Health Committee on Oct. 19th, 2011

[The Chair, Conservative, Joy Smith]

Good afternoon, everybody. Welcome to the health committee.

I'm so pleased to have you all here today. We do have a lot of witnesses today. It's very important that we get all this information, and we're very pleased that we've been able to do that so far.

In relation to the study of the chronic diseases related to aging, I'm going to ask that we pass our budget before we begin the testimony from the witnesses. The motion is that, in relation to the study of chronic diseases related to aging, the proposed budget in the amount of $ 28,700 be adopted.

[Colin Carrie, Conservative, Oshawa, ON]

I'd like to put forth the motion that we adopt the budget, as read by Madame la président.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Carrie.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Could you give us a minute or two to look at the details and see if we are satisfied with that?

[The Chair, Conservative, Joy Smith]

Basically, Dr. Morin, it is a standard budget; it is a budget to bring our witnesses in. Without the budget we cannot pay the hotels or the airfare. So rather than going over every item, are you satisfied with this?

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Let me just have a few seconds. That should be enough.

Does it include all our witnesses for the fall?

[The Chair, Conservative, Joy Smith]

It's just for this study. If you look at the budget, it's just for the witnesses who are before us, to pay for their expenses.

I think--for further information--we can have a budget of up to $50,000, and then I have to go to the liaison committee following that.

[A voice]

I think it's $40,000.

[The Chair, Conservative, Joy Smith]

Okay, it's $40,000. So this is a very standard budget. But thank you for asking.

(Motion agreed to)

Thank you.

Pursuant to Standing Order 108(2), a study of chronic diseases relating to aging, we have a witness from the Canadian Diabetes Association, Aileen Leo, associate director.

Welcome, Aileen. Is it Dr. Leo?

[Aileen Leo, Associate Director, Public Policy, Government Relations and Public Affairs, Canadian Diabetes Association]

I could pretend that it was, but sadly, it's not.

[The Chair, Conservative, Joy Smith]

That's okay. If you're here, you're an expert.

We have, from the Canadian Partnership Against Cancer, Jessica Hill, the chief executive officer, and Leanne Kitchen Clarke, vice-president of public affairs. Welcome to both of you.

From the Heart and Stroke Foundation of Canada, we have Manuel Arango, the director, health policy, and Mike Sharma, expert representative. Welcome.

From the Canadian Lung Association, Christopher Wilson will be joining us. They'll be testifying toward the end, so he'll be coming in a little later. He's the director of public affairs and advocacy. We also have Rosario Holmes, an educator. Thank you so much for being here today, Rosario.

Having said that, we're going to start with a ten-minute presentation. We will begin with the Canadian Diabetes Association. Who will be the presenter for this one?

Thank you, Ms. Leo.

[Aileen Leo]

Good afternoon, Madam Chair and members of the committee.

On behalf of the Canadian Diabetes Association, thank you so much for inviting us here today. We are very pleased to join in this discussion concerning those chronic diseases related to aging.

Given Canada's aging population, this study will be essential in the development of policy to care for our senior citizens, many of whom find themselves in vulnerable circumstances due to living with one or more chronic diseases, including diabetes and its related complications. Our remarks here today will focus on the impact of diabetes and its complications on our health care system, our economy, and those living with the disease.

The Canadian Diabetes Association leads the fight against diabetes by helping people with diabetes lead healthy lives while we work to find a cure. Established more than 50 years ago, we are a not-for-profit that has a presence in communities across Canada and we work with a strong nationwide network of volunteers, employees, health care professionals, researchers, partners and supporters. The association promotes the health of Canadians through education and services advocating on behalf of people living with diabetes, supporting research, and translating research into practical applications.

Unfortunately, diabetes is an epidemic in Canada and worldwide. The increasing prevalence of diabetes is dramatic and alarming. In 2010, 7.6% of Canadians, or 2.7 million people, had diabetes. If no action is taken by 2020, almost 11% of Canadians, or over four million people, will have diabetes. In addition, almost one million people have diabetes but don't know it because they have not yet been diagnosed. As well, over seven million people have pre-diabetes, which, if left unchecked, puts them at risk for developing type 2 diabetes.

Today more than nine million people are living with diagnosed or undiagnosed diabetes or pre-diabetes. This means that one in four Canadians is living with either pre-diabetes or diabetes. If those figures weren't alarming enough, by 2020 it will be one in three Canadians unless action is taken to stem this epidemic.

There is a strong link between age and type 2 diabetes, which comprises approximately 90% of diabetes cases. In fact, the likelihood of developing diabetes increases substantially with age. Our clinical practice guidelines generally note that being over 40 years of age and older is one of the key risk factors for developing type 2 diabetes. This is critically important, since, according to Statistics Canada, by 2036 the number of seniors in this country will more than double, to approximately 25% of the population, outnumbering children for the first time.

In addition to an aging population, rising rates of unhealthy weight and sedentary lifestyles, as well as a change in the ethnic mix of Canadians, are all drivers of the alarming increase in the prevalence of diabetes.

Given the relationship between aging and diabetes, it is no surprise that most Canadian provinces with median ages older than the national average have higher rates of diabetes, in particular, Atlantic Canada. For example, Newfoundland and Labrador has the highest median age in Canada, and also the highest rate of diabetes and pre-diabetes. By 2020, while the national prevalence rate for diabetes will approach 11%, in this province it will surpass 14% if action is not taken.

With increasing diabetes prevalence comes an increasing cost, affecting our health care system and our economy. Diabetes currently costs more than $11.7 billion in Canada and will rise to $16 billion by 2020. It's also important to point out that 80% of these costs are due to diabetes-related complications such as heart attack, stroke, kidney disease, blindness, amputation, and depression. These conditions are commonly found among elderly Canadians with diabetes, since the likelihood of developing these complications increases the longer a person has the disease.

Diabetes also costs those living with the disease. With the exception of those living on very low incomes and covered by government support, out-of-pocket costs can approach or surpass $2,000 for type 2 diabetes across income levels and provinces and territories. For those with type 1 diabetes, these costs can be even higher, especially if they use an insulin pump. These costs continue to be a barrier to effective self-management of diabetes. Over half of Canadians with type 2 diabetes indicate that they do not comply with their prescribed therapy due to the cost of medications, devices, and supplies, leaving them vulnerable to complications, which can be life-threatening.

These costs do effect the elderly. Our members who can currently afford these costs have expressed their very serious concern that they may have to compromise their self-management when they retire due to these costs.

We need to reduce the burden of diabetes and related complications. In order to do this, the Canadian Diabetes Association recommends enhanced diabetes prevention and management for elderly Canadians. Lifestyle interventions are effective in the prevention of diabetes in the elderly at high risk for the disease, including moderate weight loss and regular physical activity.

Since diabetes in the elderly is metabolically different, their management and/or therapy should reflect this. Support from health care teams, including doctors, nutritionists, dieticians, pharmacists, diabetes nurse educators, etc., have been shown to improve glycemic control in the elderly.

Nutrition education and exercise combined with medication should be carefully tailored to suit the needs of the elderly and the various sub-populations, such as those at increased risk of hypoglycemia, which is a lower-than-normal blood glucose level.

We also need to address not only the physical health needs, but the mental health needs of elderly people with diabetes. According to the Canadian Mental Health Association, depression in seniors is extremely common. Many challenges they face contribute to depression, including reduced functional ability due to physical illness, mobility impairment, chronic pain, and cognitive and sensory impairment. Other challenges, such as retirement, changes in income, widowhood, the death of friends, and new caregiving responsibilities, can lead to social and emotional isolation. This is particularly important, given that people with diabetes across the board are as twice as likely to be depressed compared to those without the disease, compromising their ability to self-manage.

People with diabetes who develop related complications such as depression are less likely to follow diet and exercise recommendations, check their blood glucose levels, or fill their prescriptions for diabetes and complications. So if you are elderly and have diabetes, your risk of depression and other serious complications is that much higher.

The increasing senior population has also led to dramatic increases in the number of seniors in long-term-care facilities. Seniors in these facilities often have undiagnosed diabetes and related complications, such as mental health disorders. Under-nutrition is also a major problem in these establishments.

In summary, the risk of developing type 2 diabetes and diabetes-related complications is higher for elderly Canadians. Diabetes currently costs Canada more than $11.7 billion, and 80% of this cost is due to diabetes-related complications.

With a growing senior population we must focus on keeping elderly Canadians with diabetes healthy to avoid or delay costly complications, and address the impact of diabetes on our health care system and economy.

Lifestyle interventions are effective in preventing diabetes in the elderly who are at risk for developing the disease. Elderly people with diabetes should have a health care team that provides education and support.

Given that elderly Canadians are vulnerable to both diabetes and depression, measures to address their needs should focus on both physical and mental well-being.

Finally, successful chronic disease prevention and management to support healthy aging starts long before age 65. We invite you to consult our recommendations to stem the course of diabetes in Canada within the Diabetes: Canada at the Tipping Point report released in April, contained within your information packages.

Thank you once again for the opportunity to convey our views today on this important issue. We'd be pleased to answer any questions you may have.

[The Chair, Conservative, Joy Smith]

Thank you very much, Ms. Leo. Those are very profound stats, aren't they? Thank you.

After everyone has presented we'll go to questions and answers.

We'll now go to the Canadian Partnership Against Cancer and Jessica Hill.

[Jessica Hill, Chief Executive Officer, Canadian Partnership Against Cancer]

Thank you very much, Madam Chair and committee members.

I am pleased to be here today with my colleague Leanne Kitchen Clarke to speak with you about the Canadian Partnership Against Cancer.

Cancer is a complex set of over 200 diseases, making a single solution to address the disease a challenge. I'm here today to tell you about some highlights of our work, particularly related to shared priorities between cancer and other chronic diseases and aging.

I would like to tell you a bit about the partnership, since we are a relatively new organization. The Canadian Cancer Society is one of the major charities in the cancer field you'd be aware of; we are not a charity nor an advocacy organization.

We were created by the federal government, in 2007, with an initial mandate of five years and funding of $250 million. We are very grateful that the government recognized the progress being made by the cancer strategy, and it renewed our mandate and funding for another five years, from 2012 to 2017.

All our work is done in a collaborative way, with and through partners across the country. To advance this work we have over 400 advisers involved in working groups and networks from cancer and chronic disease across Canada. This allows us to leverage the expertise that exists in the country and share knowledge, skills, and best practices to have a greater impact. For instance, in the area of colorectal cancer screening, we chair a network of program leads and experts in screening from the provinces to accelerate program implementation in Canada. That has happened through the collective effort of this network.

Our board consists of 19 stakeholders, including provincial deputy ministers, the Canadian Cancer Society, the Canadian Association of Provincial Cancer Agencies, cancer survivors, regional representatives with backgrounds in health and cancer, and an aboriginal person, among others.

The term “cancer control” has a World Health Organization definition, and it broadly covers a population approach to reduce the burden of cancer. Through prevention, screening, and early detection, measuring the performance of the system to inform quality initiatives, and assisting patients and families through the cancer journey, whether they survive or die of their disease, the full continuum is involved in controlling cancer.

I will not be getting into the areas of screening, diagnosis, and treatment today, given the time we have; I will focus on prevention and research. The snapshot I've provided to the clerk does cover all our initiatives, and we will follow up with additional copies for all the members.

In the work of prevention, cancer shares many common risk factors. This is where we collaborate with the Heart and Stroke Foundation and other organizations to advance our collaborative efforts.

Moving to page 4, I'm going to talk a bit about the statistics of cancer and aging. On page 5 you will note that between 2007 and 2031 it is expected that new cancer cases will increase by 71%. The population will only increase by 19% over the same period, with 40% of women and 45% of men developing cancer.

On the next page you will note there is a strong association between age and the increasing number of cancer cases. This is a result of the aging process, in part, and certainly affects the growing number of cases in the population as it's aging.

On page 7 you can see that survival has improved, with relative survival at 62% for five years, and 58% for 10 years. This is very good news, but this means we're going to have a growing population of people who are living with cancers and that the population will largely be an aging population.

The other aspect of this is comorbidity; that is, people living with diabetes and cancer, or with heart disease and cancer. That is one of the factors we are facing as a health care system.

On page 8 you see that we move into discussing the strategic priorities of the partnership. The framework indicated on page 9 is our strategic framework going forward for 2012 to 2017. This describes our vision, which is a shared vision by the cancer community: the goals, mission, strategic priorities, and core enabling functions, along with objectives we are going to achieve in this period.

Most importantly, I want to emphasize our role, which is to leverage the investment that already exists in cancer across the country, which is usually described as over $6 billion. Our funds are to leverage the whole system to be more effective. And that's just the way the strategy is implemented.

We work with and through people to develop collaborative action, to share best practices, and to ensure that people from B.C. can share their best practices with those in Ontario, and Ontario with the other provinces as well. So it's a very collaborative approach.

Quickly, on page 10, in the area of prevention, our major initiative is a strategy of drawing together coalitions linking action and science for prevention. This really supports the prevention efforts across provinces to work better together and to ensure they're able to accelerate action in their jurisdictions in the prevention agenda.

I certainly can provide more detail to the committee about that.

On page 11, we wanted to raise that we've launched a major research study called the Canadian Partnership for Tomorrow Project, a cohort study made up of five regional cohorts. This federated national platform is looking at the interactions between genetics, lifestyle, and environment and will be a major research platform for at least the next 30 years.

Page 12 describes the study. However, the stage we're at right now is that the regional cohorts are recruiting participants. What we see in the next mandate is that we will increase opportunities for Canadians to participate in the study in those provinces and territories where they aren't currently having regional studies, and in addition, we'll be working with the cardiovascular community to deepen the capture of cardiovascular indicators in the study, all of which will make this a very rich platform.

The final thing I'd like to mention is palliative and end-of-life care. Clearly, 50% of patients with cancers will die of their disease and we know many patients and families are not prepared for end-of-life decisions and conversations. So we're working with the Quality End-of-Life Care Coalition of Canada's blueprint for action, to support its efforts to ensure that we are able to advance palliative care in the country.

We also report on the system and we've provided that to the clerk.

We do system performance reports, and this is an important aspect of our work so that we can actually monitor how the system across the country is performing and work with the representatives of cancer agencies and the health care system to look at how they can make improvements that create greater coherence and actually overall respond to the needs of Canadians in the most effective way. We've had two reports and we will have a third in December, the 2011 report, which will also continue to enrich our understanding of how services are being delivered and guidelines are being adopted.

The next slide is just to say what we use to inform our work. We use evidence, we learn from the experience of patients and their caregivers, we have a video series on our portal called “The Truth of It”—stories by Canadians on their experiences—and we engage with the health system and the cancer system to make our changes.

Finally, I encourage you to visit our website www.partnershipagainstcancer.ca or our portal, which is a partner portal with more than 30 partners, called www.cancerview.ca for additional information about the work we've been undertaking in our first mandate.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much, Ms. Hill.

Now we'll go to the Heart and Stroke Foundation and we'll hear from Manuel Arango, the director.

I'm sorry, is somebody else going to be doing that?

[A voice]

Yes.

[The Chair, Conservative, Joy Smith]

So it's Dr. Mike Sharma?

Okay, thank you.

[Dr. Mike Sharma, Expert Representative, Heart and Stroke Foundation of Canada]

Madam Chair, committee members, on behalf of the Heart and Stroke Foundation, I'd like to thank you for the opportunity to appear before you to share our perspectives on chronic diseases related to aging. I'm Mike Sharma and I'm here as an expert representative of the Heart and Stroke Foundation. I'm a stroke neurologist and researcher, as well as a deputy director, clinical affairs, of the Canadian Stroke Network. Joining me is Manuel Arango, director of health policy at the foundation.

First and foremost, I'd like to express our gratitude to Parliament for a number of initiatives and commitments that will help reduce the impact of heart disease and stroke in Canada, including the recent adoption of new and improved tobacco package warnings, Bill C-32, which prohibits the use of certain flavourings in tobacco products and associated marketing; the commitment to implement defibrillators in hockey arenas across the country; and the commitment to include cardiovascular measures within the Canadian Partnership Against Cancer's longitudinal study of chronic disease known as the “Tomorrow Project”.

The Heart and Stroke Foundation is a national volunteer-based health charity founded over 50 years ago, with more than 130,000 volunteers and two million donors. We work to reduce heart disease and stroke by funding research, promoting healthy living to Canadians, and by working with all levels of government to inform and influence health policy.

We're aging. Every day 1,000 people in Canada turn 65, entering a stage of life with an increasing risk of stroke, heart disease, and dementia. The number of seniors in Canada is projected to increase from 4.2 million to 9.8 million between 2005 and 2036. Heart disease and stroke combined are the leading causes of death among Canadians 65 years of age and over, killing over 60,000 seniors annually. There are over 50,000 hospital admissions for stroke in Canada each year. That's one stroke every ten minutes. When you take into account that we don't hospitalize all strokes, the reality is that the number is much greater.

Those strokes that are hospitalized are called overt strokes, which produce acute traumatic symptoms. In addition to this, there are between five and ten times as many covert strokes. These are ones that do not produce acute manifestations but result in disability by other mechanisms. At a minimum, 300,000 Canadians are living with the effects of stroke today.

In view of the time constraints, we've chosen to focus on three main themes: stroke, aging, and economics; vascular disease of the brain and dementia; and, briefly, heart disease and aging.

In Canada, stroke is the leading cause of death and disability, costing $56,000 for the first six months of care alone. Estimated yearly costs are in excess of $5 billion. While 35% of individuals impacted by stroke are under the age of 65, age is the single strongest predictor of stroke occurrence. Stroke occurrence begins to rise at the age of 55, and doubles for each decade thereafter. Stroke results in physical, cognitive, and psychiatric dysfunction. Individuals have an impairment in their ability to make decisions, use language, think, and remember. Thirty percent are depressed at three months. Between one-third and two-thirds require rehabilitation for physical, cognitive, or communication difficulties. Fewer than 50% of individuals with stroke return to work, placing an additional burden on their caregivers and families.

In contrast to overt or large strokes, covert strokes cause functional impairment without producing overt symptoms or abrupt onset symptoms. We know that 95% of people age 65 and older show abnormalities in the brain related to disease of small blood vessels within the brain. Further, a quarter of healthy seniors aged 70 have evidence of small, silent strokes. Similar strokes are seen in 14% of Canadians aged 60. These small, silent strokes result in dementia, which in fact is a vascular disease.

Alzheimer's disease, which is often thought to be synonymous with dementia, rarely occurs alone. The vast majority of dementia consists of a combination of Alzheimer's disease and stroke, which goes by the term “mixed dementia”. By 2038, the number of Canadians with dementia will increase by a factor of 2.3, with regard to the 2008 level, which is to say, 1.1 million people. The lifetime risk for stroke or dementia in our country is one in two for women and one in three for men.

The increasing rate of obesity and diabetes, combined with aging of the population, will contribute to an increase in all forms of heart disease, including ischemic heart disease, heart failure, and cardiac arrhythmias. This will strain the health care system and have a major economic impact on the country. As an example, it is estimated that currently there are 500,000 Canadians living with heart failure and 50,000 new patients are diagnosed each year.

What can we do?

There are some changes to the health care system that will help. The Heart and Stroke Foundation is very proud to be part of the joint initiative known as the Canadian stroke strategy, a national initiative that is aimed at improving stroke care across Canada. The strategy has targeted the systematic implementation of best practices, thereby preventing stroke, minimizing damage when it occurs, and improving functional recovery.

In the upcoming health accord the federal government needs to ensure adequate transfer payments to the provinces in order to enable incorporation of the best practices from the Canadian stroke strategy, including the establishment of dedicated stroke units and improved rehabilitation and palliative care services for those living with chronic diseases.

Prevention is key. Prevention can help delay and compress chronic diseases in later life, saving money to the system and the economy and improving the quality of life. Prevention essentially is all about making the healthy choice the easy choice, creating environments that make it easy to live a healthy lifestyle.

Prevention of vascular disease requires addressing a number of risk factors, many of which can also contribute to cancer, diabetes, obesity, and other chronic illnesses. At a high level, prevention includes a healthy diet, physical activity, and avoidance of tobacco.

There are a number of potential measures to address these risk factors, but here are a few we believe we must act on now.

The brain and the heart are the primary targets of high blood pressure. High blood pressure can be prevented by healthy nutrition, especially by reductions in sodium consumption, and increased physical acitivity.

With respect to sodium consumption, the Heart and Stroke Foundation of Canada urges the federal government to act upon the recommendations of the sodium working group, who released their final report last July. In particular, we call upon the government to establish sodium reduction targets for the food industry, with an accompanying monitoring mechanism. These targets should reduce the average daily intake of salt to 2,300 miligrams by 2016. If these voluntary targets fail to produce desired outcomes, we support the implementation of regulations.

Reduction in trans-fat content in our diet is important. Trans-fat content in Canadian diets is much higher than international recommendations. We call upon the government to introduce trans-fat regulations.

Fruit and vegetable consumption is too low in this country and is getting more and more expensive for seniors living on limited budgets. The federal government should ensure that agricultural policy and subsidies facilitate the production and distribution of fresh, affordable fruit and vegetables.

Community design and infrastructure that supports active living is particularly important for older people who have conditions that make mobility more challenging. Appealing, accessible, and safe facilities for walking and cycling will make it easier for Canadians of all ages to enjoy physical activity. Also important is the provision of safe and attractive recreational facilities and parks.

We call upon the federal government to work with the provinces to establish an active transportation fund to provide long-term funding for municipal infrastructure that supports active transportation. We also urge the federal government to renew the very successful Canadian recreational infrastructure fund to ensure continued investment in recreational facilities and parks.

Tobacco is a hugely important risk factor. Smokers have strokes ten years earlier than non-smokers. It is critical that the government renew the federal tobacco control strategy and maintain the annual funding for this strategy at no less than its current funding level of $43 million per annum.

Acute treatment for strokes substantially reduces disability, but must be delivered very rapidly after stroke onset. The most common reason that these treatments are not delivered is delay. We urge the government to support public awareness campaigns that teach people to recognize the signs of stroke and respond appropriately.

Madam Chair, acting on these recommendations will help to reduce the impact of chronic diseases on our aging population and our economy.

Thank you for the opportunity to provide our perspective today before your committee.

[The Chair, Conservative, Joy Smith]

Thank you very much, Dr. Sharma. That is very useful and rather shocking information, so I'm glad you came today so we can have a discussion with you.

I notice that Mr. Wilson is not here yet, so I'll ask Ms. Holmes if she would like to make the presentation for the Canadian Lung Association.

[Rosario Holmes, Educator, Asthma and Chronic Obstructive Pulmonary Disease, Ontario Lung Association, Canadian Lung Association]

I don't have the presentation that he will make. I have a mini presentation that I can give if it is okay with you.

[The Chair, Conservative, Joy Smith]

I think that's wonderful, thank you.

[Rosario Holmes]

He was the one who was supposed to present.

[The Chair, Conservative, Joy Smith]

I understand. Thank you for filling in.

[Rosario Holmes]

I will just fill in a little bit here.

Chronic obstructive pulmonary disease is one of the leading causes of morbidity and mortality worldwide. The impact of COPD is overwhelming in every aspect in our society. This is why there's the need for a global approach. Prevention, diagnosis, and management are the major components of this approach.

Because COPD is insidious and progressive, the symptoms are ignored and sometimes misinterpreted, bringing the patient to a state of isolation, low self-esteem, financial limitations, malnutrition, depression, and death.

In the year 2000, when the Lung Association's BreathWorks program started here in Ottawa, I had the honour to be then working with patients with COPD. I am a witness to the isolation, low self-esteem, financial limitations, malnutrition, and depression of patients who don't have a family, but find comfort and support in the rehabilitation programs.

After the rehabilitation programs, the patients in the maintenance exercise program regain the desire to live. One of my patients even went to buy a table and a chair to have his meals. Before he was only eating cereal and staying on the sofa watching TV. He was so short of breath that he was not even able to make his own meals. Today, he's on oxygen. He participates three times a week in the maintenance exercise program, working very hard, and he is working to be in shape to have a lung transplant.

Pulmonary rehabilitation and maintenance are the most cost-effective and needed interventions for the management of COPD. The Lung Association has now a very special program that can be replicated in various communities to offer the COPD patients the opportunity to learn and to self-manage this chronic disease.

Thank you very much.

[The Chair, Conservative, Joy Smith]

Thank you very much, Mrs. Holmes.

Now we're going to be going into our Q and As, starting with Ms. Quach.

Would you like to start? So you have seven minutes.

Thank you.