Health Committee on Oct. 2nd, 2018

[Patrick Tohill, Director, Government Relations, Juvenile Diabetes Research Foundation Canada]

Obviously, like the other organizations here, we support the development of a national diabetes strategy and the diabetes 360° initiative that our colleagues started. We'd like more funding for research to prevent emergencies like diabetic ketoacidosis and to reduce emergency room visits due to diabetes, due to decay, and due to hyper- and hypoglycemia. These are all good areas that we should be exploring.

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

Okay.

Ms. Hanson.

[Kimberley Hanson]

I couldn't agree more with everything that the other witnesses have said. In fact, the final recommendations of diabetes 360°, which were published since we were last here at committee, really took into account all of those witness recommendations. They include that we should establish a national repository of information about diabetes; that all care should be standardized and all nurses and health care providers should be taught according to a set of standards; that better screening should be done so that everyone who lives with diabetes or is at risk of it is aware of that status; and that treatment should be standardized and made more available to all Canadians regardless of which province they live in or whether they live in a remote or a rural area, etc.

Those are all recommendations that have been factored into our approach.

[The Chair, Liberal, Bill Casey]

The time is up. Sorry.

Mr. Davies.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you, Mr. Chair.

Thank you to all the witnesses, particularly those who have come back. Actually, all of them came back.

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

Again and again.

[Don Davies, NDP, Vancouver Kingsway, BC]

Yes.

Dr. Whiteside, your website states that complications are costing us $16 billion per year and that this cost is rising in Canada.

Can you please expand on that figure and tell us a bit more about that?

[Dr. Catharine Whiteside]

That's correct. Thank you for looking at our website, Diabetes Action Canada.

The cost that has been quoted is a combination of direct and indirect costs. Direct costs refer to hospital, physician and other remunerated costs related to provinces and territories, but the indirect costs are the costs to patients and their families, societal costs. Both of these costs are rising.

The reason is that both the prevalence of diabetes and its complications are rising in a population that has increased risk for diabetes, both type 1 and type 2, in Canada. This constitutes a major epidemic, I would say, of disease in Canada. Unless we intervene in Canada and unless we intervene to provide more timely diagnosis and treatment of diabetes and its complications, those costs will continue to rise.

[Don Davies, NDP, Vancouver Kingsway, BC]

This may be an unfair question but, as succinctly as you can say, what are the top one or two things you would do to start addressing that?

[Dr. Catharine Whiteside]

The first intervention that is required is really to identify those at highest risk, and that will require intervention at the community and primary care level, using methods that are simple. In other words, it will require, in any primary care practice, enabling a prevention practitioner, for instance, who could be a nurse, to identify those individuals and intervene with them with a shared decision-making set of targets for intervention. This means glucose control, obesity control, cholesterol control—all the risk factors with intervention and early diagnosis. This has been accomplished in other countries like Sweden, where the cost of diabetes care has been reduced by intervention early on.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Ms. Hanson, Diabetes Canada's submission to this committee's study on universal pharmacare said the following:

Cost barriers are particularly difficult for chronic disease patients: research shows that 23% of people with chronic disease skipped medications due to cost, compared to 10% in the overall population. Similarly, 25% of people with diabetes who responded to a CDA’s survey in 2015 reported that their adherence to therapy was impacted by cost. In 2014, 30% of people with diabetes that responded to a Statistics Canada survey indicated they had no insurance for equipment or supplies to monitor blood glucose, and 15% had no insurance to pay for prescription medications.

I have two questions. Number one, would you favour a universal pharmacare program which ensured that all diabetes patients had universal access to the diagnostics and treatment they need? Number two, can you tell this committee a bit more about the cost-related barriers to treatment and care faced by Canadians living with diabetes?

[Kimberley Hanson]

We know that costs, as you identified, are a significant barrier for people living with diabetes. Depending on where in Canada you live, what other private insurance you have and what your treatment protocol is for your diabetes, it can cost a patient out of pocket up to $15,000 a year to live with diabetes. That's a prohibitive level of cost.

We know the vast majority of people with diabetes face costs of at least 3% of household income, or $1,500 a year, which the Romanow commission identified as a catastrophic level of out-of-pocket health costs. It really is a barrier, as you identified, Mr. Davies, to people following their prescribed care regime which imperils their health in the short term and long term, which costs our health care system.

It's critical that we address those barriers in terms of costs. Those apply, I really want to stress, not only to medications, but also to the devices and supplies required as part of diabetes care. I quip sometimes that insulin doesn't do much good if you haven't a syringe to inject it.

We would definitely support a national approach to pharmacare that would ensure that all Canadians have access to the right medications that they need at the right time. That would also include devices and supplies such as test strips, syringes, and for many with type 1, some with type 2, things like insulin pumps or continuous glucose monitors that can really make the difference in the long-term health prognosis of the individual with diabetes.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

This question is for anyone who would like to answer it. In his spring 2013 report, the Auditor General said this:

The success of the Canadian Diabetes Strategy depends on partnerships that are only partially in place. The Agency established a forum to get advice from diabetes experts, but it has not functioned as intended. A committee established to coordinate activities within the federal health portfolio is no longer active. For example, the Agency aims to deliver evidence-based diabetes policies and programs, but it has established no mechanism for collaborating regularly with the Canadian Institutes of Health Research on its research needs. As a result, federal diabetes activities are fragmented, and the impact of efforts and money spent has not been maximized.

Has anything improved in the last five years since 2013? Do you have any advice to give us as a federal committee as to how we could address those concerns?

[Kimberley Hanson]

Perhaps I could start. We really took those findings of the Auditor General very much to heart as we began the effort of developing the diabetes 360° strategy. I think a critical underpinning of it to date has been the collaboration among 120 expert stakeholders, many of whom are here today from across the country. All of our recommendations are founded on the principle that this ongoing collaboration among various levels of government, among civil society and the private sector, is critical in order to operationalize a strategy moving forward.

I think the other important thing that the Auditor General called out in that report that is a critical foundational element of diabetes 360° is that we have to establish as quickly as possible a mechanism to understand the measurable impact of the interventions that we propose.

Dr. Whiteside talked about establishing a national diabetes repository. That is essential in order for us to be able to understand whether we're actually moving the yardstick in terms of reducing the burden of diabetes on Canada with the interventions. That will be one of the key pieces we'll implement right away as part of diabetes 360°, and that will help avoid the outcome that the strategy would suffer from a lack of measurable impact the way that the last one did.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

[The Chair, Liberal, Bill Casey]

Your time is up. I'm sorry.

Mr. Grewal, you have seven minutes.

[Raj Grewal, Liberal, Brampton East, ON]

Thank you, Chair.

My apologies to the witnesses for being late. The traffic in Ottawa was more than I anticipated.

I'm a new member of this committee. I used to be on the finance committee.

I read the Auditor General's report which said, “seven years after the renewal of funding”—for the Canadian diabetes strategy—”the Agency still does not have a strategy in place to guide its activities relating to chronic diseases, including diabetes.”

As a practical example, in Brampton East, 86% of our population is associated with a visible minority, which is the second highest visible minority population in all of Canada. There is a huge South Asian population, Sikhs, Hindus and Muslims, including my own family. I just got married this summer and all the food had sugar in it, from breakfast to evening. Diabetes is a massive concern in our ethnicities. In my generation, we're much more cognizant of eating healthier, going to the gym and being physical active.

A lot of the testimony focused on prevention, to catch this early on. Why isn't it being caught early on? Is there a correlation with people not doing their annual physicals? Is that why it's not being caught early on? They do blood work every time I have a physical and they check for this stuff. Are people not having their physicals? If we had a concentrated strategy for sending people to the doctor, would that help?

They are broad-based questions, so everyone can answer.

[Dr. Catharine Whiteside]

Perhaps I could start.

We know that the prevalence of diabetes and its complications really focuses on those populations with risk related to socio-economic factors. Again, I referred to the Public Health Agency of Canada's report this summer indicating that individuals who live in a lower socio-economic bracket have over four times the risk of developing diabetes as compared to those in the highest socio-economic bracket.

The population issues are not just related to ethnicity. You are absolutely correct. South Asians and Asians are more susceptible to diabetes and its complications, but the idea is to understand how to intervene with any at-risk population early on to prevent diabetes. It's not just a health issue. It's also a social issue. It's an education issue. It's a food security issue. It's an issue that requires multiple levels of intervention, so not just health, but intervention in schools. Its a public health issue that requires intervention in communities.

I would be interested to know how the community in your riding could band together and begin a program that would intervene, with cultural sensitivity and with education, about how to prevent diabetes. It's really a multi-factor disease that requires multi-factor intervention, not just a trip to a doctor.

[Raj Grewal, Liberal, Brampton East, ON]

I didn't want to simplify it that much by inferring that it's just a trip to the doctor. I'll give you an example again, which comes from my very narrow lens on the topic.

My riding is upper middle class, where the average house price is $1 million. It's still predominantly South Asian, but the socio-economic factors aren't the factors driving the diabetes. It's the “I want to eat what I want” attitude. I have this conversation daily with my dad. He's a heart patient. He's not a diabetic, but I'm shocked that he's not. He just eats whatever he wants and that's just how he's going to live his life. There are programs in Punjabi, Hindi and Arabic about diabetes. The community knows full well that they're at the higher end of this. They hear about it on ethnic TV programs. It's not making a difference at all.

Our community also believes in going to the doctor, especially the seniors. It's almost like a social outing for them. My grandma, when she was alive, used to go to my family doctor and it was a once-a-week trip, even if there was nothing wrong with her and she wasn't sick. It goes back to the question that, for example, schools in Peel Region have made a concerted effort to take away anything that has sugar in it, from the time that I went to high school and middle school. We're obviously understanding the impact.

Parents take their kids to the doctor, so I don't understand why we wouldn't be catching it at a younger age. Kids that go to university have access to medical services as well. Every trip to the doctor is free. My question still focuses on how you get people to get the test done.

[Kimberley Hanson]

I can add to what Dr. Whiteside said. You raised some excellent points. There are so many factors that contribute to the risk of people developing diabetes. Even if everybody went to their doctor for an annual physical, one of the challenges we face right now is that not all health care practitioners are screening people for the risk of diabetes consistently with the clinical practice guidelines that are based on best practice.

One of the things that diabetes 360° would do is work to address that as quickly as possible by integrating prompts within electronic medical record systems and that kind of thing, to make sure that if your grandma goes to the doctor, any doctor or nurse she sees will screen.

The second thing is we need to make screening more available where people are, so maybe in the pharmacy or the grocery store or the community centre, so that people are more likely to become aware that they're facing the risk of diabetes.

Unfortunately, it's the kind of thing you have to keep doing, because one year you might not have diabetes or prediabetes, but the next year that might have changed. It's not a one-time thing that you can do and then you're done.

Overall, we have to try to find ways to make screening and treatment more consistent across the country, as well as improving the primary prevention environment the way that Dr. Whiteside was identifying. All of those are part of our recommendations.

[Dave Prowten]

If I could make one additional comment, it would be that there's a difference between type 1 and type 2 for prevention and screening. You're talking a lot about type 2, but there is some new research going on that suggests we could screen children and look for biomarkers at ages three and five, and determine who's on a trajectory to get this disease. If you know which individuals are predisposed to it, you could then develop intervention strategies for those people.

I just wanted to delineate the difference between a type 1 and a type 2 strategy.

[The Chair, Liberal, Bill Casey]

Thanks very much.

The time is up, but thanks for your questions, and we are certainly pleased to hear about your grandmother.

We're starting our five-minute round.

I want to go to Mr. Lobb now.

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

Thanks very much, Chair.

My parents and Mr. Grewal's parents have a lot in common. I wonder how mine don't either sometimes.

[Voices]

Oh, oh!

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

One question I have is which provinces will pay for the testing strips. Which provinces will do that today?