Type 2 Diabetes in Aboriginal Peoples

Abstract

Key Messages•Aboriginal peoples living in Canada are among the highest risk populations for diabetes and related complications. Community-based and culturally appropriate prevention strategies and surveillance of diabetes indicators among this high risk population are essential to reducing health disparities.•Efforts to prevent diabetes should focus on diabetes risk factors, including prevention of childhood, adolescent, adult, and pregravid obesity; prevention and optimal management of gestational diabetes; and prevention of modifiable risk factors, such as smoking, inactivity, stress, and unhealthy eating habits.•Screening for diabetes in adults should be considered every 1 to 2 years in Aboriginal individuals with ≥1 additional risk factor(s). Screening every 2 years also should be considered from age 10 years or established puberty in Aboriginal children with ≥1 additional risk factor(s), including exposure to diabetes in utero.•Early identification of diabetes in pregnancy should be emphasized and post-partum screening for diabetes in those with gestational diabetes should be instituted with appropriate follow-up.•Treatment of diabetes in Aboriginal peoples should follow current clinical practice guidelines using community-specific diabetes management programs developed and delivered in partnership with the target communities.•Improvements in systematic care and medical management are needed to help close the substantial care gap between Aboriginal and non-Aboriginal peoples to mitigate diabetes-related morbidity and premature mortality. •Aboriginal peoples living in Canada are among the highest risk populations for diabetes and related complications. Community-based and culturally appropriate prevention strategies and surveillance of diabetes indicators among this high risk population are essential to reducing health disparities.•Efforts to prevent diabetes should focus on diabetes risk factors, including prevention of childhood, adolescent, adult, and pregravid obesity; prevention and optimal management of gestational diabetes; and prevention of modifiable risk factors, such as smoking, inactivity, stress, and unhealthy eating habits.•Screening for diabetes in adults should be considered every 1 to 2 years in Aboriginal individuals with ≥1 additional risk factor(s). Screening every 2 years also should be considered from age 10 years or established puberty in Aboriginal children with ≥1 additional risk factor(s), including exposure to diabetes in utero.•Early identification of diabetes in pregnancy should be emphasized and post-partum screening for diabetes in those with gestational diabetes should be instituted with appropriate follow-up.•Treatment of diabetes in Aboriginal peoples should follow current clinical practice guidelines using community-specific diabetes management programs developed and delivered in partnership with the target communities.•Improvements in systematic care and medical management are needed to help close the substantial care gap between Aboriginal and non-Aboriginal peoples to mitigate diabetes-related morbidity and premature mortality. Around the globe, diabetes incidence and prevalence rates are several times higher among Indigenous peoples compared to the general population (1Yu C.H. Zinman B. Type 2 diabetes and impaired glucose tolerance in Aboriginal populations: A global perspective.Diabetes Res Clin Pract. 2007; 78: 159-170Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar). In Canada, Aboriginal peoples are a heterogeneous population comprised of individuals of First Nations, Inuit, and Métis heritage living in a range of environments from large cities to small, isolated communities. National survey data have consistently shown that the national age-adjusted prevalence of diabetes is 3 to 5 times higher in First Nations than in the general population (2Green C. Blanchard J. 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Elias B. et al.Type 2 diabetes mellitus in Canada's First Nations: Status of an epidemic in progress.CMAJ. 2000; 163: 561-566PubMed Google Scholar) and population screening has shown rates as high as 26% in individual communities (6Harris S.B. Gittelsohn J. Hanley A. et al.The prevalence of NIDDM and associated risk factors in Native Canadians.Diabetes Care. 1997; 20: 185-187Crossref PubMed Scopus (215) Google Scholar). As in most populations where incidence and prevalence rates are higher, age of diagnosis is younger in First Nations peoples (7Dyck R.F. Osgood N. Lin T.H. et al.Epidemiology of diabetes mellitus among First Nations and non-First Nations adults.CMAJ. 2010; 182: 249-256Crossref PubMed Scopus (144) Google Scholar, 8Oster R.T. Johnson J.A. Hemmelgarn B.R. et al.Recent epidemiologic trends of diabetes mellitus among status Aboriginal adults.CMAJ. 2011; 183: E803-E808Crossref PubMed Scopus (35) Google Scholar). These rates are similar in other countries where Indigenous populations have been subject to colonization (1Yu C.H. Zinman B. Type 2 diabetes and impaired glucose tolerance in Aboriginal populations: A global perspective.Diabetes Res Clin Pract. 2007; 78: 159-170Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar). In a recent profile of health status, Métis, aged 19 years and older, in Manitoba, were found to have an age and sex adjusted diabetes rate of 11.8% compared to the provincial rate of 8.8% (9Martens P.J. Bartlett J. Burland E. et al.Profile of Metis Health Status and Healthcare Utilization in Manitoba: A population-based study. Manitoba Centre for Health Policy, Winnipeg, MBJune 2010Google Scholar). In 2006, 7% of Métis were reported to have been diagnosed with diabetes while the national prevalence during the same time period was reported at 4% (10Janz T, Seto J, Turner A. Aboriginal peoples survey, 2006, no. 4. An overview of the health of the Métis population. Statistics Canada. 2009. http://www.statcan.gc.ca/pub/89-637-x/2009006/art/art1-eng.htm. Accessed July 7, 2012.Google Scholar). Among the Inuit and Alaska Natives, it has recently been shown that the diabetes prevalence rate has substantially increased and is now comparable with the general Canadian population (11Egeland G.M. Cao Z. Young T.K. Hypertriglyceridemic-waist phenotype and glucose intolerance among Canadian Inuit: The international polar year inuit health survey for adults 2007-2008.CMAJ. 2011; 183: E553-E558Crossref PubMed Scopus (72) Google Scholar, 12Narayanan M.L. Schraer C.D. Bulkow L.R. et al.Diabetes prevalence, incidence, complications and mortality among Alaska Native people 1985-2006.Int J Circumpolar Health. 2010; 69: 236-252Crossref PubMed Scopus (26) Google Scholar). The higher rate of adverse health outcomes in Aboriginal peoples is associated with a number of factors, including lifestyle (diet and physical activity), genetic susceptibility, and historic-political and psychosocial factors, stemming from a history of colonization that severely undermined Aboriginal values, culture, and spiritual practices (13Nettleton C. et al.Symposium on the social determinants of Indigenous health.in: An overview of current knowledge of the social determinants of Indigenous health. World Health Organization, Geneva, Switzerland2007Google Scholar). Barriers to care that are unique to Aboriginal settings also exacerbate the problem with fragmented healthcare, poor chronic disease management, high healthcare staff turnover, and limited or non-existent surveillance (14Gracey M. King M. Indigenous health part 1: Determinants and disease patterns.Lancet. 2009; 374: 65-75Abstract Full Text Full Text PDF PubMed Scopus (787) Google Scholar). In addition, social determinants of health, including low income, lack of education, high unemployment, poor living conditions, lack of social support, negative stereotyping and stigmatization, and poor access to health services compound the problem (14Gracey M. King M. Indigenous health part 1: Determinants and disease patterns.Lancet. 2009; 374: 65-75Abstract Full Text Full Text PDF PubMed Scopus (787) Google Scholar). Different understandings of the etiology of health and illness from the holistic, collective social experience adopted by many Indigenous peoples to the traditional biomedical model which centers the disease within the individual may also influence care (15Naqshbandi M. Harris S.B. Esler J.G. et al.Global complication rates of type 2 diabetes in Indigenous peoples: A comprehensive review.Diabetes Res ClinPract. 2008; 82: 1-17Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar). Among First Nations peoples, a gender difference exists with more females impacted by type 2 diabetes than males (7Dyck R.F. Osgood N. Lin T.H. et al.Epidemiology of diabetes mellitus among First Nations and non-First Nations adults.CMAJ. 2010; 182: 249-256Crossref PubMed Scopus (144) Google Scholar, 16Fagot-Campagna A. Pettit D.J. Engelgau M.M. et al.Type 2 diabetes among North American children and adolescents: An epidemiologic review and a public health perspective.J Pediatr. 2000; 136: 664-672Abstract Full Text PDF PubMed Scopus (934) Google Scholar). This is most striking during reproductive years, resulting in recent age standardized prevalence rates of over 20% among First Nations women compared to about 16% among First Nations men. In addition, diabetes prevalence rates have more than tripled from 1980 to 2005 among First Nations children (8Oster R.T. Johnson J.A. Hemmelgarn B.R. et al.Recent epidemiologic trends of diabetes mellitus among status Aboriginal adults.CMAJ. 2011; 183: E803-E808Crossref PubMed Scopus (35) Google Scholar, 17Dyck R.F. Osgood N.D. Gao A. et al.The epidemiology of diabetes mellitus among First Nations and non-First Nations children in Saskatchewan.Canadian Journal of Diabetes. 2012; 36: 19-24Abstract Full Text Full Text PDF Scopus (12) Google Scholar). Similarly, incidence rates of type 2 diabetes among Indigenous youth in Australia have been documented to be 6.1 times that of non-Indigenous youth (18Craig M.E. Femia G. Broyda V. et al.Type 2 diabetes in Indigenous and non-Indigenous children and adolescents in New South Wales.Med J Aust. 2007; 186: 497-499PubMed Google Scholar). Métis men and women are reported to have a similar prevalence of diabetes (10Janz T, Seto J, Turner A. Aboriginal peoples survey, 2006, no. 4. An overview of the health of the Métis population. Statistics Canada. 2009. http://www.statcan.gc.ca/pub/89-637-x/2009006/art/art1-eng.htm. Accessed July 7, 2012.Google Scholar). Aboriginal women in Canada also experience gestational diabetes mellitus (GDM) rates 2 to 3 times higher than others (19Dyck R. Klomp H. Tan L.K. et al.A comparison of rates, risk factors, and outcomes of gestational diabetes between Aboriginal and non-Aboriginal women in the Saskatoon health district.Diabetes Care. 2002; 25: 487-493Crossref PubMed Scopus (122) Google Scholar, 20Aljohani N. Rempel B.M. Ludwig S. et al.Gestational diabetes in Manitoba during a twenty-year period.Clin Invest Med. 2008; 31: E131-E137PubMed Google Scholar), in part related to an interaction of Aboriginal ethnicity with pregravid adiposity (19Dyck R. Klomp H. 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Ludwig S. et al.Gestational diabetes in Manitoba during a twenty-year period.Clin Invest Med. 2008; 31: E131-E137PubMed Google Scholar) have paralleled increases in high birth weight rates over several decades. Both maternal GDM (23Young T.K. Martens P.J. Taback S.P. et al.Type 2 diabetes mellitus in children: Prenatal and early infancy risk factors among native Canadians.Arch Pediatr Adolesc Med. 2002; 156: 651-655Crossref PubMed Scopus (172) Google Scholar) and high birth weight (24Dyck R.F. Klomp H. Tan L. From “thrifty genotype” to “hefty fetal phenotype”: The relationship between high birth weight and diabetes in Saskatchewan registered Indians.Can J Public Health. 2001; 92: 340-344PubMed Google Scholar) are predictors for type 2 diabetes in the offspring (25Dyck R.F. Cascagnette P.J. Klomp H. The importance of older maternal age and other birth-related factors for diabetes in the offspring: Particular implications for First Nations women?.Can J Diabetes. 2010; 34: 41-49Abstract Full Text Full Text PDF Scopus (6) Google Scholar) and likely contribute to the higher type 2 diabetes rates in First Nations women compared to men (7Dyck R.F. Osgood N. Lin T.H. et al.Epidemiology of diabetes mellitus among First Nations and non-First Nations adults.CMAJ. 2010; 182: 249-256Crossref PubMed Scopus (144) Google Scholar). While genetic factors are important in the epidemic of type 2 diabetes among Indigenous peoples (26Hanson R.L. Bogardus C. 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Recent research suggests that epigenetic factors play a key role in the interaction between genes and the environment, influencing the development of diabetes complications (33Pirola L. Balcerczyk A. Okabe J. et al.Epigenetic phenomena linked to diabetic complications.Nature Reviews Endocrinology. 2010; 6: 665-675Crossref PubMed Scopus (174) Google Scholar, 34Reddy M.A. Natarajan R. Epigenetic mechanisms in diabetic vascular complications.Cardiovascular Research. 2010; 90: 421-429Crossref Scopus (154) Google Scholar). Inequities in the social determinants of health brought about through colonization (14Gracey M. King M. Indigenous health part 1: Determinants and disease patterns.Lancet. 2009; 374: 65-75Abstract Full Text Full Text PDF PubMed Scopus (787) Google Scholar) contribute to the main risk factors for type 2 diabetes in Aboriginal peoples, such as decreased rates of physical activity, stress, dietary acculturation and an unhealthy diet, food insecurity, obesity/metabolic syndrome, and high rates of diabetes during pregnancy. Indigenous peoples with diabetes also experience disparities in diabetes-related complications and mortality. Higher prevalence rates of microvascular disease, including chronic kidney disease (CKD) (35Harris S.B. Naqshbandi M. Bhattacharyya O. et al.Major gaps in diabetes clinical care among Canada's First Nations: Results of the CIRCLE study.Diabetes Res Clin Pract. 2011; 92: 272-279Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar), lower limb amputation (9Martens P.J. Bartlett J. Burland E. et al.Profile of Metis Health Status and Healthcare Utilization in Manitoba: A population-based study. Manitoba Centre for Health Policy, Winnipeg, MBJune 2010Google Scholar, 36Martens P.J. Martin B.D. O'Neil J.D. et al.Diabetes and adverse outcomes in a First Nations population: Associations with healthcare access, and socioeconomic and geographical factors.Can J Diabetes. 2007; 31: 223-232Abstract Full Text Full Text PDF Scopus (24) Google Scholar), foot abnormalities (37Chuback J. Embil J.M. Sellers E. et al.Foot abnormalities in Canadian Aboriginal adolescents with type 2 diabetes.Diabet Med. 2007; 24: 747-752Crossref PubMed Scopus (18) Google Scholar, 38Rose G. Duerksen F. Trepman E. et al.Multidisciplinary treatment of diabetic foot ulcers in Canadian Aboriginal and non-Aboriginal people.Foot and Ankle Surgery. 2008; 14: 74-81Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar), and more severe retinopathy (39Ross S.A. McKenna A. Mozejko S. et al.Diabetic retinopathy in Native and nonnative Canadians.Experimental Diabetes Research. 2007; 2007: 76271Crossref PubMed Scopus (27) Google Scholar), are found in Aboriginal peoples with diabetes than in the general population with diabetes. Aboriginal peoples also are burdened by higher rates of macrovascular disease (9Martens P.J. Bartlett J. Burland E. et al.Profile of Metis Health Status and Healthcare Utilization in Manitoba: A population-based study. Manitoba Centre for Health Policy, Winnipeg, MBJune 2010Google Scholar, 15Naqshbandi M. Harris S.B. Esler J.G. et al.Global complication rates of type 2 diabetes in Indigenous peoples: A comprehensive review.Diabetes Res ClinPract. 2008; 82: 1-17Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar) and exhibit higher rates of cardiometabolic risk factors, including smoking, obesity, and hypertension (9Martens P.J. Bartlett J. Burland E. et al.Profile of Metis Health Status and Healthcare Utilization in Manitoba: A population-based study. Manitoba Centre for Health Policy, Winnipeg, MBJune 2010Google Scholar, 35Harris S.B. Naqshbandi M. Bhattacharyya O. et al.Major gaps in diabetes clinical care among Canada's First Nations: Results of the CIRCLE study.Diabetes Res Clin Pract. 2011; 92: 272-279Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 40Oster R.T. Toth E.L. Differences in the prevalence of diabetes risk-factors among First Nation, Métis and non-Aboriginal adults attending screening clinics in rural Alberta, Canada.Rural Remote Health. 2009; 9: 1170PubMed Google Scholar), that may indicate a future increase in cardiovascular morbidity and mortality. As in other Indigenous populations, First Nations people with diabetes have high rates of albuminuria (41Dyck R.F. Sidhu N. Klomp H. et al.Differences in glycemic control and survival predict higher ESRD rates in diabetic First Nations adults.Clin Invest Med. 2010; 33: E390-E397PubMed Google Scholar) and are more likely than others to progress to end-stage renal disease (ESRD) (42Dyck R.F. Osgood N.D. Lin T.H. et al.End Stage Renal Disease among people with diabetes: A comparison of First Nations people and other Saskatchewan residents from 1981-2005.Can J Diabetes. 2010; 34: 324-333Abstract Full Text Full Text PDF Scopus (15) Google Scholar). Potentially modifiable risk factors for kidney disease progression include poor glycemic control, systolic hypertension, smoking, and insufficient use of angiotensin-converting-enzyme (ACE) inhibitors (41Dyck R.F. Sidhu N. Klomp H. et al.Differences in glycemic control and survival predict higher ESRD rates in diabetic First Nations adults.Clin Invest Med. 2010; 33: E390-E397PubMed Google Scholar, 43Xu J. Lee E.T. Devereux R.B. et al.A longitudinal study of risk factors for incident albuminuria in diabetic American Indians.Am J Kidney Dis. 2008; 51: 415-424Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar) as well as periodontal disease (44Shultis W.A. Weil E.J. Looker H.C. et al.Effect of periodontitis on overt nephropathy and ESRD in type 2 diabetes.Diabetes Care. 2007; 30: 306-311Crossref PubMed Scopus (224) Google Scholar). Likely relevant for other chronic diabetic complications, longer duration of diabetes (41Dyck R.F. Sidhu N. Klomp H. et al.Differences in glycemic control and survival predict higher ESRD rates in diabetic First Nations adults.Clin Invest Med. 2010; 33: E390-E397PubMed Google Scholar, 45Pavkov M.E. Bennett P.H. Knowler W.C. et al.Effect of youth-onset type 2 diabetes mellitus on end-stage renal disease and mortality in young and middle-aged Pima Indians.JAMA. 2010; 296: 421-426Crossref Scopus (229) Google Scholar) related to younger adult onset (45Pavkov M.E. Bennett P.H. Knowler W.C. et al.Effect of youth-onset type 2 diabetes mellitus on end-stage renal disease and mortality in young and middle-aged Pima Indians.JAMA. 2010; 296: 421-426Crossref Scopus (229) Google Scholar) is associated with higher ESRD rates and differential mortality and highlights the urgent need for primary diabetes prevention. The provincial dialysis initiation rate is higher for Métis than other Manitobans (0.46% vs. 0.34%) (9Martens P.J. Bartlett J. Burland E. et al.Profile of Metis Health Status and Healthcare Utilization in Manitoba: A population-based study. Manitoba Centre for Health Policy, Winnipeg, MBJune 2010Google Scholar). On a positive note, ESRD incidence among Aboriginal peoples has stabilized since the early 1990s in both the United States (46Narva A.S. Sequist T.D. Reducing health disparities in American Indians with chronic kidney disease.Seminars Neph. 2010; 30: 19-25Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar) and Canada (42Dyck R.F. Osgood N.D. Lin T.H. et al.End Stage Renal Disease among people with diabetes: A comparison of First Nations people and other Saskatchewan residents from 1981-2005.Can J Diabetes. 2010; 34: 324-333Abstract Full Text Full Text PDF Scopus (15) Google Scholar), and is probably due to the introduction of ACE inhibitors and application of interdisciplinary chronic disease care models (46Narva A.S. Sequist T.D. Reducing health disparities in American Indians with chronic kidney disease.Seminars Neph. 2010; 30: 19-25Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar). The prevalence of metabolic syndrome is elevated among both First Nations adults (47Liu J. Hanley A.J.G. Young T.K. et al.Characteristics and prevalence of the metabolic syndrome among three ethnic groups in Canada.International Journal of Obesity. 2006; 30: 669-676Crossref Scopus (58) Google Scholar) and children (48Retnakaran R. Zinman B. Connelly P.W. et al.Nontraditional cardiovascular risk factors in pediatric metabolic syndrome.J Pediatr. 2006; 148: 176-182Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 49Kaler S. Ralph-Campbell K. Pohar S. et al.High rates of the metabolic syndrome in a First Nations community in Alberta: Prevalence and determinants in adults and children.Int J Circumpolar Health. 2006; 65: 389-402Crossref PubMed Scopus (29) Google Scholar) and, like type 2 diabetes, disproportionately affects females with rates as high as 45% in Oji-Cree women. Increased adiposity and dysglycemia are more common components than hypertension (47Liu J. Hanley A.J.G. Young T.K. et al.Characteristics and prevalence of the metabolic syndrome among three ethnic groups in Canada.International Journal of Obesity. 2006; 30: 669-676Crossref Scopus (58) Google Scholar), and non-traditional risk factors, such as elevated C-reactive protein are also elevated (48Retnakaran R. Zinman B. Connelly P.W. et al.Nontraditional cardiovascular risk factors in pediatric metabolic syndrome.J Pediatr. 2006; 148: 176-182Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar). There is a strong relationship between metabolic syndrome and later type 2 diabetes (50Ley S.H. Harris S.B. Mamakeesick M. et al.Metabolic syndrome and its components as predictors of incident type 2 diabetes mellitus in an Aboriginal community.CMAJ. 2009; 180: 617-624Crossref PubMed Scopus (48) Google Scholar, 51Wang H. Shara N.M. Umans J.G. et al.Incidence rates and predictors of diabetes in those with pre-diabetes: The Strong Heart Study.Diabetes Metab Res Rev. 2010; 26: 378-385Crossref PubMed Scopus (58) Google Scholar). Thus, Aboriginal peoples with metabolic syndrome should be targeted by programs designed to prevent type 2 diabetes since interventions, such as increased physical activity (52Mitchell M.S. Gaul C.A. Naylor P.J. et al.Habitual moderate-to-vigorous physical activity is inversely associated with insulin resistance in Canadian First Nations youth.Pediatric Exercise Science. 2010; 22: 254-265PubMed Google Scholar) and consumption of long chain omega 3 fatty acids (53Ebbesson S.O.E. Tejero M.E. Nobmann E.D. et al.Fatty acid consumption and metabolic syndrome components: The GOCADAN study.JCMS. 2007; 2: 244-249Google Scholar), have been shown to improve glucose tolerance in Aboriginal peoples. A reversal in long-term trends for decreasing mortality among American Indians since the mid-1980s appears primarily due to the direct and indirect effects of type 2 diabetes (54Kunitz S.J. Ethics in public health research: Changing patterns of mortality among American Indians.Am J of Public Health. 2008; 98: 404-411Crossref PubMed Scopus (34) Google Scholar). Surveillance data from Alberta indicate that Aboriginal peoples with diabetes have mortality rates 2 to 3 times higher than the general population with diabetes (8Oster R.T. Johnson J.A. Hemmelgarn B.R. et al.Recent epidemiologic trends of diabetes mellitus among status Aboriginal adults.CMAJ. 2011; 183: E803-E808Crossref PubMed Scopus (35) Google Scholar). Provincially, Métis with diabetes are significantly more likely to die within a 5-year period than other Manitobans with diabetes (20.8% vs. 18.6%) (9Martens P.J. Bartlett J. Burland E. et al.Profile of Metis Health Status and Healthcare Utilization in Manitoba: A population-based study. Manitoba Centre for Health Policy, Winnipeg, MBJune 2010Google Scholar). In British Columbia, First Nations peoples with diabetes have nearly twice the mortality rate than First Nations peoples without diabetes (55Public Health Agency of Canada. Report from the National Diabetes Surveillance System: Diabetes in Canada, 2009. Available at http://www.phac-aspc.gc.ca/publicat/2009/ndssdic-snsddac-09/1-eng.php. Accessed June 10, 2011.Google Scholar). Additionally, administrative data have demonstrated increased hospitalizations for heart disease among First Nations people in Ontario, despite decreases in the general population (56Shah B.R. Hux J.E. Zinman B. Increasing rates of ischemic heart disease in the Native population of Ontario, Canada.Arch Intern Med. 2000; 160: 1862-1866Crossref PubMed Scopus (74) Google Scholar). Healthcare costs for Aboriginal peoples with diabetes have been shown to be considerably higher than costs in the general population with diabetes due to higher use of physician and hospital services (57Pohar S.L. Johnson J.A. Health care utilization and costs in Saskatchewan's registered Indian population with diabetes.BMC Health Services Research. 2007; 7: 126Crossref PubMed Scopus (23) Google Scholar). Increased morbidity and mortality among First Nations people are at least partly due to poorer quality of diabetes care (35Harris S.B. Naqshbandi M. Bhattacharyya O. et al.Major gaps in diabetes clinical care among Canada's First Nations: Results of the CIRCLE study.Diabetes Res Clin Pract. 2011; 92: 272-279Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 58Oster R.T. Virani S. Strong D. et al.Diabetes care and health status of First Nations individuals with type 2 diabetes in Alberta.Can Fam Physician. 2009; 55: 386-393PubMed Google Scholar, 59Klomp H. Dyck R.F. Sidhu N. et al.Measuring quality of diabetes care by linking health care system databases with laboratory data.BMC Research Notes. 2010; 3: 233https://doi.org/10.1186/1756-0500-3-233Crossref PubMed Scopus (6) Google Scholar). Routine medical care for Aboriginal peoples of all ages should include identification of modifiable risk factors, such as obesity, abnormal waist circumference (WC) or body mass index (BMI), physical inactivity, smoking, and unhealthy eating h