Diabetes Patient Education

DIABETES
An Epidemic of the New

Millennium
Program & Policy Implications
for Canada
Dr. Stewart Harris
University of Western Ontario
Canadian Diabetes Strategy: Time For Action

Overview of Today’s Talk
• The Epidemiology
• Current Healthcare Delivery & Innovative
Models
• Future Policy & Program Direction
Canadian Diabetes Strategy: Time For Action, May 2003

Dr. Stewart Harris, UWO
The World Wide Epidemic:
Prevalence of Diabetes
5%
8%
3%
14%
4%

The Worldwide Epidemic:
Diabetes Trends
400 370
350
300
Millions with Diabetes
300
250 221
200 177
135
150
100
30
50
0
1985 1995 2000 2010 2025 2030
Sources: www.who.int
www.idf
Zimmet P. et al Nature: 414, 13 Dec 2001
Millions with Diabetes 2000 & 2030
2000
People with Diabetes
(millions)
< 30
31 - 35
36 - 40
41 - 45
46 - 50
>50
2030

Millions by Degree of Development
250 1995
2025
200
Millions with Diabetes
150
100
50
0
Developed Countries Developing Countries
REF: www.who.int Sept 2002 Fact Sheet#236

The Diabetes Epidemic
in Canada
Prevalence, Risk Factors,
and
Current Cost Implications

The Canadian Epidemic:
Prevalence of Diabetes in Canada, 1996
14%
12.6%
12%
Overall self-reported 10.2% 10.2%
10%
prevalence (15+): 9.6%
Prevalence (%)
8%
3.4% (n=786,000) 8.2%
5.9%
6%
4.4%
4%
2.7%
1.9%
2%
0.6% 0.5% 0.5% 0.7% 0.7%
0%
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+
Age Group
Source: Statistics Canada, National Population Health Survey, Public Use Microdata, 1996/97
Prevalence in Canada, 1994/95 to 2000/01, by Province
1994 - 1995 1996 - 1997 Prevalence (%)

1.30 to 2.90
3.00 to 3.40
3.50 to 3.90
4.00 to 4.40
2.7 3.90
4.60 5.00 to 5.40
3. 3.40
2.8 3.2
3.1 1 2.5 3.2
3.20
5.50 to 5.90
3.1 3.50 3.2
3.0 3.20
2.8 3.2
4.6
No data
3.6
1998 - 1999 2000 - 2001
3.2
1.3
5.8
5.2
3.4 3.9
3.1 4.0 4.0
3.1 3.1 3.4 4.1
3.10 3.1 4.0 5.0
3.6 4.2
3.3 4.4 5.1 5.2
Source: Statistics Canada: CANSIM II Canadian Diabetes Strategy: Time For Action, May 2003
These numbers are an
under-representation of
the true burden of
diabetes….

Undiagnosed DM and ‘PreDiabetes’
In international population based diabetes

prevalence studies
• American study found:
– 33% of all cases of diabetes were undiagnosed
• Australian study found:
– 50% of all cases of diabetes were undiagnosed
• For a total prevalence of 7.4%
REF: The Australian Diabetes, Obesity and Lifestyle Study, Diabetes Care, V25 5, May 2002
Harris MI, Eastman RC, Diabetes Metab Res Rev 2000 Jul-Aug;16(4):230-6
Age Distribution of Canadians with Diabetes in 2000 & 2016
400,000
350,000
2000 (n=1.4 million)
300,000
Persons with Diabetes
2016 (n=2.5 million)

250,000
200,000
150,000
100,000
50,000
0
<5 5-9 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80+
14 19 24 29 34 39 44 49 54 59 64 69 74 79
Age Group
* Source: Statistics Canada Canadian Diabetes Strategy: Time For Action, May 2003
Alberta Prevalence
First Nations
Social Services
Subsidy
No-Subsidy

Diabetes Risk Factors
Modifiable Risk Factors

•Physical Activity
• Obesity
•Diet
&
Non-Modifiable Risk Factors
•Ethnicity
•Family History

Diabetes Risk Factors:
Modifiable
Physical Activity:
Relative Risk For Developing Diabetes
2
Relative Risk
0
>7 4 to 7 2 to 4 .5 to 2 <0.5
Hours per week
Source: Choi B, Shi F. Diabetologia 2001, 44:1221-1231.

Modifiable
Healthy Diet:
Relative Risk for Developing DM
1.5
relative risk
0.5
0
5 4 3 2 1
quintiles based on fat/fibre content

Modifiable
Obesity:
Relative Risk For Developing DM
40
Relative Risk
30
20
10
0
<23 23-25 25-30 30-35 <35
BMI = wt/(ht) 2

Modifiable
• Relative risk for developing type 2 is cumulative.
– A physically inactive individual (less than 30 min/wk of
exercise)
– who consumes an unhealthy diet
– and is modestly overweight (BMI 25-30)
– would have a 30-fold increased (1.8*2*8) risk of
developing type 2 DM compared to the general
population,
• which would translate to a lifetime risk of nearly
100%
REF: Atlas of Diabetes 2nd Ed, Part 2, JS Sklyer, Editor

Diabetes Risk Factors: Modifiable
Physical Inactivity in Adults by Province, 1998-2001
1998 1999
51 47
4
60 7 55
67
67
56 57
58 63 63 68 65
69 62 72 68
6 60 61
63 65 65
3
70 73
40 to 49
2000 50 to 59
2001
60 to 69
70 to 79
58
65 49
67
65
61
56
66 62 47
63 69 65 61 59
50 59 62
59
64 62 55
63 57
Source: www.cflri.ca
Canadian Fitness & Lifestyle Research Institute
Obesity by Province: BMI 30
1985 1990 1994
< 10%
1996 1998
< 10% - 14.9%
> 15%
No data
Source: Katzmarzyk PT, CMAJ Apr. 16, 2002; 166 (8)

Obesity
• The proportion of children and
adolescents who are overweight has
tripled in the past 3 decades.
• Fat kids become fat adults
• More fat kids means more fat adults
down the road

Future Implications
Two major demographics are at play in
Canada:
• ‘Boomer’ and ‘Echo’ Generation
• Immigration and Ethnicity
– High percentage of Canadian immigrants are
from ethnic groups that are at high risk for
the development of DM

The Epidemic:
Non-Modifiable Risk Factors
Ethnicity
Age
Family History / Genetics

The Epidemic:
Ethnic Groups at High Risk for DM
Aboriginal
Latino
South East Asian
Asian
African Descent

Diabetes Risk Factors: Non-Modifiable
Aboriginal Peoples in Canada & the World

Type 2 Diabetes Prevalence Rates:
NPHS, Sandy Lake to the Canadian Population, age
adjusted prevalence (%) by sex
30
28
25 24.2
20 19.8
16.9
Sandy Lake (IGT)

15
Sandy Lake (DM)

Sandy Lake (DM)
Canadian
11
NPHS
10
NPHS (DM)
NPHS (DM)
7.1 Sandy Lake (DM)
Sandy Lake (IGT)
5
3.3 3.2
0
Male Female
REF: Harris SB et al Diabetes Care 1997;20:185-187 & NPHS

Age-Standardized Prevalence of Obesity by Glucose
Tolerance Status (BMI>27): Canada and Sandy Lake
80
77.5
70 73.1 75.1 •Both measures of obesity
60 63.9 64.6 (BMI and WHR) were
50 associated with increasing
50.9 glucose intolerance for both
40 sexes
30 35
20 27
10
0
Men Women
Canada Sandy Lake (Norm) Sandy Lake (IGT) Sandy Lake (DM)
REF: Hanley AJG, Harris SB et al Diabetes Care 1997;20:185-187.
Prevalence of Abdominal Obesity (WHR) by Glucose Tolerance
Status: Canada and Sandy Lake (Age-Standardized)
100
99.1
93.4 98.7
80 93.6
91.9
81.8
60
50
40
34 •WHR was shown
20 to be a significant
predictor for
0 diabetes
Men Women
Canada Sandy Lake (Norm)

Sandy Lake (IGT) Sandy Lake (DM)
REF: Harris SB et al Diabetes Care 1997;20:185-187.

Pediatric Obesity Study:
Sandy Lake and NHANES III Males, age 2-19

Diabetes Risk Factors: Non-Modifiable
Other High-risk Groups in Canada
• 77.1% of Canada’s immigrant population

are coming from populations which from
high risk ethnic groups
• 7.3% Latinos
– Central and South America, 7.3%
• 57.0% Asian
• 12.8% African Decent
– Caribbean and Bermuda, 5.5%
– Africa, 7.3%
REF: Statistics Canada, 1996 Census

Diabetes Complications
Macrovascular
Heart Disease and Stroke
Microvascular
Kidneys
Eyes
Feet

Macrovascular
Complications
The management of macrovascular
disease is estimated to be the largest
component of diabetes-related
complications costs, accounting for
52% of the costs
REF: Caro JJ, Diabetes Care 2002 Mar;25(3):476-81

Diabetes Complications:
Macrovascular
• DM is a major risk factor for cardiac
disease
• Acute MI occurs 15-20 years earlier in
those with DM
• Heart disease accounts for approximately
50% of all deaths among people with
diabetes in industrialized countries
REF: Diabetes in Ontario, An ICES Practice Atlas, 2002

Macrovascular
• Several large epidemiological studies
have found a strong relationship between
– glucose level and subsequent coronary
events, even at ‘pre-diabetes’ levels (IGT
and IFG)
– glucose levels that are only modestly
elevated place patients at risk.
REF: Coutiho M. et al Diabetes Care 1999;22:233-240.

& DECODE Study Group. Arch Intern Med 2001;161:397-404.
Diabetes Complications: Macrovascular
Relationship between FPG and CHD
Metaregression - 20 prospective studies
n = 95,783 - follow-up 12.4 yrs
2.5 FPG > 6 mmol/L: RR 1.38 (1.06-1.67)
Relative Risk
1.5
1
4 5 6 7 8 9
Fasting glucose (mmol/L)
REF: Coutinho et al. Diabetes Care 1999;22:233-40.

Macrovascular
Men with DM
Male No DM
Women with DM
Women No DM

Increasing Morbidity from Ischaemic
Heart Disease in Sandy Lake, Ontario
120
100
IHD 80
admissions 60
per 10,000
persons 40
20
0
1983-1987 1988-1992 1993-1997
REF: Hanley AJG, Harris SB et al Diabetes Care 1997;20:185-187.

Rates of Acute MI Admissions: 1980-1996
Native Communities, Northern Ontario, All of Ontario
60
Acute MIs per 10,000 population
50
40
30
20
10
0
1980 1982 1984 1986 1988 1990 1992 1994 1996
Native Communities Northern Ontario All Ontario
REF: Baiju R. Shah, Arch Intern Med V160, 2000

Macrovascular
Projected Number of Cardiovascular Disease (CVD) Hospitalizations
Among Persons with Diabetes, Canada
250,000 228,214
200,000
158,056
CVD Hospitalizations
150,000
98,925
100,000
50,000
0
1996 2006 2016
REF: Blanchard J. Unpublished

Microvascular
Complications
Neuropathy accounts for 17%,
retinopathy for 10%, and nephrology
21% of the costs of DM complications
REF: Caro JJ, Diabetes Care 2002 Mar;25(3):476-81

Microvascular – Amputation
• Diabetes….
– Is the leading cause of non traumatic
amputation
– Increases the risk of amputation by 20 fold
• those living in the north or in low income
neighborhoods and those with poor access to
physician services are at particular risk for
amputation.

Microvascular – Amputation
First Nations
General Population

Microvascular - Amputation
Projected Number of Lower Limb Amputations Among
Persons with Diabetes, Canada
15,275
16,000
14,000
12,000 10,573
Amputations
10,000
8,000 6,602
6,000
4,000
2,000
0
1996 2006 2016
REF: Blanchard J, Unpublished Canadian Diabetes Strategy: Time For Action, May 2003
Microvascular – Retinopathy
Diabetes
• Is a leading cause of adult-onset
blindness
• Prevalence of diabetic retinopathy is ~ 70% in persons
with type 1 and 40% with person with type 2 diabetes.

Microvascular - Nephropathy
• Diabetes
– Is the leading cause of ESRD
– Increases the risk of developing ESRD by up
to 13-fold
Refs: Meltzer S, et al CMAJ 1998; 159 (8 suppl):S1-S29, &

Parchman ML, et al Medical Care 2002; 40(2):137-144.
Social Services First Nations
Subsidy
No-Subsidy

New Persons with Diabetes on Dialysis
4000
Projected Number of New Persons with 3,533
3500 Diabetes on Dialysis, Canada
3000
2,494
2500
2000 1,574
1500
1000
500
0
1996 2006 2016
REF: Blanchard J, Unpublished.

Current Canadian Costs
The Financial Impact of

Diabetes

Cost of Diabetes:
Impact of Diabetes on Health Care Costs
Estimated Selected Direct Health Care
Costs, Manitoba 1995/96
General Population Status Population
Diabetes No Diabetes No
Diabetes Diabetes
Hospital $1196 $479 $2362 $893

PCH $340 $251 $195 $156
Professional $519 $271 $606 $267
Dialysis $114 $10 $493 $43
Total $2169 $1011 $3656 $1359
REF: Blanchard J, Unpublished, 2001
Cost of Diabetes:
The Cost in Canada, 1998
• The total economic burden (in US dollars) of diabetes
and its chronic complications in Canada for 1998 was
likely to be between $4.76 and $5.73 billion.
• In those people just with diagnosed diabetes, the direct

medical costs associated with diabetes care, before
considering complications, were $573 million.
• Of the costs associated with the complications of

diabetes, cardiovascular disease was by far the greatest
at $673 million.
REF: Dawson KG et al. Diabetes Care 2002 Aug;25(8):1303-7
Cost of Diabetes:
The Cost in United States, 2002
• In 2002, the direct and indirect expenditures attributable
to diabetes were estimated at $132 billion
– up from 1998 estimate of $92 billion
• The estimated $132 billion cost likely underestimates the

true burden because it omits intangibles,
– such as pain and suffering,
– care provided by non-paid caregivers,
– and several areas of health care spending where people with diabetes
probably use services at higher rates than people without diabetes (eg.
dental care, optometry care, and the use of licensed dieticians).
• Likely underestimating the growth of high risk

populations
REF: ADA, Diabetes Care, V26, 3 March 2003
Cost of Diabetes:
The Cost in United States, 2002
Total Cost
$23.2* billion
$132 billion Diabetes Care
$40.1 billion
Indirect
$44.1* billion *Direct Costs

General Medical
$24.6* billion Conditions
Chronic
Complications
REF: Diabetes Care Vol. 26, No. 3 March 2003

Cost of Diabetes:
The Cost in United States & Canada, 2002
• Cost projections for the United States
– Annual cost, in 2002 dollars,
$132 billion, 2002
$156 billion by 2010
$192 billion by 2020
• Cost projections for Canada
– Cost estimates based 10% of population base
– Annual cost, in 2002 dollars,
$13.2 billion, 2002
$15.6 billion by 2010
$19.2 billion by 2020
REF: Diabetes Care Vol. 26, No. 3 March 2003
Cost of Diabetes:
Pay Now or…. Pay Later
• Health care system can choose to invest

now to help manage it properly
OR
• the alternative is to wait,
• AND spend….
– $50,000/yr for kidney dialysis
– $74,000 for the cost of a leg amputation
– Etc.
REF: CDA, 2003 www.diabetes.ca

Current Diabetes Models
Status, Gaps, Barriers,

Innovations

Provisions in CDS Blueprint
• Primary Prevention
– Prevent diabetes through reduction of
modifiable risk factors in general population
• Secondary Prevention
– Screening those at high-risk for diabetes
• Tertiary Prevention
– Upon diagnosis of diabetes, prevention of
complications morbidity, and mortality
REF: Diabetes Blueprint
Primary Prevention
Population Health Model

Primary Prevention Model
• Goal
– Reducing modifiable risk factors for diabetes
• Target
– General population & high-risk groups
• Messages
– Healthy lifestyle choices
• Current Delivery Models of Primary Prevention
– Population Health
– Primary Care

Primary Prevention Model:
Population Health – National
CDS
Health Canada
NADA
REF: Health Canada
Primary Prevention Model:
Population Health
• Despite population health initiatives
• Obesity is increasing
• Diabetes is increasing
– Are these models and strategies under-funded and
maximally coordinated?
– Are the models and strategies effective?
– Are the models and strategies evaluated?
– Are these models well suited for many high-risk
groups
• Specific innovative models are needed

Primary Prevention
Primary Care Model

Primary Prevention: Primary Care Model
Role of Primary Care Physician
• First contact of patients with health care
system is with family doctors
• Role is…
– to promote healthy lifestyle
• Healthy diet
• Physical activity
• Healthy body weight

Primary Prevention: Primary Care Model
Current Status
• Large national sample of family
physicians on lifestyle management
– 96% of FPs believe that lifestyle
interventions have a role in preventing and
managing type 2 diabetes
– 86% believe that FPs should assess lifestyle
– But….96% think lifestyle
counseling and programs should
be provided by others
REF: Harris SB, Petrella RJ et al submitted Canadian Family Physician, 2003

Secondary Prevention
Screening Those at High Risk

Secondary Prevention
• Goal
– Early identification of those with dysglycemia
• Target
– High-risk individuals and groups
• Messages
– Diabetes awareness
• Current delivery model of secondary
prevention relies on primary care
Secondary Prevention:
Is It Effective?
• Yes….
– Patients diagnosed with IGT can be
prevented from progressing to type 2
diabetes
• 58% reduction with lifestyle changes (DPP, DPS)
• 30% reduction with medication (DPP, Stop
NIDDM)

Challenges
Health care system focuses on acute care
• Preventive measures difficult to achieve with this
model
• Screening measures difficult to achieve with this
model
• No systems to track and facilitate preventative
practices
• Physician shortages

Challenges
REF: Chan, CIHI, 2002

Secondary Prevention: Strategies
Clinical Practice Guidelines
• Our strategy has
been to develop
clinical practice
guidelines to assist
providers on how to
screen patients for
diabetes

Tertiary Prevention
Diabetes Management

Tertiary Prevention
• Goals
– Glucose, blood pressure, and lipid control to
reduce the development of complications
– Complication screening for early
identification and management

Tertiary Prevention:
Is it Effective?
• Yes…
– Strong evidence for tertiary prevention
particularly for microvascular disease
• DCCT, UKPDS
– How to translate this evidence into practice?

Tertiary Prevention: Current Status
Conclusions From a National Study (GPDM)
• Patients are seen frequently by their
family physicians
• Acceptable performance for
macrovascular disease complication
screening (BP, lipids)
• Major deficiencies were identified in
microvascular disease complication
screening (retinopathy, nephropathy,
neuropathy, foot)
REF: Harris SB, et al Diabetes 2001
Tertiary Prevention: Challenges
The Canadian Health Care System
• Structure of system designed for acute
care not chronic disease
• Healthcare under-funding is a barrier to
diabetes care
• Challenges to keep up with complications
management
– growing need for dialysis, costs for medications,
hospital restructuring and physician remuneration

Tertiary Prevention: Challenges
Hospital Based Model (DECs)
• Reduced funding and increased demand
• Funding mechanism is problematic
• No formal evaluation on effectiveness
• Limited flexibility in adapting to new
cultural and linguistic realities in Canada

Primary, Secondary, Tertiary
Prevention: Status
In Summary
• The models and funding have not kept
pace with the burden of disease
– Prevalence of diabetes increasing
– Recognition of new disease in IGT/IFG
– Models are not adequately designed to
prevent and care for people with diabetes

Future Policy & Program
Directions
Recommendations

Future Directions:
Wake Up Call!
• We know that diabetes is a world-wide
epidemic…
• Are we, in Canada, going to be

proactive and meet the
challenge?
– or be passive and pay the cost?

Future Directions:
Take Action!
• We CAN act on modifiable risk factors
– Aging population
– Immigration from high-risk populations
– Growth in aboriginal population
• We CAN effectively target high-risk populations
– Obesity
– Physical inactivity
– Calorie-dense/high-fat diet

Future Directions: Cost to Act
Pay Now…Pay Later
• Cost of diabetes in Canada
– 2002 $13.2 billion
– 2010 $15.2 billion
– 2020 $19.2 billion
• We CAN have an impact on the cost by
effective implementation and utilization
at all three levels of prevention

Future Directions:
Provisions of a Diabetes Model
• Public education and prevention
• Screening/Diagnosis of diabetes
• Education for those diagnosed
• Screening and treatment of associated
complications
• Treatment of diabetes/insulin
management
• Program evaluation

Future Directions:
Complexity of the Model

So…
What should a Canadian Diabetes
Strategy address?
What should the priorities be?

Future Directions:
1. National Diabetes Surveillance Strategy
• One of the gems of CDS to date has been
the establishment of National Diabetes
Surveillance System
• We need to continue and expand data

collection in other jurisdictions, and
generate quality data including cost on
an ongoing basis

Future Directions: Primary Prevention
2. National Strategies for Prevention & Promotion
• Need increased effort on a national level
targeting the general populations and
high risk groups
– Boomers
– Aboriginals
– Other high risk immigrant groups
for modifiable risk factors

– Obesity
– Physical inactivity
– Unhealthy diets

Future Directions:
3. CDS National Coordination
• Continued and enhanced effort to ensure
effective coordination with existing
federal and provincial health promotion
Nutrition
Obesity prevention
prevention programs

Future Directions: Tertiary Prevention
4. Diabetes Education Centres
• Existing Diabetes Care Models need to be

formally evaluated
• We need to know….
– who they are serving?
– how long are the waiting lists?
– are they effective in addressing needs of
patients with diabetes and ‘pre-diabetes’?
– are they cost effective?
– are the funding schemes appropriate?

Future Directions:
5. Innovative Program Fund
• We need a a program to fund and evaluate
new, innovative diabetes care models
– Current care models are stale and in need of
innovation
• Best practice model

– Target primary and secondary prevention according
to regional needs (i.e. Latinos in ON, Asians in BC, lower SES
geographic areas)
– Should support 50-100 innovative programs

Future Directions:
6. Translation of Evidence into Practice
• CDS should be supporting efforts to
implement the evidence-based clinical
practice guidelines
• Work to reduce the barriers to chronic
care management.
• Facilitate improved data collection at
primary and tertiary care level
• Implement prospective, regional registry
for diabetes
Future Directions:
7. Aboriginal Diabetes Initiative
Need to fund two corollary programs, both on
and off reserve
1) Primary Prevention
– MAJOR expansion of community-based diabetes
prevention programs needed
2) Secondary & Tertiary Prevention
– Establishment of a basic clinical diabetes and
complications prevention programs

Research
Canada has always been a
world-wide leader in diabetes
research innovations
From the discovery of insulin…
to the Edmonton protocol for
islet transplants

Future Directions:
8. Enhanced Research
• The establishment of Nutrition,
Metabolism, and Diabetes and the
Aboriginal People’s Health Institutes with
increased funding was a major
improvement in diabetes research.
• We need to continue to expand this

funding base

Future Directions:
Research Priorities should include:
• Pathophysiology of diabetes
• Translation of evidence to practice
• Health services
• Prevention
• Populations at risk (i.e. Aboriginal)

Canadian Diabetes Strategy 2005-2010
New Component Costs for CDS ($ millions)
National Diabetes Surveillance System $12 (up from $10.8)
Prevention and Promotion-National $50 (up from $41.8)
National Coordination $25 (up from $4.4)
Evaluation of Current Models $10
Innovation Funds $100
Translation $25
Aboriginal Diabetes Initiative
–Primary Prevention $75 (up from $58)
–Clinical $250
Research $50
TOTAL $597 million

(Up from $115 million)
Is this a worthwhile
investment ?
… remember the cost of
diabetes in Canada now
and over the next 20
years….
• 2002 $13.2 billion
• 2010 $15.6 billion
• 2020 $19.2 billion
$600 million for the Canadian
Diabetes Strategy…
… less than 4% of what this

disease will cost us by 2010

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DIABETES

An Epidemic of the New

Canadian Diabetes Strategy: Time For Action

Canadian Diabetes Strategy: Time For Action, May 2003

Canadian Diabetes Strategy: Time For Action, May 2003

Canadian Diabetes Strategy: Time For Action, May 2003

REF: www.who.int Sept 2002 Fact Sheet#236

Canadian Diabetes Strategy: Time For Action

1994 - 1995 1996 - 1997 Prevalence (%)

1998 - 1999 2000 - 2001

Canadian Diabetes Strategy: Time For Action

In international population based diabetes

2016 (n=2.5 million)

Canadian Diabetes Strategy: Time For Action, May 2003

Modifiable Risk Factors

Canadian Diabetes Strategy: Time For Action

Source: Choi B, Shi F. Diabetologia 2001, 44:1221-1231.

Source: Choi B, Shi F. Diabetologia 2001, 44:1221-1231.

Source: Choi B, Shi F. Diabetologia 2001, 44:1221-1231.

Canadian Diabetes Strategy: Time For Action, May 2003

1985 1990 1994

Source: Katzmarzyk PT, CMAJ Apr. 16, 2002; 166 (8)

Canadian Diabetes Strategy: Time For Action, May 2003

Canadian Diabetes Strategy: Time For Action, May 2003

Canadian Diabetes Strategy: Time For Action

Canadian Diabetes Strategy: Time For Action

Canadian Diabetes Strategy: Time For Action, May 2003

Sandy Lake (IGT)

Sandy Lake (DM)

REF: Harris SB et al Diabetes Care 1997;20:185-187 & NPHS

Canada Sandy Lake (Norm)

REF: Harris SB et al Diabetes Care 1997;20:185-187.

Canadian Diabetes Strategy: Time For Action, May 2003

• 77.1% of Canada’s immigrant population

REF: Statistics Canada, 1996 Census

Canadian Diabetes Strategy: Time For Action, May 2003

Canadian Diabetes Strategy: Time For Action

Canadian Diabetes Strategy: Time For Action

REF: Diabetes in Ontario, An ICES Practice Atlas, 2002

Canadian Diabetes Strategy: Time For Action, May 2003

REF: Coutiho M. et al Diabetes Care 1999;22:233-240.

Canadian Diabetes Strategy: Time For Action, May 2003

Canadian Diabetes Strategy: Time For Action, May 2003

REF: Hanley AJG, Harris SB et al Diabetes Care 1997;20:185-187.

REF: Baiju R. Shah, Arch Intern Med V160, 2000

REF: Blanchard J. Unpublished

REF: Caro JJ, Diabetes Care 2002 Mar;25(3):476-81

Canadian Diabetes Strategy: Time For Action

REF: Diabetes in Ontario, An ICES Practice Atlas, 2002

Canadian Diabetes Strategy: Time For Action, May 2003

REF: Diabetes in Ontario, An ICES Practice Atlas, 2002

Canadian Diabetes Strategy: Time For Action, May 2003

Refs: Meltzer S, et al CMAJ 1998; 159 (8 suppl):S1-S29, &

Social Services First Nations

Canadian Diabetes Strategy: Time For Action, May 2003

REF: Blanchard J, Unpublished.

The Financial Impact of

Canadian Diabetes Strategy: Time For Action

Hospital $1196 $479 $2362 $893

• In those people just with diagnosed diabetes, the direct

• Of the costs associated with the complications of

• The estimated $132 billion cost likely underestimates the

• Likely underestimating the growth of high risk