Improved Outcomes from Diabetes Outreach Programs in Rural and Remote Aboriginal Communities of Alberta, Canada
- 1. Improved Outcomes from Diabetes Outreach Programs in Rural and Remote Aboriginal Communities of Alberta, Canada Richard T. Oster, Kelli Ralph-Campbell, Tracy Connor, Ellen L. Toth Department of Medicine, University of Alberta k ABSTRACT Aboriginal and rural/remote communities have increased risk and prevalences of diabetes, with less access to preventive health care and less opportunities for healthy lifestyles. Since 2001, Alberta has hosted outreach and/or community- based screening programs in such communities for diabetes and diabetes risk. A total of 2879 persons with diabetes and 4663 persons without diagnosed diabetes (mostly Aboriginal and rural/remote) have been tested and counseled in over 14,000 visits. Baseline adult characteristics have been previously reported, and generally were unfavorable, showing up to 31% with pre-diabetes and 83% overweight or obese. In this study we examined, longitudinally, the diabetes-related health of returning adult individuals. “Point-of-care” lab equipment was transported to each community to screen for diabetes and cardiovascular risk; individuals with known diabetes were also screened for complications. In the current investigation, body mass index (BMI), waist circumference, hemoglobin A1c (A1c), blood pressure and total cholesterol were considered. For the longitudinal analysis, univariate general linear mixed effect models with random client effect and fixed time (year) effect were utilized to obtain overall trend estimates (considered significant if p < 0.05). Improvements in BMI, blood pressure, total cholesterol and A1c concentrations were observed among returning subjects with diabetes (p < 0.05) (N = 1415). Waist circumferences were unchanged. In contrast, subjects without known diabetes experienced improvements only in blood pressure and total cholesterol (p < 0.05), whereas both BMI and waist circumference increased over time (p < 0.05), and A1c was unaffected (N = 1398). While secular improvements in diabetes outcomes are occurring in rural Aboriginal adults exposed to diabetes outreach programs, the “dose” of such programs is likely insufficient to modify significant risk factors in pre-diabetic clients, thus different and/or more intense, and/or more integrated strategies need to be explored. For additional information contact: Richard Oster 1055 RTF bldg, University of Alberta Edmonton, Alberta, Canada T6G 2V2 780-407-8445 roster@ualberta.ca KS INTRODUCTION Statistical analysis 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. Since 2001, three separate screening programs have travelled to First Nations communities, Métis settlements, and other remote Alberta communities. Mobile clinics provide diabetes risk assessment, diabetes complications screening, and community-based care. Ethical approval was secured from the Health Research Ethics Board at the University of Alberta, and individuals consented to aggregate analysis. 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). 4. DISCUSSION The modest improvements amongst adults with diabetes imply that the outreach program care model may help support subjects to improve their health. Secular improvements in diabetes health are likely due to a combination of effects including the availability of national guidelines and the federal Aboriginal Diabetes Initiative. Unfortunately this combination is likely not enough to prevent diabetes in Aboriginal people with pre-diabetes, hence different and/or more intense, and/or more integrated strategies are needed. 5. 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. Oster RT et al. 2010. Can J Public Health. 101(5):410-414. 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 and total cholesterol (P < 0.05), whereas both BMI and waist circumference increased over time (P < 0.05). Trends for health indicators of returning subjects with diabetes over time (N = 1415). Values are estimates for the average change per year with SE. Baseline health indicators of subjects with diabetes. Values are means (± SD) or prevalences (95% CI). 3. RESULTS Subjects ranged from 20 to 92 years of age (mean 48) and the majority (64.2%) were female. Baseline co-morbidities were very common and indicators were more severe among men and those with diabetes. 2. METHODS Canadian Aboriginal Issues Database, www.ualberta.ca/ ~walld/map.html Indian and Northern Affairs Canada, www.ainc-inac.gc.ca -1.5 -1 -0.5 0 0.5 1 1.5 BMI Waist A1c MAP Systolic BP Diastolic BP Cholesterol Estimate of average change -1.5 -1 -0.5 0 0.5 1 1.5 BMI Waist A1c MAP Systolic BP Diastolic BP Cholesterol Estimate of average change Health indicator All (n = 2838) Females (n = 1732) Males (n = 1106) BMI (kg/m2) 33.6 ± 10.7 34.2 ± 12.3* 32.5 ± 7.4 % overweight 25.2% (23.6 – 27.0) 22.7% (20.7 – 24.9)* 29.1% (26.3 – 32.0) % obese 67.4% (65.6 – 69.2) 70.0% (67.6 – 72.2)* 62.5% (59.5 – 65.6) % overweight/obese 92.3% (91.2 – 93.3) 92.7% (91.3 – 94.0) 91.6% (89.7 – 93.3) Waist circumference (cm) 110.7 ± 14.7 110.9 ± 14.7 110.5 ± 14.7 % Abnormal 83.2% (81.7 – 84.6) 88.9% (87.3 – 90.4)* 73.6% (70.6 – 76.3) A1c (%) 8.0 ± 7.7 8.0 ± 9.7 8.0 ± 2.0 % Poor glucose control 57.7% (55.7 – 59.5) 55.6% (53.1 – 58.1)* 60.9% (57.8 – 63.9) Systolic blood pressure (mmHg) 131.1 ± 19.1 129.3 ± 18.7* 133.9 ± 19.2 Diastolic blood pressure (mmHg) 77.4 ± 11.0 75.7 ± 10.5* 80.0 ± 11.1 Mean arterial pressure (mmHg) 95.3 ± 12.1 93.6 ± 11.7* 98.0 ± 12.1 % Hypertensive 67.3% (65.5 – 69.0) 62.9% (60.5 – 65.2)* 74.1% (71.4 – 76.7) Total cholesterol (mM) 4.9 ± 1.2 5.0 ± 1.2 4.9 ± 1.3 % Hypercholesterolemia 36.9% (34.9 – 39.0) 38.0% (35.4 – 40.6) 35.4% (32.2 – 38.6) Health indicator All (n = 4020) Females (n = 2673) Males (n = 1347) BMI (kg/m2) 30.8 ± 6.4 31.1 ± 6.8* 30.1 ± 5.5 % overweight 31.1% (29.6 – 32.5) 27.7% (26.0 -29.5)* 37.7% (35.1 – 40.4) % obese 51.3% (49.7 – 52.9) 54.0% (43.3 – 48.7)* 46.0% (43.3 – 48.7) % overweight/obese 82.4% (81.1 – 83.6) 81.7% (80.2 – 83.2) 83.7% (81.6 – 85.6) Waist circumference (cm) 102.2 ± 15.6 101.3 ± 16.2* 104.1 ± 14.3 % Abnormal 70.9% (69.4 – 72.3) 79.3% (77.7 – 80.9)* 54.2% (51.4 – 56.9) A1c (%) 5.5 ± 0.7 5.4 ± 0.6 5.6 ± 0.9 % Undiagnosed diabetes (≥ 7%) 2.1% (1.7 – 2.6) 1.8% (1.3 – 2.4)* 2.9% (2.0 – 3.9) Systolic blood pressure (mmHg) 121.6 ± 17.9 118.5 ± 17.2* 127.6 ± 17.8 Diastolic blood pressure (mmHg) 75.3 ± 10.7 73.6 ± 10.3* 78.6 ± 10.8 Mean arterial pressure (mmHg) 90.7 ± 12.1 88.6 ± 11.6* 94.9 ± 12.0 % Hypertensive 26.2% (24.5 – 27.9) 21.5% (19.6 – 23.6)* 34.9% (31.7 – 38.1) Total cholesterol (mM) 4.8 ± 1.1 4.7 ± 1.0* 4.9 ± 1.1 % Hypercholesterolemia 32.8% (31.4 – 34.3) 30.8% (29.0 – 32.6)* 36.9% (34.3 – 39.5) 1. INTRODUCTION The health of Canadian Aboriginals (First Nations, Inuit and Métis) is markedly poorer than their non-Aboriginal counterparts, with type 2 diabetes at the forefront (1, 2). For Aboriginal peoples, many of whom live in rural/remote settings and suffer from inequities with respect to the social determinants of health, rates of type 2 diabetes and its complications are 2-5 times more common (3). In response, several outreach and/or community-based diabetes screening programs have been implemented in the province of Alberta. In this analysis we sought to examine, longitudinally, the diabetes- related health status among returning subjects with diabetes and without diabetes. Adults (≥ 20 years) enrolled through self-referral via local advertising. A total of 7542 unique subjects (2879 with diabetes, 4663 without diabetes) have been tested. Subjects were mostly First Nations (64.4%), with some Métis (21.8%) and non-Aboriginal (13.9%). Follow-up visits were available for 1415 subjects with diabetes and 1398 without diabetes. Mobile clinics equipped with healthcare personnel and portable technology travelled the communities. Detailed methodology has been reported elsewhere (4). Measurements included body mass index (BMI), waist circumference, hemoglobin A1c (A1c), blood pressure, and total cholesterol. National Cholesterol Education Program (5) and Canadian Diabetes Association (6) criteria were utilized to define overweight (BMI 25-29.9), obesity (BMI ≥ 30), abnormal WC (≥ 102 males; ≥ 88 females), poor glucose control (A1c ≥ 7%), hypertension (≥ 130/80 for diabetes; ≥ 140/90 for no diabetes, or on anti-hypertensives), and hypercholesterolemia (≥ 5.24, or on anti-hyperlipidemics). Baseline health indicators of subjects without diabetes. Values are means (± SD) or prevalences (95% CI). Trends for health indicators of returning subjects with diabetes over time (N = 1398). Values are estimates for the average change per year with SE. * denotes significant gender difference * denotes significant gender difference