ADDRESSING THE SILENT EPIDEMIC OF DIABETES IN FIRST NATIONS ON-RESERVE


WHAT IS THE ISSUE?

The International Diabetes Federation (IDF) has identified diabetes as one of the largest global health emergencies of the 21st century (1). Indigenous Peoples in Canada are among the highest-risk populations for diabetes with rates 3–5 times higher among Indigenous peoples than the general population (2, 3, 4). Diabetes is one of the fastest growing diseases among Indigenous populations and is associated with a high individual, social and economic burden (2). It poses a crucial public health challenge which cannot be disputed.


BACKGROUND

Diabetes is a growing public health concern which has reached epidemic proportions on a global scale. The IDF estimated that nearly 463 million individuals were affected by diabetes worldwide in 2019; this number is projected to reach an alarming 700 million people by 2045 (1). This burden of diabetes is disproportionately placed on Indigenous peoples. It is estimated that over 50% of Indigenous adults (>35 years of age) have type 2 diabetes mellitus (T2DM) globally (5).

An estimated 3.0 million Canadians (8.1%) were living with diagnosed diabetes in 2013–2014 (6). Indigenous Peoples in Canada are among the highest-risk population for diabetes and associated complications. However, it doesn't affect all Indigenous Peoples equally. First Nations communities face a considerably larger burden of disease than the Inuit or Métis population (2).


The Government of Canada has been making progress towards developing a systematic policy response to the diabetes burden. It introduced a pan-Canadian Diabetes Strategy as well as a Targeted Aboriginal Diabetes Strategy for the purpose of diabetes prevention and management (2). However, the overall investment in and implementation of these comprehensive strategies has been variable. This has been attributed to a paucity of surveillance data, barriers to effective diabetes care, the provision and lack of evidence on the effectiveness of these interventions in First Nations communities (2, 5).


WHAT IS THE IMPACT?

Diabetes is progressive in nature and exposes patients to an array of complications ranging from both acute and life-threatening to chronic and debilitating including cardiovascular disease, hypertension, lower limb amputation, kidney disease and neuropathy (7). Mortality rates in First Nations people with diabetes is estimated at 19.5 per 100,000 versus 13.3 per 100,000 in the general population and diabetes-related complication rates are 2–5 times higher than in the general population (5).


The increased rates of diabetes and its complications in Indigenous communities is driven by the earlier age of diabetes onset and intergenerational risk associated with gestational diabetes mellitus (GDM), greater disease severity, reduced access to health services, and the social determinants of health (4, 5).


GOALS

This is a call to action for policymakers and health professionals to improve the health and wellbeing of First Nations On-Reserve with the assistance of Internationally Trained Physicians (ITPs).


ITPs come from diverse backgrounds and most have clinical experience working within underserved communities as well as marginalized populations. This clinical experience can be translated into the setting of working with Indigenous Peoples. However, we acknowledge the need for and importance of cultural awareness, sensitivity, and competence. ITPs can be equipped with the tools needed to provide culturally sensitive therapeutic management through workshops and courses dedicated to cultural sensitivity training.


POLICY OPTIONS

To advance Canada’s commitment to improving the health and health inequity of First Nations On-Reserve, we have identified several options to reduce barriers to care which are presented below.


1. Incorporation of ITPs in health promotion campaigns aimed at targeting diabetes prevention through improved awareness of risks and complications of diabetes. This can be accomplished through the Diabetes 360 degrees strategy which would involve initiatives promoting cultural practices of healthy eating; projects targeting the risks of obesity in pre-gravid females and subsequent pregnancies; and proposals promoting the risk factors of diabetes. This will require an ongoing collaboration with community leaders, elders, health care professionals including ITPs and tribal schools.

2. Access to healthcare is a social determinant of health among Indigenous Peoples (4, 5). Incorporation of ITPs as physician extenders as per CPSO’s delegation of controlled acts will improve access to health care by increasing the human resources needed to manage mobile health units and on-site clinics. This will result in increased availability of clinic appointments and greater retention of staff. Such an initiative can lead to improved continuity of care, help rebuild trust within the healthcare system and foster much needed bonds with members of the Indigenous community.

3. ITPs can also assist in managing a diabetes registry and surveillance system for the Indigenous community which could help track and improve the quality of care.



References

1. Saeedi, P., Petersohn, I., Salpea, P., Malanda, B., Karuranga, S., Unwin, N., Colagiuri, S., Guariguata, L., Motala, A. A., Ogurtsova, K., Shaw, J. E., Bright, D., & Williams, R. 2019. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th edition. Diabetes Research and Clinical Practice. https://www.sciencedirect.com/science/article/pii/S0168822719312306

2. Halseth, R. The prevalence of type 2 diabetes among First Nations and considerations for prevention. Retrieved January 8, 2022, from https://www.nccih.ca/docs/health/RPT-Diabetes-First-Nations-Halseth-EN.pdf

3. Diabetes Canada Clinical Practice Guidelines Expert Committee, Crowshoe, L., Dannenbaum, D., Green, M., Henderson, R., Hayward, M. N., & Toth, E. (2018). Type 2 Diabetes and Indigenous Peoples. Canadian journal of diabetes, 42 Suppl 1, S296–S306.https://doi.org/10.1016/j.jcjd.2017.10.022

4. Jacklin, K., Henderson, R., Green, M., Walker, L., Calam, B., & Crowshoe, L. (2017). Health care experiences of Indigenous people living with type 2 diabetes in Canada. Canadian Medical Association Journal (CMAJ), 189(3), E106–E112. https://doi.org/10.1503/cmaj.161098

5. Harris, S. B., Tompkins, J. W., & TeHiwi, B. (2016, December 5). Call to action: A new path for improving diabetes care for Indigenous Peoples, a Global Review. Diabetes Research and Clinical Practice. Retrieved January 8, 2022, from https://www.sciencedirect.com/science/article/pii/S0168822716302467

6. Canada, P. H. A. of. (2020, August 17). Government of Canada. Canada.ca. Retrieved January 8, 2022, from https://www.canada.ca/en/public-health/services/publications/diseases-conditions/diabetes-canada-highlights-chronic-disease-surveillance-system.html

7. Nickerson, H. D., & Dutta, S. (2012). Diabetic complications: current challenges and opportunities. Journal of cardiovascular translational research, 5(4), 375–379. https://doi.org/10.1007/s12265-012-9388-1

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