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Type 2 Diabetes in Canadian Aboriginal Adolescents: Risk Factors and Prevalence
Journal of Pediatric Nursing 36 (2017) 111–117
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Journal of Pediatric Nursing
Type 2 Diabetes in Canadian Aboriginal Adolescents: Risk Factors and Prevalence Shelley Spurr a,⁎, Jill Bally a, Carol Bullin a, Krista Trinder b a b
University of Saskatchewan, College of Nursing, 104 Clinic Place, Saskatoon, Saskatchewan S7N 2Z4, Canada University of Saskatchewan, College of Medicine, 5B57.1 Health Sciences Building, Saskatoon, Saskatchewan S7N 2Z4, Canada
a r t i c l e
i n f o
Article history: Received 21 March 2017 Revised 19 May 2017 Accepted 28 May 2017 Available online xxxx Keywords: Type 2 diabetes Adolescents Aboriginal Risk factors Prevalence
a b s t r a c t Purpose: To identify the risk factors and prevalence rates of prediabetes and type 2 diabetes among northern Canadian Aboriginal adolescents. Design and Methods: In this novel exploratory, quantitative study, 160 high school students (aged 13–21) from three northern, predominantly Canadian Aboriginal communities were screened for risk for prediabetes and type 2 diabetes including demographic data, family medical history, anthropometric measurements, blood pressure, and hemoglobin A1c (HbA1c). Descriptive and inferential statistics, in addition to chi-square analysis, were used to establish risk and prevalence rates for prediabetes and type 2 diabetes in Aboriginal adolescents. Results: At least half of the adolescents presented with multiple risk factors for type 2 diabetes. In this sample, 10% had an HbA1c N 5.7%, 22.5% were overweight, 17.5% were obese, and 26.6% had prehypertension or hypertension. Conclusions: Prediabetes and type 2 diabetes are emerging as serious health concerns for young Aboriginal Canadians. This is troubling because both result from modifiable risk factors. As this study is the first to examine the prevalence of prediabetes in Canadian Aboriginal adolescents in the last decade, the findings underscore the necessity for early screening of Aboriginal adolescents for both prediabetes and type 2 diabetes. Practice Implications: Recommendations toward positive health outcomes include the introduction of early age screening programs, followed by culturally relevant interventions, specific to the modifiable risk factors (overweight/obesity and hypertension), and developed in collaboration with the communities. Such approaches have the potential to prevent the progression of prediabetes to diabetes and reduce complications related to type 2 diabetes. © 2017 Elsevier Inc. All rights reserved.
An estimated 422 million people worldwide were living with diabetes in 2014; this represents a four-fold increase over the estimated 108 million in 1980 (World Health Organization (WHO), 2016), and this number is expected to climb to 552 million by 2030 (International Diabetes Foundation, 2016). While type 2 diabetes has typically impacted middle-aged populations and the elderly, it has also become increasingly prevalent in children and adolescents (WHO, 2016). Overall, type 2 diabetes is increasing in adolescents worldwide (Amed et al., 2010; Nadeau & Dabelea, 2008), with a projected 49% incidence increase over the next 40 years (Imperatore et al., 2012). Children who come from marginalized groups, including Aboriginal descent, are disproportionately affected by type 2 diabetes (Panagiotopoulos, Riddell, & Sellers, 2013). Canadian Aboriginals (First Nation, Métis, and Inuit) in particular are excessively affected by diabetes and related complications, with a rate of incidence that is 3–5 times higher than the general Canadian population (Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, 2013b; Frohlich, Ross, & Richmond, ⁎ Corresponding author. E-mail addresses: [email protected] (S. Spurr), [email protected] (J. Bally), [email protected] (C. Bullin), [email protected] (K. Trinder).
http://dx.doi.org/10.1016/j.pedn.2017.05.011 0882-5963/© 2017 Elsevier Inc. All rights reserved.
2006). Among Canadian Aboriginals, the incidence of type 2 diabetes is estimated at 1.54 per 100,000 per year in children and adolescents b 18 years of age (Amed et al., 2010). However, Amed et al.'s (2010) study is based on census population data collected from physician visits and incidents rates that were calculated based solely on the diagnosis of type 2 diabetes. In the present study, community-based screening was undertaken to identify undiagnosed cases of prediabetes and type 2 diabetes. The prevalence of prediabetes in adolescents has not been explored in the last 20 years in Canada (Dean, 1998a). Of the risk factors for type 2 diabetes, the primary ones for children and adolescents are poor nutrition and limited physical activity, which result in an unhealthy body weight (WHO, 2016). Additional risk factors include ethnicity (Aboriginal decent), family history, smoking, genetic predisposition, and gestational diabetes (Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, 2013a). The majority of the abovementioned risk factors are modifiable, and are therefore critical to explore and address at early stages of development when healthy habits can be established and then maintained into adulthood. Early intervention in Aboriginal communities necessitates access to multi-disciplinary health care services including nursing, nutrition,
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exercise therapy, and eye-related services, which are essential for atrisk and diabetic individuals (Kim & Driver, 2015). However, Aboriginal communities are often remote and therefore geographically isolated, resulting in limited access to primary, secondary, and tertiary care (Kim & Driver, 2015). Therefore, initial screening for prediabetes must be completed in conjunction with routine follow-up and ideally performed as early as possible. Optimally, these screening clinics could be led by pediatric, community, and diabetes nurses, nurse educators, nurse practitioners, and certified diabetes educators, already located in communities, and who have specialized knowledge and clinical expertise in the prevention, detection, and treatment of type 2 diabetes. A number of studies have examined the projected incidence rates and potential risk factors for type 2 diabetes in the adolescent population (Amed et al., 2010; Dart et al., 2014; Dean, 1998a). However, the majority of data available comes from reviews of diabetic clinics, and few studies are population based (Nadeau & Dabelea, 2008). Of these studies, only one focused on an Aboriginal adolescent population (Dean, 1998b). As such, the true prevalence rate of type 2 diabetes and prediabetes may be underestimated specifically in the Aboriginal adolescent cohort. This paper reports findings from a quantitative study conducted with adolescents living in northern Canadian communities. The purpose of this study was to investigate the risk factors and prevalence rates of prediabetes and type 2 diabetes among adolescents living in northern Canadian communities of which the majority were of Aboriginal decent. In this article, new and unique findings are reported from a population-based investigation into the risk factors and prevalence of prediabetes and type 2 diabetes. To our knowledge, this is the first study examining the prevalence of prediabetes in Canadian Aboriginal adolescents in the last decade. Aboriginal peoples are a constitutionally recognized population in Canada. Those who self-identify as being Aboriginal include First Nations (North American Indian), Metis or Inuit peoples, and/or those who registered under the Indian Act of Canada, and/or those who reported membership in a First Nation or Indian band (Statistics Canada, 2015). For the purpose of the article, the general term “Aboriginal” was used. This research was guided by the following questions: 1) Are the following risk factors present in adolescents attending secondary school and living in three northern Canadian, predominantly Aboriginal communities: ethnicity; elevated body mass index; elevated blood glucose tolerance; and, elevated blood pressure? 2) What are the prevalence rates of prediabetes and type 2 diabetes in adolescents attending secondary school and living in three northern Canadian, predominantly Aboriginal communities?
Methods Ethical approval from the University Research Ethics Board, the Northern Inter-tribal Health Authority, and the Keewatin Yatthe and Mamawhetan Health Regions were obtained along with permission from the superintendent of the school systems, the principals of the participating schools, and the parents of the adolescent participants. The principles of OCAP™ (ownership, control, access, possession) were adhered to throughout the project. Participants including, parents, adolescents, teachers, and community members, were consulted regarding, and agreed to the importance of undertaking this study. Meetings were held to consult with parents of the adolescent participants, the principals, and the band leader to ensure ownership, appropriate involvement, and direction in the research project, enabling Aboriginal peoples with self-determination over research that concerns their well-being (The First Nations Information Governance Centre, 2014). Prior to data collection, the principal spoke to the adolescents and provided opportunities for involvement and understanding the research at each school. All students enrolled in the participating schools were invited to take part in this study through an informed and signed consent.
Results were explained in person and in writing to the parents by the project nurses. Study Design In this exploratory quantitative study, participants were screened for identification of risk for prediabetes and type 2 diabetes through the collection of demographic data, family history, anthropometric measurements, blood pressure (BP), and a Hemoglobin A1c (HbA1c) blood glucose test. The Sample High school students (n = 160) in three northern Canadian communities were assessed for risk and prevalence of type 2 diabetes. Response rates for all sites are outlined in Table 1. Extending the sample to three northern communities allowed for a broad sample that was predominantly representative of the Aboriginal populations. A purposeful sample of adolescents who met the inclusion criteria was recruited. The inclusion criteria were as follows: a) 13–21 years old, b) in grades 9– 12, c) enrolled in at least one class in the high school, and d) present in school on the day of data collection. Procedures Three nursing faculty completed the screening process at each of the participating schools. A research assistant (RA) distributed and collected prepackaged consent forms to the students prior to the assessment. To maintain confidentiality, all participants were provided with a unique identifying code by the RA. Informed, written consent was obtained from each participant prior to their involvement in the study. In addition, parental consent was obtained for each child who participated. During informed consent the purpose and related procedures, potential benefits and risks, confidentiality, right to withdraw, and contact information for the research team and ethics board were provided and described in detail to the participants, parents, and teachers. Additionally, students were informed that their participation in, or withdrawal from the study would not impact their academic standing in any way. Participants were told that if they had any questions, or if they wanted to find out about the results of this study they could contact a research team member at any time. Anthropometry, Blood Pressure, and Diabetes Measurements As recommended by the Canadian Diabetes Association (CDA) (Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, 2013a), anthropometric measurements included weight, Table 1 Demographics by community. Site 1
Response rate Gender Male Female Ethnicity Aboriginal Non-Aboriginal Age 13 14 15 16 17 18 19+
Site 2
Site 3
Total
N
%
N
%
N
%
N
%
59
21%
52
60%
49
46%
160
34%
29 30
49% 51%
27 25
52% 48%
25 24
51% 49%
81 79
51% 49%
48 11
81% 19%
52 0
100% 0%
48 1
98% 2%
148 12
93% 8%
0 1 16 13 13 11 5
0% 2% 27% 22% 22% 19% 8%
6 15 9 7 7 5 3
12% 29% 17% 14% 14% 10% 6%
3 10 13 4 8 5 6
6% 20% 27% 8% 16% 10% 12%
9 26 38 24 28 21 14
6% 16% 24% 15% 18% 13% 9%
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height, and body mass index (BMI) (Harris, Bhattacharyya, Dyck, & Toth, 2013). Weight and height were measured using standard procedures and then BMI was calculated and used to classify overweight and obesity according to the Center for Disease Control (CDC) growth charts (Center for Disease Control, 2010). For those students who were 19 years of age or younger, BMI was interpreted as standard deviations and percentiles in relation to age and gender. Following WHO guidelines, those with a BMI N 1 standard deviation for their age were considered overweight and those with a BMI N 2 standard deviations for their age were considered obese. For those who were N 19 years old, a BMI of 25 or greater was classified as overweight and a BMI of 30 or greater was considered obese (WHO, 2016). Blood pressure was measured in each participant. Following National Institute of Health (NIH) guidelines (2005) for those ≤19 years of age, hypertension was defined as systolic and/or diastolic blood pressure at or above the 95th percentile for gender, age, and height. Those with a systolic or diastolic measure at or greater than the 90th percentile but less than the 95th percentile were considered to have prehypertension. For those who were N19 years old, abnormal increases in BP was defined as higher than 120/80 mmHg, and the table outlined by the NIH was used to categorize the stages of high BP (NIH: National Heart, 2005). Hemoglobin A1C is used to identify those with/at risk for diabetes as it provides measurement of glycated hemoglobin (%HbA1c). Nowicka et al., 2011). An A1C Now+ (Polymer Technology Systems Inc. Indianapolis, Indiana) point-of-care assay test was used to measure levels of glucose tolerance. Percent HbA1c monitors glucose control over the last three months. Results of HbA1c approximate the following time intervals: 50% (previous month); ~ 25% (previous month to 2 months) and ~ 25% (past 2 to 3 months). (Berard, Blumer, Houlden, Miller, & Woo, 2013). Accuracy studies have been conducted with the A1C Now using 189 patients both with and without diabetes across three United States sites. A1C Now results were compared to the National Glycohemoglobin Standardization Program (NGSP) reference results, which demonstrated the capillary samples to be 99% accurate (Holmes et al., 2008). In the present study, and in keeping with the purpose of the study to screen adolescents for risk of prediabetes and type 2 diabetes, levels between 5.7 and 6.4% were considered an indicator of prediabetes, and any level above 6.5% was considered to be high risk for diabetes (American Diabetes Association, 2016). All participants who tested above 5.7% were referred to their family physician for further followup and testing. Other validated risk factors identified by the CDA were also used to screen for risk of type 2 diabetes, including demographic data and a family history in a first- or second-degree relative (Panagiotopoulos et al., 2013). Specifically, the CDA identified demographic risk factors for type 2 diabetes including age, gender, and ethnicity (Aboriginal, Métis, both Aboriginal and Métis, or Non-Aboriginal). The participants were also asked about their personal medical history related to diabetes. Analysis Descriptive and inferential statistics were computed using the Statistical Package for Social Sciences (SPSS v.22.0) and used to establish risk and prevalence rates for prediabetes and type 2 diabetes in Aboriginal adolescents living in the three northern Canadian communities. Further, chi-square analyses were conducted to investigate if the risk factors of hypertension and obesity occurred at higher frequencies for males and females who presented with an increased HbA1c level. Results A total of 160 participants were screened for risk factors and prevalence of prediabetes and type 2 diabetes. The sample had a similar representation of male (N = 81) and female (N = 79) participants. No significant differences in gender distribution were found between
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sites. Students ranged in age from 13 to 21 years old (M = 16.03, SD = 1.83). Most students had at least one risk factor, as 92.5% were of Aboriginal ancestry. Seventy-three percent of students had two or more risk factors, while 39% had at least three risk factors. Percentage of students by number of risk factors is reported in Fig. 1. Ethnicity Overall, 92.5% of students (N = 148) were of Aboriginal ancestry and 7.5% (N = 12) were not. Of those who self-identified as Aboriginal, 57.4% (N = 85) identified as First Nations, 28.4% (N = 42) identified as Métis, and 14.2% (N = 21) identified as both. Body Mass Index Height and weight were measured to calculate BMI. Overall, 60% (N = 96) were an average weight, 22.5% (N = 36) were overweight, and 17.5% (N = 28) were obese. Chi-square analyses indicated no statistically significant differences for the three sites or for gender. A notable percentage of males (33%) and females (46.8%) were classified as overweight or obese. Weight classification by gender is reported in Fig. 2. Blood Glucose Tolerance A1c point of care test was used to evaluate participant blood glucose levels. Overall, 89.9% had HbA1c levels b 5.7% and 10.1% had levels between 5.7 and 6.4%; percentages by gender are reported in Fig. 3. Statistically significant differences between sites and gender were not found. A small percentage of males and a smaller percentage of females had HbA1c values between 5.7 and 6.4%. Blood Pressure 0.09pt?>Overall, 73.4% (N = 116) had normal blood pressure and 26.6% (N = 42) had prehypertension or hypertension. Percentages by gender are reported in Fig. 4. Equivalent numbers of males and females were classified as having either prehypertension or hypertension. Statistically significant differences were not found between the three sites or gender. Blood Pressure and Weight Classification for Participants with an Elevated HbA1c Level Further analysis showed that the 50% of the participants with an elevated HbA1c were also overweight/obese and 31% were prehypertensive/hypertensive. Reaching borderline significance (p = 0.05), females with an elevated HbA1c level appear to be more likely to have hypertension than males with elevated HbA1c or males and females with normal HbA1c levels. In addition, 43% of females with an elevated HbA1c and who were classified as prediabetic were hypertensive and 14% were prehypertensive (Fig. 5). In comparison, only 11% of the males who were classified as prediabetic were hypertensive and none were prehypertensive. With respect to the risk factor of overweight or obese, chi-square analyses indicated that the percentages of students classified as average weight, overweight, and obese were not statistically different for males and females with normal or elevated HbA1c levels. Of the females who were prediabetic, however, 14% were overweight and 43% were obese. For the males who presented with prediabetes, 22% were overweight and 22% were obese (Fig. 5). Discussion The results of this study show that Aboriginal Canadian adolescents have significant risk factors for type 2 diabetes, with an average of 73%
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Fig. 1. Percentage of students by number of risk factors.
presenting with two or more risk factors including Aboriginal ethnicity, family history, overweight/obesity, and prehypertension/hypertension. This evidence is consistent with other studies examining prevalence of risk factors for type 2 diabetes in adolescents (Dean, Young, Flett, & Wood-Steiman, 1998; Dyck, Osgood, Gao, & Stang, 2012). In addition, the prevalence rates of overweight/obese (41%) and prehypertensive/ hypertensive (27%) in the present study are congruent with other studies that report an established pattern of increased levels of obesity (56.3%) in Aboriginal adolescents and hypertension (20%) in adolescents generally (Kolahdooz, Sadeghirad, Corriveau, & Sharma, 2015; McNiece et al., 2007).These results confirm that this trend persists in Aboriginal adolescents living in northern Canadian communities. Because overweight and hypertension are modifiable risk factors for type 2 diabetes, validating the prevalence of these risk factors in Aboriginal adolescents illustrates the continued need to develop culturally appropriate interventions in collaboration with the community members and are designed to promote healthy body weights, physical activity, and healthy eating in this population. In addition to the increased number of risk factors in this population are data indicating increasing prevalence of type 2 diabetes in adolescents (Dean, 1998b). One study reported incidence rates of type 2 diabetes in Canadian adolescents as 1.54/100,000 children (Amed et al.,
2010); 58% of these clients were female and 44% of newly diagnosed cases of type 2 diabetes were Aboriginal children. A unique finding of the present study is that 10% of the participants were prediabetic with an HbA1c N 5.7%, with similar numbers for males (11%) and females (9%). These rates of prediabetes are significantly higher than the reported prevalence of type 2 diabetes (Amed et al., 2010; Dean, 1998b) and illustrate large numbers of young Aboriginal adolescents may remain undiagnosed in northern Canadian communities. These results are disconcerting as these adolescents are at increased risk of developing type 2 diabetes. In addition, recent research suggests that the development of complications with type 2 diabetes in adolescents may occur more quickly than in adults, and thus may impact their future health and quality of life (Dyck, Jiang, & Osgood, 2014). As such, these new and unique findings related to prevalence rates for prediabetes confirm the need for renewed vigilance to promote early and targeted screening for prediabetes and type 2 diabetes in Aboriginal adolescents. Another unique finding is that hypertension occurred at a high overall frequency (31%) for those participants with an elevated HbA1c. An additional concern relates to the borderline significance (p = 0.05) whereby females with an elevated HbA1c level appear to be more likely to have hypertension than males with elevated HbA1c or males and females with normal HbA1c levels. Also alarming was the finding that
Fig. 2. Weight classification by gender.
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Fig. 3. A1C classification by gender.
over half of the prediabetic (57%) females were prehypertensive/ hypertensive in comparison to the prediabetic males (11%). These blood pressure results are significantly higher than a previous study in which 28% of the adolescents (males and females) were hypertensive at the time of diagnosis of type 2 diabetes (Amed et al., 2010). This first assessment of hypertension in prediabetic adolescents provides additional insight into understanding type 2 diabetes in Aboriginal adolescents. Specifically, the high rate of prehypertension/hypertension in prediabetic females is a new and unique finding. These results illustrate the need to explore possible gender differences in relation to prehypertension/hypertension and the prevalence of type 2 diabetes in Aboriginal adolescents. Diagnosis at a younger age is potentially protective, and therefore, the importance of implementing a type 2 diabetes screening program for young Aboriginal adolescents is highlighted (Dart et al., 2014). In addition to the elevated blood pressure in the prediabetic participants were elevated rates of overweight/obesity (50%). Again, the female rates (57%) were higher than the males (44%). A National Surveillance study reported a clinical feature of increased obesity (95%) rates at the time of type 2 diagnosis (Amed et al., 2010). In addition, and similar to the present study's findings, previous researchers argue that the epidemic of childhood obesity has disproportionately
affected young Aboriginal females (Dyck et al., 2012). Because obesity is the most important risk factor for type 2 diabetes, the prediabetic adolescents identified as overweight/obese in this study may be at serious risk of many health problems including the development of type 2 diabetes (Amed et al., 2010). As such, the findings of this study reaffirm the need to initiate diabetes prevention programs and campaigns to attempt to slow the increasing rates of obesity and type 2 diabetes in Aboriginal adolescents (Canadian Pediatric Society, 2016). Practice Implications The findings reported herein provide a deeper understanding of the prevalence and risk of type 2 diabetes in northern Canadian Aboriginal adolescents. The rate of prediabetes is a new and unique finding to this population and is relevant to a multitude of health care providers, particularly nurses who are most often the first point of entry into the health system. As such, nurses are in an optimal position to consider establishing health promoting strategies and screening programs that are adapted to the realities and culture of Aboriginal peoples (Venne, 2011). For example, the proposed lifestyle interventions for enhancing healthy body weights include increased physical activity and healthy eating which require a highly intensive, individualized plan delivered by a
Fig. 4. Blood pressure classification by gender.
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Fig. 5. Blood pressure and weight classification for those with elevated A1C by gender.
multidisciplinary team including pediatric, community, and diabetes nurses, nurse educators, certified diabetes educators, exercise specialists, registered dieticians, and physicians. This plan should be personalized taking into account financial resources, and emphasize the importance of all health care providers being receptive and respectful of the cultural practices of the family (Samaan, 2013). Given the finding that Aboriginal Canadian adolescents have significant risk factors for type 2 diabetes including Aboriginal ethnicity, family history, overweight/obesity, and prehypertension/hypertension, consideration for cultural practices that may contribute to childhood obesity need to be considered. Cultural practices may include child feeding habits, food consumption, utilization of health services, physical activity, and perception of risk associated with obesity (Caprio et al., 2008). Pediatric, community, and diabetes nurses, nurse educators, certified diabetes educators, and clinical nurse specialists work closely with families and adolescents and are well-positioned to better understand the cultural context associated with the experience of diabetes, including the cause, course, and perceptions of diabetes as an illness (Caprio et al., 2008). These nurses have the opportunity to play a key role in the promotion of healthy lifestyles with the goal of improving health outcomes in Aboriginal adolescents. Due to the increased risk of developing prediabetes and type 2 diabetes, it is important that health care providers engage and collaborate with Aboriginal communities to develop culturally appropriate screening and health promoting strategies.
diabetes, including Aboriginal ancestry, family history, overweight/obesity, and hypertension. Of the adolescents included in this study, 10% had an HbA1c N 5.7%, 22.5% were overweight, 17.5% were obese, and 26.6% had prehypertension or hypertension. This is troubling because prediabetes and type 2 diabetes result from these modifiable risk factors. As this study is the first to examine the prevalence of prediabetes in Canadian Aboriginal adolescents, the findings underscore the necessity for early screening of Aboriginal adolescents for both prediabetes and type 2 diabetes. Recommendations toward positive health outcomes include consistent screening beginning at an early age, followed by culturally appropriate interventions that are specific to the modifiable risk factors (overweight/obesity and hypertension), including those that promote healthy body weights, physical activity, and healthy eating in this population. Importantly, future research should be not only directed toward the development of interventions but also address how the social determinants of health impact the effectiveness of interventions in this population. Further research is also needed to explore possible gender differences in relation to prehypertension/hypertension and the prevalence of type 2 diabetes in Aboriginal adolescents. Continued research and the development of modifiable risk factor interventions have the potential to prevent the progression of prediabetes to diabetes and reduce complications related to type 2 diabetes in young Aboriginal adolescent populations.
Limitations
Acknowledgments
This study was conducted using a modest sample of adolescents. However, the participants were from three northern Canadian communities, which allowed for a broad sample that was representative of Métis and First Nation populations. As such, these findings are reflective of Aboriginal adolescents in a western Canadian province and appear congruent with global findings (Pinhas-Hamiel & Zeitler, 2005; WHO, 2016). Further investigation with a larger sample inclusive of other locations and subsequent research designs including a glucose challenge or fasting blood glucose measurement for type 2 diabetes is indicated to validate these results.
Funding to conduct this research was provided by the Retina Foundation of Canada. This organization was not involved in any of the research processes including the writing of this manuscript nor the decision to submit for publication.
Conclusions Prediabetes and type 2 diabetes are emerging as serious health concerns for Aboriginal adolescents living in northern Canadian communities. This exploratory study has identified that a high percentage of the sample presented with multiple risk factors for prediabetes and type 2
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Kim, J., & Driver, D. D. (2015). Teleophthalmology for First Nations clients at risk of diabetic retinopathy: A mixed methods evaluation. JMIR Medical Information, 3(1), e10. Kolahdooz, F., Sadeghirad, B., Corriveau, A., & Sharma, S. (2015). Prevalence of overweight and obesity among Aboriginal populations in Canada: A systematic review and metaanalysis. Critical Reviews in Food Science and Nutrition Retrieved from http://www. ncbi.nlm.nih.gov/pubmed/26566086. McNiece, K. L., Poffenbarger, T. S., Turner, J. L., Franco, K. D., Sorof, J. M., & Portman, R. J. (2007). Prevalence of hypertension and pre-hypertension among adolescents. Journal of Pediatrics, 150(6), 640–644 644 e1. Retrieved from http://www.ncbi.nlm. nih.gov/pubmed/17517252. Nadeau, K., & Dabelea, D. (2008). Epidemiology of type 2 diabetes in children and adolescents. Endocrine Research, 33(1–2), 35–58. National Institutes of Health: National Heart, L., and Blood Institute (2005o). Diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Retrieved from https://www.nhlbi.nih.gov/files/docs/resources/heart/hbp_ped.pdf. Nowicka, P., Santoro, N., Liu, H., Lartaud, D., Shaw, M. M., Goldberg, R., ... Caprio, S. (2011). Utility of hemoglobin A(1c) for diagnosing prediabetes and diabetes in obese children and adolescents. Diabetes Care, 34(6), 1306–1311 Retrieved from. http://www. ncbi.nlm.nih.gov/pubmed/21515842. Panagiotopoulos, C., Riddell, M. C., & Sellers, E. A. (2013). Type 2 diabetes in children and adolescents. Canadian Journal of Diabetes, 37(Suppl. 1), S163–S167 Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24070942. Pinhas-Hamiel, O., & Zeitler, P. (2005). The global spread of type 2 diabetes mellitus in children and adolescents. Journal of Pediatrics, 146(5), 693–700 Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15870677. Samaan, M. C. (2013). Management of pediatric and adolescent type 2 diabetes. International Journal of Pediatrics, 2013, 1–9. Statistics Canada (2015). Aboriginal identity of person. Retrieved from http://www. statcan.gc.ca/eng/concepts/definitions/aboriginal2. The First Nations Information Governance Centre (2014). The First Nations Information Governance Centre. Ownership, Control, Access and Possession (OCAP™): The path to first nations information governance. Retrieved from http://fnigc.ca/sites/ default/files/docs/ocap_path_to_fn_information_governance_en_final.pdf. Venne, J. (2011). Aboriginal Canadians' ocular and visual health: A daunting challenge. Opt!k, 10, 36–53. World Health Organization (2016). Growth reference 5–19 years. Retrieved from http:// www.who.int/growthref/who2007_bmi_for_age/en/. World Health Organization (WHO) (2016). Global report on diabetes. Retrieved from http://apps.who.int/iris/bitstream/10665/204871/1/9789241565257_eng.pdf.
Contents lists available at ScienceDirect
Journal of Pediatric Nursing
Type 2 Diabetes in Canadian Aboriginal Adolescents: Risk Factors and Prevalence Shelley Spurr a,⁎, Jill Bally a, Carol Bullin a, Krista Trinder b a b
University of Saskatchewan, College of Nursing, 104 Clinic Place, Saskatoon, Saskatchewan S7N 2Z4, Canada University of Saskatchewan, College of Medicine, 5B57.1 Health Sciences Building, Saskatoon, Saskatchewan S7N 2Z4, Canada
a r t i c l e
i n f o
Article history: Received 21 March 2017 Revised 19 May 2017 Accepted 28 May 2017 Available online xxxx Keywords: Type 2 diabetes Adolescents Aboriginal Risk factors Prevalence
a b s t r a c t Purpose: To identify the risk factors and prevalence rates of prediabetes and type 2 diabetes among northern Canadian Aboriginal adolescents. Design and Methods: In this novel exploratory, quantitative study, 160 high school students (aged 13–21) from three northern, predominantly Canadian Aboriginal communities were screened for risk for prediabetes and type 2 diabetes including demographic data, family medical history, anthropometric measurements, blood pressure, and hemoglobin A1c (HbA1c). Descriptive and inferential statistics, in addition to chi-square analysis, were used to establish risk and prevalence rates for prediabetes and type 2 diabetes in Aboriginal adolescents. Results: At least half of the adolescents presented with multiple risk factors for type 2 diabetes. In this sample, 10% had an HbA1c N 5.7%, 22.5% were overweight, 17.5% were obese, and 26.6% had prehypertension or hypertension. Conclusions: Prediabetes and type 2 diabetes are emerging as serious health concerns for young Aboriginal Canadians. This is troubling because both result from modifiable risk factors. As this study is the first to examine the prevalence of prediabetes in Canadian Aboriginal adolescents in the last decade, the findings underscore the necessity for early screening of Aboriginal adolescents for both prediabetes and type 2 diabetes. Practice Implications: Recommendations toward positive health outcomes include the introduction of early age screening programs, followed by culturally relevant interventions, specific to the modifiable risk factors (overweight/obesity and hypertension), and developed in collaboration with the communities. Such approaches have the potential to prevent the progression of prediabetes to diabetes and reduce complications related to type 2 diabetes. © 2017 Elsevier Inc. All rights reserved.
An estimated 422 million people worldwide were living with diabetes in 2014; this represents a four-fold increase over the estimated 108 million in 1980 (World Health Organization (WHO), 2016), and this number is expected to climb to 552 million by 2030 (International Diabetes Foundation, 2016). While type 2 diabetes has typically impacted middle-aged populations and the elderly, it has also become increasingly prevalent in children and adolescents (WHO, 2016). Overall, type 2 diabetes is increasing in adolescents worldwide (Amed et al., 2010; Nadeau & Dabelea, 2008), with a projected 49% incidence increase over the next 40 years (Imperatore et al., 2012). Children who come from marginalized groups, including Aboriginal descent, are disproportionately affected by type 2 diabetes (Panagiotopoulos, Riddell, & Sellers, 2013). Canadian Aboriginals (First Nation, Métis, and Inuit) in particular are excessively affected by diabetes and related complications, with a rate of incidence that is 3–5 times higher than the general Canadian population (Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, 2013b; Frohlich, Ross, & Richmond, ⁎ Corresponding author. E-mail addresses: [email protected] (S. Spurr), [email protected] (J. Bally), [email protected] (C. Bullin), [email protected] (K. Trinder).
http://dx.doi.org/10.1016/j.pedn.2017.05.011 0882-5963/© 2017 Elsevier Inc. All rights reserved.
2006). Among Canadian Aboriginals, the incidence of type 2 diabetes is estimated at 1.54 per 100,000 per year in children and adolescents b 18 years of age (Amed et al., 2010). However, Amed et al.'s (2010) study is based on census population data collected from physician visits and incidents rates that were calculated based solely on the diagnosis of type 2 diabetes. In the present study, community-based screening was undertaken to identify undiagnosed cases of prediabetes and type 2 diabetes. The prevalence of prediabetes in adolescents has not been explored in the last 20 years in Canada (Dean, 1998a). Of the risk factors for type 2 diabetes, the primary ones for children and adolescents are poor nutrition and limited physical activity, which result in an unhealthy body weight (WHO, 2016). Additional risk factors include ethnicity (Aboriginal decent), family history, smoking, genetic predisposition, and gestational diabetes (Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, 2013a). The majority of the abovementioned risk factors are modifiable, and are therefore critical to explore and address at early stages of development when healthy habits can be established and then maintained into adulthood. Early intervention in Aboriginal communities necessitates access to multi-disciplinary health care services including nursing, nutrition,
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exercise therapy, and eye-related services, which are essential for atrisk and diabetic individuals (Kim & Driver, 2015). However, Aboriginal communities are often remote and therefore geographically isolated, resulting in limited access to primary, secondary, and tertiary care (Kim & Driver, 2015). Therefore, initial screening for prediabetes must be completed in conjunction with routine follow-up and ideally performed as early as possible. Optimally, these screening clinics could be led by pediatric, community, and diabetes nurses, nurse educators, nurse practitioners, and certified diabetes educators, already located in communities, and who have specialized knowledge and clinical expertise in the prevention, detection, and treatment of type 2 diabetes. A number of studies have examined the projected incidence rates and potential risk factors for type 2 diabetes in the adolescent population (Amed et al., 2010; Dart et al., 2014; Dean, 1998a). However, the majority of data available comes from reviews of diabetic clinics, and few studies are population based (Nadeau & Dabelea, 2008). Of these studies, only one focused on an Aboriginal adolescent population (Dean, 1998b). As such, the true prevalence rate of type 2 diabetes and prediabetes may be underestimated specifically in the Aboriginal adolescent cohort. This paper reports findings from a quantitative study conducted with adolescents living in northern Canadian communities. The purpose of this study was to investigate the risk factors and prevalence rates of prediabetes and type 2 diabetes among adolescents living in northern Canadian communities of which the majority were of Aboriginal decent. In this article, new and unique findings are reported from a population-based investigation into the risk factors and prevalence of prediabetes and type 2 diabetes. To our knowledge, this is the first study examining the prevalence of prediabetes in Canadian Aboriginal adolescents in the last decade. Aboriginal peoples are a constitutionally recognized population in Canada. Those who self-identify as being Aboriginal include First Nations (North American Indian), Metis or Inuit peoples, and/or those who registered under the Indian Act of Canada, and/or those who reported membership in a First Nation or Indian band (Statistics Canada, 2015). For the purpose of the article, the general term “Aboriginal” was used. This research was guided by the following questions: 1) Are the following risk factors present in adolescents attending secondary school and living in three northern Canadian, predominantly Aboriginal communities: ethnicity; elevated body mass index; elevated blood glucose tolerance; and, elevated blood pressure? 2) What are the prevalence rates of prediabetes and type 2 diabetes in adolescents attending secondary school and living in three northern Canadian, predominantly Aboriginal communities?
Methods Ethical approval from the University Research Ethics Board, the Northern Inter-tribal Health Authority, and the Keewatin Yatthe and Mamawhetan Health Regions were obtained along with permission from the superintendent of the school systems, the principals of the participating schools, and the parents of the adolescent participants. The principles of OCAP™ (ownership, control, access, possession) were adhered to throughout the project. Participants including, parents, adolescents, teachers, and community members, were consulted regarding, and agreed to the importance of undertaking this study. Meetings were held to consult with parents of the adolescent participants, the principals, and the band leader to ensure ownership, appropriate involvement, and direction in the research project, enabling Aboriginal peoples with self-determination over research that concerns their well-being (The First Nations Information Governance Centre, 2014). Prior to data collection, the principal spoke to the adolescents and provided opportunities for involvement and understanding the research at each school. All students enrolled in the participating schools were invited to take part in this study through an informed and signed consent.
Results were explained in person and in writing to the parents by the project nurses. Study Design In this exploratory quantitative study, participants were screened for identification of risk for prediabetes and type 2 diabetes through the collection of demographic data, family history, anthropometric measurements, blood pressure (BP), and a Hemoglobin A1c (HbA1c) blood glucose test. The Sample High school students (n = 160) in three northern Canadian communities were assessed for risk and prevalence of type 2 diabetes. Response rates for all sites are outlined in Table 1. Extending the sample to three northern communities allowed for a broad sample that was predominantly representative of the Aboriginal populations. A purposeful sample of adolescents who met the inclusion criteria was recruited. The inclusion criteria were as follows: a) 13–21 years old, b) in grades 9– 12, c) enrolled in at least one class in the high school, and d) present in school on the day of data collection. Procedures Three nursing faculty completed the screening process at each of the participating schools. A research assistant (RA) distributed and collected prepackaged consent forms to the students prior to the assessment. To maintain confidentiality, all participants were provided with a unique identifying code by the RA. Informed, written consent was obtained from each participant prior to their involvement in the study. In addition, parental consent was obtained for each child who participated. During informed consent the purpose and related procedures, potential benefits and risks, confidentiality, right to withdraw, and contact information for the research team and ethics board were provided and described in detail to the participants, parents, and teachers. Additionally, students were informed that their participation in, or withdrawal from the study would not impact their academic standing in any way. Participants were told that if they had any questions, or if they wanted to find out about the results of this study they could contact a research team member at any time. Anthropometry, Blood Pressure, and Diabetes Measurements As recommended by the Canadian Diabetes Association (CDA) (Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, 2013a), anthropometric measurements included weight, Table 1 Demographics by community. Site 1
Response rate Gender Male Female Ethnicity Aboriginal Non-Aboriginal Age 13 14 15 16 17 18 19+
Site 2
Site 3
Total
N
%
N
%
N
%
N
%
59
21%
52
60%
49
46%
160
34%
29 30
49% 51%
27 25
52% 48%
25 24
51% 49%
81 79
51% 49%
48 11
81% 19%
52 0
100% 0%
48 1
98% 2%
148 12
93% 8%
0 1 16 13 13 11 5
0% 2% 27% 22% 22% 19% 8%
6 15 9 7 7 5 3
12% 29% 17% 14% 14% 10% 6%
3 10 13 4 8 5 6
6% 20% 27% 8% 16% 10% 12%
9 26 38 24 28 21 14
6% 16% 24% 15% 18% 13% 9%
S. Spurr et al. / Journal of Pediatric Nursing 36 (2017) 111–117
height, and body mass index (BMI) (Harris, Bhattacharyya, Dyck, & Toth, 2013). Weight and height were measured using standard procedures and then BMI was calculated and used to classify overweight and obesity according to the Center for Disease Control (CDC) growth charts (Center for Disease Control, 2010). For those students who were 19 years of age or younger, BMI was interpreted as standard deviations and percentiles in relation to age and gender. Following WHO guidelines, those with a BMI N 1 standard deviation for their age were considered overweight and those with a BMI N 2 standard deviations for their age were considered obese. For those who were N 19 years old, a BMI of 25 or greater was classified as overweight and a BMI of 30 or greater was considered obese (WHO, 2016). Blood pressure was measured in each participant. Following National Institute of Health (NIH) guidelines (2005) for those ≤19 years of age, hypertension was defined as systolic and/or diastolic blood pressure at or above the 95th percentile for gender, age, and height. Those with a systolic or diastolic measure at or greater than the 90th percentile but less than the 95th percentile were considered to have prehypertension. For those who were N19 years old, abnormal increases in BP was defined as higher than 120/80 mmHg, and the table outlined by the NIH was used to categorize the stages of high BP (NIH: National Heart, 2005). Hemoglobin A1C is used to identify those with/at risk for diabetes as it provides measurement of glycated hemoglobin (%HbA1c). Nowicka et al., 2011). An A1C Now+ (Polymer Technology Systems Inc. Indianapolis, Indiana) point-of-care assay test was used to measure levels of glucose tolerance. Percent HbA1c monitors glucose control over the last three months. Results of HbA1c approximate the following time intervals: 50% (previous month); ~ 25% (previous month to 2 months) and ~ 25% (past 2 to 3 months). (Berard, Blumer, Houlden, Miller, & Woo, 2013). Accuracy studies have been conducted with the A1C Now using 189 patients both with and without diabetes across three United States sites. A1C Now results were compared to the National Glycohemoglobin Standardization Program (NGSP) reference results, which demonstrated the capillary samples to be 99% accurate (Holmes et al., 2008). In the present study, and in keeping with the purpose of the study to screen adolescents for risk of prediabetes and type 2 diabetes, levels between 5.7 and 6.4% were considered an indicator of prediabetes, and any level above 6.5% was considered to be high risk for diabetes (American Diabetes Association, 2016). All participants who tested above 5.7% were referred to their family physician for further followup and testing. Other validated risk factors identified by the CDA were also used to screen for risk of type 2 diabetes, including demographic data and a family history in a first- or second-degree relative (Panagiotopoulos et al., 2013). Specifically, the CDA identified demographic risk factors for type 2 diabetes including age, gender, and ethnicity (Aboriginal, Métis, both Aboriginal and Métis, or Non-Aboriginal). The participants were also asked about their personal medical history related to diabetes. Analysis Descriptive and inferential statistics were computed using the Statistical Package for Social Sciences (SPSS v.22.0) and used to establish risk and prevalence rates for prediabetes and type 2 diabetes in Aboriginal adolescents living in the three northern Canadian communities. Further, chi-square analyses were conducted to investigate if the risk factors of hypertension and obesity occurred at higher frequencies for males and females who presented with an increased HbA1c level. Results A total of 160 participants were screened for risk factors and prevalence of prediabetes and type 2 diabetes. The sample had a similar representation of male (N = 81) and female (N = 79) participants. No significant differences in gender distribution were found between
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sites. Students ranged in age from 13 to 21 years old (M = 16.03, SD = 1.83). Most students had at least one risk factor, as 92.5% were of Aboriginal ancestry. Seventy-three percent of students had two or more risk factors, while 39% had at least three risk factors. Percentage of students by number of risk factors is reported in Fig. 1. Ethnicity Overall, 92.5% of students (N = 148) were of Aboriginal ancestry and 7.5% (N = 12) were not. Of those who self-identified as Aboriginal, 57.4% (N = 85) identified as First Nations, 28.4% (N = 42) identified as Métis, and 14.2% (N = 21) identified as both. Body Mass Index Height and weight were measured to calculate BMI. Overall, 60% (N = 96) were an average weight, 22.5% (N = 36) were overweight, and 17.5% (N = 28) were obese. Chi-square analyses indicated no statistically significant differences for the three sites or for gender. A notable percentage of males (33%) and females (46.8%) were classified as overweight or obese. Weight classification by gender is reported in Fig. 2. Blood Glucose Tolerance A1c point of care test was used to evaluate participant blood glucose levels. Overall, 89.9% had HbA1c levels b 5.7% and 10.1% had levels between 5.7 and 6.4%; percentages by gender are reported in Fig. 3. Statistically significant differences between sites and gender were not found. A small percentage of males and a smaller percentage of females had HbA1c values between 5.7 and 6.4%. Blood Pressure 0.09pt?>Overall, 73.4% (N = 116) had normal blood pressure and 26.6% (N = 42) had prehypertension or hypertension. Percentages by gender are reported in Fig. 4. Equivalent numbers of males and females were classified as having either prehypertension or hypertension. Statistically significant differences were not found between the three sites or gender. Blood Pressure and Weight Classification for Participants with an Elevated HbA1c Level Further analysis showed that the 50% of the participants with an elevated HbA1c were also overweight/obese and 31% were prehypertensive/hypertensive. Reaching borderline significance (p = 0.05), females with an elevated HbA1c level appear to be more likely to have hypertension than males with elevated HbA1c or males and females with normal HbA1c levels. In addition, 43% of females with an elevated HbA1c and who were classified as prediabetic were hypertensive and 14% were prehypertensive (Fig. 5). In comparison, only 11% of the males who were classified as prediabetic were hypertensive and none were prehypertensive. With respect to the risk factor of overweight or obese, chi-square analyses indicated that the percentages of students classified as average weight, overweight, and obese were not statistically different for males and females with normal or elevated HbA1c levels. Of the females who were prediabetic, however, 14% were overweight and 43% were obese. For the males who presented with prediabetes, 22% were overweight and 22% were obese (Fig. 5). Discussion The results of this study show that Aboriginal Canadian adolescents have significant risk factors for type 2 diabetes, with an average of 73%
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Fig. 1. Percentage of students by number of risk factors.
presenting with two or more risk factors including Aboriginal ethnicity, family history, overweight/obesity, and prehypertension/hypertension. This evidence is consistent with other studies examining prevalence of risk factors for type 2 diabetes in adolescents (Dean, Young, Flett, & Wood-Steiman, 1998; Dyck, Osgood, Gao, & Stang, 2012). In addition, the prevalence rates of overweight/obese (41%) and prehypertensive/ hypertensive (27%) in the present study are congruent with other studies that report an established pattern of increased levels of obesity (56.3%) in Aboriginal adolescents and hypertension (20%) in adolescents generally (Kolahdooz, Sadeghirad, Corriveau, & Sharma, 2015; McNiece et al., 2007).These results confirm that this trend persists in Aboriginal adolescents living in northern Canadian communities. Because overweight and hypertension are modifiable risk factors for type 2 diabetes, validating the prevalence of these risk factors in Aboriginal adolescents illustrates the continued need to develop culturally appropriate interventions in collaboration with the community members and are designed to promote healthy body weights, physical activity, and healthy eating in this population. In addition to the increased number of risk factors in this population are data indicating increasing prevalence of type 2 diabetes in adolescents (Dean, 1998b). One study reported incidence rates of type 2 diabetes in Canadian adolescents as 1.54/100,000 children (Amed et al.,
2010); 58% of these clients were female and 44% of newly diagnosed cases of type 2 diabetes were Aboriginal children. A unique finding of the present study is that 10% of the participants were prediabetic with an HbA1c N 5.7%, with similar numbers for males (11%) and females (9%). These rates of prediabetes are significantly higher than the reported prevalence of type 2 diabetes (Amed et al., 2010; Dean, 1998b) and illustrate large numbers of young Aboriginal adolescents may remain undiagnosed in northern Canadian communities. These results are disconcerting as these adolescents are at increased risk of developing type 2 diabetes. In addition, recent research suggests that the development of complications with type 2 diabetes in adolescents may occur more quickly than in adults, and thus may impact their future health and quality of life (Dyck, Jiang, & Osgood, 2014). As such, these new and unique findings related to prevalence rates for prediabetes confirm the need for renewed vigilance to promote early and targeted screening for prediabetes and type 2 diabetes in Aboriginal adolescents. Another unique finding is that hypertension occurred at a high overall frequency (31%) for those participants with an elevated HbA1c. An additional concern relates to the borderline significance (p = 0.05) whereby females with an elevated HbA1c level appear to be more likely to have hypertension than males with elevated HbA1c or males and females with normal HbA1c levels. Also alarming was the finding that
Fig. 2. Weight classification by gender.
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Fig. 3. A1C classification by gender.
over half of the prediabetic (57%) females were prehypertensive/ hypertensive in comparison to the prediabetic males (11%). These blood pressure results are significantly higher than a previous study in which 28% of the adolescents (males and females) were hypertensive at the time of diagnosis of type 2 diabetes (Amed et al., 2010). This first assessment of hypertension in prediabetic adolescents provides additional insight into understanding type 2 diabetes in Aboriginal adolescents. Specifically, the high rate of prehypertension/hypertension in prediabetic females is a new and unique finding. These results illustrate the need to explore possible gender differences in relation to prehypertension/hypertension and the prevalence of type 2 diabetes in Aboriginal adolescents. Diagnosis at a younger age is potentially protective, and therefore, the importance of implementing a type 2 diabetes screening program for young Aboriginal adolescents is highlighted (Dart et al., 2014). In addition to the elevated blood pressure in the prediabetic participants were elevated rates of overweight/obesity (50%). Again, the female rates (57%) were higher than the males (44%). A National Surveillance study reported a clinical feature of increased obesity (95%) rates at the time of type 2 diagnosis (Amed et al., 2010). In addition, and similar to the present study's findings, previous researchers argue that the epidemic of childhood obesity has disproportionately
affected young Aboriginal females (Dyck et al., 2012). Because obesity is the most important risk factor for type 2 diabetes, the prediabetic adolescents identified as overweight/obese in this study may be at serious risk of many health problems including the development of type 2 diabetes (Amed et al., 2010). As such, the findings of this study reaffirm the need to initiate diabetes prevention programs and campaigns to attempt to slow the increasing rates of obesity and type 2 diabetes in Aboriginal adolescents (Canadian Pediatric Society, 2016). Practice Implications The findings reported herein provide a deeper understanding of the prevalence and risk of type 2 diabetes in northern Canadian Aboriginal adolescents. The rate of prediabetes is a new and unique finding to this population and is relevant to a multitude of health care providers, particularly nurses who are most often the first point of entry into the health system. As such, nurses are in an optimal position to consider establishing health promoting strategies and screening programs that are adapted to the realities and culture of Aboriginal peoples (Venne, 2011). For example, the proposed lifestyle interventions for enhancing healthy body weights include increased physical activity and healthy eating which require a highly intensive, individualized plan delivered by a
Fig. 4. Blood pressure classification by gender.
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Fig. 5. Blood pressure and weight classification for those with elevated A1C by gender.
multidisciplinary team including pediatric, community, and diabetes nurses, nurse educators, certified diabetes educators, exercise specialists, registered dieticians, and physicians. This plan should be personalized taking into account financial resources, and emphasize the importance of all health care providers being receptive and respectful of the cultural practices of the family (Samaan, 2013). Given the finding that Aboriginal Canadian adolescents have significant risk factors for type 2 diabetes including Aboriginal ethnicity, family history, overweight/obesity, and prehypertension/hypertension, consideration for cultural practices that may contribute to childhood obesity need to be considered. Cultural practices may include child feeding habits, food consumption, utilization of health services, physical activity, and perception of risk associated with obesity (Caprio et al., 2008). Pediatric, community, and diabetes nurses, nurse educators, certified diabetes educators, and clinical nurse specialists work closely with families and adolescents and are well-positioned to better understand the cultural context associated with the experience of diabetes, including the cause, course, and perceptions of diabetes as an illness (Caprio et al., 2008). These nurses have the opportunity to play a key role in the promotion of healthy lifestyles with the goal of improving health outcomes in Aboriginal adolescents. Due to the increased risk of developing prediabetes and type 2 diabetes, it is important that health care providers engage and collaborate with Aboriginal communities to develop culturally appropriate screening and health promoting strategies.
diabetes, including Aboriginal ancestry, family history, overweight/obesity, and hypertension. Of the adolescents included in this study, 10% had an HbA1c N 5.7%, 22.5% were overweight, 17.5% were obese, and 26.6% had prehypertension or hypertension. This is troubling because prediabetes and type 2 diabetes result from these modifiable risk factors. As this study is the first to examine the prevalence of prediabetes in Canadian Aboriginal adolescents, the findings underscore the necessity for early screening of Aboriginal adolescents for both prediabetes and type 2 diabetes. Recommendations toward positive health outcomes include consistent screening beginning at an early age, followed by culturally appropriate interventions that are specific to the modifiable risk factors (overweight/obesity and hypertension), including those that promote healthy body weights, physical activity, and healthy eating in this population. Importantly, future research should be not only directed toward the development of interventions but also address how the social determinants of health impact the effectiveness of interventions in this population. Further research is also needed to explore possible gender differences in relation to prehypertension/hypertension and the prevalence of type 2 diabetes in Aboriginal adolescents. Continued research and the development of modifiable risk factor interventions have the potential to prevent the progression of prediabetes to diabetes and reduce complications related to type 2 diabetes in young Aboriginal adolescent populations.
Limitations
Acknowledgments
This study was conducted using a modest sample of adolescents. However, the participants were from three northern Canadian communities, which allowed for a broad sample that was representative of Métis and First Nation populations. As such, these findings are reflective of Aboriginal adolescents in a western Canadian province and appear congruent with global findings (Pinhas-Hamiel & Zeitler, 2005; WHO, 2016). Further investigation with a larger sample inclusive of other locations and subsequent research designs including a glucose challenge or fasting blood glucose measurement for type 2 diabetes is indicated to validate these results.
Funding to conduct this research was provided by the Retina Foundation of Canada. This organization was not involved in any of the research processes including the writing of this manuscript nor the decision to submit for publication.
Conclusions Prediabetes and type 2 diabetes are emerging as serious health concerns for Aboriginal adolescents living in northern Canadian communities. This exploratory study has identified that a high percentage of the sample presented with multiple risk factors for prediabetes and type 2
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