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