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The Epidemiology of Diabetes in the Manitoba-Registered First Nation Population Current Patterns and Comparative Trends

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The Epidemiology of Diabetes in the Manitoba-Registered First Nation Population Current Patterns and Comparative Trends Epidemiology/Health Services/Psychosocial Research ORIGINAL ARTICLE The Epidemiology of Diabetes in the Manitoba-Registered First Nation Population Current patterns and comparative trends 1 3 CHRIS GREEN, BA, MHSC T. KUE YOUNG, MD, FRCPC, PHD in the incidence and prevalence of diabe- 2 2 JAMES F. BLANCHARD, MD, MPH, PHD JANE GRIFFITH, MA, PHD tes among Registered First Nation adults in Manitoba from 1989 to 1998. Compar- isons are made to the non–First Nation adult population to highlight the magni- tude of the diabetes epidemic in First Na- OBJECTIVE — This study provides an overview of the epidemiology of diabetes in the Mani- tion people. The geographic variation in toba First Nation population. diabetes rates across Manitoba is also examined. RESEARCH DESIGN AND METHODS — The study uses data derived from the pop- The study was conducted in the Ca- ulation-based Manitoba Diabetes Database to compare the demographic and geographic patterns of diabetes in the Manitoba First Nation population to the non–First Nation population. nadian province of Manitoba. Manitoba has a population of 1.14 million people, RESULTS — Although the prevalence of diabetes rose steadily in both the First Nation and the of whom more than one-half (645,000) non–First Nation populations between 1989 and 1998, the epidemiological pattern of diabetes reside in the City of Winnipeg, the pro- in these two populations differed significantly. The First Nation population was observed to have vincial capital. The majority of Manito- age-standardized incidence and prevalence rates of diabetes up to 4.5 times higher than those bans are of European descent, whereas found in the non–First Nation population. The sex ratio and the geographic patterning of ϳ10% of the population is self-identified diabetes incidence and prevalence in the two study populations were reversed. as having Aboriginal ancestry (2). Mani- toba has a universal health insurance CONCLUSIONS — The results of the study suggest that diabetes prevalence will likely plan, and all residents of the province are continue to rise in the Manitoba First Nation population into the foreseeable future, and that the impact of this rising diabetes prevalence can only be effectively managed through a population- eligible to receive health care services based public health approach focusing on primary and secondary prevention. The dramatically with no payments required at the time of higher rates of diabetes in Manitoba First Nation population as compared with the non–First service. Nation population highlight the urgency of this activity. These prevention efforts need to be supported by further research into the reasons for the unique epidemiological patterns of dia- RESEARCH DESIGN AND betes incidence and prevalence in the First Nation population observed in this study. These include investigating why First Nation populations living in the Northern areas of the province METHODS seem to be protected from developing high rates of diabetes and why First Nation women experience much higher rates of the disease. Data sources The data used for this study were derived Diabetes Care 26:1993–1998, 2003 from the Manitoba diabetes database (MDD), which has been described previ- ously (3). This database contains a longi- iabetes is increasingly responsible and its devastating effects in First Nation tudinal record for Manitoba residents of for substantial morbidity and mor- people requires accurate population- all physician contacts and hospital sepa- D tality in Canada’s First Nation pop- based data on the temporal trends and ration records that cited a diagnosis of di- ulations. Planning and implementing geographic distribution of diabetes (1). abetes (ICD-9-CM code 250) between 1 effective primary and secondary interven- This study uses Manitoba Health ad- April 1984 and 31 March 1999. Individ- tion programs to deal with this disease ministrative databases to examine trends uals are categorized as having diabetes if they have had at least two separate physi- ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● cian contacts for diabetes within 2 years of From the 1Epidemiology Unit, Manitoba Health, Winnipeg, Canada; the 2Department of Community Health 3 each other or at least one hospital separa- Sciences, University of Manitoba, Manitoba, Canada; and the Department of Public Health Sciences, Uni- tion for diabetes. Cases of gestational di- versity of Toronto, Toronto, Canada. Address correspondence and reprint requests to Chris Green, Epidemiology Unit, 4058-300 Carleton St., abetes are excluded from the MDD. The Winnipeg, Manitoba, Canada R3B 3M9. E-mail: [email protected]. sensitivity of this database for detecting Received for publication 9 November 2002 and accepted in revised form 27 March 2003. clinically diagnosed cases of diabetes has Abbreviations: CCA, community characterization area; MDD, Manitoba diabetes database; RHA, re- been demonstrated, and the validity of the gional health authority. A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion methodology has been discussed previ- factors for many substances. ously (3). This methodology is unable to © 2003 by the American Diabetes Association. distinguish between type 2 and type 1 di- DIABETES CARE, VOLUME 26, NUMBER 7, JULY 2003 1993 Diabetes in the Manitoba population abetes. Individuals who move from the province subsequent to being identified as having diabetes are included in the MDD only for the years that they are res- idents in the province. Manitoba’s First Nation population is comprised of individuals who are regis- tered under the Indian Act of Canada and living in Manitoba. To identify people be- longing to Manitoba’s First Nation popu- lation, the Manitoba Health population registry was used. As part of the process for registration within Manitoba Health’s insurance system, an attempt is made to verify whether new registrants are regis- tered as Indian. If so, their First Nation affiliation is recorded. It is important to Figure 1—Point prevalence of diabetes in the Manitoba population. Aged Ն20 years; standard- note that for a variety of complex histori- ized to the 1991 Canadian population. FN, First Nation. cal and political reasons many individuals of Aboriginal ancestry are not eligible for registration under the Indian Act of Can- calculated to maximize rate stability when in 1989 to 248.7/1,000 in 1998. Among ada. These individuals are therefore not making geographic comparisons. To fa- First Nation men, there was a 1.6-fold in- identified as First Nation in this study. cilitate comparisons across time and with crease from 104.2/1,000 in 1989 to 170/ Also, approximately only 70% of the reg- other published reports and studies, age- 1,000 in 1998. There were also increases istered First Nation population living in adjusted rates were computed for both in- in prevalence among non–First Nation the province of Manitoba is identified as cidence and prevalence by the direct men (1.4-fold, from 41.9 to 59.63/1,000) being First Nation in the Manitoba Health method using the 1991 Canadian popu- and women (1.4-fold, from 37.1 to 53.5/ population registry. lation as the standard. 1,000). Throughout the study period, To examine the geographic variations First Nation men had an average diabetes Estimating incidence and prevalence in cases of diabetes, the province was di- prevalence rate 2.5 times higher than The diagnosis date of incident cases was vided into 22 regions. The City of Win- non–First Nation men, whereas First Na- defined based on the first physician con- nipeg was divided into 12 community tion women had an average diabetes prev- tact for a diagnosis of diabetes, which was characterization areas (CCAs). CCAs are alence rate 4.5 times higher than non– followed within 2 years by a subsequent administrative areas used by the Win- First Nation women. physician contact or by the hospitaliza- nipeg Regional Health Authority to de- The age-adjusted incidence of diabe- tion for diabetes, whichever came first. liver health services. CCAs were used in tes among individuals aged Ն20 years in- The annual incidence rates were calcu- this study because Ͼ60% of the prov- creased slightly for First Nation men and lated using the mid-year population at ince’s population resides within Win- Non–First Nation men and women be- risk based on the Manitoba population nipeg. Rural Manitoba was divided into tween 1989 and 1998. The incidence in registry. The population at risk is the pop- 10 regional health authority (RHA) areas. First Nation women did not change dur- ulation at mid-year without diabetes. The The two northern RHAs of Burntwood ing this period. Among First Nation men, average annual incidence rates for the and Churchill were combined for this there was 1.4-fold increase from 15.3/ years 1994–1998 were computed by cu- study to maintain the population size re- 1,000 in 1989 to 21.1/1,000 in 1998. mulating all incident cases and summing quired to ensure stable rate calculations. There were also increases in incidence the mid-year population at risk for those The average population size of each re- among non–First Nation men (1.25-fold, years. The point prevalence at December gion was ϳ50,000. Age-adjusted inci- from 5.44/1,000 to 6.8/1,000) and of each year was estimated by determin- dence and prevalence rates for each women (1.2-fold, from 4.7/1,000 to 5.7/ ing the number of cases that had previ- region were calculated using the 1991 Ca- 1,000). Throughout the study period, ously been diagnosed who had neither nadian population as a standard. First Nation men had an average diabetes died nor left the province at that time. incidence rate three times higher than This was done using the Manitoba Health RESULTS non–First Nation men, whereas First Na- population registry, which is routinely tion women had an average diabetes inci- updated and closely matches census pop- Time trends dence rate 3.7 times higher than non– ulation estimates.
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