Health Committee on Oct. 2nd, 2018

[Kimberley Hanson]

I think, if their health care team asserts that they need it, then yes, I do think we should be covering it.

Diabetes kills a minimum of over 7,000 people in Canada; that is, diabetes is listed as the cause of death for over 7,000 people a year. We know that diabetes is a leading cause of heart disease, stroke and kidney failure, which can also be listed as the causes of death. We think that 7,000 is masking the real number, which is likely in the tens of thousands of people who die due to diabetes or its complications in Canada every year.

It's a disease that we kind of think of as not a big deal. You take a pill, you watch what you eat a little bit and you live a long life. For some people, that is true, but it is more true for more of us that it is debilitating. It impedes our financial productivity and our ability to work. That costs our employers as well as our health care system. The more we can do to help people live well with it now and manage it well, the more we can save costs down the road.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Thank you, Mr. Chair.

[The Chair, Liberal, Bill Casey]

The time is up.

I'm going to propose we have another five-minute round of questions.

Every time somebody asks a question, you open a new page for us, and you shine a light on something that we didn't even know about.

We're going to go an extra round. We'll start with Mr. McKinnon.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Thank you, Chair.

I'm going to start with Ms. Hanson, because I'm a techie.

You showed us your continuous glucose monitor. You mentioned that you also have an insulin pump. Are these things interconnected? Is that something that can be done? Is it a good idea?

[Kimberley Hanson]

Yes, it can be done, and it often is done. In fact, there's exciting technology that's just recently been made available in the United States and that we're hoping is coming to Canada in the next little while that would not only allow the insulin pump to have the readout from the continuous glucose monitor, which is possible today, but would allow the glucose monitor to talk to the insulin pump and say, “Oh, she's starting to go lower on her blood sugar. Please give her less insulin so that she won't have a crisis that puts her in a coma” or “She's stressed out because she's stuck in traffic and she's late for HESA. Give her a bit more.”

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

That sounds a little bit invasive. You would have to do blood tests on a continuous basis. Is there a periodic pinprick all the time?

[Kimberley Hanson]

Yes, if a patient wears a continuous glucose monitor, currently, with most systems, they have to calibrate it at least twice a day, which means take the finger prick and use the test strips that are more commonly used. The continuous glucose monitor checks my blood sugar every five minutes and sends the readout to my phone. In that regard, it's much less invasive. Before I had my continuous glucose monitor, I was testing my blood sugar by pricking my finger up to 12 times a day.

Right now, the technology has gotten more all-consuming, but it's provided us with better care, so most people are willing to make the trade-off of dealing with the technology more often in order to feel better. As technology continues to improve, we're hoping that it's going to make the disease less invasive to manage, as well as provide better care.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

You mentioned this is quite expensive. We heard the cost of an insulin pump is $8,000 to purchase initially and $3,000 a year to operate. We heard that the glucose monitor is $3,000 a year or so to operate. What is its initial price?

[Kimberley Hanson]

The system that I wear costs about $2,000 to set up, and then about $50 a week to continue to operate.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

I'm going to follow up on some of your conversation with Ms. Gladu. You mentioned that many of the people who had been denied disability tax credits had been re-evaluated and only 42% of them were rejected again.

Can you tell me on what basis they were rejected a second time?

[Kimberley Hanson]

Regrettably, I can't, because I don't know what their applications were. I obviously can't see their applications, and because many of those people aren't aware that the review of their file has been concluded, they haven't reached out to JDRF or Diabetes Canada to say they've been re-rejected and ask for help.

We're assuming that a portion of those applications may have contained errors or were legitimately ineligible for the disability tax credit, but 42% seems like a high percentage to have legitimately been disqualified.

Pat, do you want to add anything?

[Patrick Tohill]

It could be there was information that CRA was looking for from the doctors. It could be that incorrect boxes were ticked.

I agree with Kim that it does seem really strange that such a high number would be disallowed. If there are 2,300 adults being assessed every year, if this year was a typical example, or this eight-month period was a typical example, and 42% of them are being denied, that does seem like a very high rate of denial.

CRA likes to say their overall numbers for life-sustaining therapy have an 80% approval rate, which is a 20% denial rate, but if it's 42% for adults with type 1, that's concerning.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

This 42% was not out of the general number of people who had applied, but of the people who had previously been denied. The more interesting question is the 58% who had been previously denied and were subsequently accepted. One of the things the government had done was provide more medically trained people to evaluate these claims. I believe they mentioned nurse practitioners.

Could that have been a factor in why they were accepted on their second go around, or whether there's any other factor that you can think of?

[Patrick Tohill]

Well, remember that all of these claims were being reassessed because of a directive and some new clarification language that was added to the clarification letters which said that adults with type 1 would not generally qualify unless they had one or more chronic conditions in addition to their diabetes. The ones who would have been accepted prior to the review presumably had other chronic conditions that caused them to be approved. These people were all denied on the basis of that clarification letter, so they would normally have been approved prior to May 2017.

[Kimberley Hanson]

We think the bigger impact was likely that on December 8, Minister Lebouthillier asked the CRA to revert to its previous language in its clarification letter. That had been in place before May and we think it's the removal of that interpretation that allowed the 58% to be approved.

There remain significant issues with how the CRA is assessing the applications of people with diabetes, and we continue to try to work with them to have these addressed. We really support the recommendations of the Senate Standing Committee on Social Affairs, Science and Technology on the disability tax credit and the registered disability savings program, because it's a system that is not working for many of the people who need it most right now.

[The Chair, Liberal, Bill Casey]

Ms. Gladu, you have five minutes.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Thank you, Chair.

I've heard there is an artificial pancreas technology that is available. Does anybody have a status update on that?

[Kimberley Hanson]

That's the technology I was describing a couple of minutes ago: the insulin pump that can talk to the continuous glucose monitor and make adjustments. It's the closest thing to an artificial pancreas that has yet been developed. It's currently available in the United States and has been for about the last 10 months. The company that manufactures it, Medtronic, has told us that their application is with Health Canada. Really, it's up to Health Canada when or whether they will make it available for sale in Canada, but I for one am really hoping that will be sooner rather than later.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

That's very good.

I have looked at the diabetes 360º report, and it looks to me like the government doesn't need to go out and develop a framework. They just need to do that one.

If you haven't looked at it, you should look at page 12, which has a beautiful table of the summary of all recommendations. It looks like a very well-thought-out plan of what you should do to address this issue in Canada.

Specifically, on obesity, I think this is an area where we need to do something more. We've fallen away from many of the interventions that happened when I was growing up and we had Participaction, where they made us run around and do all kinds of sit-ups and things. I think that in public schools the amount of physical activity that's happening has been reduced, and I know that in high schools, in many cases, people are allowed to opt out totally from physical education. They're not made to run around or dance or do anything like that. Then, of course, we come to our professional careers. As a parliamentarian, I certainly would say that you have to be extremely disciplined to make sure that you get your exercise in.

Because obesity is such a hugely important factor in diabetes, I think we have to do something on that in conjunction with the provinces. There's another thing that would be very helpful. I know that there was a day on the Hill when people came and did the screening for us to see whether or not we had diabetes. It didn't take very much time, and it was something that I could see being transferred to public schools, through the public health nurses or a mechanism like that, where kids could be screened and interventions could be taken.

Do you have any helpful suggestions on what we should do about obesity or how better to get screening happening early?

[Kimberley Hanson]

All your points are very well taken.

Primary prevention of type 2 diabetes is a critical piece of the strategy that we're recommending. To my knowledge, I think it's a much stronger element of the strategy than it was in the previous strategy.

It means ensuring that we address food insecurity so that people have access to healthy food. For many people who are living in poverty, it's just really impossible to eat a healthy diet due to costs and due to the availability of foods.

Also, it's really important that we ensure every Canadian is getting their 150 minutes of moderate to vigorous physical activity every week. We were really fortunate to have Participaction as part of one of our working groups in developing the diabetes 360º strategy. Implementing these recommendations would be a partnership with organizations such as Participaction, which are experts in making sure that we're getting everybody moving to the greatest extent possible.

We really have to do a number of things to improve the environment in which we all live, including everything from ensuring movement to making healthy options available in the vending machines. My child plays competitive hockey. It's terrible trying to eat while you're on the road. We need to make healthier options available more regularly.

Then, in terms of screening, I think that anywhere we can screen, we ought to, with the understanding that it's not as easy as just bringing a glucometer or a questionnaire and getting people to fill it out wherever they are. If we can't help to put some context around what the results mean for that individual and then guide them towards the appropriate health care intervention if they need it, it falls a bit short.

What diabetes 360º recommends is that we first of all make sure that all health care professionals who are seeing patients are screening according to the guidelines, and then, secondly, that we do a number of initiatives based on those that have been proven by research to make screening more available where people are—in pharmacies.

If you are on the Hill on November 6, we're bringing a bus here for our Diabetes Day on the Hill, and we'll do a screening not only for diabetes but for all cardiovascular risks. There are limited spots. Do sign up now.

[The Chair, Liberal, Bill Casey]

Your time is up.

Mr. Davies.

[Don Davies, NDP, Vancouver Kingsway, BC]

We've heard over and over again that among the various vulnerable populations, diabetes rates are disproportionately high among indigenous Canadians. What I want to turn to is what to do about it.

A lot of health care programs, of course, are delivered by the provinces, but indigenous health is squarely within the purview and the responsibility of the federal government and the role of our committee here. What specifically can the federal government do to better support the health of indigenous people living with diabetes? What concrete actions can we take to address, as you called it, Dr. Whiteside, an epidemic?

[Dr. Catharine Whiteside]

I'd like to start by indicating that the calls to action of the Truth and Reconciliation Commission really must be addressed.

In Diabetes Action Canada we have a large contingency of indigenous people who are engaged with our researchers. They have articulated that it's very clear that just trying to address food security and physical activity is necessary, but it's not sufficient.

I'll bring to your attention a very impressive program that has been established by some of our investigators called the aboriginal youth mentorship program. This is a program that is in 13 first nations communities today in Canada, including one in inner city Toronto, whereby the youth are mentored by older adolescents and elders to understand what is important about their health. This is physical health, spiritual health, mental health. It's a community engagement program that is truly creating good results. It's preventing type 2 diabetes in aboriginal youth. This is a program that we hope will be scaled up to at least 30 communities in Canada. I think it presents an excellent model for indigenous communities about the engagement of youth and adolescents to prevent obesity and type 2 diabetes in their communities.

[Don Davies, NDP, Vancouver Kingsway, BC]

If I could pick up from there, we also know that nutrition and diet are huge, particularly in type 2 diabetes. I'll put a couple of proposals out.

Is it time for a sugary drink tax in this country? Is it time for a national school nutrition program in this country? Are these good ideas?

[Kimberley Hanson]

Those are certainly ideas that Diabetes Canada is in support of our looking into further, because we know that the impact of consuming sugary drinks can increase the risk of even a person of a normal BMI developing type 2 diabetes. They've consumed too much in certain populations and they can really increase the risk of those people developing chronic diseases, including diabetes. I think that a school nutrition program is also an excellent thing for us to consider because we have to make healthy foods available to everyone in Canada.

In terms of supporting the unique needs of indigenous people, we had a working group look specifically at those unique needs as part of developing our diabetes 360° strategy. In addition, I would echo Dr. Whiteside's call that we implement the health-related recommendations in the Truth and Reconciliation Commission's report. We also need to ensure that we enable any indigenous nation or group that wishes to embrace or adopt a diabetes strategy for themselves to do so. It would be the approach of diabetes 360° when implemented to partner with any groups or nations wishing to embrace that in order to support them in doing so.

I think that some of the recommendations we would propose for the general population will really help address some of the key issues that are experienced disproportionately by indigenous nations. For example, many people in indigenous communities are unable to access medical care physically. We can do a lot to provide them with remote-based telemedicine that can really help improve their management of diabetes, or the risk of developing it. There are a number of interventions that we can start to put in place for the whole population that will have an extra big benefit on those communities because of some of the ways they are disadvantaged right now.