Diabetes Policy Review - Report of the Expert Panel

Setting the Context

Diabetes

Different Types of Diabetes and Complications

Diabetes is a group of diseases characterized by high levels of blood glucose. It is a chronic condition that results from the body's inability to sufficiently produce and/or properly use insulin, a hormone that regulates blood glucose.

• Type 1 diabetes develops when the body's immune system destroys the cells which make insulin. An adequate supply of insulin is needed to help the body function; without regular administration of insulin, type 1 diabetes is "rapidly fatal".³ Type 1 diabetes typically develops in childhood or adolescence. Currently, there is no way to prevent type 1 diabetes.
• Type 2 diabetes normally begins with insulin resistance, where the body's cells are unable to use insulin properly, and is followed with a declining ability to produce insulin. Type 2 diabetes comprises 90% of people with diabetes around the world.⁴ People are typically diagnosed with type 2 diabetes after the age of 40; however, there are increasing reports of type 2 diabetes in children worldwide.⁵
• Another type of diabetes, known as gestational diabetes, occurs during pregnancy and usually disappears after delivery; however women who had gestational diabetes have an increased risk of developing type 2 diabetes later in life.

The risk of type 2 diabetes is clearly associated with an increasing prevalence of obesity, largely as a result of changing dietary and lifestyle patterns,⁶ and aging. The risk of developing type 2 diabetes may be reduced, or its onset delayed, by eating a healthy diet, maintaining a healthy weight and regular physical activity as well as smoking cessation.

Over time, diabetes can damage the heart, blood vessels, eyes, kidneys as well as nerves. According to the World Health Organization, the overall risk of death among people with diabetes is at least twice as high as that of people without diabetes.⁷ Serious debilitating complications of diabetes include, but not limited to, the following:

• Diabetic retinopathy is a leading cause of blindness, and occurs as a result of accumulated damage to the small blood vessels in the retina.
• Diabetic neuropathy is damage to the nerves as a result of diabetes, with common symptoms being tingling, pain, numbness, or weakness in the feet and hands.
• Combined with reduced blood flow, neuropathy in the feet increases the chance of foot ulcers and eventual limb amputation.
• Diabetes is among the leading causes of kidney failure.
• Diabetes increases the risk of heart disease and stroke.⁸

The risk of developing these complications, however, may be reduced by managing levels of blood glucose, blood pressure and blood lipids to recommended clinical targets through preventive measures and appropriate care.

Pre-diabetes

Pre-diabetes is "a condition where blood glucose levels are abnormally high, but not high enough for a full-blown diabetes diagnosis".⁹ Pre-diabetes is measured using two blood tests (fasting plasma glucose and oral glucose tolerance test), which are the same ones used to diagnose diabetes, except with lower cut-points. Diagnostic cut-points have changed as a result of change in the cut-point for diabetes diagnosis.¹⁰

In 2003, about 314 million people, or 8.2%, in the population aged 20 to 79 had impaired glucose tolerance around the globe.¹¹ Pre-diabetes is also a major public health problem worldwide, both because of its association with the incidence of diabetes and its own association with an increased risk of the development of cardiovascular disease. If left untreated, over half of people with pre-diabetes are expected to develop type 2 diabetes within 8-10 years. Evidence from intervention studies in the United States and other countries indicates that the incidence of diabetes may be prevented by lifestyle change and the use of insulin-sensitizing drugs among a large proportion of people with pre-diabetes.¹²

Prevalence of diabetes

Global Prevalence of Diabetes

The International Diabetes Federation estimates that approximately 246 million people worldwide had diabetes in 2007.¹³ This number is projected to rise to 366 million in 2030.¹⁴ It is also estimated that in 2005, 1.1 million people died from diabetes around the globe; when deaths in which diabetes was a contributing condition are taken into account, approximately 2.9 million deaths per year are estimated to be attributable to diabetes.¹⁵

The "global explosion" in type 2 diabetes is being driven by a complex interplay of genetic, social and environmental factors.¹⁶ Today, diabetes, largely type 2, is estimated to affect 5.9% of the world's adult population. The regions with the highest rates of the prevalence are the Eastern Mediterranean and Middle East (9.2% among the adult population) and North America (8.4%), while the highest numbers are found in the Western Pacific (67 million), followed by Europe (53 million).¹⁷ India and China have the highest number of people with diabetes with a current figure of 40.9 million and 39.8 million, respectively. They are followed by the United States, Russia, Germany, Japan, Pakistan, Brazil, Mexico and Egypt.¹⁸

Prevalence of Diabetes in Canada

In 2004-05, approximately 1.8 million Canadians of all ages, or 5.5% of the population had diagnosed diabetes - an increase from 1.3 million or 4.2% in 2000-2001. Among adults aged 20 and older, 7.1% had diabetes in 2004-05. The prevalence rates increase with age from approximately 2% among individuals in their 30's to approximately 21% in those aged 75 to 79. The prevalence rate is higher for males (5.8%) than for females (5.2%).¹⁹

The incidence of diabetes is on the rise largely "due to an aging, inactive and overweight population"²⁰ and immigration from high-risk countries. With current trends expected to continue, the number of individuals with diagnosed diabetes in Canada is projected to increase to 2.4 million in 2016.²¹ In addition, it is also estimated that a substantial proportion of Canadians live with undiagnosed type 2 diabetes. A 2001 randomized study found that 2.2% of over 9,000 Canadians aged 40 and over who visited family physicians for routine care had previously undiagnosed type 2 diabetes.²² Another 2001 study also found that 2.2% of the adult population of Manitoba had undiagnosed diabetes.²³

Aboriginal people (First Nations, Inuit and Métis) in Canada are at particularly high risk for developing diabetes. First Nations have the highest rates with 19.7% of adults having diagnosed diabetes in 2002-2003.²⁴ The incidence of type 2 diabetes is also increasingly observed among First Nations children and adolescents. The prevalence rates among the non-reserve Métis and Inuit populations aged 15 and over were 6.0% and 2.3%, respectively in 2003.²⁵ It is estimated that the prevalence of diabetes among Aboriginal people are two to three times higher due to a large number of undiagnosed cases.

Available data indicates that the prevalence of diabetes is closely associated with the income level. The risk of developing diabetes is significantly higher among Canadians with a lower socio-economic status, compared to that of Canadians with a higher socio-economic status. In 2005, among Canadians aged 18 and older, 7.4% of males and 7.4% of females in the lowest income decile²⁶ had diagnosed diabetes, compared to 3.2% and 1.5% among those in the highest decile. The highest prevalence rate was found among males in the second lowest decile, with 9.2%, while the lowest rate among females was in the highest decile, with 1.5%.²⁷

Pre-diabetes in Canada

In addition to type 2 diabetes, pre-diabetes also constitutes "a major public health issue in Canada, one which can be effectively prevented or delayed through appropriate target screening and intervention strategies."²⁸ The number of Canadians with pre-diabetes is expected to grown significantly over the next decade, due to the aging population, the growth in obesity, and the increase in the high-risk ethnic group populations. Measured population level estimates of the prevalence and incidence of pre-diabetes are currently lacking in Canada, as the key oral glucose tolerance test was not included in the latest Canadian Health Measures Survey. However, based on the information from the United States' National Health and Nutrition Examination Survey adjusted for differences in age, sex, ethnicity (proportion of the non-white population) and obesity rates (body mass index) between the two countries, it is estimated that the number of Canadians over age 20 with pre-diabetes was about 5 million in 2004, and is projected to increase to over 6.3 million by 2016. Among those aged 40 to 74, this number is projected to increase from about 3 million in 2004 to 4.3 million in 2016.²⁹

Burden of diabetes

Living with diabetes

The personal costs of diabetes may include a reduced quality of life and the increased likelihood of complications. Consistent with the World Health Organization's estimates, Canadian data indicates that overall, death rates are twice as high among adults aged 20 and older with diabetes, compared to those without the disease. In 2004-05, individuals with diabetes died at rates that are 4 to 10 times higher among adults aged 20 to 44 and 2 to 3 times higher among those aged 45 to 79³⁰. Life expectancy is shortened for all ages. For example, in 2004-05, life expectancy for both men and women in the 25 to 39 year age groups with diagnosed diabetes was shorter by approximately 9 years, compared to those without the disease.³¹

Furthermore, compared to those without diabetes, adults (aged 20 and older) with diagnosed diabetes were hospitalized:

• 24 times more often for lower limb amputations;
• 7 times more often for chronic kidney disease;
• 4 times more often for hypertension or heart failure;
• 3 times more often for heart attack; and
• 3 times more often for stroke.³²

In addition to reduced quality of life and the increased likelihood of complications, people living with diabetes face a huge financial burden. People with diabetes incur medical costs that are two to two to three times higher than those without the disease. Direct costs for medication and supplies can range from $1,000 to $15,000 a year.³³

Economic impacts

The cost implications of the increasing incidence of diabetes are enormous. In 2004-2005, adults aged 20 to 49 with diagnosed diabetes had 2 to 2.5 times more visits to family physicians and specialists than individuals without diabetes.³⁴ Among the older age groups, individuals with diagnosed diabetes also visited physicians approximately 2.1 times more than those without the disease. A 2000 study of 26,000 working-age people in Manitoba found that individuals with diabetes who had complications were twice as likely not to be in the workforce as individuals without diabetes and earned 72% of the income of those without diabetes.³⁵

There is little updated information on the costs of diabetes in Canada. The latest available information indicates that in 2000, chronic diseases cost the Canadian health care system an estimated $108.7 billion ($38.4 billion in the direct costs of hospitals, drugs, physician care and other institutions, and $70.3 billion in the indirect costs associated with mortality, and short-term and long-term disability). This represented approximately 10% of GDP in the same year. The health care costs associated with diabetes were estimated to be $2.7 billion with just under $1 billion in the direct costs and $1.7 billion in the indirect costs; however, these figures exclude the economic burden attributed to various complications of diabetes, such as loss of vision, kidney disease and cardiovascular disease and therefore only represent significant underestimates of the actual health care costs associated with diabetes.³⁶ Another study, using 1996 administrative data from Saskatchewan Health, estimated the total health care costs of diabetes to be $4.66 billion in 2000, with a projection for an increase to $8.14 billion in 2016 (1996 dollar values).³⁷

Also, there is little information on the indirect economic costs of diabetes, or the cost of lost production. A recent study by the American Diabetes Association estimates that the total cost of diabetes in the United States in 2007 was US$174 billion, including US$116 billion in excess medical expenditures and US$58 billion in reduced national productivity. Health care costs associated with diabetes include US$27 billion for the treatment/care of diabetes, US$58 billion for the treatment/care of the portion of chronic complications that are attributed to diabetes, and US$31 billion in excess general health care costs.³⁸ Given the differences in the size of the population and the economy between two countries, it is estimated that the total cost of diabetes in Canada could be roughly 10% of the US figure, or $17 billion.

Federal role in health and health care

The role and powers of the federal and provincial governments in health have been established by the Constitution as well as by practice over time.³⁹ The provincial governments, based on Section 92 (7) of the Constitution Act, 1867,⁴⁰ hold the majority of responsibility for delivering health and other social services.

The federal government's role in health is derived from its constitutional powers over criminal law, spending, and peace, order and good government.⁴¹ In particular, spending power is the basis for its financial support of provincial health care systems through the Canada Health and Social Transfer and the Canada Health Act. The federal government's responsibilities in the Canadian health care system include:

• Setting and administering national principles for the system under the Canada Health Act;
• Financial support to the provinces and territories;
• Direct delivery of primary and supplementary services to certain groups of people;
• Public health programs to prevent disease, and to promote health and educate the public on health implications of the choices they make;
• Health protection; and
• Funding for health research and health information activities.⁴²

Throughout the consultation process, a number of stakeholders discussed the issues related to the roles and responsibilities of the two levels of government in the delivery of health services to people with diabetes and made suggestions for improving the current health care system in order to better address the problem of diabetes in Canada. The Panel acknowledges the value of this input; however, in conformity with the mandate of the Policy Review, as stipulated in the Terms of Reference, the recommendations presented in this Report primarily pertain to the areas for which the federal government is, or is deemed to be, responsible.