Poverty drives diabetes epidemic
TheStar.com – healthzone.ca/health/your health
November 3, 2010. Moira Welsh, Staff Reporter
Every morning before breakfast Edgar Dawson pricks a tiny needle into the tip of his finger.
He smears a drop of his blood onto a paper test strip in his glucose meter and waits to see if the flashing digital numbers tell him that his blood sugar level is okay.
It’s a routine test that many with diabetes use, but Edgar — and thousands of low-income earners like him — can’t afford to follow his doctor’s orders by checking another four times a day.
“I try to live within my means,” Dawson, says in the modest Scarborough townhouse he calls home. “I try not to let it bother me too much.”
Dawson, 58, says he and his partner spend roughly $100 a month to manage his Type 2 diabetes with test strips, needles (known as lancers) for the glucose meter and other costs such as fresh vegetables and salads.
To follow his doctor’s orders, and test between three to five times, he says he would have to spend another $200 a month.
“I can’t afford to pay more, so I am forced to compromise how I manage my diabetes,” he explains.
It is a struggle that could have dire consequences for Dawson, and others living on a low income. They are at high risk because research shows that poverty is a leading predictor of the chronic disease, and its devastating side effects. Some experts also say that immigrants from South Asia, Asia and Canadian aboriginals — many of whom live in poorer neighbourhoods — are genetically at high risk of developing the disease.
Unmanaged by healthy eating, exercise and medication, diabetes can lead to amputations, blindness, kidney failure and heart attacks. These carry a tremendous personal cost to people such as Dawson — and impose an enormous financial burden on society. Experts say kidney dialysis, for example, can cost up to $80,000 a year. Diabetics can be on dialysis for decades.
The costs of type 1 and type 2 diabetes are expected to skyrocket in the next 10 years. A recent study by the Canadian Diabetes Association (CDA) says, in Ontario, the disease will affect 1.9 million in 2020 — that’s nearly 12 per cent of the population. Today, 1.7 million Ontarians have diabetes, just over eight per cent of the population.
The economic burden of diabetes will be staggering to the health care system and economy. The association’s report estimates the costs will jump from $4.9 billion in 2010 to $7 billion in 2020.
The indirect costs of diabetes — the amputations, blindness and kidney disease — account for nearly 80 percent of Ontario’s $4.9 billion figure today, the association reports.
“The numbers are staggering,” said Michael Cloutier, chief executive officer of the CDA. “We are suggesting to the government, the private sector, and to the general population that something needs to be done . . . . There is a tremendous urgency that is required.”
Dr. Rick Glazier, a senior scientist with the Institute for Clinical Evaluative Sciences (ICES) is calling for a major campaign — akin to the anti-smoking crusade — to stop the rapid development of the disease.
“Smoking isn’t gone, but it is certainly about half the rate it was 25 or 30 years ago,” Glazier said. “We need to do all of those things . . . in the world of obesity. Unlike smoking, you can’t live without eating, so we have a much greater challenge on our hands.”
In 2007, Glazier co-authored an ICES report that found Toronto’s inner suburbs — where many of the city’s poor live — are the epicentre of an epidemic of obesity and diabetes.
These neighbourhoods have limited access to transit, making it difficult for residents without cars to get to grocery stores for fresh and healthy food to stave off obesity. Even walking is difficult because some areas are unsafe, with poor street lighting or no sidewalks, the report said.
Now, Glazier is calling for a major shift in the way governments approach the disease.
On the micro level, he says people need regular health counseling, affordable medication and visits with dieticians, which “would have been the equivalent to smoking and pill patches.”
On the municipal level, he recommends better public transportation so low-income people can get to grocery stores that sell healthy food instead of depending on transit that takes more than 30 minutes each way.
And on the macro level, Glazier believes there are options for government policy that would fight obesity. For example, governments could tax unhealthy food and use that money to subsidize nutritious food, he said.
“We are looking at the first generation in history (today’s teens) that will not live longer than their parents because this generation is much more obese, they have very unhealthy lifestyles and don’t have any physical activity in the course of a day,” Glazier said.
Dennis Raphael, a professor of health policy and management at York University, has published numerous studies concluding that poverty is the main cause of diabetes.
Raphael argues that the only way to put a dent in the explosive growth of the disease is to focus on social justice — and the jobs that allow people to emerge from poverty.
“The better argument is to say that today’s generation will not be as healthy as we are because of growing income inequality, insecure employment and a lack of affordable housing,” he said.
The myth, he said, is that governments can intervene on obesity and “that would make everything fine.”
“In Scandinavia, governments recognize that it all has to do with deprivation, so they do everything they can to deal with it at the source.”
Dr. Joshua Tepper, an assistant deputy minister with Ontario’s health ministry agrees that poverty is a leading cause of diabetes.
“As a family doctor who works with inner city health populations every week, I would certainly agree with that . . . . The nature of poverty makes the risk higher and . . . it makes management of the disease much harder.”
Tepper says the government is pushing forward with a four-year, $740-million plan to fight diabetes. It began in 2008 and involves education programs, connects diabetics to healthcare providers and targets at-risk immigrant and aboriginal groups through public health or religious leaders.
Even incremental success has a major impact, Tepper said.
For example, a one percent reduction in long-term blood sugar levels can lead to a 16 percent reduction in congestive heart failure and a 14 percent reduction in heart attacks, he said.
“That is the really large and important silver lining,” Tepper said.
Cloutier, of the Canadian Diabetes Association, says his organization is pushing governments for sweeping change he says is necessary because almost 12 per of the population will suffer from diabetes in 2020.
“At that point, it is considered a significant disease, catastrophic in nature. It is no longer just a health concern, but also a societal concern,” he said.
While the association lobbies for a high-level campaign, along with prevention strategies for at-risk groups and those prone to complications, front-line workers such as Michelle Westin are focused on one person at a time.
Westin is a health worker at the Black Creek Community Health Centre in Toronto’s west end, in one of Toronto’s poorest neighbourhoods, where diabetes rates are very high.
Westin said she watches her clients struggle to manage the disease, forced to choose between groceries or diabetes test strips, which can cost almost a $1 a strip — a problem if they need to test their blood three to five times a day.
“It is definitely a balancing act,” Westin said. “People have to make choices. It is something we come across quite often.”
Westin said the health centre runs numerous programs to help diabetics manage the disease, and has a dietician who teaches people how to shop for the groceries and cook healthy food.
For those who already live under the weight of poverty, getting the diagnosis of diabetes can be terrifying.
“But,” she said, “I also see an incredible resilience.”
Edgar Dawson in Scarborough says, “I try not to think about it too much, I just do the best I can.”
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