Health Committee on May 28th, 2018

[The Vice-Chair, Conservative, Marilyn Gladu]

Very good. Thank you very much. That's your time.

We will now hear from Dr. Mélanie Henderson.

Welcome. Can you hear us?

[Dr. Melanie Henderson, Pediatric endocrinologist and Associate Professor, Centre hospitalier universitaire Sainte-Justine]

Yes, thank you.

I can speak in English actually. It might be easier. Is that okay?

[The Vice-Chair, Conservative, Marilyn Gladu]

Either language suits us fine.

You have 10 minutes, if you want to start.

[Dr. Mélanie Henderson]

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.

[The Vice-Chair, Conservative, Marilyn Gladu]

Thank you very much.

Now we're going to begin our round of questions, seven minutes each.

We'll begin with my colleague John Oliver, who is sharing his time with Sonia Sidhu.

[John Oliver, Liberal, Oakville, ON]

Thank you very much for your presentations and also for the clarity of your recommendations. It was great that both of you took time, after a statement of the problems, to be very clear in what you thought the committee should be doing.

I do have a couple of quick follow-up questions for you, Dr. Henderson.

During your testimony you talked about obesity and a number of childhood risk factors, and then you said that we really should be working to identify at-risk individuals in order to begin interventions. I notice that your five recommendations would probably be much more effective if we were targeting those who are at risk. Did you have any thoughts on how at-risk individuals could be identified? Is it just the behavioural stuff, like growing obesity and inactivity, or are there other ways we could screen for at-risk individuals?

[Dr. Mélanie Henderson]

First, there are a lot of well-established risk factors for type 2 diabetes in children in particular. Obviously, obesity is the number one risk factor. Certain ethnic backgrounds are more at risk. Obviously sedentary behaviour, low physical activity, and poor nutrition are risk factors. The notion of having been exposed to gestational diabetes, which the previous speaker also discussed, is also a risk factor.

Primary caregivers could be sensitized to a number of risk factors, which would help us to identify the at-risk individuals and to be able to intervene. I think though, if you look at the population, the problem is that already 27% of Canadian children and adolescents are either overweight or obese. One in four children are affected. As clinicians, I think we have a role to identify at-risk youth. As a society we probably have to rethink some of the public health strategies we can use to prevent the onset of obesity, and also help to treat those who are already affected.

[John Oliver, Liberal, Oakville, ON]

I know you are based in Quebec. Do you have any experience or awareness of the difficulty of accessing either drugs or specialized equipment for people with diabetes because of affordability?

In other words, if you are a child and your parent doesn't have insurance, is there a problem accessing drugs?

[Dr. Mélanie Henderson]

That's a very good question. I'm going to answer it in two ways.

Certainly there are technologies of interest for the treatment of type 1 diabetes in particular. I know the committee discussed the difference between type 1 and type 2 at the last session, but I'll just refresh everyone's memory.

Type 1 diabetes requires insulin administration via injections or an insulin pump, with a regular and routine blood glucose measurement. Currently there's no harmonized process across Canada for accessibility to pumps. Some provinces allow people to have access to pumps no matter what their age.

For example, in Quebec, if you're under 18 you have access to government coverage for a pump, but if you're over 18 you don't. If I have patients who are diagnosed at 17 and a half, I have six months to try to have them learn about type 1 diabetes, how to manage it, and then consider the pump. Because I know that after that, they won't be admissible for coverage. For the first year of the pump, that certainly means $10,000 of expenses.

In a similar vein, there are some very new technologies for monitoring blood glucose in a continuous fashion. Traditionally, we use a finger poke to check our blood sugar. There are devices now that can monitor it 240 times in a day without your having to poke yourself 240 times a day, which is obviously impossible. These technologies have a really significant impact on my management of my patients. That's not covered. It may be covered by some private insurance, but not universally.

Obviously, insulin is covered for children across Canada. That's fantastic. Access to insulin is not equal across the world. We're privileged in that sense. I think we do have some work to do to make some of the newer technologies for individuals with type 1 diabetes more accessible in a universal fashion.

[John Oliver, Liberal, Oakville, ON]

Standardized treatment was your third recommendations?

[Dr. Mélanie Henderson]

Yes, it was.

My third recommendation also spoke to some of the particularities that the previous speakers also addressed in culturally sensitive programs to treat kids from specific vulnerable groups, for example, first nations. I think there's a lot of work to be done in that respect.

[John Oliver, Liberal, Oakville, ON]

Thanks very much.

I'm going to share my time with Ms. Sidhu. I want to leave her a couple of minutes.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, John, for sharing your time with me.

Dr. Coutinho or Dr. Henderson, it is very difficult to get access to a doctor with patients often travelling far to urban centres to access care.

Last year I had the chance to visit Global Health Innovations; they showed me a behavioural mobile health app. They help individuals better manage diabetes.

Do you think virtual care centres or these kinds of apps will help those individuals?

Anyone can answer.

[Dr. Agnes Coutinho]

I can add my comment.

I think it really depends on the age group and accessibility to the Internet, for example. If you are addressing youth who are connected to devices and have uninterrupted access to the Internet, then that potentially may be a tool; however, if you're looking at more elderly individuals, those who may not have access to the Internet on a continuous basis—for example, in northern communities—those devices and apps and programs are not going to be as important and successful

[Sonia Sidhu, Liberal, Brampton South, ON]

Last year I went to IDF's conference. Their emphasis is on prenatal care. Do you think it's important that we emphasize that? Dr. Henderson said the obesity rate is very high—one in four children. If we can emphasize prenatal care—

[The Vice-Chair, Conservative, Marilyn Gladu]

I'm sorry, you're out of time on that question.

We'll go to my colleague, Mr. Lobb, for seven minutes.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Thanks very much.

If somebody already mentioned this, I might have missed it. Is there a distinguishable difference in the occurrence of type 1 between the indigenous community and others? Is there a difference in the percentages?

[Roslynn Baird]

It's been prevalently type 2 diabetes, but according to the regional health survey, type 1 is increasing.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Around the type 2 component, what have you done on the mental health side? Is that something you're looking to do? I noticed in the reading I've done leading up to the meeting that of course, mental health has a big impact for people with type 2 diabetes.

[Dr. Mélanie Henderson]

Can I answer that?

[Ben Lobb, Conservative, Huron—Bruce, ON]

Sure, go ahead.

[Dr. Mélanie Henderson]

I love that question, because indeed, youth with type 2 diabetes are more at risk of binge eating and depression. In fact, at baseline, in some of the studies, 15% already have symptoms of depression. In addition, those who are obese, which is 95% of them, often live a lot of deleterious experiences. Their self-esteem is low. Their body image is low. They're often victims of bullying. And don't kid yourself. Bullying is not just in the schoolyard. It's also at home, with family members making derogatory comments about the person's weight. It's a very important problem.

Certainly in Quebec, clinicians have very few tools to address this. There are very few psychologists and psycho-educators there to support us. That's something we've integrated within our CIRCUIT program, because we felt it was very important to empower these families to make lifestyle changes and support their kids through some of the challenges they are living with.

[Roslynn Baird]

I'll just add that in our programming, we emphasize holistic care. It is the teaching of the medicine wheel. We're addressing the mental, physical, spiritual, and emotional aspect of the disease; and the person, the community, and the family. As well, we're coming from a trauma-informed care model, so our programming addresses stress and factors that influence a healthy outcome.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Do you think the government is making progress, or have we been spinning our wheels for a decade on addressing issues like this?

You can be honest.

[Roslynn Baird]

I also work in an indigenous program that's funded through the Ministry of Health and Long-Term Care. I've been the executive director of the Indigenous Diabetes Health Circle for about 20 years, and we do grassroots programming. Since the Truth and Reconciliation Commission calls to action, we've been called upon in droves; the non-indigenous community, the health care community, all really want to work with us now. I think there is a lot of opportunity coming up.