 Diabetes
and Change
Diabetes
and Ageing in Aboriginal Communities
by Susan Judith
Ship
Type 2 Diabetes: Rapid
Acculturation and the Emergence of Chronic Diseases
Diabetes was relatively unknown among Aboriginal peoples prior
to 1940. Today, diabetes is three to six times higher in Aboriginal
communities than among the non-Aboriginal population in Canada.
Although diabetes rates were traditionally low among Aboriginal
peoples, its emergence as a "silent epidemic" is a
consequence of the erosion of traditional ways of life in tandem
with the rapid transition to a western industrial lifestyle.
Type 2 diabetes, the predominant form, is a steadily
increasing health problem among Aboriginal people in most age
groups in Canada and throughout the world. However, First Nations
elders are more likely to have diabetes, suffer from complications
of diabetes and are more likely to die from diabetes and associated
complications.
Although there is an important genetic component to diabetes,
its precise role is unclear and the subject of debate among academics
and researchers. Whatever the genetic susceptibility, it is "unmasked
by rapid and unfavourable changes in lifestyle and environment
(acculturation) that First Nations and Inuit communities are
currently experiencing," as are other Aboriginal peoples
elsewhere. The Royal Commission on Aboriginal Peoples notes that:
"Chronic conditions
are sometimes called the diseases of modernization, or western
diseases, because they attend to lifestyles typical of western
industrial nations: reduced physical exercise; diets overloaded
with fat and sugar; high levels of stress; and increased exposure
to a wide range of pollutants in the air, water, and food supply.
These risk factors set the stage for a wide range of diseases
including cancer, heart disease, obesity, gall bladder disease,
and diabetes."
Despite the important
genetic role, Type 2 diabetes should be considered as a potentially
preventable disease. Research supports specific preventive action
for those modifiable determinants of diabetes: decreasing fat
body mass, physical activity and reducing fat, starches and sugar
in the diet.
Type 2 Diabetes in Aboriginal
Communities: A Statistical Overview
Aboriginal People at Risk: A Growing Problem
In 1987, the incidence of Type 2 diabetes among First Nations
people living on reserve, was two to five times higher among
the non-Aboriginal population. In 1997, the incidence of Type
2 diabetes increased to three to six times higher in First Nations
communities.
Table 1: Percentage of
Aboriginal People and the Canadian Population as a Whole Diagnosed
with Diabetes, 1991.
First
Nations
on-reserve |
First
Nations
off-reserve |
Metis |
Inuit |
Total
Aboriginal |
Total
Canada |
|
8.5% |
5.3% |
5.5% |
1.9% |
6.0% |
3.1% |
Source: MacMillan et al., "Aboriginal Health." CMAJ
1996:155 (11): 1574, Bobet, Diabetes among First Nations People.
Ottawa. Health Canada, (1997:3)
Elders at Risk: Diabetes
Rates Rise with Age
Seventy per cent of adults with diabetes are over the age of
40. Diabetes rates are highest among elders. First Nations elders
have higher rates of diabetes than Inuit and non-Aboriginal elders.
Table 2: Diagnosed Cases of Diabetes by Age Group in the First
Nations Population (1991 APS) and in the Canadian Population
(1994-1995).
|
AGE |
FIRST NATIONS |
CANADIAN POPULATION |
|
15-19 |
1% |
- |
|
20-24 |
2% |
- |
|
25-29 |
3% |
- |
|
30-39 |
5% |
1%* |
|
40-49 |
10% |
2%* |
|
50-64 |
18% |
5% |
|
65+ |
23% |
11% |
* High sampling variability
Source:Bobet, Diabetes Among First Nations People. Ottawa,
Health Canada, (1997:5).
Women at Risk
Diabetes rates are higher for First Nations women, with rates
varying by community and region from two-thirds to double the
rates for First Nations men. The tendency is for women's rates
to be higher in most age groups, although in the younger age
ranges, part of this difference is a result of gestational diabetes.
Diabetes rates for men and for women are similar in the Canadian
population.
Table 3: Male-Female Differences in Diabetes Prevalence Rates
among First Nations Peoples, 1991 APS.
|
Sex |
Crude
Rate |
Age Standardized
Rate |
|
Women |
7.6% |
11% |
|
Men |
5.3% |
8% |
Source: Bobet,
Diabetes among First Nations People. Ottawa, Health Canada,
(1997:5).
Southern Communities at
Risk
Diabetes rates vary by community, culture and region. The 1991
Aboriginal Peoples Survey found that diabetes rates were lowest
in the north and British Columbia and highest in the Ontario-Manitoba-Saskatchewan
region.
Table 4: Percentage
of First Nations People with Diabetes by Region, 1991 APS.
|
Region |
Atlantic |
Que. |
Ont. |
Man. |
Sask. |
Alberta |
B.C. |
Yukon |
NWT |
|
% |
6.9% |
6.7% |
8.1% |
8.7% |
7.6% |
5.2% |
4.1% |
- |
- |
* -- figure too small
and variable to be shown
Source: Bobet, Diabetes among First Nations People. Ottawa,
Health Canada (1997:6 ).
First Nations People
on Reserve and in Rural Areas at Risk
The 1991 Aboriginal Peoples Survey found diabetes to be higher
among First Nations people on reserve and in rural areas than
among First Nations people living off the reserves and in urban
areas.
Table 5: Diabetes
Rates among First Nations People On and Off-Reserve and by Area
of Residence, 1991 APS.
|
Area of
Residence |
On-Reserve |
Off-Reserve |
Urban |
Rural |
|
% with
diabetes |
8.4% |
5.7% |
5.3% |
8.1% |
Source: Bobet,
Diabetes among First Nations People. Ottawa, Health Canada,
(1997:7).
Diabetes and Ageing: First
Nations Elders at Risk
Type 2 diabetes is a metabolism disorder, characterized by insulin
resistance, and usually occurs in adulthood. Type 2 diabetes
is largely a lifestyle disease. The risk factors include: age,
heredity / family history, obesity, physical inactivity, a diet
high in fats, starches and sugar, metabolic factors, and stress.
First Nations Elders are
at a Higher Risk of Developing Diabetes
Unhealthy Ageing: 'The
Legacy of Disadvantage'
"Old age"
is normally defined
socially and legally as beginning at age 65, based on current
retirement norms and legislation. But "old age, in reality,
is whenever health and functioning deteriorate to a level that
results, as we age, in decreasing independence and mobility."
Aboriginal people:
 Have the lowest life
expectancy in Canada.
Are more likely to develop degenerative diseases commonly associated with old age
earlier in their lives and with greater intensity.
Are more likely to experience some
of the social and psychological
consequences frequently
identified with progression into old age and deterioration of
the sense of well-being, such as loss of friends, spouse and
relatives earlier in their lives.
As such, because of a
disadvantaged health status, an Aboriginal senior is any person
over the age of 55 years.
Cultural Disruption, Lifestyle
Change and Poverty
Diabetes is usually viewed as 'an older person's disease. However,
intertwined processes of cultural disruption and rapid lifestyle
change including a diet high in fat, starches and sugar and lower
levels of physical activity, poverty, unhealthy living conditions,
high levels of psycho-social stress and limited access to adequate
health care and support services put First Nations elders at
a greater risk of Type 2 diabetes in comparison with non-Aboriginal
seniors.
Increasing acculturation is leading to higher rates of diabetes
among Inuit elders as well.
Obesity
As people grow older, there is frequently a tendency towards
reducing physical activity without reducing food intake. As a
result, an increase in body weight occurs that can lead to health
problems such as obesity,i.e., being 20 per cent or more above
one's ideal body weight.
Obesity has been identified as a growing health problem in First
Nations communities, in all age groups and in particular, among
women. This is a consequence of the erosion of traditional ways,
including the declining use of traditional foods and lower levels
of physical activity, combined with increasing acculturation
to a western industrial lifestyle.
Diet High in Fats, Starches
and Sugar
Cultural disruption, cultural transformation, socio-economic
change and environmental damage have brought with them the growing
tendency to replace wild meat and other traditional foods with
store-bought products that are less nutritious, and high in fats,
starches and sugar. Dietary change and the declining use of traditional
foods are linked to higher rates of obesity, diabetes, high blood
pressure, heart disease, and dental decay.
Eating well on a low income is a special challenge for many First
Nations and Inuit elders as is meeting their specific nutritional
needs, especially in remote communities where the variety and
availability of affordable and nutritious store-bought foods
are particularly limited. Moreover, many elders may be unaware
of the hazards of processed "convenience" foods, particularly
those who do not speak or read English or French fluently.
Physical Inactivity
/ Reduced Fitness Levels
The erosion of traditional ways of life related to hunting, trapping
and fishing, as a result of cultural disruption, cultural change
and environmental damage has entailed a shift towards less physically
active lifestyles and lower levels of fitness for many elders.
"Many middle-aged and older Aboriginal people experience
decreased mobility that is akin to being disabled;" a consequence
of poor health. Moreover, "several studies have found that
nearly half of the older Aboriginal people almost never leave
their house for more than an hour a day." This may result
from physical health problems, lack of affordable transportation,
lack of social, recreational and fitness activities or programs
for elders and in some cases, the weather.
Stress
Aboriginal elders are more likely to live with elevated levels
of stress in their lives as a result of poverty, unhealthy living
conditions, cultural disruption and the related social problems
in the family and in the community. Elevated levels of stress
are also related to loss of language, loss of culture and loss
of positive self-identity, and a range of personal, family and
social problems resulting from residential schooling syndrome,
racism, ageism, sexism, discrimination and stigmatized minority
status.
First Nations Elders Have
the Highest Rates of Diabetes
Table 6: Diagnosed Cases of Diabetes by Age in the First Nations
Population (1991 APS) and in the Canadian Population (1994-1995).
|
Age |
First
Nations |
Canadian
Population |
|
30-39 |
5% |
1% |
|
40-49 |
10% |
2% |
|
50-64 |
18% |
5% |
|
65+ |
23% |
11% |
Source: Bobet, Diabetes among First Nations People. Ottawa,
Health Canada, (1997:5).
First Nations Elders are
Most Likely to Have Complications Associated with Diabetes
Complications of diabetes increase with age, with the oldest
adults having the highest rates of complications. First Nations
people in Canada are more likely to have complications associated
with diabetes than non-Aboriginal people.
Table 7: Percentage of First Nations People (FN) and the Canadian
Population (CAN) with One or More Complications, by Age Group
and Presence or Absence of Diabetes, 1991 APS.
|
|
FN --------
CAN |
FN -------
CAN |
FN -------
CAN |
FN ----CAN |
|
Age range |
30-39 |
40-49 |
50-64 |
65+ |
|
%age with diabetes |
36% ---------3% |
44%----------8% |
64%---------47% |
77%------58% |
|
No diabetes |
12% -------- |
20%----------- |
35%---------22% |
50%-------44% |
Source: Bobet, Diabetes among First Nations People. Ottawa,
Health Canada (1997:11-12).
Hypertension (High Blood
Pressure)
First Nations people are more likely to have high blood pressure.
Older First Nations people have the highest rates of high blood
pressure.
Table 8: Percentage
of First Nations People (FN) and the General Canadian Population
(CAN) with High blood Pressure, with and without Diabetes, 1991
APS
|
|
FN --------CAN |
FN -------CAN |
FN --------CAN |
FN --------CAN |
|
Age range |
30-39 |
40-49 |
50-64 |
65+ |
|
With diabetes |
31% ------- |
37% ------- |
54% ------36% |
56% ------38% |
|
No diabetes |
9% ---------3% |
14% --------6% |
29% ------17% |
31% ------27% |
Source: Bobet,
Diabetes Among First Nations People. Ottawa, Health Canada
(1997:13-14)
Heart Disease
First Nations people with diabetes, particularly men, are more
likely to have heart disease. Older First Nations people with
diabetes are more likely to have heart disease.
Table 9: Percentage of
First Nations People (FN) and the General Canadian Population
(CAN) with Heart Disease, with and without Diabetes, by Age Group,
1991 APS
|
|
FN ---------CAN |
FN ----------CAN |
FN ----------CAN |
|
Age range |
15-40 years |
40 years + |
Total 15 years + |
|
With diabetes |
11% ------- |
28% ---------19% |
23% ---------19% |
|
No diabetes |
3% -----------1% |
13% ----------7% |
6% -----------4% |
Source: Bobet, Diabetes among First Nations People. Ottawa
Health Canada (1997:15-16).
Vision Problems
Loss of vision is a normal part of the ageing process. First
Nations people with diabetes are more likely to have vision problems.
An Alberta study identified a high prevalence of serious and
untreated diabetic retinopathy in both insulin and non-insulin
dependent First Nations people.
Amputations
People with diabetes generally suffer from a higher risk of lower-extremity
amputations as a result of reduced sensitivity to pain, poorer
circulation and greater susceptibility to infection. Studies
have shown that the incidence and prevalence (number of cases
in a given time) of amputations related to diabetes has been
increasing among Native Americans.
End Stage Renal Disease
(ESRD)
The overall risk of ESRD from all causes among Aboriginal people
in Canada was 2.5 to four times higher than in the general Canadian
population in 1987, The risk of ESRD among Aboriginal people
with diabetes was three to five times higher than among the general
Canadian population in 1987.
Complications
Diabetes is associated with high risks of various acute and chronic
long-term complications that may lead to premature death. Aboriginal
people are more likely to die from diabetes than non-Aboriginal
people in Canada and the United States. It is estimated that
four times as many Aboriginal people will die from diabetes as
non-Aboriginal people. The risk of death from renal disease,
coronary heart disease and stroke is higher for First Nations
people.
Challenges in Diabetes
Prevention, Treatment and Care for Elders
Physical Challenges can occur as a result of:
-inadequate medical services
-insufficient early screening for
diabetes or complications
-lack of culturally appropriate diabetes
resources, programs and materials
-poverty
-inadequate living conditions
-lack of transportation
-unhealthy lifestyle
-inadequate self-care
Social Challenges can occur as a result of :
-inadequate home care
supports
-inadequate social supports
-lack of family support
-lack of support for caregivers
-weak community involvement in health and prevention
Mental-Emotional Challenges can
can occur as a result of:
-denial of illness
-lack of knowledge about diabetes
-inability to overcome negative emotions
-loss of control
-loss of self-esteem
-difficulty making lifestyle changes
-cultural and language communication barriers
Spiritual Challenges can occur as a result of :
-loss of inner balance
-loss of meaning and purpose in life
-limited opportunity for healing
-loss of culture
-loss of connectedness and sense of belonging to something larger
than oneself
-declining traditional roles in family and community
-stress
Principles for Community-Based
Culturally Relevant Diabetes Prevention, Treatment and Care for
Elders
Primary Prevention
Reduce the risk, of or prevent
the occurrence of Type 2 diabetes
Protect health through individual
and community-wide efforts.
Objectives
Raise awareness about diabetes
as a growing and serious health problem.
Emphasize prevention of Type 2
diabetes by encouraging communities and people of all ages to
develop and maintain a healthy lifestyle and a healthy body weight
by balancing diet and exercise.
Encourage individuals, families
and communities to take responsibility and control over their
health
Individuals encourage
individuals to:
- Develop and maintain a healthy lifestyle
- Become more aware of diabetes as a health problem
- Reduce the risk of diabetes
- Get tested regularly, especially if high-risk
Family encourage families
to:
- Become aware of and learn about diabetes in their family.
- Get involved in community health activities and programs as
a family.
- Provide support to family members in developing and maintaining
healthy lifestyles.
- Provide support for regular testing of high risk family members.
Community
- Develop community awareness and prevention campaigns.
- Increase community knowledge of diabetes risk factors and ways
to reduce risk.
- Provide regular screening, particularly for high-risk individuals
and groups.
- Foster health promotion by setting up community activities
and programs, aimed to improve health, fitness and balanced eating.
Second Level Treatment
and Care
Early detection of Type 2 diabetes
Effective intervention to manage
and care for elders with diabetes
Identification of high-risk individuals.
Objectives
Raise individual, family and community
awareness of the signs and symptoms of diabetes.
Promote a wholistic approach to
diabetes care based on restoring physical, mental-emotional,
social and spiritual balance.
Individuals
- Promote diabetes self-care
- Self-monitoring
- Developing coping skills
- Gradual lifestyle change
- Ongoing learning about diabetes
- Prevention and early detection of complications
Family
- Encourage family members to learn more about diabetes.
- Provide emotional and social support for elder with diabetes.
- Support elders efforts to control blood sugar through diet
and physical activity.
- Assist elder's when blood sugar level is high or low.
- Recognize diabetes symptoms in an elder before it is too late
and reduce risk of complications.
Community
- Develop diabetes self-management community education programs
for elders.
- Develop support groups for elders with diabetes.
- Provide screening programs for early detection and prevention
of complications of diabetes.
- Develop community diabetes education programs, emphasizing
greater family involvement and community support.
- Establish a diabetes program coordinated by a Diabetes Team
and ensure that they serve as liaisons with elders with diabetes.
Third Level Treatment
and Care
Reduce, eliminate or treat long-term
damage and disabilities
Minimize suffering and promote
adjustment to irreversible damage
Objectives
Raise individual, family and community
awareness and knowledge about complications of diabetes.
Make information available about
the Donor programs and specialized facilities, closest to home
for treatment of complications.
Individuals
- Learn more about preventing, managing and coping with complications.
- Learn more about available options for treatment of complications.
Family
- Learn more about preventing, managing and coping with complications.
- Provide emotional and social support for elders with complications.
- Assist elders to be as independent as possible by providing
home supports.
Community
- Ensure appropriate medical care for the treatment and monitoring
of elders with complications associated with diabetes.
- Develop home care services for elders with diabetes who have
difficulty managing on their own or who can no longer do so.
- Ensure access to specialized services within the community
& outside, as close to home as possible.
- Address the need for support services, particularly care for
the caregiver.
A Wholistic Approach to
Diabetes Prevention, Treatment
and Care for Elders
Living Well...With
Diabetes
Primary
Prevention
Develop and maintain a healthy, balanced lifestyle
Regular screening for diabetes for high-risk people
Second Level Treatment and Care
Early detection and effective management of diabetes
Self-care and Self-monitoring
Lifestyle change and restoring balance
Screening for complications
Third
Level Treatment and Care
Early detection and treatment of complications
Minimize suffering
Enhance quality of life, despite disability
Strengthening Social Supports
Easy access to home supports
Care for the caregiver
Build support groups and services
Increase family involvement
Enhance community support
Enhance community involvement
Developing a Positive
Attitude
Accept illness
Take control
Restore balance
Self-care
Make lifestyle changes
Reach out to others
Healing the Spirit
Heal the Self
Develop inner balance
Reduce stress
Maintain meaning and purpose in
life
Renew bonds to culture and spiritual
centre
copyright © 1998 NIICHRO
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