Message from Ontario's Chief Medical Officer of Health
Diabetes : A Public Health Challenge
What is Diabetes?
Why is Diabetes Such an Important Public Health Issue?
The Economic Impact of Diabetes
A Dangerous Lack of Awareness
How Can We Identify People at Risk and Prevent Diabetes and Its Complications?

Risk Factors for Diabetes
Type 1 Diabetes
Type 2 Diabetes

Strategies for Prevention
Changing Risk Factors
Early Identification and Effective Management
Rehabilitation

Age
Socio-Economic Issues
Ethnic and Cultural Groups
Aboriginal People

For Individuals and Families
For Communities
For Health Care Providers
For Federal and Provincial Governments

Northern Diabetes Health Network
Southern Ontario Aboriginal Diabetes Initiative (SOADI)
Seniors and Diabetes Initiative
Diabetes Complication Prevention Strategy
Evaluation
Non-Governmental Organizations

Everyone in Ontario needs to understand the seriousness of this disease because all of us are susceptible to diabetes and its resultant impact on health.

The prevalence of diabetes is alarmingly high and is expected to increase over the next century. In Ontario, over 600,000 people have been diagnosed with diabetes; at least another 300,000 people don't know they have it. Four out of 10 people with diabetes will develop debilitating and long-term complications.

Diabetes is a major cause of premature death, blindness, kidney disease, heart disease, stroke, limb amputation and other significant health problems. With diabetes, life expectancy is significantly reduced. One of the hidden impacts of diabetes is the loss of productivity from disability, sickness, premature retirement and premature death. Diabetes is estimated to cost the Ontario health system just under one billion dollars annually.

For my first report as Ontario's Chief Medical Officer of Health, I am highlighting the growing public health problem of diabetes and recommending preventive strategies for reducing the incidence of diabetes and its complications. This report will focus on type 2 diabetes which accounts for 90 per cent of all diabetes and is the most preventable. Although we have no control over our family history and age, which are two important risk factors for diabetes, we can practice healthy behaviors. Even slight changes in physical activity and diet can provide long-term benefits for the individual, the community, and the province.

By promoting the importance of lifestyle changes and creating the social and environmental supports needed for these changes, we can promote health, save lives, and reduce the burden of diabetes in Ontario.

Colin O. D'Cunha, MBBS, MHSc, FRCPC
Chief Medical Officer of Health

In Ontario today, 628,000 people - or six per cent of the population - have been diagnosed with diabetes. In fact, one Ontarian is newly diagnosed with diabetes every 20 minutes! Diabetes was the cause of death for more than 2,200 people in 1996. Forty per cent of people with diabetes will develop debilitating complications such as blindness, kidney failure, or heart disease. In addition, some people will undergo foot, toe or leg amputations. All these complications from diabetes are devastating for the individual, the family, and the province's health system.

Besides physical problems, people with diabetes can experience anxiety and depression from living a restricted lifestyle. They may lose productivity due to work or school absences. They may see a decrease in their earning potential because of the development of complications. As well, changing personal routines can affect other family members. Because the physical, social, economic and emotional burden of diabetes is substantial, diabetes is a major public health concern.

Diabetes is a disease that can affect anyone. A projected rise in the incidence of type 2 diabetes in Ontario is related to the aging of the population and increasing obesity and physical inactivity. This report will focus on type 2 diabetes because it represents 90 per cent of all cases and is the most preventable by changes to lifestyles.

It is very disturbing that 35 to 44 per cent of people with diabetes don't know they have it. As a long-lasting disease with serious consequences if left untreated, diabetes requires appropriate and timely intervention. Symptoms of diabetes often do not show up until several years after the onset of the disease. In fact, someone may have had diabetes for up to 12 years before diagnosis.

Since people with diabetes generally feel well during the initial stages of the disease, many people are only diagnosed once they develop complications. For example, 21 per cent of people with diabetes have eye disease before being diagnosed. Late diagnosis results in delayed treatment, which can be less effective in preventing or decreasing further complications.

Even though diabetes is a serious problem, this disease is manageable if individuals, communities, health care providers, and policy-makers are given and use the information and tools to motivate and support behavioural change.

Currently, few health programs educate the public about preventing diabetes. Despite educational programs for preventing complications, the proven effectiveness of lifestyle changes, and advances in treatment, some people remain unaware, or unconvinced, of the seriousness of this disease. Research advances in diabetes, including new drug therapies, are often not communicated effectively. Type 2 diabetes is often not managed aggressively. The result: many people with diabetes are not motivated when diagnosed to change their lifestyles.

The ideal public health approach to diabetes would emphasize prevention and education for the whole community. It would :

• advocate for environments and policies that support healthy lifestyles, including healthy eating and physical activity;
• increase awareness of the symptoms and long-term complications of diabetes among both the public and health care providers;
• promote access to resources for people with diabetes; and
• monitor the effect of diabetes through data collection systems.

Diabetes is a disease characterized by the body's inability to produce insulin (type 1 diabetes) or to use insulin effectively (type 2 diabetes). (See Appendix A for descriptions of the different types of diabetes.) Insulin, a hormone produced by the pancreas, is essential for regulating glucose (sugar) levels in the blood and for taking glucose into body cells. Without insulin or the ability to use insulin, the body's main source of energy - glucose - becomes unavailable to cells.

A person with diabetes develops hyperglycemia (high blood glucose). Persistent hyperglycemia can lead to long-term damage to the heart, kidneys, eyes, nervous system, and gastrointestinal system. Diabetes causes heart disease, kidney failure, blindness, and poor circulation to the lower extremities, too often leading to amputations.

People with poorly controlled type 1 or type 2 diabetes experience frequent urination, excessive thirst, and unusual weight loss. In addition, people with type 2 diabetes may experience other symptoms such as recurring skin, gum, or bladder infections; cuts and bruises that are slow to heal; and tingling sensations in the hands or feet. (See Appendix B for more details on the symptoms of diabetes.) Symptoms may not be easily recognizable during the early stages of the disease. More awareness of diabetes is important since management to prevent complications is more successful if started early.

If a person with diabetes takes insulin as part of the treatment program, hypoglycemia (low blood glucose) can suddenly occur if the insulin dosage is not adjusted according to changing needs. Hypoglycemia - more common in type 1 than in type 2 diabetes -- can occur if the person does not eat at the appropriate time, inadvertently takes too much insulin, or exercises too much. Symptoms of hypoglycemia include confusion and inattention, lack of coordination, drowsiness, pale complexion, sweating, headache, trembling, sudden hunger, dizziness, and moodiness.

Four out of 10 people with diabetes will develop long-term complications. Damage to large blood vessels may lead to high blood pressure, heart attacks, and strokes. Damage to small blood vessels contributes to blindness, impotence, amputations, and kidney failure. (See Appendix C for details of long-term complications of diabetes.)

In addition to physical symptoms and complications, diabetes can cause emotional strain. A person with diabetes must make numerous lifestyle changes including altering diet and exercise habits, regularly using insulin or drugs, self-monitoring, developing coping strategies, shifting eating schedules, and varying family routines and social outings.

Because of the demands of managing this disease, a person with diabetes may experience a diminished quality of life. This is especially true if social supports are inadequate, if the person constantly experiences stress and time pressures, or if the person's health beliefs are contrary to the treatment program. In fact, 25 per cent of people with diabetes suffer from recurring depression, anxiety, or eating disorders. Emotional distress can seriously lessen a person's capacity for self-care and increase the risk of blood vessel diseases.

Between 1993 and 1995, diabetes was the sixth leading cause of death among Ontario females and the seventh leading cause among Ontario males. In 1996, diabetes was listed as the cause of death for 2,292 Ontarians. The death rate for diabetes increased by nearly 25 per cent between 1986 and 1996; the increase was 33 per cent for males and 16 per cent for females. Yet the number of deaths related to diabetes is substantially underestimated due to the method by which deaths are recorded. Because people with diabetes often die from diabetic complications such as heart disease, the complications are recorded as the cause of death, instead of diabetes.

More than 600,000 people in Ontario have been diagnosed with diabetes. Up to 300,000 more are estimated to have diabetes but not yet know it. The number of people with diabetes will more than double by 2016. This increase is due to longer life expectancy and the number of baby boomers who are growing older.

The prevalence of diabetes increases with age - three per cent of people aged 35-64 and 10 per cent of people 65 and older - are currently diagnosed with diabetes in Canada. Among Aboriginal people, 10 per cent of the population aged 15 and over, and 23 per cent of the population 65 and older have been diagnosed with diabetes. Demographic changes alone will increase the proportion of Ontarians diagnosed with diabetes from today's one in 20 to one in 10 people.

The prevalence of diabetes is also expected to increase because risk factors associated with type 2 diabetes, such as obesity and physical inactivity, have become too common in our society. According to the Ontario Health Survey (1996/97), 34 per cent of males and 21 per cent of females are overweight, with a body mass index greater than 27. (See Appendix D.) As well, 54 per cent of Ontario males and 59 per cent of Ontario females are physically inactive.

Canada spends $9 billion annually on health care, disability, work loss, and premature death costs related to diabetes. Ontario spends nearly $1 billion annually for treatment of diabetes and its complications. An American study suggests that 14 per cent of the U.S. health care budget (or one in seven U.S. health care dollars) is spent on diabetes.

With the anticipated increase in people developing diabetes, Ontario is expected to have an increasingly heavy economic burden related to the treatment of diabetes and its complications. A person with diabetes typically has medical costs that are two to five times higher than costs for a person without diabetes. Treating and managing diabetes can amount to $4,500 per year for each person with the disease.

People with diabetes are at high risk for developing complications. Treating these complications is more expensive to the health system than intensively managing the disease and preventing complications. For example, cost-effectiveness studies on preventing diabetes show a reduction of $877,000 in annual treatment costs for every one per cent increase in the number of Canadians who are physically active.

The person with diabetes has numerous medical and personal costs related to the care and management of the disease. Improving and maintaining glucose levels is critical to prevent or delay long-term complications. Medical costs associated with controlling glucose levels such as insulin, oral medications, lancets, glucose meters, and glucose meter strips, as well as dietary changes, can be prohibitive without insurance or government coverage. Other costs for medical treatment can include transportation to health facilities, lodging, and child care.

Indirect costs include decreases in productivity due to absence from work, decreased earning potential because of potential complications and disabilities, lost earnings due to premature death or retirement, and increased insurance costs.

A high disease burden, a rapid increase in disease occurrence (suggesting that the disease is preventable), and universal public concern make for a public health issue. While diabetes in Ontario meets the first two criteria, the public remains dangerously complacent. In comparison to many other diseases, there is little recognition of diabetes as an important public health issue. Too many people, including those with the disease and health care providers, remain either uninformed, or unconvinced, of the potentially devastating complications and seriousness of diabetes. Increased awareness about the seriousness of diabetes, its frequency, its complications, and its associated costs, is essential for the public to realize that diabetes is a concern that applies to them.

The causes of diabetes are not fully understood. It is believed that environmental factors and behavioural patterns often hasten the disease in genetically susceptible people. The interaction between genetic and environmental risks varies among populations and ethnic groups.

By changing environmental risk factors, people can reduce their risk of developing type 2 diabetes. By increasing awareness of diabetes and identifying people at risk of the disease, high risk behaviours can be modified to prevent, or delay type 2 diabetes.

Although preventive measures for type 1 diabetes remain elusive, diagnostic screening can delay the progression of diabetes and reduce the risk of long-term complications.

A person immediately related to someone with type 1 diabetes is one to 10 per cent more likely to develop the disease than someone who does not have a family history of diabetes. Type 1 diabetes is most frequently associated with the Caucasian ethnic group. Researchers have identified several "susceptibility genes" linked with type 1 diabetes, but have been unable to find a single gene that can accurately predict the development of diabetes.

Studies suggest possible risk factors for type 1 diabetes include exposure to auto-antibodies and cow's milk protein in infancy.

Heredity plays a significant role in the development of type 2 diabetes. A person related to someone with type 2 diabetes should be alert for symptoms of diabetes and should consult a doctor to screen for the disease.

Certain ethnic groups such as Aboriginal, African, Latin-American, and Asian have a rate of type 2 diabetes that is two to six times greater than that found in the Caucasian population. The rates of kidney failure, amputations, and eye disease are also significantly higher for these groups.

The risk factors of family history, insulin resistance, obesity, history of diabetes related to pregnancy, impaired glucose tolerance, and physical inactivity are equally distributed between all populations. The disproportionate impact of diabetes among different ethnic groups may be the result of genetic risk factors interacting with environmental risk factors.

Obesity
Being overweight is the most recognized environmental trigger for type 2 diabetes. Obesity is found among 80 per cent of people with this disease. Some studies have also identified an association between certain genes linked to obesity and type 2 diabetes.

Diabetes is associated with the level and duration of obesity, as well as type of body fat distribution. A body mass index (BMI) greater than 27 signifies risk for the development of diabetes. (See Appendix E for how to calculate BMI.) A person with an apple-shaped body with excess fat above the hips is more likely to get diabetes than a person of similar weight with a pear-shaped body having excess fat on the hips and thighs.

Compared to people who have healthy weights, people who are overweight generally require more insulin to maintain normal blood glucose levels. As a person's body fat increases, insulin becomes less effective at regulating levels of blood glucose. A condition known as insulin resistance can develop, as the body tries to compensate by producing more insulin. People who are unable to produce more insulin develop type 2 diabetes. Even moderate weight loss in an obese person can substantially reduce insulin resistance.

Age
The incidence of type 2 diabetes increases with age. Half of all new cases of type 2 diabetes occur over the age of 55. As people age, their cells are increasingly unresponsive to insulin. This deterioration may result in type 2 diabetes. Older people tend to have physical limitations on their ability to exercise and tend to gain weight as they age, further increasing their risk for diabetes.

While type 2 diabetes usually starts after age 45, it is not exclusively an adult condition. Increasing numbers of children - as young as six to eight years of age - are now being diagnosed with this long-lasting disease.

Physical Activity
Type 2 diabetes is often found among people who lead inactive, sedentary lifestyles. Research has shown that non-obese people living in cities are more likely to develop type 2 diabetes than non-obese people living in rural areas. This relates to the difference in physical activity between city and country dwellers.

Diet
Excess food energy intake is associated with obesity, a risk factor for type 2 diabetes. Decreased sensitivity to insulin and glucose intolerance are linked to a diet low in fibre and high in saturated fat.

Research into the effects of specific nutrients on diabetes is not conclusive. However, general nutrition recommendations for preventing other chronic diseases including heart disease, cancer, and osteoporosis, are consistent with promoting healthy weights and overall well-being.

Glucose Intolerance
Glucose intolerance can precede the diagnosis of type 2 diabetes. People with glucose intolerance are unable to use glucose effectively after consuming large amounts of carbohydrate. This condition worsens with age and leads to insulin resistance. Researchers have found that for every 10 people with glucose intolerance, one person will progress to type 2 diabetes within five years. Preventive strategies for people with glucose intolerance include lifestyle modifications and annual screenings. Long-term results and the cost-benefit analysis of annual screenings have yet to be explored.

History of Diabetes Related to Pregnancy
As a result of hormonal changes during pregnancy, an expectant mother can develop temporary insulin resistance which results in gestational diabetes. This condition occurs in two to four per cent of all pregnancies. Women who develop this temporary condition are at increased risk for glucose intolerance, fat abnormalities, and type 2 diabetes. Some studies show that nearly 40 per cent of women who have experienced gestational diabetes will develop type 2 diabetes within five to ten years of giving birth. Changes in nutrition and physical activity may lessen the progress of this temporary state to type 2 diabetes.

Cholesterol Abnormalities and High Blood Pressure
The development of type 2 diabetes in people aged 45 years and over is associated with high levels of LDL (bad) cholesterol, low levels of HDL (good) cholesterol, and pre-existing blood vessel disease. As well, people with high blood pressure appear to have an increased incidence of type 2 diabetes. More frequent and/or earlier screening for diabetes is recommended for people with cholesterol abnormalities and/or high blood pressure.

The best prevention for diabetes and its complications should use three strategies :

• changing risk factors and conditions by promoting healthy eating, physical activity, and emotional well-being;
• early identification and effective management of the disease; and
• rehabilitation.

The healthy modification of lifestyle factors such as physical activity, eating habits, and weight can benefit people by decreasing the incidence of diabetes and improving overall health. However, changing the health behaviour of a population is not simple. People need to appreciate the benefits of a healthy lifestyle, and people need to be able to take part in this strategy. For example, without an adequate income or education, an individual may be disadvantaged in making healthy choices about diet. Healthy environments where people are safely able to participate in physical exercise such as volleyball, running or playing sports are to be encouraged.

Promoting changes for the general population, and creating and implementing policies that can support a healthy environment and lifestyle require leadership from government, local communities, non-governmental organizations, the business sector, and committed individuals.

Because of our limited understanding of the causes of diabetes, large-scale population prevention models specifically targeting diabetes have not yet been implemented. However, heart disease and high blood pressure prevention programs throughout the world have incorporated behaviour modification approaches suitable for the prevention of type 2 diabetes. Considering the potential benefits, we can recommend the adoption of healthy lifestyles at home, school, work, and during times of leisure, to reduce the incidence of type 2 diabetes and other chronic illnesses.

A prevention strategy directed towards high risk populations also has the potential to reduce the incidence of diabetes. International and Canadian studies are examining lifestyle modification and drug therapy to stop glucose intolerance from progressing to full-blown diabetes. Large-scale public health initiatives for changing risk factors for type 2 diabetes await the results of these studies.

The familial nature of type 2 diabetes allows for identifying and applying prevention strategies to high risk individuals. For instance, studies have recently identified some genetic markers that define susceptibility for diabetes. Rapid advances in molecular genetics should improve the ability to identify individuals at high risk of developing type 2 diabetes and allow for preventive strategies before the development of glucose intolerance.

While the burden of diabetes will be reduced through the promotion of healthy diets, healthy weights, and active living among high risk individuals, most diabetes will occur among people with moderate risk. Therefore, it is essential that a comprehensive prevention strategy for type 2 diabetes incorporate both the population-based and high risk approaches.

Currently, there are no well-defined strategies for preventing type 1 diabetes.

Between three and five per cent of adults have unrecognized type 2 diabetes. Screening for high blood glucose levels can identify people with early stage diabetes, and allow for timely intervention. The risk of developing complications can decrease significantly with the early treatment of hyperglycemia and a reduction in high risk behaviours. Because of the relatively low overall rate of diabetes in the general population, mass screening is not cost-beneficial and is not recommended.

Targeted screening for type 2 diabetes among people with identifiable risk factors should be considered. These risk factors include :

• obesity;
• age 45 years and older;
• a close relative with diabetes;
• member of a high risk ethnic group such as African, Hispanic, Asian, or Aboriginal;
• a history of glucose intolerance;
• a previous diagnosis of diabetes related to pregnancy, or having had a baby weighing more than 4 kilograms;
• high blood pressure;
• cholesterol abnormalities; and
• the presence of diabetes-associated complications.

No research to date has established the benefits of screening for type 1 diabetes among people at increased risk, such as those with auto-antibodies or with a family history of diabetes. As with all screening, the benefits must be weighed against the drawbacks. Drawbacks include fostering negative psycho-social effects by telling well people that they are at increased risk for developing a debilitating disease.

Evidence emerging over the past 10 years conclusively supports strict management of glucose levels and prompt treatment of complications. The prevention and delay of complications requires a comprehensive and integrated health care team to help the person with diabetes. People with diabetes should visit their health care provider every two to four months. During these visits, the provider must determine how well the individual is managing the disease, whether the treatment plan needs adjusting, and whether any complications are developing. A person's quality of life, sense of well-being, personal preferences and views toward treatment and self-management should also be fully examined. This process helps motivate the individual to engage in self-management, a necessary component for prevention of complications.

Although information about preventing and delaying type 2 diabetes and its complications is available, access to diabetes resources is not consistent throughout Ontario. Barriers to equitable access include geographic isolation, costs, cultural differences, linguistic issues, physical infirmity, illiteracy, and lack of awareness or attention by health care providers.

A provincial approach to preventing diabetes must continue to improve access to diabetes resources and tailor programs to suit the needs of different people. These tailored programs will need to emphasize and encourage behaviour modification.

The following section addresses the challenges faced by people in different age, socio-economic and ethnic groups in preventing diabetes and its complications.

Diabetes is a disorder that affects people of different ages. Preventive measures and disease management should differ accordingly.

• Children
  According to the 1995 National Health and Nutrition Examination Survey (NHANES III), 11 per cent of American children six to 17 years of age were overweight, thus putting themselves at risk for developing diabetes. This percentage is more than twice that of the 1960s, and is linked to physical inactivity and high-fat, high-calorie diets. Excessive time spent watching television, the consumption of foods high in fat, and a decline in physical activity contribute to this epidemic of childhood obesity.

  Children with type 2 diabetes, as with type 1 diabetes, must learn to cope with the physical, emotional, and intellectual changes normally associated with growing, as well as the management of their chronic condition. They require specialized care, education, and support to maintain the high levels of daily attention needed for managing this disease.

  In addition to lifestyle changes, diabetes can also affect a child's self-image, interaction with peers, and hope for the future. The child needs ongoing support and age-appropriate education on diabetes to gain knowledge and skills towards self-sufficiency.

• Adults
  Undiagnosed type 2 diabetes becomes more common in people 45 years and older. Often people are unaware of the onset of their diabetes since symptoms of the disease can remain undetected for many years. Even worse, complications such as eye disease can begin to develop seven years before diagnosis. During the time that diabetes remains undiagnosed and untreated, complications are developing without the person's knowledge. Regular visits to the doctor and diabetes screening tests for people over 45 years of age can help prevent the development of diabetes-related complications.

• Seniors
  Seniors are especially at high risk for developing diabetes. As they age, seniors are less likely to be physically active, either by choice or because of disabling conditions. The risks of obesity and abdominal fat accumulation are increased. The combination of high risk factors and the aging process increases the occurrence of type 2 diabetes with age. The rate of diabetes in Ontario is increasing along with the growth of its aging population.

  Type 2 diabetes is a major cause of disability and death in the elderly. The disease is often difficult to diagnose in the elderly population. Symptoms of hyperglycemia may not appear at first and the symptoms are generally non-specific such as fatigue, depression, and failure to thrive. Because of this, seniors often have already developed long-term complications before being diagnosed.

  Diabetes can be particularly life threatening in the frail elderly. Seniors with diabetes who are generally healthy should aim for blood glucose levels that will reduce the development and progression of complications. Seniors with other health problems should avoid both high and low blood sugar levels because either extreme can complicate their fragile health.

  There are a variety of challenges to consider when addressing the needs of seniors with diabetes. Some seniors on fixed incomes may be unable to afford the medication, food, and support services needed for managing diabetes. Access to services and appointments because of physical limitations or minimal transportation services could be limited. Older people can often become depressed from isolation, which can lead to obesity, malnutrition, and minimal physical activity. The lack of coordination in services can be confusing for seniors who need support from community and health professionals. Seniors with diabetes may need someone who can voice their needs if their condition deteriorates and they are unable to care for themselves.

Studies show an association between diabetes and socio-economic status. Developed countries report more diabetes among persons with low incomes and low education. These people may be limited in their ability to select healthier diets and may be less aware of the benefits of physical activity. Many people living on a low income have limited food choices, relying on food banks or whatever is available on the street. Physical activity is less of a priority than worrying about the next meal or a place to sleep.

Diabetes occurs more frequently in certain ethnic groups such as Hispanic, African, Asian, and Aboriginal. When developing programs to control diabetes, health and program planners need to understand the cultural context and the impact of making changes to an individual's lifestyle. Considerations include: language barriers; the customs, values, and beliefs of a culture; traditional foods; general views towards health, healing, disease and prevention; and how the individual interacts with the health system and the community.

Newcomers to Canada may be limited in their ability to access health services. Their knowledge of English or French may be limited. If they need an interpreter, they may feel intimidated and uncomfortable when visiting a health professional. Cultural differences such as a gender preference for a health care provider may also inhibit their dealings with the health system. Among certain immigrant and refugee groups, education levels and average household incomes are lower than the average population. Studies show that people with lower levels of education and income tend to have poorer health.

Before 1940, there was no evidence of diabetes among Aboriginal people in Canada. Today, this disease is reaching epidemic proportions among the Aboriginal population, with rates approximately three times the national average. Traditionally, Aboriginal people led physically active lifestyles and lived off nutritious "land food". The combination of genetic susceptibility, transition to a sedentary lifestyle, and adoption of a diet high in fats and sugar are major contributors to this dramatic increase in type 2 diabetes among Aboriginal people.

Type 2 diabetes is increasingly frequent among Aboriginal children, especially adolescent females who have a higher rate of obesity than young males. The youngest age at which type 2 diabetes has been diagnosed is six years. Complications of diabetes are also becoming more frequent at earlier ages.

Given current trends, it is estimated that 27 per cent of Aboriginal people will get diabetes within 20 years. In fact, Sandy Lake Reserve in Northwestern Ontario already has the third highest rate of diabetes in the world. At least 26 per cent of its population has type 2 diabetes, and another 14 per cent have glucose intolerance.

Aboriginal communities need resources to improve their diabetes situation. When creating community-based programs for diabetes education, prevention, care and support, many issues need to be addressed including :

• poverty;
• the availability and affordability of healthy food choices;
• the remote locations of many communities;
• limited access to preventive health services;
• unavailable or inconsistent diabetes screening and education programs;
• cultural and language differences;
• jurisdictional issues over the coordination of health services;
• the breakdown and disruption of families; and
• the relocation of family members to cities.

1. Reduce obesity
   Being overweight is the major preventable risk factor for diabetes. Everyone shares the responsibility of preventing or reducing obesity by :
Increasing physical activity
• Exercise improves insulin sensitivity and enhances glucose tolerance. It removes glucose from the blood during activity and for several hours afterward. Exercise helps prevent obesity, a leading risk factor for type 2 diabetes.
• Regular physical activity can improve overall health and help protect against heart disease. It can improve mental outlook and increase energy.
• Before beginning an exercise program, people should consult a doctor about suitable activities, and use Canada's Physical Activity Guide to Healthy Active Living for guidance in types of physical activity, duration, and intensity.
• People should take up more leisure activities that involve physical activity, instead of ones that are inactive, such as watching television.
Maintaining healthy weights
• People should develop and maintain healthy eating habits and activities that do not contribute to weight gain.
• Obese individuals at high risk for diabetes can reduce their risk with moderate weight loss.
• Achieving and maintaining a healthy weight is often difficult. Achieving a healthy weight is more likely to occur through changes in both eating habits and physical activity, rather than through focusing on eating habits alone.
• An approach that balances the physical, emotional and behavioural needs of someone trying to lose weight will more likely result in the permanent maintenance of a healthy weight.
Eating a healthy and balanced diet
• The amount of calories consumed is more important in decreasing the risk for diabetes than the types of food eaten. The amount consumed determines an individual's weight, and being overweight is a significant risk factor for diabetes.
• There is no evidence that eating or avoiding a specific food prevents diabetes. But a diet low in saturated fat and sugar, and high in complex carbohydrates and dietary fibre such as one with fruits, vegetables, whole grains, and legumes, is strongly recommended for promoting overall health.
• The nutritional needs of people with or without diabetes should be consistent with Canada's Food Guide to Healthy Eating.
2. Develop awareness of diabetes symptoms and screening guidelines
• The early detection and treatment of diabetes can lead to preventing or delaying complications. Consult a doctor if you are at high risk for developing diabetes (Appendix D) or if you have symptoms of diabetes (Appendix B).
3. Do not smoke if you have diabetes
• Smoking is a risk factor for diabetes-related complications. It also reduces a person's ability to take part in regular physical activity.
4. Reduce stress
• Stress can alter routines for diabetes management. It can break down stored forms of glucose and elevate glucose in the blood. Reducing stress can decrease the risk for diabetes-related complications and increase emotional stability and well-being. Tips for managing stress include exercise, meditation and relaxation, counseling, and a diabetes support group.

1. Boards of health must provide leadership for prevention

   Ontario's boards of health have a mandate to promote health and prevent disease. One of their goals is to reduce premature death from preventable chronic diseases such as diabetes. Strategies for encouraging healthy eating, healthy weights, and regular physical activity include increasing public awareness and education, building skills, and developing policies for supportive social and physical environments.

• Boards of health must emphasize the need for preventive strategies for diabetes within the Ministry of Health and Long-Term Care Mandatory Health Program and Service Guidelines.
• Boards of health must develop partnerships with community agencies, school boards, workplaces, health professionals, restaurants, food banks, grocery stores, and recreational facilities to increase access to regular physical activity and to sufficient, safe, nutritious and personally acceptable food.
• Health promotion programs must inform the public about the need for preventing diabetes, and empower people to make healthy decisions. Programs must target people at high risk for diabetes, people with undiagnosed diabetes, homeless and low-income people, and people without regular access to public health information. Messages must be consistent and promote standardized referral to diabetes resources.
2. Communities must promote physical activity, healthy eating, and healthy weights

   To foster a healthy community, opportunities for improving physical fitness, promoting healthy eating, and maintaining healthy weights must be made available to everyone in the community.

   • Schools should encourage at least 30 minutes of physical activity every day until the end of high school. Schools must ensure that the cafeteria and vending machines provide healthy food. The early adoption of healthy lifestyle practices increases the likelihood of a person maintaining physical activity levels and healthy eating habits well into adulthood. Schools should be supported in implementing curriculums which include education about physical activity, nutrition, and the consequences of smoking.
   • Communities should provide adequate resources to encourage physical activity and to should provide affordable services at recreational facilities. More neighbourhoods require clean and safe parks and walking paths to encourage residents to participate in outdoor physical activities. Communities can join together to create leagues for team sports. More neighbours can come together to develop community kitchens and gardens, and they can encourage local markets to sell a better selection of healthy food.
   • Employers should promote healthy lifestyles by increasing employees' access to physical activity and ensuring the availability of healthy food choices in cafeterias.

3. Communities must advocate that diabetes receive priority consideration in local health and education initiatives

   Advocacy is an important way to support people with, and at risk for, diabetes. Governments, non-governmental agencies, health care providers, and workplaces need to be aware of the needs of people with diabetes.

   • The planning and delivery of diabetes health care in the community must involve people with diabetes.
   • Advocacy groups must continue to ensure that diabetes remains high on the public health agenda and that high-quality, cost-effective, and integrated diabetes care is provided to everyone with diabetes.
   • More health promotion programs are needed to inform the public about the importance of preventing diabetes and its complications. The public needs to be fully informed about the costs associated with diabetes including costs for health care, lost productivity, disability, and premature death. They also need to know about the decrease in the quality of life of people with diabetes and the variation in accessibility to health resources and services.
   • Discrimination is an emerging concern. People with diabetes experience the denial of jobs and insurance, limitations on careers and licenses, and tax and health care cost penalties. The situation of each person with diabetes needs to be assessed on an individual basis. Much discrimination results from a poor understanding of diabetes and the fact that people with diabetes can lead productive lives.

Doctors, medical specialists, diabetes educators, and staff from hospitals, community-based education centres, and public health units need to :

1. Learn and adopt clinical practice and prevention guidelines for diabetes
   • According to current screening guidelines, health care providers should identify people at high risk of developing diabetes, including people aged 45 and older. Providers should assess obesity and activity levels of their clients, and treat or counsel them accordingly. If a person is diagnosed with diabetes, the health care provider should administer appropriate care for preventing or delaying complications. Early diagnosis and strict management of blood glucose levels represent a good start towards preventing complications from diabetes.

2. Educate clients about the prevention and treatment of diabetes

Diabetes education provides the necessary information and skills to reduce the incidence of diabetes. Diabetes education can increase the number of people who monitor their blood glucose levels and comply with overall management of the disease, leading to a reduction in diabetic complications.

• A public health strategy for diabetes must involve an educational component for clients with or without diabetes. Education and behavioural change strategies need to vary according to the client population. Strategies should empower clients to participate in decisions about behaviour modification and management of the disease. Without their input, clients are less likely to modify their behaviours or practise them on a daily basis.
• Generic home-based educational materials are appropriate for educated populations but are less successful for low-income populations with high rates of illiteracy, or in ethnically diverse populations where language barriers exist. Audio, video or computer-based information, either at home or at a health centre, are additional ways to communicate.
• Community-based initiatives can provide outreach to various low-income or ethnic populations.
• Diabetes guidelines must prioritize recommendations and promote the need for individualized treatment. The tailoring of strategies, such as different approaches to diet, physical activity, and medication for each individual, should be emphasized to motivate clients.
• Health care providers need ongoing training and support for approaches to enhance behavioural change in clients.
3. Provide comprehensive and coordinated health care to prevent and lessen serious and long-term complications
• An interdisciplinary team care approach is essential for managing diabetes and meeting the educational and psycho-social needs of clients. This approach requires the coordinated effort of doctors, diabetes educators, dietitians, and behavioural specialists. Most of all, it requires that the person with diabetes and family members be involved in making decisions about the individual's treatment plan.
• Changes in the delivery of health care are required to support a public health approach. Medical encounters should change from a diagnose-and-cure strategy to a coaching strategy with a planned schedule for care and screening. Follow-up care should involve preventive screening and assessing behavioural change and efforts at self-management. Follow-up care can include face-to-face visits, telephone interviews, video conferencing, and fax or e-mail correspondence. Mailed reminders, questionnaires, and patient-carried medical records or care plans can be used to encourage follow-up care.
• Our health system needs changes to reorganize the delivery of services for preventing diseases and complications.
4. Encourage aggressive anti-smoking education among people with diabetes, as well as the general population

Smoking is a significant risk factor for the development of complications of diabetes. It reduces insulin action and promotes narrowing of the arteries.

• Health care providers need to acknowledge the psycho-social reasons for smoking and provide the necessary educational and emotional support for dealing with the stress related to having diabetes.

1. Establish a tracking system for diabetes

   Information about rates of diabetes and its complications in Ontario is very limited because of the lack of a strategy for keeping track of all people diagnosed with diabetes in the province.

• A system is needed to monitor the health impact of diabetes on the population, to study risk factors in the population, to track treatment and follow-up procedures, to monitor the incidence of diabetes-related complications, and to evaluate programs that have been implemented.
2. Ensure accessibility to diabetes care
   • Efforts must be made to ensure the best coordination and comprehensive care for all Ontarians with diabetes.

3. Create accessible resources to support diabetes education for clients, health care professionals, the public, and policy-makers
• More diabetes education and programs are needed to increase knowledge about diabetes These programs need to be dispersed according to demographics and tailored to the needs of the population. For the public, education programs should raise awareness of the risk factors associated with diabetes and of the substantial burden that individuals, families, and caregivers endure as a result of diabetes. Educational programs should also provide people with diabetes and their families with information for managing the disease.
  Educational resources can include health fairs and readily accessible books, pamphlets, audio, video, or computerized information. Accessible sites for educational outreach include workplaces and grocery stores.
  The province can exercise a leadership role with the federal government to address this issue in the context of a national diabetes strategy.
• Creation of environments and access to curriculum resources to support students' physical activity and healthy eating should continue.
• The education of policy-makers, who provide leadership and accountability, is critical for implementing recommendations. Policy-makers must be informed about the broad determinants of health and the specific strategies that can help stem the diabetes epidemic. Policy-makers need to be aware of the current and projected economic impact of diabetes, its incidence and prevalence, and its distribution in Ontario.
4. Provide consumer information on the content of all foods

   Food labels promote healthy eating by enabling people to make wise choices in food selection.

• The federal government should introduce policies for meaningful product labeling of all foods.
• The information on labels should be presented in user-friendly ways so people can easily understand what they are buying. To encourage consumers to read and understand labels, consumer education programs are needed when new labeling is implemented.
5. Provide more funding for research projects in diabetes-related fields

   Diabetes research should focus on understanding the causes of diabetes and reducing the burden of the disease and its complications. Much research is still needed in the areas of effective community-based prevention strategies, improvements in quality of life and clinical management, behaviour modification, and reduction of the economic and social costs of diabetes. Researchers need to collaborate, cooperate, and network to ensure that research funds are used efficiently. The public health sector through the Public Health Research, Education and Development Program and other initiatives can share leadership in this area.

Diabetes is a major public health problem in Ontario with rising numbers of people with diabetes and disease-related complications. The health care, human, and social costs of diabetes are overwhelming, and the projections for improvement are not favourable.

Diabetes can potentially affect anyone in Ontario. Most people have at least one major risk factor for diabetes: a family history of diabetes; obesity; physical inactivity; being 45 years or older; belonging to a high risk ethnic group, including Aboriginal, African, Asian, or Hispanic; having had diabetes related to pregnancy or a diagnosis of glucose intolerance. As diabetes is a disease that generally hides for years until one's health begins to deteriorate, many people walk around as time bombs, not realizing they have the condition.

With diabetes rapidly increasing as a public health concern, Ontario clearly needs an agenda for action. This action must involve commitment from the individual, community, health district, and provincial and federal governments.

As we enter the new millennium, we all need to work towards improving our lifestyles by increasing physical activity, maintaining healthy weights, and eating healthy diets. These behaviour modifications can improve our chances of preventing or delaying the onset of diabetes. Developing awareness of the symptoms of diabetes can lead to early diagnosis and prevent or delay complications.

Communities need to take action and provide the resources for encouraging behavioural change. Health care providers need to assess risks, screen appropriately, and educate the public on diabetes prevention. Boards of health need to provide leadership in the move towards the prevention of diabetes. And governments need to implement policies that foster healthy lifestyles.

When designing strategies to reduce the risk of diabetes and its complications, Ontario should adopt both general population and high risk approaches. For best results, these strategies need to address the broad determinants of health, especially socio-economic status, education, physical environment, and employment and working conditions. Through small changes in the way people lead their lives, we can significantly improve the health of Ontario's population and reduce the burden of diabetes.

The Steering Committee wishes to acknowledge the assistance provided in the preparation of this document by the Ministries of Health for the Provinces of Saskatchewan, Manitoba, and Prince Edward Island.

Type 1 diabetes occurs when a person's pancreas produces little or no insulin. The body's own immune system destroys the pancreas' insulin-producing cells. Often diagnosed in children, type 1 diabetes represents 10 per cent of people with diabetes.

People who have type 1 diabetes often complain of the sudden onset of symptoms such as : frequent urination, excessive thirst, hunger, rapid weight loss, weakness or drowsiness, nausea and vomiting, or blurred vision. People with type 1 diabetes must inject insulin every day for survival and carefully monitor their blood glucose levels, physical activity, and food.

Type 2 diabetes occurs when the pancreas produces insulin but the body cannot use it effectively, or the amount is too small to produce any effect. Type 2 diabetes usually occurs in adults over 40. Approximately 90 per cent of people with diabetes have type 2.

The symptoms are similar to type 1, but tend to be less profound. They may also include: recurring skin, gum, and bladder infections; cuts and bruises that are slow to heal; and tingling/numbness in the hands or feet. Type 2 diabetes is often not diagnosed until complications have started.

Treatment includes weight loss, a proper diet, and exercise. If blood glucose cannot be controlled by lifestyle changes, oral drugs or insulin injections are required.

Gestational diabetes affects two to four per cent of pregnant women. Women with gestational diabetes do not produce enough insulin, or their bodies becomes insulin resistant during pregnancy. Although often managed with proper diet and exercise, some mothers may need insulin treatment.

Although gestational diabetes normally disappears after giving birth, the mother has a 30 to 40 per cent risk of developing type 2 diabetes within five to 10 years. The baby also has an increased risk for developing type 2 diabetes.

Other specific types of diabetes consist of genetically determined forms of diabetes, and diabetes associated with other diseases or drug use.

Symptoms of type 1 diabetes include :

• frequent urination, in large quantities;
• unusual and excessive thirst;
• extreme hunger at all times;
• unusual weight loss;
• extreme fatigue;
• irritability;
• nausea and vomiting; and
• sweet smelling breath.

Symptoms of type 2 diabetes are similar to those of type 1 but may also include :

• frequent infections such as recurring skin, gum, or bladder infections;
• cuts and bruises that are slow to heal;
• tingling or numbness in the hands or feet;
• itching of the skin and genitals; and
• drowsiness.

Symptoms of type 2 diabetes usually progress at a slow rate. Diagnosis of type 2 diabetes may occur during a non-related medical examination. People need to be fully aware of their bodies and of the symptoms related to diabetes, since early diagnosis can lead to prevention and delay of complications.

Cardiovascular problems are two to six times more likely to occur in people with diabetes than in people without diabetes. Twenty-one per cent of people with diabetes (four per cent without diabetes) will develop heart disease or have a stroke.

High blood glucose is associated with narrowing of arteries, high blood pressure, increased blood levels of fats, and decreased levels of good cholesterol -- all risk factors for cardiovascular disease.

Retinopathy (damage to the retina of the eye) is a major cause of adult blindness in North America. High blood glucose, especially coupled with high blood pressure, damages the small blood vessels in the retina of the eye. Fifty per cent of all blindness occurs among people with diabetes. A person with diabetes is four times more likely to become blind than a person without diabetes. People with diabetes are also at increased risk of developing cataracts and glaucoma.

Neuropathy (damage to the vessels supplying blood to the nervous system) affects sensation, especially in the hands and feet. Approximately 60 per cent of people with diabetes are affected by this condition. They may experience numbness or tingling sensation, pain, increased sensitivity, weakness, muscle wasting, gastrointestinal problems and impotence. People with diabetes have an increased risk for foot ulcers and amputation of toes, feet, and legs. Lower limb amputations generally result from a foot infection that has not healed and has developed gangrene. The initial wound often results from a lack of protective sensory function in the foot and the inability of the wound to heal properly is associated with the decrease in blood and nutrient flow to the lower limbs. Fifty per cent of all amputations occur in people with diabetes.

Nephropathy (kidney disease) is a major cause of illness and early death for people with diabetes. This disease results from chronic high blood glucose levels that damage small vessels in the kidney which filter waste from the blood. Diabetes often results in a need for dialysis and kidney transplants. Twenty-six to 28 per cent of kidney dialysis is performed on people with diabetes. A person with diabetes is 20 times more likely to develop kidney failure than a person without diabetes.

Dental disease occurs with greater frequency and severity among people with diabetes. Thirty per cent of people 19 years or older with type 1 diabetes have gum disease which can lead to tooth loss.

Complications of pregnancy can occur among women with diabetes. Among women with diabetes, three to five per cent of pregnancies will result in the death of the newborn (1.5 per cent among women without diabetes).

A mother who develops gestational diabetes has a 30 to 40 per cent risk of developing type 2 diabetes within five to 10 years. The child also has an increased risk of developing diabetes later in life.

Impotence occurs in 50 to 60 per cent of men with diabetes. Some impotence is a result of medications prescribed to control diabetes. This dysfunction affects both the person with diabetes and the sexual partner.

Illnesses and infections are common among people with diabetes. They are susceptible to infections of the mouth and gums, urinary tract, lower extremities and incisions after surgery. They are more likely to die of pneumonia or influenza than people who do not have diabetes.

Greatest Risk Factors

• I am over the age of 45.
• My body mass index (BMI) is greater than 27.
(See Appendix E)
• I am inactive or don't get enough exercise.

If you have checked two or more of these items, you may be at a great risk of developing diabetes. You may even have diabetes now and not know you have it.

Additional Risk Factors

• I have a parent, brother or sister who has diabetes.
• I am of Hispanic, African, Asian, or Aboriginal descent.
• I have given birth to a large baby (over 4 kg or 9 lbs).
• I have already been diagnosed with glucose intolerance (higher blood sugar levels).

If you have checked any of the last four items, you may have some risk of developing diabetes.

To reduce your risk for diabetes, you need to maintain a healthy weight and exercise regularly. This quiz is intended to make you aware of the serious risk factors of diabetes. You should see your doctor to determine if you have diabetes.

(Adapted from the Canadian Diabetes Association)

A quick way to assess whether an adult's weight represents an increased risk for developing diabetes is to determine waist size. Waist sizes more than 100 cm (39.5 inches) in men and 95 cm (37.5 inches) in women suggest increased risk.

In 1992, the Ontario Ministry of Health announced diabetes reform as a strategic priority and established a Diabetes Advisory Committee. This committee developed a 10-year strategic plan for designing and implementing effective programs to prevent diabetes and its complications. The plan focused on people and communities at greatest risk with these initiatives :

Before 1992, diabetes services were severely lacking in Northern Ontario. The North had the highest rates of diabetes-related death and hospitalization in Ontario. A network of 37 diabetes education programs in local and remote communities across northern Ontario was established to improve access to coordinated and comprehensive services. Innovative outreach initiatives include culturally appropriate programs for Aboriginal people, foot care services, and college certificate programs for diabetes education.

Approximately half of the Aboriginal population in Ontario now live in southern Ontario because of educational and job opportunities. In 1994, SOADI was created to develop and implement diabetes-related programs and services for Aboriginal people in southern Ontario. These programs and services focus on health promotion, disease prevention and diabetes management using both Western and traditional approaches such as traditional medicines, teachers and healers.

In 1994, the Ministry of Health established a Seniors and Diabetes Committee to study diabetes as it affects seniors and to link seniors' issues to the overall diabetes strategy. The committee promotes a consistent, interdisciplinary clinical/management approach for seniors with type 2 diabetes who live in Long-Term Care Centres. Working groups are developing a step-by-step disease management approach for these seniors and a diabetes management manual for front-line workers. The Seniors and Diabetes Committee will be expanding its focus to include seniors with type 2 diabetes living in the community.

Four out of every 10 people with diabetes will develop debilitating and often life-threatening complications. In 1996, the Diabetes Complication Prevention Strategy was initiated to reduce and prevent diabetes-related complications such as eye, kidney and degenerative nerve disease by as much as 50 per cent.

Thirty-three new or expanded diabetes education programs have since begun in southern Ontario. Four regional adult and four regional pediatric networks have been incorporated as the Diabetes Complication Prevention Cooperative (DCPC). Members of the networks reflect the cultural mix of the regional populations and the needs of people with diabetes from all age groups. The DCPC will help ensure that people have prompt access to a range of coordinated services aimed at preventing complications.

The Ontario Diabetes Status Index consists of 10 indicators that measure the effect of diabetes on health and on health care services. Another set of data reflects the costs of diabetes care under major programs funded by the Ministry of Health and Long-Term Care. The Index and costing charts help in planning and evaluating diabetes services, determining if changes in services are improving people's health, and evaluating whether health care dollars are spent effectively to reduce the impact of diabetes.

Many non-governmental organizations including the Canadian Diabetes Association, the Juvenile Diabetes Foundation, and the Diabetes Council of Canada provide diabetes resources for Ontario and link with many other organizations. By establishing partnerships and working together, these organizations can offer a strong voice for diabetes concerns and establish diabetes as a high priority issue at both the provincial and federal levels.

The website for the Canadian Diabetes Association, www.diabetes.ca, links to many other websites with diabetes-related information.

November 1999