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Diabetes Presentation to the Hamilton Niagara Haldimand Brant (HNHB)

Local Health Integration Network (LHIN) Board of Directors – Education Session

Dr. Jennifer EversonPhysician Lead, Clinical Health System Transformation, HNHB LHIN

& Peter Dilworth, Director Health Wellness, North Hamilton CHC

May 29, 2013

AgendaPart 1 • Diabetes

• What it is • Person experience • The Magnitude• Changing face of diabetes• System impact

Part 2 • North Hamilton Community Health Centre’s Diabetic Education Program

(DEP)

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Diabetes Mellitus (DM) --- What is it?

• Diabetes Mellitus or simply diabetes, is a disease in which a person has high blood sugar, either because the pancreas does not produce enough insulin, or because cells do not respond to the insulin that is produced.

• There are three main types of diabetes mellitus (DM).

• Type 1 – body's failure to produce insulin, (currently requires the person to inject insulin or wear an insulin pump). This form was previously referred to as "insulin-dependent diabetes mellitus" (IDDM) or "juvenile diabetes".

• Type 2 –the body does not produce enough insulin or fails to use the insulin properly. This form was previously referred to as non insulin-dependent diabetes mellitus (NIDDM) or "adult-onset diabetes".

• Gestational diabetes - occurs when pregnant women without a previous diagnosis of diabetes develop a high blood glucose level.

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Diabetes ---- The Patient Experience

• Diabetes – if not treated (sugars remain high) can lead to:

• Stroke - 80% of Canadians with diabetes die from a heart attack or a stroke;

• Heart disease – Cardiovascular disease is the leading cause of death among people with diabetes.

• Kidney failure –Diabetes is the leading cause of kidney failure in Canada and is responsible for 50% of the new cases starting dialysis

• Vision loss - Diabetes is the single leading cause of blindness in Canada

• Poor circulation contributes to poor healing and potential amputations 7 of 10 non-traumatic limb amputations are the result of diabetes complications

• Nerve damage - sharp shooting pain, burning, numbness

• Life Expectancy - shortened by as much as 15 years (Type 1) and 5-10 years (Type 2)

4Source: Institute for Clinical Evaluative Sciences : Regional Measures for Diabetes Burden in Ontario April 2012Canadian Diabetes Society http://www.diabetes.ca Accessed May 18, 2012

Diabetes --- The Magnitude • Number of people with diabetes expected to

quadruple from 546,000 in 2000 to 1.9 million by 2020

• Type 1 accounts for 10% of cases and is not preventable (genetic)

• Type 2 account for 90% of cases and if often preventable (sedentary lifestyle and diet)

• In 2011, HNHB LHIN reported the 3rd largest number of individuals (121,559) with diabetes (1-Central, 2 Central East LHINs)

• Diabetes –especially Type 2 has grown significantly as a health problem in Ontario

5

0

500000

1000000

1500000

2000000

2000 2011 2020

Popu

latio

n (m

illion) 

Diabetes Prevalence 

Source: MOHLTC 2012, Auditor General Report 3.03 Diabetes Management Strategy Institute for Clinical Evaluative Sciences : Regional Measures for Diabetes Burden in Ontario April 2012

Percentage Growth in Diabetes Prevalence 2000-2020 by Province

Number & Percent of Adults with Diabetes in Ontario by LHIN on March 31, 2011

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LHIN Number of Persons with Diabetes

% of All Ontarians with Diabetes

Central 157,276 13.51Central East 155,250 13.33HNHB 121,559 10.44Champlain 98,803 8.48Mississauga Halton 95,319 8.19Toronto Central 93,327 8.01Central West 82,943 7.12South West 78,487 6.74Erie St. Clair 60,962 5.24North East 59,919 5.15Waterloo Wellington 54,956 4.72South East 45,415 3.90North Simcoe Muskoka 37,192 3.19North West 23,084 1.98Total 1,164,492 100.00

Note: Adults were defined as those aged 20 years or olderOntario Diabetes Database: Registered Persons Database

Diabetes --- HNHB Higher Rates of Amputations

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• HNHB LHIN - nearly 9 of every 1,000 adults with diabetes experienced a lower limb amputation between 2006/07 and 2010/11.

• HNHN LHIN reported higher rate (89/10,000) than the Ontario average 74/10,000

• Rate varied more than 8 fold across the LHIN – the highest in the New Credit and Six nations subLHIN (187). High rates also seen in Hamilton Urban Core, East Niagara, Haldimand and Norfolk

Source: Institute for Clinical Evaluative Sciences : Regional Measures for Diabetes Burden in Ontario April 2012

Diabetes --- People with Diabetes & Another Chronic Disease in HNHB LHIN

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• HNHB LHIN – overall 57 of every 100 adults with diabetes reported at least one other chronic condition.

• HNHN LHIN reported higher rate (57/100) than the Ontario average (54.8/100)

Diabetes – The Changing Face

• Type 2 diabetes was once a condition that occurred primarily, if not exclusively, in adults.

• Today, this condition is increasingly appearing in adolescents and even in children

• Type 2 diabetes is being diagnosed in Canadian First Nations Children as young as eight (8) years old and the incidence appears to be increasing rapidly.

• In the next 15 years it is anticipated that the global incidence of Type 2 diabetes in children will increased by up to 50%

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Source Canadian Diabetes Society http://www.diabetes.ca Accessed May 18, 2012

Diabetes --- Type 2

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• Factors contributing to the increase of Type 2 diabetes include

• Aging population

• Obesity - about 95% of children with Type 2 diabetes are overweight when diagnosed

• Almost 80% of new Canadians come from populations that are at higher risk for Type 2 diabetes (Hispanic, South Asian, African descent)

• Canadian lifestyles are increasingly sedentary

• Aboriginal people are 3-5 times more likely than the general population to develop type 2 diabetes

Source: Canadian Diabetes Society http://www.diabetes.ca Accessed May 18, 2012

Diabetes --- System Impact • People with diabetes:

• use the health care system about twice the rate of the general population

• incur medical costs that are approximately twice as high as those without diabetes

• costs the Ontario healthcare system $3,000 more a year, this can rise to $5,000 if the person experiences complications.

• Diabetes complications account for:• 69% of limb amputations• 53% of kidney dialysis and transplants• 39% of heart attacks• 35% of strokes

• The Canadian Diabetes Association estimated that the cost of diabetes to the healthcare system in Canada was $6.3 billion in 2000 and is expected to increase to over $16.9 billion in 2020

11Source: MOHLTC 2012, Auditor General Report 3.03 Diabetes Management Strategy Canadian Diabetes Society http://www.diabetes.ca Accessed May 18, 2012

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Questions?

North Hamilton DEPs Enabling Health Through Healing Hope and Wellness

NHCHC’s  History of Diabetes Programming

2013

2005

2009

2007

2001

2011

2010

First Diabetes Program funding received at NHCHC 

Enhanced funding from the MOHLTC to expand to fullteam

Feet First Steps for Health opens at NHCHC

Diabetes Outreach Partnership started

Diabetes Moves to The LHIN

Chronic Disease Self Management offered to clients

NHCHC move to new Site  438 Hughson Street North

2012 Feet First Expansion Funded

Program Offerings Diabetes Education Diabetes Groups and Kitchens Outreach and Mental Wellness Foot Care Active Living and Fitness Multidisciplinary Team Support, Primary Care, Pharmacy, Rehabilitation, Social Work, Chronic Disease Management

Health Promotion and Volunteer Opportunities

Diabetes Education Diabetes education and management services are tailored to the needs of clients and encompass a broad range of services to support self‐management, e.g., nutritional counseling, medication management, self‐glucose monitoring, insulin management and managing diabetes during periods of illness.

Services are provided in a culturally sensitive environment in the language of choice, when possible.

Service provided through established  partnerships, accessible locations throughout Hamilton.

The Diabetes Outreach Program (DOP) identifies at‐risk communities where people lack resources or information regarding diabetes prevention or treatment. These populations include newcomers to Canada, ethnic minority groups, individuals without a family physician, as well as those with low income, mental illness, and at‐risk or experiencing homelessness.

The Program’s goal is to prevent long term complications of diabetes and improve the quality of life by removing barriers and ensuring equal access to diabetes evidenced based support services in the community

The DOP strives to increase public awareness regarding the seriousness of diabetes and promotes lifestyle and behaviour changes, as well as self‐care skills through individual and group education.

Diabetes Outreach

• Men’s, women’s, and family shelters located in downtown Hamilton • Food banks  • Family physician offices• Pharmacies• Subsidized apartment buildings in Hamilton• Lodging homes• Retirement homes• Hamilton Program for Schizophrenia & Canadian Mental Health  Association• Victorian Order of Nurses• Hamilton Urban Core Community Health Centre• City Recreation Centres• Home visits

The Diabetes Outreach Program provides services in Hamilton,Stoney Creek, and Jordan Station.

Outreach Partnerships

Diabetes Groups and Kitchens

Why is a Healthy Lifestyle Important? Nutrition education alone can decrease A1C by up to 2.0%

Medical nutrition therapy can prevent and manage medical issues related to diabetes including, but not limited to: Neuropathy Retinopathy Heart disease Stroke Renal failure 

"You don't drown by falling in the water. You drown by staying there.“ -unknown author

"Those who think they have no time for healthy eating, will sooner or later have to find time for illness.” – Edward Stanley

Diabetes Kitchen Dietitian led, monthly group education designed to improve/sustain 

cooking skills and techniques, create flavours, and proper food handling while using whole ingredients.

Encompassing both practical and educational components: lecture series includes: Food label reading 

Carb Counting

Mindless Eating

Holiday/Summer Eating Strategies

Shopping Tips

Kitchen assisted by volunteers from nutritional sciences program from an accredited university to develop recipes with the latest flavours and trends that can assist in their future career.

Diabetes Kitchen Actively uses a local Good Food Box for ingredient selection, 

which encourages community  awareness of this program and assists with food security issues.

Culturally Specific: When need/demand is assessed.  In previous years communities in different cultures have been 

invited to share their cuisine with the Diabetes team (Chinese, Caribbean, Afghani, Portuguese). Healthy suggestions or substitutions is provided by RD. 

Portuguese Kitchen series was created. 

Evaluation – pre and post program evaluations are provided to monitor self efficacy of participants and provide an opportunity for program improvement feedback.

Evidenced based advanced practice team model with Chiropodists and RPN’s.

Fully accessible senior friendly locations with easy access (no physical barriers),  most sites no parking costs.

Service available Monday to Friday. Evening hours available at several sites.

Cultural Interpretation and transportation support for clients.

Linking clients with Diabetes Education programs and other community resources such as wound care, orthotic prescription, chronic disease self‐management opportunities, falls prevention programming, fitness opportunities and rehabilitation services.

Diabetes foot care self‐management classes.

Community engagement education sessions, care giver education, shoe drives and other client support interventions.

Feet First Steps for Health Program

Feet First visits 2009/10

Total clients = 1649,  Total Visits = 4633

Feet First Visits/All Sites 12/13

Active Living and Fitness

What if there was one prescription

that could prevent and treat

dozens of diseases, such as diabetes, hypertension

and obesity?

-Robert E. Sallis, M.D., M.P.H., FACSM, Exercise is Medicine™ Task Force Chairman

Overview of Diabetes Fitness Program The diabetes physical activity program is an educational and activity 

program designed to encourage people living with diabetes to increase their daily physical activity.

Graduation leads to positive self‐efficacy, taking ownership and the readiness to make positive lifestyle choices leading to an improved quality of life.

Clients are offered a custom made, medically supervised exercise program that includes both an individualized gym program, as well as a group exercise component to help them achieve their personal fitness goals. 

Program is based on CDA Guidelines, CSEP(Canadian Society for Exercise Physiology).

Monitoring: Blood Pressure, Blood Glucose, BMI, as well as a screening tool for other conditions. 

Diabetes Group ExerciseAerobic exercise in the pool which uses resistance from water to provides full body strengthening.  Great for individuals with joint pain, arthritis, or those having trouble balancing or walking. 

A full body dance and aerobic workout that pays special attention to strengthening the core and posture while having fun with the music.  

or  chair exercises, include a short warm‐up, strengthening with resistance bands, free weights and stretching.  Modifications are made for physical limitations, making this class great for people of any fitness level.

A mind body exercise engaging the whole body to promote relaxation and internal massage.  Aids in improving balance, flexibility, muscle strength, relaxation, and overall health. Specially adapted so that it can be done from a lying down or sitting position. 

Form of traditional Chinese mind & body exercise, using slow sets of body movements and controlled breathing for specific positions. Great for improving balance, strength, relaxation, and overall health.

Answer OptionsVery 

SatisfiedSatisfied Neutral Dissatisfied

Very Dissatisfied

n % n % n % n % n %

a. How satisfied are you with Foot Care?43 79.6 7

13.0

1 1.9 2 3.7 1 1.9

b. How satisfied are you with the amount of time the Foot Care workers spend with you?

41 77.4 815.1

2 3.8 1 1.9 1 1.9

Answer OptionsVery 

SatisfiedSatisfied Neutral Dissatisfied

Very Dissatisfied

n % n % n % n % n %a. How satisfied are you with Diabetes services (Dietitian, Diabetes Nurse)?

39 78 10 20 0 0 1 2 0 0

b. How satisfied are you with the amount of time the Diabetes services workers (Dietitians, Diabetes Nurses,) spend with you?

35 70 13 26 2 4 0 0 0 0

Diabetes Services

Foot Care Services

Client Satisfaction 2012 Results

Client Experience at NHCHC