How embracing diversity can improve diabetes care in Canada
Canada is a country rich in ethnocultural diversity. Boasting the highest percentage of foreign-born citizens of any G8 country, more than 200 ethnic origins were reported in Canada in the 2011 census. The largest racialized groups in 2011 were South Asian, Chinese, and Black. All of which have been identified as being at high risk for diabetes.
Over the last several decades, the rate of diabetes in Canada has steadily increased. The current estimated prevalence is 3.4 million or 0.3% of the population; this is predicted to rise to 5 million – that’s 12.1% of the population - by 2025. Diabetes is the leading cause of blindness, end stage renal disease and non-traumatic amputation in Canada, and it significantly increases an individual’s likelihood of dying due to cardiovascular disease.
And yet, studies have shown that culturally appropriate diabetes education works. By incorporating cultural and faith traditions, values and beliefs, and adapted cultural dietary advice, patients know more about the disease. Their management of the disease, through behaviour, improves and they have better clinical outcomes.
Dr. Robyn Houlden, a Professor in the Department of Medicine and Chair, Division of Endocrinology, sees patients with diabetes in her clinics every day. And she has seen firsthand the importance of incorporating ethnocultural diversity in diabetes care. “It’s critical to spend time understanding patients’ unique perspectives, backgrounds and needs,” says Dr. Houlden, “only then can I provide care that is culturally safe. Providing care this way is not just respectful, it’s also more effective when looking at the long term outcomes for patients.”
As a professor in the School of Medicine, Dr. Houlden uses her time with med students to have real conversations about the situations that they may encounter as physicians. Much of her teaching is case-based and her case studies are centered on high risk ethnic groups for diabetes. One case, designed to stimulate discussion on management of type 2 diabetes, centers on a South Asian woman. Students practice offering dietary advice that reflects her cultural preferences. At one point in the case study, the woman asks for advice on managing her diabetes during Ramadan fasting. Dr. Houlden, who developed a position statement for Diabetes Canada on people with Type 1 or Type 2 diabetes who fast during Ramadan, helps students to navigate unique questions like this that may come up. “It’s not about memorizing the right answer for every situation,” says Dr. Houlden, “it’s about translating knowledge with the needs of the patient in mind. And then thinking: what is the best solution here?”
In looking at populations that benefit from specialized diabetes care, Dr. Houlden is quick to point out that Indigenous peoples should also be front of mind. According to research from Dr. Michael Green, who heads the Department of Family Medicine at Queen’s, diabetes rates are 3 to 5 times higher in Indigenous populations in Canada.
This problem is compounded by barriers to care for many Indigenous peoples. Indigenous peoples are generally diagnosed at a younger age than non-Indigenous people, and Indigenous women experience higher rates of gestational diabetes than non-Indigenous women.
In 2018, Dr. Houlden had the honour of chairing the Diabetes Canada Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. One of her initiatives was to have the chapter on Type 2 Diabetes and Indigenous Peoples written by a panel of Indigenous authors with expertise in diabetes management. The chapter provides an important lens for recognizing the diabetes epidemic and challenges in providing diabetes care to Indigenous populations. It acknowledges the legacy of colonization and residential school and their ongoing effects on Indigenous health, as well as the call to action of the 2015 Truth and Reconciliation Commission related to Indigenous healthcare.
Dr. Bikram Sidhu, an endocrinologist and Assistant Professor in the Department of Medicine has been working alongside Dr. Houlden to identify ways to improve diabetes treatment for Indigneous populations in Canada. Dr. Sidhu has recently initiated a remote diabetes program with Weeneebayko.
Weeneebayko is a territory that wraps around James and Hudson Bay wherein community members who need care often must travel to healthcare centres for appointments and treatment. The remote diabetes program aims to reduce barriers to care – like having to travel - by offering on-site clinics, appointments by phone, text-based follow-up and eConsults as a follow-up tool. “Once the program has been fully implemented, it could serve as a model for how a satellite multidisciplinary specialty clinic can be run for remote populations,” says Dr. Sidhu.
Like Dr. Houlden, Dr. Sidhu also believes that equipping med students with a strong understanding of the specific health needs of populations like Indigenous peoples is critical. He has a developed a self-directed learning module for second year medical students that highlights the high rates of diabetes and diabetes-related complications in Indigenous populations, as well as inequities in accessing diabetes care.
Together, Drs. Houlden and Sidhu, along with Dr. Laura Gaudet from the Department of Obstetrics and Gynecology, hold a weekly clinic for pregnant women with diabetes. Many of these patients are from Weeneebayko. Although many of their visits need to be in-person for obstetrical assessment, the endocrinologists provide much of the in-between in-person visits virtually through the Ontario Telemedicine Network. Much like what is envisioned for the remote diabetes program, this reduces the need for women to travel to Kingston as frequently while removing a barrier to care.