Type 2 Diabetes in Aboriginal Peoples

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Stewart B. Harris MD, MPH, FCFP, FACPM Onil Bhattacharyya PhD, MD, CCFP Roland Dyck MD, FRCPC Mariam Naqshbandi Hayward BA, MSc Ellen L. Toth MD, FRCPC

Slides Video
  • Key Messages
  • Recommendations
  • Figures
  • Full Text
  • References

Chapter Headings

Key Messages

  • •Aboriginal peoples living in Canada are among the highest risk populations for diabetes and related complications. Community-based and culturally appropriate prevention strategies and surveillance of diabetes indicators among this high risk population are essential to reducing health disparities.
  • •Efforts to prevent diabetes should focus on diabetes risk factors, including prevention of childhood, adolescent, adult, and pregravid obesity; prevention and optimal management of gestational diabetes; and prevention of modifiable risk factors, such as smoking, inactivity, stress, and unhealthy eating habits.
  • •Screening for diabetes in adults should be considered every 1 to 2 years in Aboriginal individuals with ≥1 additional risk factor(s). Screening every 2 years also should be considered from age 10 years or established puberty in Aboriginal children with ≥1 additional risk factor(s), including exposure to diabetes in utero.
  • •Early identification of diabetes in pregnancy should be emphasized and post-partum screening for diabetes in those with gestational diabetes should be instituted with appropriate follow-up.
  • •Treatment of diabetes in Aboriginal peoples should follow current clinical practice guidelines using community-specific diabetes management programs developed and delivered in partnership with the target communities.
  • •Improvements in systematic care and medical management are needed to help close the substantial care gap between Aboriginal and non-Aboriginal peoples to mitigate diabetes-related morbidity and premature mortality.

Introduction

Around the globe, diabetes incidence and prevalence rates are several times higher among Indigenous peoples compared to the general population (1). In Canada, Aboriginal peoples are a heterogeneous population comprised of individuals of First Nations, Inuit, and Métis heritage living in a range of environments from large cities to small, isolated communities. National survey data have consistently shown that the national age-adjusted prevalence of diabetes is 3 to 5 times higher in First Nations than in the general population (2–5) and population screening has shown rates as high as 26% in individual communities (6). As in most populations where incidence and prevalence rates are higher, age of diagnosis is younger in First Nations peoples (7,8). These rates are similar in other countries where Indigenous populations have been subject to colonization (1). In a recent profile of health status, Métis, aged 19 years and older, in Manitoba, were found to have an age and sex adjusted diabetes rate of 11.8% compared to the provincial rate of 8.8% (9). In 2006, 7% of Métis were reported to have been diagnosed with diabetes while the national prevalence during the same time period was reported at 4% (10). Among the Inuit and Alaska Natives, it has recently been shown that the diabetes prevalence rate has substantially increased and is now comparable with the general Canadian population (11,12).

The higher rate of adverse health outcomes in Aboriginal peoples is associated with a number of factors, including lifestyle (diet and physical activity), genetic susceptibility, and historic-political and psychosocial factors, stemming from a history of colonization that severely undermined Aboriginal values, culture, and spiritual practices (13). Barriers to care that are unique to Aboriginal settings also exacerbate the problem with fragmented healthcare, poor chronic disease management, high healthcare staff turnover, and limited or non-existent surveillance (14). In addition, social determinants of health, including low income, lack of education, high unemployment, poor living conditions, lack of social support, negative stereotyping and stigmatization, and poor access to health services compound the problem (14). Different understandings of the etiology of health and illness from the holistic, collective social experience adopted by many Indigenous peoples to the traditional biomedical model which centers the disease within the individual may also influence care  (15).

Among First Nations peoples, a gender difference exists with more females impacted by type 2 diabetes than males (7,16). This is most striking during reproductive years, resulting in recent age standardized prevalence rates of over 20% among First Nations women compared to about 16% among First Nations men. In addition, diabetes prevalence rates have more than tripled from 1980 to 2005 among First Nations children (8,17). Similarly, incidence rates of type 2 diabetes among Indigenous youth in Australia have been documented to be 6.1 times that of non-Indigenous youth (18). Métis men and women are reported to have a similar prevalence of diabetes (10).

Aboriginal women in Canada also experience gestational diabetes mellitus (GDM) rates 2 to 3 times higher than others (19,20), in part related to an interaction of Aboriginal ethnicity with pregravid adiposity (19,21). High GDM rates preceded the appearance of the type 2 diabetes epidemic in remote communities surveyed in the early 1990s (22) and increasing GDM rates (20) have paralleled increases in high birth weight rates over several decades. Both maternal GDM (23) and high birth weight (24) are predictors for type 2 diabetes in the offspring (25) and likely contribute to the higher type 2 diabetes rates in First Nations women compared to men (7).

While genetic factors are important in the epidemic of type 2 diabetes among Indigenous peoples (26), its rapid appearance over a few decades in genetically diverse populations is likely the result of an interaction of local genetic mutations with numerous social stressors and lifestyle factors (27–32). Recent research suggests that epigenetic factors play a key role in the interaction between genes and the environment, influencing the development of diabetes complications (33,34). Inequities in the social determinants of health brought about through colonization (14) contribute to the main risk factors for type 2 diabetes in Aboriginal peoples, such as decreased rates of physical activity, stress, dietary acculturation and an unhealthy diet, food insecurity, obesity/metabolic syndrome, and high rates of diabetes during pregnancy.

Complications and Mortality Due to Diabetes

Indigenous peoples with diabetes also experience disparities in diabetes-related complications and mortality. Higher prevalence rates of microvascular disease, including chronic kidney disease (CKD) (35), lower limb amputation (9,36), foot abnormalities (37,38), and more severe retinopathy (39), are found in Aboriginal peoples with diabetes than in the general population with diabetes. Aboriginal peoples also are burdened by higher rates of macrovascular disease (9,15) and exhibit higher rates of cardiometabolic risk factors, including smoking, obesity, and hypertension (9,35,40), that may indicate a future increase in cardiovascular morbidity and mortality.

As in other Indigenous populations, First Nations people with diabetes have high rates of albuminuria (41) and are more likely than others to progress to end-stage renal disease (ESRD) (42). Potentially modifiable risk factors for kidney disease progression include poor glycemic control, systolic hypertension, smoking, and insufficient use of angiotensin-converting-enzyme (ACE) inhibitors (41,43) as well as periodontal disease (44). Likely relevant for other chronic diabetic complications, longer duration of diabetes (41,45) related to younger adult onset (45) is associated with higher ESRD rates and differential mortality and highlights the urgent need for primary diabetes prevention. The provincial dialysis initiation rate is higher for Métis than other Manitobans (0.46% vs. 0.34%) (9). On a positive note, ESRD incidence among Aboriginal peoples has stabilized since the early 1990s in both the United States (46) and Canada (42), and is probably due to the introduction of ACE inhibitors and application of interdisciplinary chronic disease care models (46).

The prevalence of metabolic syndrome is elevated among both First Nations adults (47) and children (48,49) and, like type 2 diabetes, disproportionately affects females with rates as high as 45% in Oji-Cree women. Increased adiposity and dysglycemia are more common components than hypertension (47), and non-traditional risk factors, such as elevated C-reactive protein are also elevated (48). There is a strong relationship between metabolic syndrome and later type 2 diabetes (50,51). Thus, Aboriginal peoples with metabolic syndrome should be targeted by programs designed to prevent type 2 diabetes since interventions, such as increased physical activity (52) and consumption of long chain omega 3 fatty acids (53), have been shown to improve glucose tolerance in Aboriginal peoples.

A reversal in long-term trends for decreasing mortality among American Indians since the mid-1980s appears primarily due to the direct and indirect effects of type 2 diabetes (54). Surveillance data from Alberta indicate that Aboriginal peoples with diabetes have mortality rates 2 to 3 times higher than the general population with diabetes (8). Provincially, Métis with diabetes are significantly more likely to die within a 5-year period than other Manitobans with diabetes (20.8% vs. 18.6%) (9). In British Columbia, First Nations peoples with diabetes have nearly twice the mortality rate than First Nations peoples without diabetes (55). Additionally, administrative data have demonstrated increased hospitalizations for heart disease among First Nations people in Ontario, despite decreases in the general population (56). Healthcare costs for Aboriginal peoples with diabetes have been shown to be considerably higher than costs in the general population with diabetes due to higher use of physician and hospital services (57). Increased morbidity and mortality among First Nations people are at least partly due to poorer quality of diabetes care (35,58,59).

Screening

Routine medical care for Aboriginal peoples of all ages should include identification of modifiable risk factors, such as obesity, abnormal waist circumference (WC) or body mass index (BMI), physical inactivity, smoking, and unhealthy eating habits. Screening for diabetes with a fasting plasma glucose (FPG) test, an A1C, or an oral glucose tolerance test (OGTT) should be considered every 1 to 2 years in individuals with ≥1 additional risk factor(s). Screening every 2 years also should be considered from age 10 or established puberty (60) in Aboriginal children with ≥1 additional risk factor(s), including exposure to diabetes in utero (see Screening for Type 1 and Type 2 Diabetes chapter, p. S12). Regular screening and follow-up should be done in children who are very obese (BMI ≥99.5 percentile) (see Type 1 Diabetes in Children and Adolescents, p. S153; Type 2 Diabetes in Children and Adolescents, p. S163). While an OGTT remains the standard for the diagnosis of diabetes, the A1C has a distinct appeal for testing in this population as it is relatively inexpensive and does not require fasting.

Systematic screening for diabetes and related complications has taken place in several Aboriginal community settings across North America. Screening has proved possible in both rural and remote communities through appropriate dialogue, respect and planning, the provision of concomitant health education and care, and the promotion of follow-up (58,61–64). In the United States, a kidney evaluation program screened 89,552 participants in 49 states, 4.5% of whom were Native Americans (63). In Alberta, substantial numbers of Aboriginal individuals with abnormalities have been identified through community-based screening (64), particularly First Nations people with documented risk factors.

Regular screening, follow-up, and surveillance in individuals with prediabetes (IFG and/or IGT), history of GDM, or polycystic ovary syndrome (PCOS) should be encouraged, as 20 to 50% of high risk individuals with IFG may have a 2-hour plasma glucose ≥11.1 mmol/L (65). Lifestyle or metformin should be initiated as treatment of prediabetes and ongoing monitoring should be instituted.

Primary Prevention

Efforts to prevent diabetes should focus on all diabetes risk factors, including prevention of childhood, adolescent, adult, and pregravid obesity; and prevention and optimal management of diabetes in pregnancies to reduce macrosomia and diabetes risk in offspring. Prevention strategies in communities should be implemented in collaboration with community leaders, healthcare professionals, and funding agencies to engage entire communities, promote environmental changes, and prevent increased risk of diabetes (66,67). Such partnerships are important in incorporating traditions and local culture, building both trusting relationships and community capacity, and increasing diabetes-related knowledge (68). Programs should be developed in collaboration with communities and implemented within the framework of available health resources and infrastructure of each community and promote traditional activities and foods (provided they are safe, acceptable, and accessible).

Prevention of childhood obesity through moderate interventions, starting in infancy, has shown promise (69). In Zuni First Nations children in the United States, an educational component targeting decreased consumption of sugared beverages, knowledge of diabetes risk factors, and a youth-oriented fitness centre significantly decreased insulin resistance (70). These types of interventions aimed at decreasing childhood obesity, as well as efforts to promote breast-feeding in the first year of life (23), may help to reduce the risk for diabetes. As well, strategies aimed at the prevention of pregravid obesity prior to first conception or subsequent pregnancy may be important tools to decrease the incidence of GDM and type 2 diabetes in pregnancy, thereby potentially decreasing the incidence of diabetes in subsequent generations of Aboriginal peoples (71–73).

Management

Lifestyle intervention programs targeted towards Aboriginal people with diabetes show modest results. Targeted programs to improve diet and increase exercise have been effective in improving glycemic control (74,75), reducing caloric intake (76), reducing weight (74), reducing WC and diastolic blood pressure (77), and increasing folate intake (78). A key component to all successful programs is cultural appropriateness.

Similar to prevention strategies, treatment of diabetes in Aboriginal peoples should be in the context of local traditions, language, and culture, while also adhering to current clinical practice guidelines. While most diabetes education programs work most effectively when delivered by multidisciplinary teams, in Aboriginal communities, where access to physicians is often limited, strategies to improve care should focus on building capacity of existing front-line staff (community health care providers, nurses) to implement clinical practice guidelines (58,79,80).

Working with community healthcare providers and community leaders assures that local resources and challenges, such as access to healthy foods, geographic location, and isolation level, are acknowledged and considered and that programs developed are community-directed (81–84). A diabetes management program incorporating self-management and patient education addressing diet and exercise within a Hawaiian/Samoan Indigenous population utilized community health workers in the application of clinical practice guidelines and a chronic disease management model. The study demonstrated a significant improvement in A1C levels and important changes in patient knowledge of reducing consumption of non-healthy foods (82). Maori and Pacific Islander adults with type 2 diabetes and CKD received community care provided by local healthcare assistants to manage hypertension and demonstrated a reduction in systolic blood pressure and in 24-hour urine protein, and a greater number of prescribed antihypertensives. Left ventricular mass and left atrial volume progressed in the usual care group, but not in the intervention group (85).

Systems Intervention

Comprehensive management of diabetes in small remote communities (where many Aboriginal people live) remains difficult due to discontinuities in staffing, lack of work-practice support, and services not adapted to individual's needs (86). Existing intervention studies have assessed impact on clinical outcomes, process measures of care, lifestyle changes, and patient satisfaction. The main types of interventions that have been tested include: expanding the scope of practice for nurses and allied care (82,87–89), increasing access to care and screening (90,91), multifaceted interventions designed to improve quality of care, and targeting patients through lifestyle programs (92).

Expanding the scope of practice for nurses and allied health professionals in diabetes care is an effective strategy, and particularly important where doctors are scarce. The DREAM 3 study used home and community care workers to implement a nurse-led algorithm-driven hypertension management program which produced sustained reductions in blood pressure in a Saskatchewan First Nations community through a randomized controlled trial (87–89). Algorithm-based screening and management of renal and cardiovascular abnormalities by local health workers supported by nurses and physicians reduced renal failure (93,94). Algorithm-based, nurse-led management showed improvement in hypertension and cholesterol (95–97). Nurse case management has shown benefit in urban and rural settings, increasing screening rates and compliance (98,99). Multidisciplinary teams, occasionally including Aboriginal health workers, also have shown benefit (100–102). The SANDS study demonstrated that aggressive lipid targets could be safely maintained in Indigenous peoples with diabetes with the help of standardized algorithms, point-of-care lipid testing, and non-physician providers (103).

For mitigation of geographic access to diabetes care, mobile screening and treatment units that target Aboriginal communities have been found to be effective in Western Canada. Mobile units equipped with staff, lab, and diagnostic equipment showed significant improvements in BMI, blood pressure, A1C, and lipid levels (90,91). An outreach team conducting small group academic detailing with clinicians improved blood pressure and client satisfaction (104). Retinal photography has been shown to be an effective strategy to increase access to screening for diabetic retinopathy in remote communities (105).

Given the multiple barriers to high quality care, multifaceted interventions also have shown benefit. These include: diabetes registries, recall systems, care plans, training for community health workers, and an outreach service. These have been found to be effective in Australia, but it is not clear which elements are key (86,106–108).

There is an urgent need for systematic and validated surveillance of prevalence, incidence, and morbidity and mortality rates due to type 2 diabetes in First Nations communities (35). Surveillance systems in Australia monitoring diabetes rates in their Aboriginal peoples have shown improvements in quality of care (109). In the United States, federally funded on-reserve programs include diabetes registries, use of flow charts, annual chart audits with continuous quality assurance, full-time dedicated diabetes clinical staff, and funding for community initiatives. These programs have been associated with consistent improvements in diabetes quality measures (110). The James Bay Cree in Quebec have instituted a regional diabetes surveillance system that tracks clinical outcomes, including complications (111,112). A registry program also has been developed for Queensland in Australia (113). Surveillance systems incorporating diabetes registries would allow organizations and providers to document clinical care, monitor trends in care, identify community needs, evaluate programs, and facilitate policy development (8,55,109,114). A national surveillance program should be considered in Canada for on- and off-reserve Aboriginal communities.

Recommendations

  1. 1.Starting in early childhood, Aboriginal people should be evaluated for modifiable risk factors of diabetes (e.g. obesity, lack of physical activity, unhealthy eating habits), prediabetes, or metabolic syndrome [Grade D, Consensus, see Type 2 Diabetes in Children and Adolescents, p. S163].
  2. 2.Screening for diabetes in Aboriginal children and adults should follow guidelines for high risk populations (i.e. earlier and at more frequent intervals depending on presence of additional risk factors) [Grade D, Consensus, see Screening for Type 1 and Type 2 Diabetes, p. S12; Type 2 Diabetes in Children and Adolescents, p. S163].
  3. 3.Culturally appropriate primary prevention programs for children and adults should be initiated in and by Aboriginal communities with support from the relevant health system(s) and agencies to assess and mitigate the environmental risk factors, such as:
    • •geographic and cultural barriers
    • •food insecurity
    • •psychological stress
    • •insufficient infrastructure
    • •settings that are not conducive to physical activity
    • [Grade D, Consensus].
  4. 4.Management of prediabetes and diabetes in Aboriginal peoples should follow the same clinical practice guidelines as those for the general population with respect for, and sensitivity to, particular language, cultural history, traditional beliefs and medicines, and geographic issues as they relate to diabetes care and education in Aboriginal communities across Canada. Programs should adopt a holistic approach to health that addresses a broad range of stressors shared by Aboriginal peoples [Grade D, Consensus].
  5. 5.Aboriginal peoples in Canada should have access in their communities to a diabetes management program that would include an interprofessional nurse-led team, diabetes registries, and ongoing quality assurance and surveillance programs [Grade D, Level 4 (35,80,87)].
  6. 6.Aboriginal women should attempt to reach a healthy body weight prior to conception to reduce their risk for gestational diabetes [Grade D, Level 4 (6,19)].
  7. 7.Programs to detect pre-gestational and gestational diabetes, provide optimal management of diabetes in pregnancy, and timely post-partum follow-up should be instituted for all Aboriginal women to improve perinatal outcomes, manage persistent maternal dysglycemia, and reduce type 2 diabetes rates in their children [Grade D, Level 4 (115,116), see Diabetes and Pregnancy, p. S168].

Related Websites

First Nation, Inuit and Aboriginal Health. Available at: http://www.hc-sc.gc.ca/fniah-spnia/diseases-maladies/diabete/index-eng.php. Accessed March 21, 2013.

National Aboriginal Diabetes Association. Available at: http://www.nada.ca. Accessed March 21, 2013.

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