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Improved Outcomes from Diabetes Outreach Programs in Rural and Remote Aboriginal Communities of Alberta, Canada
 

Improved Outcomes from Diabetes Outreach Programs in Rural and Remote Aboriginal Communities of Alberta, Canada

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2011 (Jun) American Diabetes Association 71st Annual Scientific Sessions, poster presentation by BRAID Research

2011 (Jun) American Diabetes Association 71st Annual Scientific Sessions, poster presentation by BRAID Research

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    Improved Outcomes from Diabetes Outreach Programs in Rural and Remote Aboriginal Communities of Alberta, Canada Improved Outcomes from Diabetes Outreach Programs in Rural and Remote Aboriginal Communities of Alberta, Canada Presentation Transcript

    • Improved Outcomes from Diabetes Outreach Programs in Ruraland Remote Aboriginal Communities of Alberta, CanadaRichard T. Oster, Kelli Ralph-Campbell, Tracy Connor, Ellen L. TothDepartment of Medicine, University of AlbertakABSTRACTAboriginal and rural/remote communitieshave increased risk and prevalences ofdiabetes, with less access to preventivehealth care and less opportunities forhealthy lifestyles. Since 2001, Albertahas hosted outreach and/or community-based screening programs in suchcommunities for diabetes and diabetesrisk. A total of 2879 persons withdiabetes and 4663 persons withoutdiagnosed diabetes (mostly Aboriginaland rural/remote) have been tested andcounseled in over 14,000 visits. Baselineadult characteristics have beenpreviously reported, and generally wereunfavorable, showing up to 31% withpre-diabetes and 83% overweight orobese. In this study we examined,longitudinally, the diabetes-relatedhealth of returning adult individuals.“Point-of-care” lab equipment wastransported to each community toscreen for diabetes and cardiovascularrisk; individuals with known diabeteswere also screened for complications. Inthe current investigation, body massindex (BMI), waist circumference,hemoglobin A1c (A1c), blood pressureand total cholesterol were considered.For the longitudinal analysis, univariategeneral linear mixed effect models withrandom client effect and fixed time (year)effect were utilized to obtain overalltrend estimates (considered significant ifp < 0.05). Improvements in BMI, bloodpressure, total cholesterol and A1cconcentrations were observed amongreturning subjects with diabetes (p <0.05) (N = 1415). Waist circumferenceswere unchanged. In contrast, subjectswithout known diabetes experiencedimprovements only in blood pressureand total cholesterol (p < 0.05), whereasboth BMI and waist circumferenceincreased over time (p < 0.05), and A1cwas unaffected (N = 1398). While secularimprovements in diabetes outcomes areoccurring in rural Aboriginal adultsexposed to diabetes outreach programs,the “dose” of such programs is likelyinsufficient to modify significant riskfactors in pre-diabetic clients, thusdifferent and/or more intense, and/ormore integrated strategies need to beexplored.For additional information contact:Richard Oster1055 RTF bldg, University of AlbertaEdmonton, Alberta, CanadaT6G 2V2780-407-8445roster@ualberta.caKSINTRODUCTION Statistical analysisAnalyses were done with SPSS 17.0. Mean baseline and subsequentindicators were compared for individuals over time with a univariategeneral linear mixed effect model. Those with and without diabeteswere analyzed separately. Resultant overall trend estimates for eachindicator were considered significant if P < 0.05.Since 2001, three separate screening programs have travelled to FirstNations communities, Métis settlements, and other remote Albertacommunities. Mobile clinics provide diabetes risk assessment, diabetescomplications screening, and community-based care. Ethical approvalwas secured from the Health Research Ethics Board at the University ofAlberta, and individuals consented to aggregate analysis.For returning subjects with diabetes, significant improvements inoverall trend estimates for BMI, blood pressure, total cholesterol andA1c concentrations were observed (P < 0.05).4. DISCUSSIONThe modest improvements amongst adults with diabetes imply thatthe outreach program care model may help support subjects toimprove their health. Secular improvements in diabetes health arelikely due to a combination of effects including the availability ofnational guidelines and the federal Aboriginal Diabetes Initiative.Unfortunately this combination is likely not enough to preventdiabetes in Aboriginal people with pre-diabetes, hence differentand/or more intense, and/or more integrated strategies are needed.5. REFERENCES1. Adelson N. 2005. Can J Public Health. 2. Gracey M, King M. 2009. Lancet. 374:65-75.96(S2):S45-S61.3. Young TK et al. 2000. CMAJ. 163:561-566. 4. Oster RT et al. 2010. Can J Public Health.101(5):410-414.5. NCEP Expert Panel. 2002. Circulation . 6. Canadian Diabetes Association. 2008. Can J106(25):3143-3421. Diabetes. 32(S1):S1-S201.In contrast, subjects without known diabetes experiencedimprovements only in blood pressure and total cholesterol (P < 0.05),whereas both BMI and waist circumference increased over time (P <0.05).Trends for health indicators of returning subjects with diabetes over time (N =1415). Values are estimates for the average change per year with SE.Baseline health indicators of subjects with diabetes. Values are means (± SD) orprevalences (95% CI).3. RESULTSSubjects ranged from 20 to 92 years of age (mean 48) and the majority(64.2%) were female. Baseline co-morbidities were very common andindicators were more severe among men and those with diabetes.2. METHODSCanadian Aboriginal IssuesDatabase, www.ualberta.ca/~walld/map.htmlIndian and NorthernAffairs Canada,www.ainc-inac.gc.ca-1.5 -1 -0.5 0 0.5 1 1.5BMIWaistA1cMAPSystolic BPDiastolic BPCholesterolEstimate of average change-1.5 -1 -0.5 0 0.5 1 1.5BMIWaistA1cMAPSystolic BPDiastolic BPCholesterolEstimate of average changeHealth indicator All (n = 2838) Females (n = 1732) Males (n = 1106)BMI (kg/m2) 33.6 ± 10.7 34.2 ± 12.3* 32.5 ± 7.4% overweight 25.2%(23.6 – 27.0)22.7%(20.7 – 24.9)*29.1%(26.3 – 32.0)% obese 67.4%(65.6 – 69.2)70.0%(67.6 – 72.2)*62.5%(59.5 – 65.6)% overweight/obese 92.3%(91.2 – 93.3)92.7%(91.3 – 94.0)91.6%(89.7 – 93.3)Waist circumference (cm) 110.7 ± 14.7 110.9 ± 14.7 110.5 ± 14.7% Abnormal 83.2%(81.7 – 84.6)88.9%(87.3 – 90.4)*73.6%(70.6 – 76.3)A1c (%) 8.0 ± 7.7 8.0 ± 9.7 8.0 ± 2.0% Poor glucose control 57.7%(55.7 – 59.5)55.6%(53.1 – 58.1)*60.9%(57.8 – 63.9)Systolic blood pressure (mmHg) 131.1 ± 19.1 129.3 ± 18.7* 133.9 ± 19.2Diastolic blood pressure (mmHg) 77.4 ± 11.0 75.7 ± 10.5* 80.0 ± 11.1Mean arterial pressure (mmHg) 95.3 ± 12.1 93.6 ± 11.7* 98.0 ± 12.1% Hypertensive 67.3%(65.5 – 69.0)62.9%(60.5 – 65.2)*74.1%(71.4 – 76.7)Total cholesterol (mM) 4.9 ± 1.2 5.0 ± 1.2 4.9 ± 1.3% Hypercholesterolemia 36.9%(34.9 – 39.0)38.0%(35.4 – 40.6)35.4%(32.2 – 38.6)Health indicator All (n = 4020) Females (n = 2673) Males (n = 1347)BMI (kg/m2) 30.8 ± 6.4 31.1 ± 6.8* 30.1 ± 5.5% overweight 31.1%(29.6 – 32.5)27.7%(26.0 -29.5)*37.7%(35.1 – 40.4)% obese 51.3%(49.7 – 52.9)54.0%(43.3 – 48.7)*46.0%(43.3 – 48.7)% overweight/obese 82.4%(81.1 – 83.6)81.7%(80.2 – 83.2)83.7%(81.6 – 85.6)Waist circumference (cm) 102.2 ± 15.6 101.3 ± 16.2* 104.1 ± 14.3% Abnormal 70.9%(69.4 – 72.3)79.3%(77.7 – 80.9)*54.2%(51.4 – 56.9)A1c (%) 5.5 ± 0.7 5.4 ± 0.6 5.6 ± 0.9% Undiagnosed diabetes (≥ 7%) 2.1%(1.7 – 2.6)1.8%(1.3 – 2.4)*2.9%(2.0 – 3.9)Systolic blood pressure (mmHg) 121.6 ± 17.9 118.5 ± 17.2* 127.6 ± 17.8Diastolic blood pressure (mmHg) 75.3 ± 10.7 73.6 ± 10.3* 78.6 ± 10.8Mean arterial pressure (mmHg) 90.7 ± 12.1 88.6 ± 11.6* 94.9 ± 12.0% Hypertensive 26.2%(24.5 – 27.9)21.5%(19.6 – 23.6)*34.9%(31.7 – 38.1)Total cholesterol (mM) 4.8 ± 1.1 4.7 ± 1.0* 4.9 ± 1.1% Hypercholesterolemia 32.8%(31.4 – 34.3)30.8%(29.0 – 32.6)*36.9%(34.3 – 39.5)1. INTRODUCTIONThe health of Canadian Aboriginals (First Nations, Inuit and Métis) ismarkedly poorer than their non-Aboriginal counterparts, with type 2diabetes at the forefront (1, 2). For Aboriginal peoples, many of whomlive in rural/remote settings and suffer from inequities with respect to thesocial determinants of health, rates of type 2 diabetes and itscomplications are 2-5 times more common (3).In response, several outreach and/or community-based diabetesscreening programs have been implemented in the province of Alberta.In this analysis we sought to examine, longitudinally, the diabetes-related health status among returning subjects with diabetes andwithout diabetes.Adults (≥ 20 years) enrolled through self-referral via local advertising. Atotal of 7542 unique subjects (2879 with diabetes, 4663 without diabetes)have been tested. Subjects were mostly First Nations (64.4%), with someMétis (21.8%) and non-Aboriginal (13.9%). Follow-up visits were availablefor 1415 subjects with diabetes and 1398 without diabetes.Mobile clinics equipped with healthcare personnel and portabletechnology travelled the communities. Detailed methodology has beenreported elsewhere (4). Measurements included body mass index (BMI),waist circumference, hemoglobin A1c (A1c), blood pressure, and totalcholesterol. National Cholesterol Education Program (5) and CanadianDiabetes Association (6) criteria were utilized to define overweight (BMI25-29.9), obesity (BMI ≥ 30), abnormal WC (≥ 102 males; ≥ 88 females),poor glucose control (A1c ≥ 7%), hypertension (≥ 130/80 for diabetes; ≥140/90 for no diabetes, or on anti-hypertensives), andhypercholesterolemia (≥ 5.24, or on anti-hyperlipidemics).Baseline health indicators of subjects without diabetes. Values are means (± SD)or prevalences (95% CI).Trends for health indicators of returning subjects with diabetes over time (N =1398). Values are estimates for the average change per year with SE.* denotes significant gender difference* denotes significant gender difference