2010 University of Alberta - School of Internal Medicine Research Day, poster presentation by Richard Oster (BRAID Research)

1. TRENDS IN DIABETES-RELATED HEALTH INDICATORS IN
ABORIGINAL COMMUNITIES OF NORTHERN ALBERTA
Richard T. Oster, Department of Medicine, University of Alberta
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ABSTRACT
Introduction: The Mobile Diabetes
Screening initiative (MDSi) screens for
diabetes and related risk factors in northern
Alberta remote and off-reserve Aboriginal
communities. In addition to providing
diabetes screening, diabetes education, and
community-based care, MDSi also aims to
identify and refer individuals needing
medical attention. Our objective was to
examine, longitudinally, diabetes-related
risk factors among returning MDSi clients.
Methods: Data was collected between
November 2003 and December 2009 as
mobile vans equipped with health
professionals and portable diagnostic
equipment traveled to the communities.
Body mass index (BMI), waist
circumference, hemoglobin A1c (A1c),
blood pressure and total cholesterol at
baseline and subsequent visits were
compared over time for 809 self-referred
adult (≥ 20 years of age) individuals (mostly
Métis; 180 with diabetes; 629 without
diabetes). A mixed effects model was
applied to get overall trend slopes for each
risk factor longitudinally.
Results: Significant improvements in BMI,
blood pressure, total cholesterol and A1c
concentrations were identified (P < 0.05) in
returning subjects with diabetes.
Conversely, for clients without known
diabetes, improvements were only observed
in blood pressure (P < 0.05), and BMI and
waist circumference actually increased over
time (P < 0.05).
Discussion: Although baseline clinical
characteristics were worrisome, diabetes-
related health seems to be improving
amongst MDSi clients with diabetes.
Unfortunately, this is not the case for those
without diabetes, whose health appears to
be worsening.
SUPERVISOR: Dr. Ellen L. Toth
KS
INTRODUCTION
Over the past century, Canadian Aboriginals (First Nations, Inuit and
Métis) have experienced a profound epidemiological shift in their health
status (1). The starvation, infectious diseases and depopulation that
accompanied colonization has given way to both re-population and an
accelerated increase in chronic diseases, including type 2 diabetes (2).
Among First Nations peoples, type 2 diabetes and its complications are
2-5 times more common than in the non-First Nations population (3).
Although prevalence rates appear to be higher than that of the general
population (4), very little is known about diabetes-related health status
among Métis people in Canada.
The Mobile Diabetes Screening initiative (MDSi) is part of the 10 year
Alberta Diabetes Strategy (2003-2013). MDSi serves Métis and off-
reserve Aboriginal communities in northern Alberta, providing diabetes
and cardiovascular risk screening, diabetes education, and community-
based care. The objective of this study was to examine, longitudinally,
the diabetes-related health status of returning MDSi clients.
Statistical analyses were done with SPSS 17.0. Mean baseline and
subsequent indicators were compared for individuals over time with a
univariate general linear mixed effect model. Those with and without
diabetes were analyzed separately. Resultant overall trend estimates
for each indicator were considered significant if P < 0.05.
MDSi was implemented as a partnership between Alberta Health and
Wellness, Alberta’s Métis communities and the University of Alberta.
MDSi was approved by the Health Research Ethics Board at the
University of Alberta, and individuals consented to aggregate analysis.
Mobile vans, equipped with
portable diagnostic equipment and
health professionals, travelled to
communities (including all 8 Métis
Settlements) twice per year. Adult
subjects (aged ≥ 20) enrolled
through self-referral in response to
local advertising. Diabetes was
confirmed by medications, chart
review, or infrequently, nurse
history. A total of 809 individuals
(180 with diabetes, 629 without
known diabetes) were included.
Subjects were mostly Métis
(65.8%), with some non-Aboriginal
(17.9%) and First Nations (16.3%).
Indicators of diabetes-related health measured included body mass
index (BMI), waist circumference (using a standard measuring tape at
the iliac crest), hemoglobin A1c (A1c), blood pressure (BP), and total
cholesterol. Blood was collected via a single finger puncture with the
Accu-Chek Safe-T-Pro (Roche Diagnostics) lancet. Cholesterol and A1c
concentrations were analyzed using the Cholestech L.D.X™ portable
analyzer and the Bayer DCA2000®+ analyzer respectively.
Criteria from the National Cholesterol Education Program Adult
Treatment Panel III (NCEP-ATP III) (5), were utilized to define
overweight (BMI 25-29.9), obesity (BMI  30) and abnormal waist
circumference (≥ 102 cm for males; ≥ 88 cm for females). Poor glucose
control was assessed according to the Canadian Diabetes Association
Clinical Practice Guidelines (CPGs) cutoff (A1c ≥ 7%) (6). BP ≥ 140/90
mmHg for those without diabetes and ≥ 130/80 for those with diabetes
was used to identify hypertension, whereas total cholesterol
concentration ≥ 5.24 mM indicated hypercholesterolemia (5).
For returning subjects with diabetes, significant improvements in
overall trend estimates for BMI, blood pressure, total cholesterol and
A1c concentrations were observed (P < 0.05).
DISCUSSION
The observed improvements amongst adults with known diabetes
imply that MDSi’s care model may play a role in supporting clients to
improve their health. However, since no control group was included,
MDSi’s contribution cannot be quantitated. Secular improvements in
diabetes health are likely due to a combination of effects including the
availability of CPGs and the federal Aboriginal Diabetes Initiative. For
those without diabetes, risk appears to be increasing. Further work will
be required to address this risk.
REFERENCES
1. Adelson N. 2005. Can J Public Health. 2. Gracey M, King M. 2009. Lancet. 374:65-75.
96(S2):S45-S61.
3. Young TK et al. 2000. CMAJ. 163:561-566. 4. Ralph-Campbell et al. 2009. Int J Circumpolar
Health. 68(5):433-442.
5. NCEP Expert Panel. 2002. Circulation . 6. Canadian Diabetes Association. 2008. Can J
106(25):3143-3421. Diabetes. 32(S1):S1-S201.
In contrast, subjects without known diabetes experienced
improvements only in blood pressure (P < 0.05), whereas both BMI
and waist circumference increased over time (P < 0.05).
BMI
Waist
A1c
Systolic BP
Diastolic BP
MAP
Cholesterol
BMI
Waist
A1c
Systolic BP
Diastolic BP
MAP
Cholesterol
Health indicators of returning subjects with diabetes (N = 180).
Values are estimates for the average change per year with 95% CI.
Baseline diabetes health indicators. Values are means (± SD) or
prevalences (95% CI).
Health indicators of returning subjects without diabetes (N = 629).
Values are estimates for the average change per year with 95% CI.
RESULTS
Subjects ranged from 20 to 91 years of age (mean 49). The majority of
subjects (69.0%) were female. We identified high baseline rates of
overweight and obesity (87.3%), abnormal waist circumference
(78.7%), poor glucose control (12.6%), hypertension (26.1%) and
hypercholesterolemia (33.8%). Baseline indicators were more severe
among those with diabetes compared to those without the disease.
Estimate of average change
Estimate of average change
METHODS
Canadian Aboriginal
Issues Database,
www.ualberta.ca/~wall
d/map.html
Variables
With diabetes
(N = 180)
Without diabetes
(N = 629)
Total
(N = 809)
BMI (kg/m2)
% Overweight (25-29.9)
% Obese (≥ 30)
33.4 ± 6.2
29.5%
(17.0 - 42.0)
67.1%
(58.6 - 75.7)
31.0 ± 6.3
32.0%
(25.6 - 38.4)
52.8%
(47.4 - 58.2)
31.5 ± 6.3
31.4%
(25.7 - 37.1)
55.9%
(51.3 - 60.5)
Waist circumference (cm)
% Abnormal (≥ 102
males; ≥ 88 females)
108.6 ± 13.9
95.9%
(92.9 - 98.9)
101.6 ± 14.7
72.8%
(68.7 - 76.9)
103.2 ± 14.8
78.7%
(75.5 - 81.9)
A1c (%)
% Poor glucose control
( ≥ 7%)
7.3 ± 1.6
50.0%
(41.3 - 58.7)
5.5 ± 0.8
1.6%
(0.1 - 3.1)
N A
N A
Systolic BP (mmHg)
Diastolic BP (mmHg)
MAP (mmHg)
% Hypertensive (≥
130/80 with diabetes;
140/90 without diabetes)
136.9 ± 19.0
77.4 ± 9.8
97.3 ± 12.1
69.5%
(61.3 - 77.7)
123.8 ± 21.4
75.3 ± 10.4
91.5 ± 12.6
21.8%
(14.9 - 28.7)
126.7 ± 20.3
75.8 ± 10.3
92.7 ± 12.4
32.3%
(26.6 - 38.0)
Total cholesterol (mM)
% Hypercholesterolemia
(≥ 5.24)
4.7 ± 1.1
30.8%
(18.4 - 43.2)
4.9 ± 1.1
34.6%
(28.3 - 40.9)
4.8 ± 1.1
33.8%
(28.1 - 39.5)