Submission to Standing Committee on Health With no leadership, Canada s diabetes crisis will continue to get worse Diabetes Canada May 23, 2018
Overview Diabetes Canada is very proud to represent the estimated 11 million people living with diabetes or pre-diabetes. We are committed to helping those at risk of diabetes avoid developing this condition and to helping those who have it live well. In Canada today, one in three people lives with prediabetes or diabetes. In some communities that rate soars above 60 per cent. Canadians under 20 years of age now face a 50 per cent chance of developing the disease in their lifetime. For Indigenous Peoples in Canada, that risk is 80 per cent. By any definition, a disease affecting that proportion of the population is an epidemic. In the case of diabetes, which affects close to 425 million people worldwide, it is a pandemic. Yet it s not an epidemic that Canadians or governments are taking concerted and coordinated efforts to address. Though the World Health Organization recommends every country have a national diabetes strategy, our last one fizzled away in 2013 following a scathing report on its underperformance by the Auditor General. All that remains of our previous national strategy is the Aboriginal Diabetes Initiative. While 2
this has demonstrated successes, it is clearly not enough. Our last federal budget contained only one mention of the word diabetes in its 376 pages. Diabetes is just not a top priority in our country. But it must be. If we continue with the status quo, the direct costs to our healthcare system will top $5 billion per year within a decade and the indirect costs will be three times that amount. And the human suffering involved is incalculable, particularly for the most vulnerable in our society Globally, the number of adults living with diabetes has quadrupled since 1980, from just over 100 million to 425 million. In 2012, the disease directly caused 1.5 million deaths and elevated blood glucose levels linked to diabetes were responsible for an additional 2.2 million deaths that year. The International Diabetes Federation lists Canada among the worst OECD (Organization for Economic Co-operation and Development) countries for diabetes prevalence. Canada is in the top 10 OECD countries for both total and mean healthcare expenditure related to diabetes. More than twice as many Canadians live with diabetes today as did in 2000. Both prevalence and direct costs of treating the disease in Canada have been rising at a rate of 4per cent per year and show no signs of slowing down. Diabetes or prediabetes affect 11 million Canadians and yet 7 million of them don t know it. Diabetes is an even larger burden within many Canadian sub-groups. For example, seniors make up over half of the people diagnosed with diabetes in Ontario, and close to 40 per cent of new diagnosed cases of diabetes in 2018 will occur in the senior population in Canada. People of South Asian, Asian, African, Latin American or Polynesian ethnic backgrounds are particularly at risk of developing diabetes. Canadians with lower incomes have a much higher prevalence of diabetes and greater challenges accessing supports. For Indigenous Peoples, the probability that they will develop diabetes is 3 to 5 times greater, and the rates of complications are at least twice as high compared to non- Indigenous Canadians. 3
Issues of health inequality are at the core of the diabetes epidemic, and addressing this epidemic is wholly reliant on addressing health inequities. Many Canadians do not fully appreciate how debilitating a diagnosis of diabetes can be. Diabetes-related complications can be serious and life-threatening. People with diabetes account for 30 per cent of the strokes, 40 per cent of heart attacks, 50 per cent of kidney failure requiring dialysis and 70 per cent of amputations in Canada each year. The life expectancy of a person with diabetes is shortened by an average of 13 years. Statistics Canada lists diabetes as the seventh leading cause of death in Canada, and a key contributor to people developing the top three causes (cancer, heart disease and stroke). Between 2004 and 2008, when rates of diabetes in Canada were much lower, diabetes contributed to an additional10.6 per cent of all deaths. It is reasonable to assume that that rate has been maintained if not increased in the intervening years, which could mean that nearly 30,000 Canadians died of diabetes in 2015 (the last year for which data is available). With statistics like these, it s easy to wonder why we re not all panicking about this epidemic. And yet, like the proverbial frog in the pot, we seem unaware of the boiling water that surrounds us. 4
It s time for urgent change. This epidemic cannot be addressed by encouraging Canadians to exert more will power or by shaming them into lifestyle changes. Although we frequently discuss diabetes (and other chronic diseases) as being lifestyle diseases, the capacity to live a healthy lifestyle is not equally distributed among the population. To blame and stigmatize those living with type 2 diabetes for their disease is not only unhelpful, it is a vast oversimplification. Type 2 diabetes is caused by a complex array of factors including genetics, lifestyle and environmental factors such as poverty, reduced access to clean drinking water, food insecurity, and a disease promoting food and physical environment. In the case of Indigenous Peoples, it is related to the history of colonization. It is also not a problem that can be effectively addressed without concerted, coordinated effort. Provinces and territories each working on diabetes in their own way will not facilitate economies of scale and rapid knowledge-sharing that are the hallmarks of transformative change. Canada has benefited in the past from the focussed initiatives led by the successful Canadian Partnership Against Cancer (CPAC) and the Mental Health Commission of Canada (MHCC) to develop and implement national strategies, which have had proven and measurable impacts. While the federal government alone can t solve a health crisis, it can play a critical leadership role in convening and coordinating provincial, territorial and municipal partners. As the recent report on pan-canadian health organizations points out: there can be no health for Canadians without the discharge of a wide range of duties and responsibilities that can be traced directly to the federal government. Other nations have benefitted greatly from adopting national strategies on diabetes. A majority of countries in the European Union have such strategies, and those strategies are paying dividends. Finland, for example, implemented a national approach in 2000 to preventing diabetes and its complications that provided an overarching framework for activities but where specific design was left to partners locally. This led to a range of new models and practices to be developed bottom-up, taking account of local needs, resources and initiatives. This approach is recognized internationally as having been successful in reducing the burden of diabetes on the Finnish people. Similar successes are being experienced due to national strategies in place in New Zealand, India and Portugal, among many others. 5
To really turn the tide of the diabetes tsunami, we need a nation-wide approach that helps all Canadians know their risks of diabetes, reduces individual risk factors, promotes healthier environments and creates measurable, attainable health outcomes for patients. In 2018, Diabetes Canada is spearheading just such an approach. We re building on a successful model implemented in the HIV/AIDS community that has been credited for transformational breakthroughs in the treatment and management of HIV/AIDS and adapting it to tackle diabetes in Canada. Implementing such an approach would mean that, in time, 100 per cent of Canadians would live in an environment that does not promote the development of diabetes; 90 per cent of Canadians would know whether they re at risk for or living with diabetes; 90 per cent of those with prediabetes or diabetes would be engaged in appropriate interventions to avoid developing diabetes or its complications and, in consequence, 90 per cent of them would be achieving improved health outcomes. We know from research that when someone who is at risk of developing type 2 diabetes makes only moderate lifestyle adjustments (losing 5-10 per cent of their body weight, for example), they are 60 per cent less likely to develop the disease. That could 6
mean that if we increase risk awareness, create health-promoting environments and then provide adequate support, we could help 3.5 million Canadians make meaningful changes to avoid or significantly delay developing diabetes. This could translate into preventing diabetes in millions of Canadians who are currently on track to develop it. Millions of Canadians with diabetes who are at risk of serious complications like blindness, kidney failure or amputation would see that risk reduced. And significant time and money would be saved and used more efficiently by our health-care system. For example, we estimate that there will be 220, 000 newly diagnosed Canadians in 2018. If we had offered a tried and true prevention program to these high risk individuals before they developed the condition, we could have prevented about 110,000 cases if diabetes and a potential savings to the health care system of over $124 million. Over ten years, that is $1.24 billion a huge savings, and these do not include the savings that could be achieved by preventing complications in people with diabetes through more effective management. Greater still, perhaps, would be the reduction in the human toll that diabetes places on the workforce, society, families and individuals living with the disease. To develop the best approach possible to tackling the diabetes problem, Diabetes Canada is working with more than 120 expert stakeholders from nearly 100 organizations in health care, government, private sector and education from coast to coast to coast to recommend how Canada can develop and implement a new approach that will bring real results. The teams are working hard to bring forward a recommendation to our government s pre-budget consultation process this summer, but by way of preview it will include important initiatives such as: Health inequities and food insecurity will be tackled. The healthy food choice will be the easy choice through measures like Canada s Healthy Eating Strategy. Regular physical activity will be facilitated for all Canadians. Children and families are taught about healthy living from birth. Screening for risk of diabetes and for its complications will be done more consistently according to best practice. 7
Stigma about diabetes and its causes will be minimized. The health care delivery system will be adjusted to ensure that each patient gets the most appropriate care provider for their situation, and that health care resources are used most efficiently. Each person with diabetes will be fully supported in managing their disease. Patient interventions will incorporate a holistic view of patient wellness, and leverage interdisciplinary care providers to support it. The rate of complications of diabetes (amputation, heart attack, stroke, etc.) will be reduced. The sense of overall wellbeing of people living with diabetes will improve. Our recommendations will include laying a foundation for all of the above by evaluating and optimizing the health care delivery system to ensure it is focused on and incenting patient wellness throughout and by leveraging technology and data to continuously improve patient interventions and outcomes. Specifically, Diabetes Canada anticipates recommending that the federal government establish a focused initiative for a period of time (approximately 5 to 7 years) to plan and implement a national approach to the prevention and management of diabetes in Canada. Like CPAC and MHCC, such an organization would collaborate with provinces and territories and with Indigenous Peoples to optimize disease prevention and health care delivery for people with diabetes, with a goal of sunsetting itself as quickly as possible. Specific estimates of cost are not yet available, but for reference, CPAC and MHCC receive annual federal grants of approximately $47 and $15 million respectively. Canada has a proud history of being on the forefront of diabetes treatment, including Dr. Frederick Banting s role in the discovery of insulin in Toronto. A decision by the federal government to support a new national approach to diabetes could put Canada in a position of global leadership in the treatment of diabetes in time for the 100th anniversary of the discovery of insulin in 2021. That is something we could all be proud of. Desmond Tutu once said There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they re falling in. 8
When it comes to the millions upon millions of Canadians who already have or are well on their way to developing diabetes and its many complications we must support them to achieve their health potential with evidence-based treatments and care. For those Canadians for whom the progression to diabetes can be prevented, the time to move upstream and fix the problem is now. With expert guidance and input from hundreds of knowledgeable Canadians, in 2018 Diabetes Canada, along with a broad array of partners, plans to chart a path to doing just that. 9