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Be concerned, be very concerned

Type 2 diabetes like a health-care tsunami

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Imagine yourself stretched out on a towel on a beautiful sandy beach, not a care in the world, soaking up the sun as you squint through your sunglasses at swarms of other carefree beach-goers.

You couldn't be feeling better.

Now imagine a deadly tsunami is racing towards the beach at breakneck speed.

A few people decide to flee for higher ground, but most continue slathering on sunscreen, flipping the pages of the latest summer blockbuster and shaking stray grains of sand off their tuna fish sandwiches.

Why aren't they panicking?

 

Because most of the people basking in peaceful oblivion have no idea they are in danger; they believe only the overweight guy on the towel next to them will be swept away.

It's not a perfect analogy -- especially given this year's horrors in Japan -- but it comes close to describing the situation surrounding Type 2 diabetes, the fastest-growing chronic disease in Canada, a multibillion-dollar crisis that threatens to not only swamp our health system, but drain our economy.

Health experts, politicians and advocacy groups use words such as "tsunami," "storm" and "hurricane" to drive home the threat posed by this often debilitating, sometimes fatal, frequently misunderstood disease that is at epidemic levels throughout the world as populations age and grow more obese.

The experts aren't exaggerating. The numbers are staggering and poised to get much worse. Experts say more than 20 people are diagnosed with diabetes every hour of every day. In Canada, rates have almost doubled in the last decade and the number of confirmed diabetics is expected to rise to 4.2 million people (10.8 per cent of the population) from 2.7 million people (7.6 per cent of the population) by the end of the decade.

And because diabetics die from the complications of the disease, few people realize that it is a killer.

 

"People die by inches... you see it eating into people's quality of life. As their vision deteriorates and their kidneys fail, their ability to be a productive member of society goes down the tubes," said Dr. Sora Ludwig, one of Canada's leading diabetes specialists, site director for endocrinology at St. Boniface General Hospital as well as an associate professor with the University of Manitoba's medical faculty.

"The numbers are overwhelming... it's going to put a huge burden on the health-care system."

Counting those with pre-diabetes, in which blood sugars are higher than normal but not high enough for a diagnosis of diabetes, along with an additional one million people living with undiagnosed diabetes, one out of every three Canadians (11.7 million people) will be affected by the disease by 2020.

In Manitoba, the number of confirmed diabetics soared to 94,000 in 2010 from 53,000 in 2000. By the end of the decade, more than 139,000 Manitobans (10.1 per cent of the province's population) are expected to suffer from the disease, a nation-leading 48 per cent increase.

Manitoba is hit harder than most because the province has higher obesity rates and the largest concentration of aboriginal people -- 15.47 per cent of our population -- in Canada. People of First Nations descent are three to five times more likely than the general population to develop diabetes.

And make no mistake: Like a real tsunami, diabetes is a killer on a grand scale. The most recent figures from Statistics Canada rank it as the sixth-leading cause of death in the country, claiming 7,394 people in 2007.

But the Canadian Diabetes Association says the real story is much more alarming. It's not the diabetes that kills you; it's the complications. And there are a lot of them. It's the leading cause of blindness, kidney failure and amputations, and a driving factor behind strokes and heart attacks.

Statistics show 80 per cent of Canadians with diabetes will eventually die of a heart attack or stroke. It accounts for one-quarter of the deaths in Manitoba each year.

 

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Michael Cloutier, president and CEO of the Canadian Diabetes Association, delivered a "frank warning" to Manitoba MLAs in February, stating Canada now has the third-highest rate of mortality due to diabetes among its peer countries.

"Six thousand Canadians die each month from diabetes or a downstream condition," Cloutier declared. "This means that every year, diabetes takes approximately 72,000 people -- or more than the combined populations of Brandon, Thompson and Portage la Prairie."

You'd expect the mere mention of a debilitating disease like that, one that kills and maims thousands of Canadians every year, to inspire terror.

But you'd be wrong. As epidemics go, diabetes is an exceedingly quiet one. Despite the devastation it wreaks, it doesn't generate the terror or the media frenzy associated with H1N1 or even the seasonal flu, let alone our most feared killer -- cancer.

"The vast majority of people are oblivious to what diabetes is, what causes it and why it's increasing so alarmingly," Cloutier says. "Most people just think it has something to do with sugar."

Doctors and nurses are loathe to prescribe panic, but when it comes to diabetes, they tend to agree it wouldn't hurt if we became a little more alarmed and a lot more informed. They say one of the biggest reasons diabetes poses such a huge threat is the fact Canadians know so little about it.

And what they do know is often wrong.

"The misconceptions go on and on," groans Jacqueline Gregoire, a nurse educator at the Youville Diabetes Centre on Marion Street, one of only two health centres in Winnipeg focusing solely on self-management education for diabetics.

"It's mind-boggling," Gregoire says. "Some think it skips a generation. Or only the men in a family get diabetes. There's this belief that diabetes is temporary, that it will go away. That misconception continues today.

"Some people think it's not serious because they're not on insulin and only people on insulin have bad diabetes. News flash: There is no such thing as good diabetes. But that's the community's impression."

Those on the front lines say the epidemic is worsening because diabetes isn't on our radar, meaning we are largely unaware of the extent of the crisis, whether we're at risk, and how to keep the disease and it's potential complications at bay.

When we talk about a "diabetes tsunami," we're talking about Type 2 diabetes, the most common form of the disease, affecting nine out of 10 Canadian diabetics.

In Type 2 diabetes, the pancreas doesn't produce enough insulin or the body is not able to use the insulin it makes. Insulin is a hormone that helps with the conversion of glucose (sugar) into the energy the body needs. Without it, sugar builds up in the blood instead of being converted into energy. Chronic high blood sugars are the culprit behind the horrific complications associated with diabetes.

It's an insidious disease, a silent killer that sneaks up on its victims over time, quietly numbing nerves, clogging the cardiovascular system and damaging small blood vessels.

People with Type 2 diabetes may not exhibit symptoms -- such as excessive thirst, increased urination, fatigue, numbness of the feet and blurred vision -- for years or decades. About half end up diagnosed only after arriving at a doctor's office to be treated for one of diabetes' many complications.

By the time the disease is finally diagnosed, blood sugars may have been so high for so long much damage has already been done to the body.

"Diabetes is present for six to nine years before it's diagnosed in a typical individual, and we're talking about people who actually access health care," says Lori Berard, nurse manager of the Diabetes Research Group at the Health Sciences Centre and Canada's diabetes educator of the year in 2009.

Type 2 diabetes is often called a "silent" or "slow-motion killer." Even though your blood sugars are dangerously high, you may feel perfectly fine.

"With diabetes, a lot of people don't feel sick with elevated blood sugars, so they may minimize the impact," Dr. Ludwig points out. "The thing is, the complications clock has started ticking long before the diagnosis."

 

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The exact causes of Type 2 diabetes are not completely understood. Genetics plays a substantial role, with people of Hispanic, Asian, South Asian and, most especially, aboriginal descent being at far greater risk. Poverty is also a factor, with an increasing amount of research showing a clear link between Type 2 diabetes and lower incomes.

But doctors and researchers lay the vast majority of blame for the "quiet epidemic" on an aging population and rising obesity rates, fuelled by increasingly sedentary lifestyles and a modern banquet of processed foods rich in both fat and sugar.

Our genetics haven't changed that much, but the way we eat has. In the past, humans had to burn energy to find calories; now the reverse is true -- fast food is easy to find, but you have to hunt to find ways to burn energy.

"This tsunami is driven primarily through an aging population and a population that is increasingly unhealthy because of unhealthy weights, sedentary lifestyles and poor nutrition," explains Cloutier, whose advocacy group is becoming more vocal in an effort to lessen the human impact and financial toll of the disease.

"In an increasingly large percentage of individuals, it's more related to lifestyle than anything else," says Cloutier. "Over the last few decades we've seen BMIs (body mass indexes) rising and far greater levels of obesity. What's really alarming is the level of childhood obesity."

But Type 2 diabetes is not simply a punishment for overweight, sedentary people. While 80 to 90 per cent of those who acquire the disease are obese or unfit, it also strikes those who eat properly and exercise daily.

Along with the sneaky nature of the disease, Cloutier says the epidemic doesn't provoke the fear it deserves because too many Canadians think the problem ended with the discovery of insulin.

"A lot of people think diabetes is cured," he says. "No, it's not cured! Insulin is what allows people to live, but the disease has not gone away."

"It's not seen as a front-line killer like cancer or the way SARS was or H1N1," says St. Boniface Hospital's Dr. Ludwig. "It doesn't engender that kind of fear factor. No. 1, you can't catch diabetes. No. 2, people don't identify diabetes as a cause of death in the way they do with cardiovascular diseases or cancer."

The specialist says, unlike cancer patients, diabetics have to learn to be the captains of their own ship, managing the disease, taking control of diet and lifestyle, monitoring blood sugars and taking medications as prescribed.

"The onus is on the individual with diabetes to self-manage the disease," she says. "The whole team -- the primary doctor, the diabetes specialist, the diabetes educator -- gives them the skills to manage their disease. That's a different approach to cancer, where the treatment is surgery or radiation or chemotherapy, but (the doctors) are going to decide. You're not as active a participant in your illness."

Most importantly, unlike a real tsunami, the experts say the massive wave of Type 2 diabetes rolling towards us is largely preventable through lifestyle changes. Studies have shown more than 50 per cent of Type 2 diabetes cases could be prevented by healthier eating and increased physical activity.

The message is this: If you're going to the beach, do a few pushups and eat carrot sticks instead of french fries.

"At the end of the day, the best chance we have to reduce the impact of this tsunami and its disastrous impact is related to lifestyle and achieving healthy weights through good nutrition and exercise," Cloutier says.

"There's good reason for optimism. We just need to get at it right now. We can make a difference. It's people taking personal responsibility. And it's critical we're supported in that by governments and the private sector.

"We have a chance to win this, but we have to be urgent. The clock is ticking."

doug.speirs@freepress.mb.ca

Republished from the Winnipeg Free Press print edition July 2, 2011 J1

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