In the past six months, the Auditor Generals of both Canada and Ontario have turned their attention to problems with strategies designed to tackle one of Canada’s biggest health threats—the epidemic of diabetes.
The government watchdogs have scrutinized the value that Canadians have received from the hundreds of millions of dollars expended on the Canadian Diabetes Strategy and the Ontario Diabetes Strategy.
As diabetes rates in Canada continue on a steady and alarming uphill climb, the auditors reports conclude that both strategies have come up seriously wanting.
The prevalence of diabetes among Canadians increased by 70% in one decade (1999 to 2009), with an estimated 2.4-million Canadians (6.8% of the population) now suffering from the chronic, and often preventable, condition, according to the federal report, which was released at the end of last month.
In Ontario alone, it’s estimated that the number of people with diabetes will reach 1.9-million by 2020, up from the 1.2-million in 2010 and 546,000 in 2000, 1.2-million people, according to the December 2012 report from the Auditor General of Ontario.
How important is it to have a comprehensive strategy?
The burden of illness linked with diabetes is alarming
The burden of illness associated with diabetes is alarming. In Ontario, for example, people with diabetes account for 69% of limb amputations, 53% of kidney dialysis, 39% of heart attacks and 35% of strokes, according to the Ontario report.
On average, medical expenses for diabetics are two times that of the rest of the population, the report notes, and mortality rates are twice that of people without diabetes.
Ontario is one of three provinces with the highest age-standardized prevalence rates of diabetes (the two others are Newfoundland and Labrador, and Nova Scotia), while Alberta (along with Nunavut and Quebec) had the lowest such rates, according to the Public Health Agency of Canada.
Despite this difference, Alberta and Ontario are tied for second place when it comes to projections about the rate of increase of the chronic condition, according to the Ontario report.
Alberta,Ontario face huge increases in prevalence but take different approaches
It’s estimated that by 2020, each of the two provinces will have—in the period since 2000—experienced a 250% increase in prevalence of diabetes. (Only British Columbia is expected to experience a slightly higher increase.)
To tackle this problem—prevent new cases, monitor patients to reduce serious complications, and provide timely treatment—Ontario and Alberta have adopted different approaches.
Both provinces have had formal diabetes strategies for a number of years, but they differ significantly. And while Ontario’s has been extended to 2016, the Alberta strategy, launched in 2003, formally ended two months ago.
Last year Alberta changed tack, turning to networks of patients and providers to devise improvements in diabetes prevention and care.
Only 3% of Ontario’s $746-million spent on prevention
Ontario launched the multi-pronged Ontario Diabetes Strategy (ODS) in 2008 with $742-million of funding.
The ODS set out to take steps to (among other initiatives) improve access to primary care for early identification, expand diabetes education programs, create an insulin pump program, and increase provision of bariatric surgery in the province.
While prevention was part of the ODS mandate, the Auditor’s report notes that only 3% of the total funding went to prevention.
In contrast, the Alberta Diabetes Strategy, which was launched in 2003, placed an emphasis on primary prevention. It aimed to address the risk factors common to several chronic diseases (excess body weight, lack of exercise, poor nutrition) with a goal of reducing the incidence of Type 2 diabetes.
It’s estimated that in Canada between 90 and 95% of cases of diabetes are Type 2, which is largely preventable and modifiable. Type 1 diabetes is usually diagnosed in childhood and individuals are insulin dependent.
No tally of total spending on Alberta’s defunct diabetes strategy
The Alberta strategy was funded in part by the Canadian Diabetes Strategy. It had a variety of stakeholder/funders, and as a result a total funding figure is not readily available, a spokesperson for Alberta Health says. (The federal Auditor General’s report released last week comments on the Canadian strategy, including how money was dispersed to projects across the country.)
Alberta’s strategy had a low profile, although the Canadian Diabetes Association commends its mobile diabetes screening initiative, and the diabetes surveillance system that was developed, with separate funding from Alberta Health and Wellness (now Alberta Health) by a team based at the University of Alberta.
That surveillance system, however, which led to three editions of an Alberta Diabetes Atlas, revealed that diabetes rates in Alberta continued to increase— in 2009, 206,000 people were living with diabetes in the province, 2.5 times more people than 15 years earlier.
Justin Balko, a family physician who heads up the Leduc Beaumont Devon Primary Care Network, says diabetes care itself is a high profile issue locally, and multidisciplinary teams have had some success helping people improve their health, but adds he was not aware that there was a provincial strategy.
Alberta turns to networks of providers and patients to help solve access, quality issues
Balko is, however, quite familiar with the more recent initiative that Alberta Health Services is taking to address the major health concern—the province-wide strategic clinical network (SCN) on obesity diabetes and nutrition that was created last June. (This SCN is one of six networks that have been established to address different areas of health care.)
The obesity, diabetes and nutrition SCN facilitates meetings among patients, physicians, nurses, researchers, and dieticians, who share experience with different aspects of diabetes care.
The network’s mandate is to examine ways to improve access to care and quality of care and, by eliminating ineffective treatments, to improve sustainability, explains Alun Edwards, an active clinician who is senior medical director for the network.
Edwards says that although it’s important that health care be supported by the best evidence and be cost effective, it could be a “major challenge” to spearhead a successful push to eliminate ineffective, but widely used, treatments. The SCN’s scientific director, Jeff Johnson, helped create the Alberta Diabetes Atlas, and the SCN expects to be able to replicate, and add to, the information that was gathered in the atlas, Edwards says.
Edwards says he is excited about the SCNs as a “from the grassroots up” endeavour, given that it is usually a “struggle for government to get front line workers involved.”
Still, the network has no authority to launch programs—its role is to bring people together to talk strategy and create policy, and it makes recommendations to Alberta Health Services, which has the responsibility for implementation.
Ontario’s strategy run out of ministry’s accountability division
Last spring, Ontario’s Ministry of Health and Long Term Care (MOHLTC) announced that the Ontario Diabetes Strategy would receive another $152-million in additional funding, and be extended through to 2016.
This phase of the strategy will focus on populations and communities with the highest prevalence of diabetes and place more emphasis on screening and early intervention, according to the MOHLTC.
The diabetes strategy is being led out of the ministry’s health system accountability and performance division, though the ministry recently transferred responsibility for oversight of diabetes education programs to the province’s 14 local health integration networks.
The 2012 report of Ontario’s Auditor General found that, compared to baseline data, not much improved over the first few years of the strategy. For example, excess weight, poor nutrition and low levels of physical exercise are risk factors for diabetes, but by 2011 more Ontarians were overweight or obese and rates of physical activity had decreased.
Hospitalization rates for diabetes patients— for infections, ulcers and amputations—increased and there was only a slight improvement, to 39.6 from 37.6, in the percentage of patients who received the three key tests (blood glucose, cholesterol, eye exam) as recommended in clinical guidelines for the condition, the report states.
Further, the report found that more than $24-million (including $4.4-million for outside consultants) was spent on development of a diabetes registry, intended to improve diabetes care, before the project was scrapped (its termination is now the subject of litigation).
Hertzel Gerstein is the director of the diabetes care and research program at Hamilton Health Sciences and he holds a Population Health Institute chair in diabetes research.
He stresses the need for primary care practitioners, who provide the bulk of diabetes care, to have access to clinical expertise and leadership from care providers at secondary and tertiary care institutions. “Not all policy makers understand the importance of having both levels of care in all regions.”
Built-in evaluation missing from Ontario strategy, researcher says
Diabetes is “not going away” and rates have gone up remarkably, Gerstein observes. However, he maintains that an ongoing evaluation strategy is missing from the Ontario Diabetes Strategy, and hence “good evidence of what makes a difference” is missing.
Asked to respond to criticism about a lack of built-in evaluation the MOHLTC, in an email response, states that the strategy’s “initiatives are evaluated to ensure that money is appropriately spent to promote health outcomes for Ontarians impacted by diabetes.”
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As a GP in Ontario, I find that the awareness among diabetic sufferers and compliance is improving. We have much more options now to treat Diabetes yet, the prevalence rates and complications have not abated. Perhaps our strategy should change to inculcate very early the preventative strategies that we know will help reduce the prevalence of this condition. One strategy should include mandatory 30 minutes of aerobic type exercises, 3 times every week at school and mandatory healthy cooking lessons as part of the volunteer requirements for the Ontario high school diploma. If we start these types of programs early, it just could significantly contribute to a healthier adult life to saving us from the heavy burden, financial and otherwise that the individuals and the collective currently bear. The focus on the MOLHTC alone instead of including the grade school system in chronic disease prevention which includes Diabetes, Hypertension, Obesity and so on is grossly inadequate.
How about coming up with a cure? Its funny years ago they use to find cures with a microscope and brainpower today they have super computers state of the art equipment and more information you could possibly need and we get NOTHING!!
Diets high in refined (and cheap) carbohydrates cause insulin resistance and T2 obesity.
Treat and prevent it with a low carb diet. Exercise not needed.
http://www.nutritionjrnl.com/article/S0899-9007%2812%2900073-1/abstract
I reversed my type 2 diabetes with a low carb high fat diet. It was surprisingly easy for me to do. The trick was to figure out that the Canada food guide is just about completely incorrect.
Lets take a look at the social determinants of health-most are not being met in low income populations-food banks have junk food, families suffering due to high cost of living and on and on it goes. When this government decides to work with health care providers and dicuss what they are seeing then and only then will governmnet understand the full impact of not meeting such determinants. Priority for those with diabetes-whether they can afford rent and food or thier medications and test strips.
It bothers me that the ministryof health does not hire nurses who are working with such populations-instead they hand out money to those who have business degrees with no clue as to the clients needs. In the end it is a misappropiration of funds and the closing of clinics-and in the end the people suffer. Believe me I have tried to contact MP’s and the government of which I always get the reply-we are unavailable for comment……
honestly, it’s not that hard! you can take a map of high prevalence diabetes regions or neighbourhoods and it will almost perfectly overlap with low income regions or neighbourhoods – tackle poverty, diabetes rates will go down – number one rule for staying healthy? “don’t be poor’ followed by number two – “don’t have poor parents” – i’ve said it many times, if the ontario ministry of community and social services won’t pay, the ministry of health will
Like so many other ‘government’ programs the money gets spent in ways that do not improve front line care nor improve patient outcomes.
Governments are not designed or structured to develop, execute, and evaluate programs. They should ensure the correct policies are in place and remove structural barriers that will allow patients and providers to work together in creative ways to improve outcomes.
Will the evaluation take into consideration the impact of genetically altered foodstuffs ( e.g. wheat )?
It is Public Health’s mandate to focus on prevention. I think 3% of the money spent from the Ontario Diabetes Strategy is pretty good, (that represents 22+ million) when you consider how much money Public Health receives.
I think if we showed prospective diabetics graphic pictures of diabetic feet, living with a white cane, bilateral amputations and what its like to live 3x per week on dialysis, it might move some people to a higher level of physical activity other than lifting a fork to a mouth. But in my experience until the diagnosis happens, nothing will change and even then it would take Mohammed himself to move the patient to a greater level of personal responsibility. And until that happens nothing will change. All the strategies in the world won’t keep the cheesies out of the mouth.
As a Medical Foot Specialist, focusing on Diabetic Care and Wound Prevention, I must disagree with Mr Hook. It serves no one, for long in any case, to throw graphic scare tactics in the centre stage. People disassociate. I recommend instead the proactive Wellness approach. Choice, and personal goal setting holds the greatest potential to support change.
For example, i never tell a patient their shoes are awful, and need replacing. It is both insulting and it challenges the patient to defend the shoe not change them. Instead, I refer to their shoes and highlight any positive attributes, inexpensive, comfortable, easy access flip flops, can be improved by having cross straps instead of between toe straps, wider for greater stability, a heel strap could assist retaining sole to foot, non slip treads would improve traction and reduce falls, and better still a closed toe would save the most commonly injured areas, the toes. ( After all who hasn’t broken their baby toe or lost a nail?) Relatable, visual, with choices and options.
Scare tactics dont work. Not in a meaningful way.
As an American emergency physician working in Ontario Canada, I am extremely impressed with how much lower diabetic rates are in Canada than the US. Although Ontario’s strategy should be subjected to scrutiny, let’s remember that no one knows what the most effective way is to prevent new cases of diabetes. Alberta’s emphasis on going with what we know (lose weight, exercise, and eat a reasonable diet) seems like a winner although as a doctor in the trenches, I must say that convincing people to change lifestyles is difficult to sell. Kudos to ALL provinces for trying to reduce this terrible disease. I am more and more impressed with the Canadians the longer I work in their system!
I think Ontario’s Endocrinologists, or whatever practitioners work out of the Diabetic Care Centres need to be watched.
Take our situation – My husband is a very brittle Type 2. He has had 2 Endo’s before one out of the centre… The first worked on scare tactics and wanted him to have a Gastric Bypass which would ‘solve it’… the second saw him for under 2 minutes during visits and didn’t tweak insulin, or anything, talked about diet only and started him on neuropathy meds. The current one out of the Diabetic Clinic has told him to NOT follow the insulux meter which gives him doses depending on what his blood sugar is – and has told him the amount he should be giving himself – he is on two different insulins; has taken him off ALL oral meds; has barely done anything about his diabetic neurophathy in his legs from the knees down and his hands; seems reluctant to do anything except what has always been done.
Over the last decade he has almost died and had several bouts of septecemia because doctors are not paying attention to his diabetes and/or refuse to look at new or alternate treatments.
Prevention is great, but since his pancreas is damaged just doing the basic little things – has done nothing to help him… in fact, now that the current Doctor has removed all orals and given him a ridiculously low dose of insulin, his BS is in the stratosphere. If he disobeys the doc and adjusts his insulin to treat the number – he’s a problem patient. So what happens – nothing changes.
%featured%Where is the doctor’s accountability for following up on new information, trying new things… with the new system I haven’t seen any changes. There are a lot of my own family members that are Type 2 – it is hereditary in my family… they are spread all over Canada… and all over Canada the treatment is the same. Nothing changes in the treatment… so nothing changes the diabetes.%featured%
Lifestyle choices – yes my husband is/has made them to no change in his diabetes… and since the Doctor’s who ‘specialize’ in treating diabetes don’t change and update – you guessed it – nothing changes. No wonder the numbers are increasing!
RE: predisposing elements
Have you researched the impact of genetically altered foodstuffs ( e.g. wheat)?
Several members of my own family are markedly healthier since adopting a gluten-free(GF) diet. This trend has seen mainstream acceptance and supermarkets devoting sections to GF food. Also popular is a book written by physician William Davis ( Wheat Belly ).
Companion ailments to the gliadin sensitivity are consistently referred to as: osteoarthritis; non-hodgkins lymphoma; psoriasis ; metabolic syndrome; herpetiform dermatitis ; hypertension . Strict adherence to the GF diet removes these symptoms over time.
Most of the people with type 2 diabetes that I have met (I have type 1) don’t understand their disease and neither does the GP who is lazily saying watch what you eat and then prescribing metformin at the followup appointment 6 months later. %featured%Serious education or reeducation of GPs needs to happen if there is any hope of truly helping those with diabetes. %featured%That, and serious funding for test strips, healthy foods and medication will make a huge difference. Without those things, its like sending a child to school and asking them to learn without a teacher, books or supplies.
Hi Jennifer, thanks for your comment. On the question of test strips, you might find this Healthy Debate article on test strips of interest (we’ve put it up in this week’s Editor’s Picks section: http://healthydebate.ca/2011/03/_mailpress_mailing_list_healthydebate-news/diabetes-test-strips
Please consider the data and conclusions from this new review article about the value of blood glucose test strips and the potential to improve patient outcomes.
Self-Monitoring of Blood Glucose in Type 2 Diabetes: Recent Studies. Oliver Schnell et al. Journal of Diabetes Science and Technology, March 2013, Volume 7, Issue 2: pages 478–488
http://www.journalofdst.org/March2013/
One reality about science is that new evidence can and does emerge that may call into question conclusions based on prior evidence. The real challenge is to be flexible enough to change ones view and then to foster a new dialogue.
The debate should be about how to encourage patients and healthcare professionals to test with a purpose and then to utilize these data to make appropriate changes to enhance outcomes.
%featured%One issue neither government seems to address is a holistic one — there are a multitude of factors that influence a person’s health, including diabetes. %featured% To name just a few: people in precarious employment (economic stability poor), people in lower income areas (food deserts), people working multiple jobs to keep a roof overhead (time poor), people without the economic means to access fitness facilities, people without the taught skills to cook from scratch.
Until a comprehensive strategy addresses the sum of all the parts of individuals, such piece-meal attempts to mitigate health problems directly related to so-called ‘life style’ choices will not meet their desired outcomes.
mel
I absolutely agree, diabetes is a more systemic issue than can be addressed with one initiative. Well said, mel.
You have some good points Mel. But I don’t agree with the one about access to exercise facilities. Most of our population has feet and has access to the outdoors. No need for a gym, walking 30 or more minutes a day at a moderate pace is sufficient. Any form of exercise will make the cell membranes more receptive to insulin by inhibiting the production of certain proteins. Many people do not have the time (usually because of poor time management skills) so if you can read a label and digest the information, that is the next best thing, and also shop the perimeter. Most people can cook a piece of meat and chop veggies – no Michael Smith skills there.
One point that needs to be made is how many people who are within the definition of metabolic syndrome but are not taking it seriously. These people should be receiving the same education as diabetics, and this education needs to take place in a timely manner – like within two weeks of diagnosis. This delivers a state of urgency to the patient.
A final point is the cost of medications for many patients who are on the economic fringes.
What about pharmacists doing random finger prick tests for their clients who fit the profile for metabolic syndrome. Many patients who have metabolic syndrome are not routinely tested for blood sugars.