it will hit low-income families the hardest and lead to job losses. Where does the government draw the line?

From the Globe and Mail, October 14, 2017

Does SSB consumption cause type 2 diabetes?

• Weak satiating effects therefore risk of overconsumption

• Meta-analysis by Wang: high SSBs increased risk of diabetes by 1.30 times vs for low consumption

• This risk persisted after adjusting for BMI.

• EPIC-InterAct study showed HR of 1.22 for type 2 diabetes with one 12 oz SSB daily. After adjustment for energy intake and BMI, HR 1.18, 95% CI 1.06 to 1.32

How can we reduce over-consumption of SSBs?

• Free and safe water

• Education and awareness

•More informative labeling

•Restrictions on marketing to kids

• Taxation

“We don’t need a tax… we just need to educate people”

0

10

20

30

40

50

60

70

1982 1984 1986 1988 1990 1992 1994 1995

% w

ho

kn

ow

he

alth

eff

ect

of

die

tary

fat

“We don’t need a tax… we just need to educate people”

5

10

15

20

25

30

0

10

20

30

40

50

60

70

1982 1984 1986 1988 1990 1992 1994 1995

% O

bese

% w

ho k

now

hea

lth e

ffec

t of

diet

ary

fat

Year

Knowledge Obesity

Impact of Tax in other Jurisdictions

•Mexico

•Berkeley

•Chicago

•Philadelphia

What would the impact of a tax be in Canada?

•Over the next 25 years, a 20% tax on SSBs is projected to:• Prevent over 200,000 cases of type 2 diabetes

• Avoid over 13,000 premature deaths

• Generate health care savings of $11.5Bn

• Raise $43.6Bn in tax revenue that can be invested in health promotion

Summary

•Diabetes is an epidemic that imposes huge burdens on Canadians and threatens the sustainability of the healthcare system

•While individual efforts are important, they are not sufficient

•Healthy public policy is urgently needed

Questions?

Extra slides

Falling Complication Rates over Time

Gregg et al. N Engl J Med 2014; 370:1514-1523