This post is the beginning of an integrated analysis of type 2 diabetes mellitus (T2DM) in Canada, drawing from the topics covered in #MHST601 #CriticalFoundationsinHealthDisciplines. Throughout this course, I have been continually challenged to learn more about T2DM and other health issues from multiple viewpoints and backgrounds of my classmates’ areas of interest.
Introduction
Nearly one-third of Canadians live with T2DM (Diabetes Canada, 2017). Public Health Ontario describes diabetes as “a chronic disease that occurs when the body is unable to sufficiently produce or use insulin, a hormone that regulates blood sugar” (Public Health Ontario [PHO], n.d.). Uncontrolled diabetes can lead to heart disease, kidney disease, eye disease, and lower limb amputation (PHO, n.d.; Whittemore et al., 2004). Depression is also more common among people with diabetes than in the general population (Diabetes Canada, 2020). T2DM develops due to a combination of genetic, environmental and lifestyle factors (Northwest LHIN, 2017). In many cases, the development of type 2 diabetes can be prevented or delayed (Diabetes Canada, n.d.).
Figure 1
Common diabetes mellitus complications
What is health for a type 2 diabetic?
In a previous blog post, I reviewed the World Health Organizations’s definition of health and concluded it is aspirational but not realistic. This is especially true for people who live with T2DM. While those with T2DM cannot obtain complete physical and mental, and social well-being, and these three domains of health are more difficult to overcome because of physical and psychological comorbidity, possibly resulting, in part, from social comorbidity, it is possible for diabetics to live ‘healthy’ lives. For a diabetic to maintain health, regardless of the point in the disease process they are in, health professionals encourage physical activity (150 minutes of moderate- to vigorous-intensity aerobic exercise each week), healthy food choices, living an enriching life, and medication compliance (Diabetes Canada, 2018a; Public Health Agency of Canada [PHAC], 2011). Glycated hemoglobin (HbA1c) target levels for most diabetics are 6.5-7.0% to reduce the risk of chronic kidney disease and retinopathy. The clinical practice guidelines allow flexibility in those parameters up to 8.5% HbA1c to minimize the risk of symptomatic hyperglycemia and acute and chronic complications (Diabetes Canada, 2018a).
Federal and Provincial Health Systems in Canada
As discussed in a previous blog post, the federal governance of provincial health care systems is determined by the Canada Health Act (Government of Canada, n.d.-a). The federal government also provides health care directly to Indigenous peoples and through the Public Health Agency of Canada (Government of Canada - Indigenous Services, n.d.; PHAC, 2011). “The increasing prevalence of diabetes and its complications pose a serious and growing burden on individual Canadians, Canada’s publicly funded health care system, and our economy.” (Diabetes Canada, 2017, p. 1). Diabetes Canada (2017) suggests that by 2026, the cost of diabetes to our public health care system will be approximately $5 billion. Sugar-sweetened beverage taxes have been recommended at both the provincial and federal levels by Diabetes Canada to help address the impact of diabetes and inform future policy (Diabetes Canada, 2017). “A modernized Canada Health Act will demonstrate a commitment to frequent review and an ability to prioritize emerging needs” rather than reactively or without direction (McMurran, M., 2022).
The Government of Ontario employs legislative documents to govern the provision of medically necessary care, as well as funding that is distributed to health administered through various Ministries. The Ministry of Health and the Ministry of Long Term Care distribute funds to Ontario Health, which then flow either to Home and Community Care Support Services (formerly the LHINs), the Aboriginal Health Access Centres or specific health care organizations (Martin, 2022). In 2008, the Government of Ontario introduced its first four-year Ontario Diabetes Strategy, whose purpose was to reduce diabetes risk and prevalence in the province, provide disease management support to patients, and improve access and quality of services and care to those impacted by diabetes; this was followed by an enhanced plan for the prevention and management of diabetes in 2012 (Diabetes Canada, 2018b). This strategy has not been renewed or expanded upon since (Diabetes Canada, 2018b). While the government of Ontario has taken steps to improve access to medications, devices, and supplies for those with type 1 diabetes mellitus, those with T2DM have very limited access to government assistance (Diabetes Canada, 2018b). Ontario’s Trillium Drug Program is available for those with T2DM who have high prescription drug costs in relation to their net household income (MoH, n.d.). For those that qualify, Trillium’s deductible costs about 3-4% of a person’s net income, and there is a $2 co-pay for each prescription refill (Diabetes Canada, 2018b; Ministry of Health [MoH], n.d.). Public Health Ontario is funded both by the municipalities and the province (PHO, n.d.). They provide scientific and technical advice and support to clients working in government, public health, health care, and related sectors. Regional Public Health Units (PHUs) are similarly funded and governed (PHO, n.d.). Regional public health units utilize health promotion strategies, create and promote social marketing campaigns, provide health care, and promote health equity specific to the populations they serve at the local level (NWHU, 2020). Federal and provincial policymakers, researchers and care administrators play a role in the prevention and management of T2DM in Canada.
Figure 2
Social ecological model of health overview
Multilevel understanding of type 2 diabetes
In this blog post, I reviewed Antonovsky’s salutogenic model of health, which helped me understand more fully how coping and coherence can be affected from a multilevel perspective.
This current article will provide a high-level overview of T2DM through the social ecological model of health. The social ecological theory attempts to comprehensively address the interdependencies between individual, interpersonal, community, organizational, environmental, and governmental levels (Whittemore et al., 2004).
On the individual level, genetic, biological, and personal history factors contribute to health status (Whittemore et al., 2004). Examples of personal history factors that affect the individual level are age, education, income, substance use status, and past trauma (Centers for Disease Control and Prevention [CDC], 2022). Whittemore et al. (2004) acknowledge that the majority of individuals who develop T2DM have a genetic predisposition compounded with health behaviours such as food choices and activity levels. Other individual-level characteristics that might impact T2DM diagnosis are income, education, dyslipidemia, obesity, sedentary lifestyle, illness, stress, steroid, or other medication use (Kino & Kawachi, 2020; Whittemore et al., 2004).
The interpersonal level includes the individual’sAntonovsky’s relationships with others (MCH Training Program, 2017). Interpersonal relationships can positively or negatively influence individual behaviours that contribute to the likelihood that a person might develop T2DM; examples of this include a social club that meets for an hour snowshoe every Saturday morning versus a spouse that brings home many desserts on their way home from work, 2-3 times a week (CDC, 2022). Interpersonal relationships contribute to a stronger social security network (Coffey et al., 2002).
The community level includes a larger group that can promote or inhibit behaviours and policies that might impact diabetes prevalence and prognosis. As noted previously, in Ontario, regional public health units and Home and Community Care Support Services. These organizations use evidence-informed approaches to plan and provide care (Northwest LHIN, 2017; NWHU, 2020). The visibility of these organizations within a community and distinct community culture and participation in any activities can partially impact disease outcomes (Northwest LHIN, 2017; NWHU, 2020). The socioeconomic status of the community and the economy of the community can also contribute to T2DM outcomes (Raphael, 2010).
The organizational level includes an individual’s workplace or school policies. Workplaces that encourage healthy behaviours such as lunchtime walking groups or fitness challenges or inclusion of a gym membership and prescription drug coverage in the benefits package foster healthy organizations. For those already diagnosed with the disease, workplace policies promote good disease management, such as flexibility in the schedule for breaks to have a snack. Many other organizational factors, such as employment security, could impact blood glucose levels, as stress can play a large part in disease management (Raphael, 2010). The organization’s health and stability also impact attitude and health status (discussed in the social determinants of health section of this post) (Raphael, 2010).
The environmental level refers to the health of the place where someone lives. Examples of T2DM prevention and management impact include proximity to green spaces, rural- and remote-dwelling, and air quality.
As discussed in-depth above, public policy from the governmental level also significantly impacts the individual (Government of Canada, n.d.-b; Meili, 2012).
In order to understand and address T2DM, the interplay between each of the aforementioned levels must be acknowledged. By acknowledging this interplay and understanding that this interplay varies across the life course, we can begin to treat T2DM more holistically and without a one-size-fits-all approach (National Institutes of Health [NIH], 2011).
Determinants of Health
The social determinants of health greatly inform all multilevel models of health. Canada officially recognizes twelve determinants of health (Government of Canada, n.d.-b). Income and social status, employment and working conditions, education and literacy, childhood experiences, physical environments, social supports and coping skills, healthy behaviours, access to health services, biology and genetic endowment, gender, culture, and race. Some of these will be investigated more in-depth throughout this post.
In Ontario, public coverage for drug therapy to treat diabetes varies based on a person’s income level and prescribed therapy: the level of coverage impacts out-of-pocket costs (Diabetes Canada, 2018b). For many Canadians with diabetes, treatment adherence is affected by cost. When people with type 2 diabetes reach 65 years of age, many expenses are covered by the Ontario Drug Benefit program (ODB); however, not all needed medications are insured by ODB, and some are overly restricted (Diabetes Canada, 2017). Most Canadians with diabetes pay more than 3% of their income or over $1,500 per year for prescribed medications, devices, and supplies out-of-pocket (Diabetes Canada, 2020). There are currently no caps on the price of necessary diabetes medication, supplies, and devices (Goldman, 2019). The prevalence of diabetes among adults in the lowest income groups is 4.9 times that of adults in the highest income group (Diabetes Canada, 2020).
Overly active work can impact those people with T2DM, while overly sedentary work can be a risk factor for T2DM and complications of this chronic disease (Raphael, 2010). Health and extended health benefits associated with many secure full-time workplaces have also been shown to impact the likelihood of developing T2DM as well as minimize the risk of serious complications (Raphael, 2010). Adults who are permanently unable to work have a diabetes prevalence 2.9 times that of employed adults (Diabetes Canada, 2020). Adults who have not completed high school have a diabetes prevalence 5.2 times that of adults with a university education (Diabetes Canada, 2020).
The customs and social institutions of a particular region or group of people play a role in T2DM diagnosis. In Canada, diabetes rates are highest among First Nations, Metis, and Inuit cultures. Rates of diabetes are higher in northern rural and remote regions of Canada and Newfoundland and Labrador, another place where culture significantly impacts health (Diabetes Canada, 2017).
The prevalence of diabetes among South Asian and Black adults is 8.1 times and 6.6 times higher, respectively than the prevalence among White adults (Diabetes Canada, 2017). Refugee groups are also at risk (Diabetes Canada, 2020).
Specific populations and diabetes
The prevalence of diabetes and its complications are disproportionately higher among lower-income earners and Indigenous communities. Diabetes rates are 3–5 times higher in First Nations than in the general population. Other populations at higher risk of type diabetes include those of Asian, South Asian, African, and Hispanic descent and those over 45 (Diabetes Canada, 2017, pp. 1–2).
The age-standardized prevalence rates for diabetes are:
14.4% among people of South Asian descent
12.9% among people of African descent
9.4% among people of Arab/West Asian descent
8.2% among people of East/Southeast Asian descent
4.5% among people of Latin American descent
17.2% among First Nations individuals living on reserve
10.3% among First Nations individuals living off-reserve
7.3% among Métis people
(Diabetes Canada, 2020)
Figure 3
Age-mortality rates for diabetes in Ontario
Chronic disease prevention and management
Public Health Ontario reports an average mortality rate of 18 compared to a mainly rural dwelling mortality rate of 24.5. The Northwestern health until has the highest diabetes age-mortality rate in Ontario at 42.4. (Figure 1).
The northwestern health unit has some of the poorest health outcomes in Ontario, with some of the highest rates of chronic disease (NWHU, 2020).
Chronic disease prevention is one of the Northwest LHIN’s (now transitioning to home and community support) top priorities (Northwest LHIN, 2017). Close communication between DEPs, FHTs and OHT partners decreased duplication and improved access to care while optimizing human health resources (Northwest LHIN, 2017). The LHIN advocates for and supports the use of technologies in the self-management of diabetes through remote care monitoring services. To address the unique concerns of remote first nations communities in Northern Ontario by training community health workers in treatment plan support for chronic conditions such as diabetes to bridge gaps in care in their communities (Northwest LHIN, 2017). The northwest LHIN (2017) describes the role of community health workers in T2DM care as primary adherence to treatment plans, monitoring, appointment facilitation, and associated clerical work. This also provides continuity of care by keeping regular providers from within communities to liaise with the rotation of primary care providers that is common in the North (Northwest LHIN, 2017).
Coffey et al. (2002) applied quality of life measures to life-adjusted years to review T1- and T2DM prognostic indicators in non-obese diabetics. They used these measures to compare medical treatments with different clinical outcomes and impacts on survival in determining the health utilities associated with diabetes complications and comorbidities. The implications of this study were to help guide management strategies in the most economical way to care for diabetics. To keep blood glucose under control and prevent or manage complications, many people with diabetes take multiple medications: 32% of Canadians reported taking three to four medications, 40% reported taking five to nine, and 12% reported taking ten medications or more, which significantly impacts quality of life (Coffey et al., 2002; Diabetes Canada, 2018).
Future directions for diabetes care
“The costs to Canadian employers are equally troubling. Employees with type 2 diabetes cost employers an estimated $1,500 annually per employee due to reduced productivity and missed work. Drug plan spending for employees treating type 2 diabetes is four times the amount for all other claimants. For employees who must take disability leave because of their diabetes, the leaves are 15% longer in duration.” (Diabetes Canada, 2017, p. 3). Some employees with diabetes rely so heavily on group health benefits to manage their disease that they necessarily limit their employment prospects (Diabetes Canada, 2017).
Diabetes Canada (2017) recommends that the government strengthen healthy eating initiatives by implementing a levy on sugar-sweetened beverages, to be applied to manufacturers and consumers. In 2014, Mexico introduced the sugar-sweetened beverage tax and consumption of those drinks dropped by 12% in the first year (Diabetes Canada, 2017, p. 4).
A provincial Diabetes Strategy that incorporates a 90-90-90 target for diabetes could mean:
More people at risk of developing diabetes would be aware of their status and take preventative measures, thereby avoiding developing the disease.
More people who develop diabetes would know sooner, minimizing complications and maximizing opportunities to reverse or slow the pace of the disease.
More people living with diabetes would be receiving specialized counselling and care, thereby experiencing fewer complications and adverse health outcomes.
Fewer people with diabetes would develop serious complications, which would reduce high costs to the health care system.
(Diabetes Canada, 2018b, p. 4).
As stated in an earlier post on modernizing the Canada health act, small actions can be taken to improve the portability of care by having inter-regional or inter-provincial collaboration for health systems or records release on behalf of the patients, as well as similar fees for prescriptions and drug programs across Canada to minimize the impact being greater in some provinces for certain chronic health conditions.
In addition, utilizing technologies specific to diabetes diagnosis and management will be imperative in future directions for health care in Canada. In one study, 30% of diabetic respondents reported a willingness to adopt Remote Care Monitoring technologies, even if they offered little health improvement compared to their current monitoring. Most believed they would be willing to adopt minimally-invasive technologies but sought a greater degree of effectiveness if the technology was perceived to be more invasive (Oikonomidi et al., 2021). AI for T2DM care can be better incorporated if different technologies could pair and exchange the gathered biometrics (Dankwa-Mullan et al., 2019). To improve early diagnosis and improved diagnosis of vulnerable populations, non-invasive tools such as facial and tongue feature recognition, clinical decision making and diagnosis support, EMR cohorting, and predictive population risk stratification (Dankwa-Mullan et al., 2019). Self-management tools such as artificial pancreas, continuous glucose monitoring, Remote Care Monitoring, food recognition and calculation software, and diabetes-specific activity information cal help empower people with T2DM to take control of their health condition and become more involved in their care plan (Dankwa-Mullan et al., 2019).
Conclusion
Writing this post brought together the concepts covered in this course to “scratch the surface,” so to speak, on influences on T2DM prevalence and prognostic factors within our Canadian care system. Because diabetes continues to increase in prevalence, the time to address these factors at each level of impact, both through upstream and downstream means, is imperative to reduce the burden on the Canadian health care system and, most importantly, the lives of our patients.
References
Centers for Disease Control and Prevention. (2022, January 18). The social-ecological model: A framework for prevention. CDC website. https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html?msclkid=97a1718cb4dd11eca20a9b9ffd002b91
Coffey, J., Brandle, M., Zhou, H., Marriott, D., Burke, R., Tabaei, B. P., Engelgau, M. M., Kaplan, R. M., & Herman, W. H. (2002). Valuing health-related quality of life in diabetes. Diabetes Care, 25(12), 2238–2243. https://doi.org/10.2337/diacare.25.12.2238
Dankwa-Mullan, I., Rivo, M., Sepulveda, M., Park, Y., Snowdon, J., & Rhee, K. (2019). Transforming diabetes care through artificial intelligence: The future is here. Population Health Management, 22(3), 229–242. https://doi.org/10.1089/pop.2018.0129
Diabetes Canada. (n.d.). Canada needs a nation-wide diabetes strategy now. Diabetes Canada Website. Retrieved January 30, 2022, from https://www.diabetes.ca
Diabetes Canada. (2017). Diabetes Canada calls upon the federal government: 2018 pre-budget submission (Diabetes Charter for Canada) [Recommendations]. https://www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Submissions%20to%20Government/Federal/2018-Federal-PBS.pdf#:~:text=Diabetes%20Canada%20calls%20upon%20the%20federal%20government%20to,consequently%20is%20being%20considered%20for%20other%20communicable%20diseases.?msclkid=c8930440b37711ecac829526005af86f
Diabetes Canada. (2018a). Diabetes Canada 2021 clinical practice guidelines for prevention and management of diabetes in Canada. Canadian Journal of Diabetes, 42(Suppl 1), S1–S325.
Diabetes Canada. (2018b). Diabetes Canada calls upon the Ontario government: 2018 pre-budget consultation submission (Issues Summary). https://www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Submissions%20to%20Government/Provincial/2018_Ontario_Pre-Budget_Submission_011718_Final.pdf#:~:text=Issue%3A%20Diabetes%20Canada%20is%20urging%20the%20Government%20of,people%20with%20diabetes.%204%20those%20living%20with%20diabetes.2?msclkid=d82932f5b37a11ecba4593724649dc14
Diabetes Canada. (2020). Diabetes in Canada (Backgrounder) [Report]. https://www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Backgrounder/2020_Backgrounder_Canada_English_FINAL.pdf
Goldman, B. (2019, January 28). The soaring cost of insulin. Dr. Brian’s Blog - CBC. Retrieved March 18, 2022, from https://www.cbc.ca/radio/whitecoat/blog/the-soaring-cost-of-insulin-1.4995290
Government of Canada - Indigenous Services. (n.d.). Non-insured health benefits for First Nations and Inuit. Retrieved January 30, 2022, from https://www.sac-isc.gc.ca/eng/1572537161086/1572537234517
Government of Canada. (n.d.-a). Canada’s health care system. Health Canada. Retrieved January 30, 2022, from https://www.canada.ca/en/services/canada-health-care-system.html
Government of Canada. (n.d.-b). Social determinants of health and health inequalities. Retrieved April 4, 2022, from https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html
Kino, S., & Kawachi, I. (2020). How much do preventive health behaviors explain education- and income-related inequalities in health? results of oaxaca–blinder decomposition analysis. Annals of Epidemiology, 43, 44–50. https://doi.org/10.1016/j.annepidem.2020.01.008
Martin, B. (2022). Health care in Canada: How do we fit together? (Blog). https://bmartin1192.wixsite.com/website/post/health-care-in-canada-where-do-we-fit-in
MCH Training Program. (2017, February 7). Intro to the Ecological Model [Video]. YouTube. https://youtu.be/5NNw0GSUR-c
Meili, R. (2012). A healthy society: How a focus on health can revive Canadian democracy. Purich Publishing.
Ministry of Health. (n.d.). Publicly funded drug programs. Ontario MOHLTC. Retrieved April 5, 2022, from https://www.health.gov.on.ca/en/pro/programs/drugs/funded_drug/fund_trillium.aspx?msclkid=fa50bcfab53511eca630702b5f5207fc
National Institutes of Health. (2011, May 6). Multilevel interventions in health care conference: Introduction by Stephen Taplin, MD, MPH [Video]. YouTube. https://www.youtube.com/watch?v=nWAEvyOXWpU
Northwest LHIN. (2017). Advancing the future of health care (Annual Report 2016-17). http://healthcareathome.ca/northwest/en/performance/Documents/2021/AR%20and%20Financials/2016-2017%20North%20West%20LHIN%20Annual%20Report-ENG.pdf
Northwestern Health Unit. (2020). 2019 Public health report card [Report]. https://www2.nwhu.on.ca/wp-content/uploads/2021/01/Public-Health-Report-Card-2019.pdf?x62978
Oikonomidi, T., Ravaud, P., Cosson, E., Montori, V., & Tran, V. (2021). Evaluation of patient willingness to adopt remote digital monitoring for diabetes management. JAMA Network Open, 4(1), e2033115. https://doi.org/10.1001/jamanetworkopen.2020.33115
Public Health Agency of Canada. (2011). Diabetes in Canada: Facts and figures from a public health perspective. [Report]. Health Canada. https://www.phac-aspc.gc.ca/cd-mc/publications/diabetes-diabete/facts-figures-faits-chiffres-2011/pdf/facts-figures-faits-chiffres-eng.pdf
Public Health Ontario. (n.d.). Public Health Ontario website. Retrieved January 30, 2022, from https://www.publichealthontario.ca
Public Heath Ontario. (2015). Mortality from diabetes >> age-standardized rate (both sexes) >> 2015 [Data set]. https://www.publichealthontario.ca/en/data-and-analysis/chronic-disease/chronic-disease-mortality
Raphael, D. (2010). Health and illness. Fernwood Publishing.
Whittemore, R., Melkus, G. D., & Grey, M. (2004). Applying the social ecological theory to type 2 diabetes prevention and management. Journal of Community Health Nursing, 21(2), 87–99. https://doi.org/10.1207/s15327655jchn2102_03
Comments