Thank you.
I wish to thank the committee for the invitation to speak and to provide a pediatric perspective on diabetes in Canada.
I'm a pediatric endocrinologist and researcher at the CHU Sainte-Justine and co-director of a cardiovascular disease risk prevention program at Sainte-Justine called CIRCUIT.
Obesity is the number one risk factor for type 2 diabetes in children. Ninety-five per cent of children diagnosed with type 2 diabetes in Canada are obese. The prevalence of obesity in Canadian children has tripled over the last three decades. This is particularly alarming given the adverse consequences of obesity on type 2 diabetes and cardiovascular disease. This is compounded by the fact that obese children tend to become obese adults, with the substantial consequent morbidity and mortality associated with adult obesity.
Adolescent overweight is a predictor of mortality in adulthood regardless of adult weight and is in fact a stronger risk factor than adult overweight, underscoring the urgency to intervene early. Childhood obesity is a multifactorial condition. Lifestyle factors, such as low physical activity, sedentary behaviours, and poor nutrition, play an important role in its development and its maintenance.
Research tells us that higher physical activity levels and less screen time can lower the risk of type 2 diabetes in children, yet only 7% of children in Canada reach the recommended guidelines for levels of physical activity daily, whilst 45% exceed screen time recommendations. What's more, the level of physical activity is even lower among teenagers and children with obesity.
Sugar-sweetened beverage consumption is associated with prediabetes and obesity, and yet it still accounts for 2% to 18% of total caloric intake among children in Canada. Increasing fruit and vegetable intake may reduce the risk of type 2 diabetes, yet their consumption is inadequate or insufficient in Canadian children and adolescents.
Limiting saturated fat intake may also be beneficial to preventing diabetes in childhood, yet the highest consumers of fast food in Canada are adolescents. Clearly there is room to improve Canadian children's lifestyle habits.
Several countries have seen their rates of pediatric type 2 diabetes increase over the past years, mirroring the increase in obesity rates. While the actual prevalence of type 2 diabetes in Canadian children remains uncertain, hospital-based prevalence estimates have increased parallel to the increased prevalence in obesity. Moreover, prediabetic conditions are on the rise in youth, particularly obese youth. In fact more than a quarter of obese youth have been reported to have prediabetes. This is very, very significant given that obesity was traditionally an adult-onset disease with late-life complications. You can imagine when I'm treating a 14-year-old who has type 2 diabetes what that means in terms of eventual mortality and morbidity for that young person.
Importantly, type 2 diabetes appears to be much more aggressive in children than it is in adults. Indeed, among newly diagnosed youth with type 2 diabetes, 6% already have kidney complications at diagnosis; 13% already display eye complications at diagnosis; 4.5% have abnormal cholesterol levels at diagnosis; and 11.6% have high blood pressure at diagnosis. In addition, it appears that youth with type 2 diabetes require a rapid intensification of treatment, so they rapidly fail on a single oral medication and often require the use of insulin injections for treatment.
Recent evidence suggests that individuals diagnosed with type 2 diabetes at a young age are victims of cardiovascular disease events early on in life and that they will lose about 15 years of life expectancy on average.
The economic consequences of pediatric type 2 diabetes have been poorly documented, but understanding the economic burden of obesity is imperative given that it is the main cause of type 2 diabetes among children. At the national level, direct costs of overweight and obesity are estimated to be between $3.9 billion and $6 billion, which represents 4% of the total health care budget. This figure does not even take into account indirect costs.
The true cure for type 2 diabetes is probably to identify at-risk individuals and avoid deterioration through preventive strategies targeting childhood obesity and its associated lifestyle determinants. There is extensive evidence supporting the fact that lifestyle intensification and interventions in adults delay or possibly entirely prevent the transition from prediabetes to overt type 2 diabetes. While the evidence remains limited, similar findings in children have been demonstrated by my group and others.
Childhood represents a critical time frame in which to intervene to prevent and treat obesity by enhancing the adoption of healthy lifestyle habits and ultimately preventing type 2 diabetes and later cardiovascular disease in these vulnerable youth.
In addition to the increasing rates of childhood type 2 diabetes, recent reports show evidence of worldwide increases in the incidences of type 1 diabetes mellitus, particularly among children less than five years of age. Since 1990, the global incidence of type 1 diabetes has increased by 2.8% each year among youth less than 15 years of age, and Canada has not been spared by this increase.
Type 1 diabetes accounts for 90% of child and youth diabetes and is also among the most prevalent childhood chronic diseases in Canada. In 2010, the estimated economic burden of diabetes in Canada was $12.2 billion and projected to increase by another $4.7 billion by 2020.
The early onset of type 1 diabetes is particularly worrisome given its strong association with a marked increased risk of cardiovascular disease. In fact, individuals with type 1 diabetes are 10 times more likely to die of heart disease than their healthy peers.
While heart attacks and strokes occur in adulthood, atherosclerosis begins in childhood. This is well documented. Atherosclerosis in individuals with type 1 diabetes appears to be more aggressive. It occurs earlier; it is more diffuse; and it leads to higher death rates, cardiac failure, and shorter survival than in the general population.
Childhood represents a pivotal time period to prevent obesity and consequently type 2 diabetes but also the deleterious consequences, namely cardiovascular disease, of both type 1 and type 2 diabetes.
Recommendations emanating from this committee need to address the specific needs of children and adolescents. I humbly propose five recommendations to be considered by the committee.
The first is to provide access across Canada to proven, evidence-based, multidisciplinary programs to ensure the treatment of obesity, such as the CIRCUIT program at CHU Sainte-Justine. Children and adolescents will also benefit from access to proven, community-based obesity and cardiovascular disease prevention programs that target youth and are tailored to the community's needs.
Second, we should be favouring healthy lifestyle habits early in life and integrating them into preschool and school curriculums. As an example, mandatory daily physical education courses should be implemented in schools.
Third, treatment programs for the management of children with type 1 and type 2 diabetes should be tailored to their needs—in particular, those of vulnerable communities, such as first nations, which was clearly pointed out by the previously speakers.
Fourth, funding of high-quality research in the fields of pediatric obesity, type 1 diabetes, and type 2 diabetes is urgently needed in order to enhance our understanding of what the best strategies are for prevention and treatment to ultimately optimize the care of affected children and adolescents who will become the next generation of adults.
Finally, I think it's important that we implement educational efforts to sensitize families and primary health care providers to the early symptoms of diabetes for early screening and diagnosis among children and adolescents.
I wish to thank you for your time and for allowing me to give a voice to children and adolescents with diabetes, and I welcome any questions you may have.