CMAJ Research

Epidemiology of diabetes mellitus among First Nations and

non-First Nations adults

Roland Dyck MD, Nathaniel Osgood PhD, Ting Hsiang Lin PhD, Amy Gao BSc, Mary Rose Stang PhD

Previously published at [Link]

Abstract In Saskatchewan in 1937, diabetes was not detected among

the 1500 First Nations people who underwent a tuberculosis
Background: First Nations people in Canada experience a survey.4 By 1990, almost 10% of the province’s First Nations
disproportionate burden of type 2 diabetes mellitus. To
adults had diabetes;5 by 2006, the proportion was over 20%,6
increase our understanding of this evolving epidemic, we
compared the epidemiology of diabetes between First
while it remained at about 6% in the general population.5,6
Nations and non-First Nations adults in Saskatchewan from Although an increased prevalence of diabetes among First
1980 to 2005. Nations people has also been documented in other Canadian
provinces,3 only recently have consistent diabetes case defini-
Methods: We used administrative databases to perform a
tions applied to health care system administrative databases
population-based study of diabetes frequency, incidence and
prevalence in adults by ethnic background, year, age and sex.
been used to compare differences between large populations
of First Nations and non-First Nations people.7–9
Results: We identified 8275 First Nations and 82 306 non- We sought to describe the epidemiology of diabetes in
First Nations people with diabetes from 1980 to 2005. Over- Saskatchewan from 1980 to 2005. We reasoned that finding
all, the incidence and prevalence of diabetes were more
ethnicity-based differences in trends and patterns of type 2
than 4 times higher among First Nations women than
among non-First Nations women and more than 2.5 times
diabetes over the longest period reported for a Canadian juris-
higher among First Nations men than among non-First diction would help to clarify the underlying mechanisms
Nations men. The number of incident cases of diabetes was behind known disparities and translate into more effective
highest among First Nations people aged 40–49 ,while the diabetes prevention and management initiatives.
number among non-First Nations people was greatest in
those aged 70 or more years. The prevalence of diabetes Methods
increased over the study period from 9.5% to 20.3%
among First Nations women and from 4.9% to 16.0% Study population
among First Nations men. Among non-First Nations people,
The population of Saskatchewan was about one million peo-
the prevalence increased from 2.0% to 5.5% among
women and from 2.0% to 6.2% among men. By 2005, ple throughout the study period. About 99% (both First
almost 50% of First Nations women and more than 40% of Nations and non-First Nations people) were beneficiaries of a
First Nations men aged 60 or older had diabetes, compared universal health care system and were recorded in the Min-
with less than 25% of non-First Nations men and less than istry of Health’s insurance registry.10 These health care bene-
20% of non-First Nations women aged 80 or older. ficiaries made up the total annual populations for this study,
Interpretation: First Nations adults are experiencing a dia- as they have for other population-based research.11,12 We sub-
betes epidemic that disproportionately affects women during divided the annual populations into First Nations and non-
their reproductive years. This ethnicity-based pattern suggests First Nations people. First Nations people are indigenous to
diverse underlying mechanisms that may include differences Canada and, for the purposes of this study, were identifiable
in the diabetogenic impact of gestational diabetes. in the Ministry of Health databases as individuals (both those
who lived on- or off-reserve) registered under Section 6 of the
Indian Act of Canada and who were assigned a 10-digit num-

T
he global epidemic of type 2 diabetes mellitus dis- ber in the Indian Registry.13 The proportion of all provincial
proportionately affects indigenous and developing health care beneficiaries represented by registered First
populations.1 Although genotypic variants related to Nations people grew from about 5% to 10% during the study
energy balance may underlie this epidemic,2 the rapid emer-
DOI:10.1503/cmaj.090846

gence of type 2 diabetes in genetically diverse populations

worldwide is most likely caused by environmental factors. From the Departments of Medicine (Dyck), Computer Science (Osgood, Gao)
and Community Health and Epidemiology (Dyck, Osgood), University of
Increasing rates of type 2 diabetes among Canada’s First Saskatchewan, Saskatoon, Sask.; the Department of Statistics (Lin), National
Nations people, for example, parallel an epidemic of over- Taipei University, Taiwan; and the Ministry of Health (Stang), Government
of Saskatchewan, Regina, Sask.
weight and obesity that has coincided with socio-cultural
disruption and a loss of traditional lifestyles.3 CMAJ 2010. DOI:10.1503/cmaj.090846

CMAJ • FEBRUARY 23, 2010 • 182(3) 249

© 2010 Canadian Medical Association or its licensors
Research

period.14 Most people categorized as “non-First Nations” are year in which the individual met the diabetes case definition
of European origin but about 5% are of mixed European and (after two years with no diabetes diagnosis). The incident
First Nations heritage (Metis). Less than 0.5% of the non- counts for 2004 and 2005 were underestimated because meet-
First Nations population are nonregistered First Nations peo- ing the case definition required up to two years. For each year
ple who are not in the Indian Registry.15 after the diabetes incident year, the case was counted as a
This study was approved by the University of Saskatch- prevalent case. Annual prevalence counts did not include inci-
ewan Ethics Review Board. dent cases. We could not distinguish between types 1 and 2
We identified people with diabetes using a validated algo- diabetes, but less than 2% of patients with new diabetes each
rithm16 based on the National Diabetes Surveillance System case year are under age 20,17 which is the age group with the high-
definitions.7 The case definition required one hospital discharge est incidence of type 1 diabetes.18
(hospital separation database), two physician service claims
(medical claims database) or a physician service claim followed Statistical analysis
by a hospital discharge for diabetes (ICD-9 250 or ICD-10-CA We obtained de-identified diabetes incident and prevalent
E10–E14) within any 730 day period. We excluded diabetes case counts by five-year age group, sex and First Nations sta-
records related to gestational records to ensure that gestational tus for 1980–2005 from the Ministry of Health. We deter-
diabetes cases were not counted as diabetes cases. mined the annual crude, age- and sex-specific and age-stan-
We defined the diabetes incident year as the first calendar dardized incidence and prevalence rates of diabetes for First

Table 1: Case counts and age-standardized incidence of diabetes by sex and ethnic background among adults,1980–2005

First Nations Non-First Nations First Nations Non-First Nations

women women men men
Year No. Per 1000 No. Per 1000 Incidence ratio No. Per 1000 No. Per 1000 Incidence ratio
(95% CI) (95% CI)

1980 118 22.71 1 389 4.50 5.05 (4.31–5.91) 79 12.06 1 636 5.07 2.38 (1.97–2.87)
1981 84 15.15 1 404 4.46 3.40 (2.82–4.09) 69 11.24 1 627 5.03 2.23 (1.83–2.74)
1982 106 19.82 1 343 4.22 4.70 (3.98–5.54) 88 13.43 1 596 4.95 2.71 (2.27–3.25)
1983 120 21.13 1 352 4.19 5.05 (4.31–5.90) 89 12.48 1 638 5.03 2.48 (2.07–2.97)
1984 122 23.06 1 339 4.07 5.66 (4.85–6.61) 90 12.11 1 506 4.57 2.65 (2.22–3.17)
1985 121 22.73 1 185 3.53 6.44 (5.50–7.53) 86 12.59 1 399 4.20 3.00 (2.50–3.60)
1986 127 22.00 1 312 3.92 5.61 (4.81–6.53) 104 14.62 1 533 4.64 3.15 (2.67–3.72)
1987 146 21.97 1 273 3.76 5.85 (5.07–6.75) 117 15.72 1 540 4.67 3.37 (2.87–3.94)
1988 121 16.48 1 292 3.81 4.32 (3.70–5.06) 114 15.43 1 537 4.65 3.32 (2.83–3.90)
1989 114 13.63 1 222 3.58 3.81 (3.24–4.47) 105 12.32 1 464 4.42 2.79 (2.36–3.29)
1990 128 16.08 1 143 3.33 4.83 (4.15–5.63) 89 10.22 1 397 4.21 2.43 (2.03–2.91)
1991 153 17.03 1 145 3.33 5.12 (4.44–5.90) 102 12.37 1 409 4.32 2.86 (2.42–3.39)
1992 155 19.38 1 347 3.91 4.95 (4.31–5.70) 117 11.55 1 507 4.54 2.54 (2.17–2.98)
1993 168 19.12 1 285 3.68 5.20 (4.54–5.95) 127 12.75 1 529 4.63 2.75 (2.37–3.21)
1994 190 17.41 1 191 3.42 5.09 (4.47–5.78) 134 12.81 1 434 4.33 2.95 (2.55–3.43)
1995 184 16.38 1 259 3.59 4.56 (4.00–5.19) 150 13.37 1 499 4.50 2.97 (2.58–3.42)
1996 184 15.29 1 268 3.60 4.25 (3.74–4.84) 137 12.42 1 616 4.79 2.59 (2.24–3.00)
1997 196 15.68 1 580 4.47 3.51 (3.10–3.97) 159 13.26 1 762 5.30 2.50 (2.18–2.87)
1998 206 16.83 1 508 4.24 3.97 (3.52–4.49) 203 16.73 1 904 5.60 2.99 (2.64–3.37)
1999 245 19.10 1 612 4.46 4.28 (3.83–4.80) 208 17.08 2 035 5.86 2.92 (2.59–3.29)
2000 244 19.57 1 759 4.92 3.98 (3.56–4.45) 202 16.38 2 036 5.99 2.73 (2.42–3.09)
2001 298 19.96 1 796 4.99 4.00 (3.61–4.44) 216 16.28 2 282 6.62 2.46 (2.19–2.76)
2002 280 18.06 1 974 5.42 3.33 (3.00–3.70) 246 17.73 2 504 7.26 2.44 (2.19–2.73)
2003 263 17.95 1 883 5.29 3.39 (3.05–3.78) 249 17.80 2 315 6.77 2.63 (2.36–2.93)
2004* 250 18.23 1 956 5.44 3.35 (3.00–3.74) 245 18.49 2 311 6.67 2.77 (2.48–3.09)
2005* 223 13.43 1 585 4.32 3.11 (2.76–3.50) 203 14.81 1 886 5.44 2.72 (2.41–3.07)
Total 4 546 37 403 3 729 44 903

Note: CI = confidence interval.

*Case counts and incidence are underestimated for 2004 and 2005 because the case definition required up to 2 years.

250 CMAJ • FEBRUARY 23, 2010 • 182(3)

 Research

Nations and non-First Nations adults (aged ≥ 20 years). For The highest diabetes rates were among First Nations women,
diabetes prevalence calculations, we included all Ministry of while non-First Nations women had the lowest rates (Fig-
Health beneficiaries in the denominator.10,14 To calculate dia- ure 1, Figure 2). There was a slight convergence in diabetes
betes incidence, we first subtracted prevalent diabetes cases. rates between First Nations men and women over time, which
Age-standardized rate calculations used the direct method was associated with a decrease in the incidence of diabetes
standardized to the 1991 Canadian census population. We among women and an increase among men. However, the
compared the rates in First Nations and non-First Nations prevalence of diabetes remained more than 25% higher
people by calculating annual incidence and prevalence rate among First Nations women than among First Nations men
ratios. by 2005. From 1980 to 2005, the prevalence of diabetes more
than doubled among First Nations women (9.51% to 20.33%)
Results and more than tripled among First Nations men (4.94% to
16.01%). Among non-First Nations people, the rates of
Of the 90 581 cases of incident diabetes from 1980 to 2005 change were similar, with an increase from 2.01% to 5.51%
(Table 1), 8275 were in First Nations people (45% men) and among women and from 2.01% to 6.24% among men.
82 306 were in non-First Nations people (55% men). Overall, Figure 3 shows the age-specific diabetes incident case
the incidence (Table 1) and prevalence (Table 2) were more counts and incidence over time. The most consistent finding
than 4 times higher among First Nations women than among was a progressive increase in the number of new cases within
non-First Nations women and more than 2.5 times higher each age group between 1980 2005. Exceptions were older
among First Nations men than among non-First Nations men. non-First Nations adults who experienced a slight decline in

Table 2: Case counts and age-standardized prevalence of diabetes by sex and ethnic background among adults, 1980–2005

First Nations Non-First Nations First Nations Non-First Nations

women women men men
Year No. Per 100 No. Per 100 Prevalence ratio No. Per 100 No. Per 100 Prevalence ratio
(95% CI) (95% CI)

1980 532 9.51 6 601 2.01 4.72 (4.62–4.83) 323 4.94 6 933 2.01 2.46 (2.39–2.54)
1981 635 11.10 7 496 2.25 4.94 (4.84–5.04) 387 5.76 8 058 2.31 2.50 (2.43–2.57)
1982 695 11.73 8 461 2.48 4.73 (4.64–4.82) 449 6.41 9 138 2.59 2.48 (2.41–2.54)
1983 781 12.73 9 311 2.68 4.75 (4.67–4.84) 522 7.30 10 158 2.85 2.56 (2.50–2.62)
1984 883 14.00 10 123 2.86 4.90 (4.82–4.99) 594 8.06 11 168 3.09 2.60 (2.55–2.66)
1985 972 14.90 10 903 3.02 4.93 (4.85–5.01) 659 8.60 11 998 3.28 2.62 (2.56–2.67)
1986 1 056 15.48 11 480 3.15 4.92 (4.84–5.00) 711 9.11 12 695 3.45 2.64 (2.59–2.70)
1987 1 151 15.81 12 185 3.30 4.80 (4.72–4.87) 786 9.71 13 418 3.61 2.69 (2.64–2.74)
1988 1 269 16.13 12 794 3.42 4.71 (4.64–4.78) 883 10.38 14 207 3.80 2.73 (2.68–2.78)
1989 1 347 15.77 13 462 3.57 4.42 (4.36–4.49) 969 10.84 14 966 3.99 2.72 (2.67–2.76)
1990 1 425 15.82 14 008 3.67 4.31 (4.25–4.37) 1 043 11.11 15 555 4.13 2.69 (2.64–2.73)
1991 1 514 16.30 14 465 3.78 4.32 (4.26–4.38) 1 093 11.37 16 012 4.27 2.67 (2.62–2.71)
1992 1 611 16.28 14 900 3.84 4.24 (4.19–4.30) 1 156 11.49 16 471 4.35 2.64 (2.60–2.69)
1993 1 726 16.71 15 496 3.95 4.23 (4.17–4.29) 1 231 11.58 17 042 4.45 2.60 (2.56–2.64)
1994 1 846 17.13 15 961 4.04 4.24 (4.18–4.29) 1 313 11.97 17 603 4.59 2.61 (2.57–2.64)
1995 1 982 17.25 16 303 4.09 4.22 (4.17–4.27) 1 391 11.99 17 978 4.64 2.58 (2.55–2.62)
1996 2 124 17.43 16 780 4.17 4.18 (4.13–4.24) 1 500 12.24 18 468 4.71 2.60 (2.56–2.64)
1997 2 248 17.63 17 188 4.26 4.14 (4.09–4.19) 1 582 12.63 18 989 4.84 2.61 (2.57–2.65)
1998 2 388 17.66 17 857 4.38 4.03 (3.99–4.08) 1 694 12.74 19 609 4.93 2.58 (2.55–2.62)
1999 2 531 17.81 18 481 4.46 3.99 (3.95–4.04) 1 849 13.12 20 395 5.04 2.60 (2.57–2.64)
2000 2 706 18.67 19 170 4.68 3.99 (3.94–4.03) 1 981 13.80 21 227 5.33 2.59 (2.56–2.62)
2001 2 869 18.77 19 876 4.81 3.90 (3.86–3.94) 2 125 14.15 21 991 5.45 2.60 (2.57–2.63)
2002 3 105 19.24 20 649 4.96 3.88 (3.84–3.92) 2 280 14.63 23 042 5.65 2.59 (2.56–2.62)
2003 3 302 19.76 21 623 5.20 3.80 (3.76–3.84) 2 460 15.46 24 242 5.96 2.59 (2.56–2.62)
2004 3 478 19.95 22 333 5.33 3.74 (3.70–3.78) 2 624 15.60 25 139 6.08 2.57 (2.54–2.59)
2005 3 659 20.33 23 280 5.51 3.69 (3.65–3.73) 2 791 16.01 26 118 6.24 2.57 (2.54–2.59)

Note: CI = confidence interval.

CMAJ • FEBRUARY 23, 2010 • 182(3) 251

Research

the number of diabetes cases in the late 1980s and early age group (≥ 70 years). There were more diabetes cases in
1990s. The most striking difference between First Nations First Nations women than men, particularly during the repro-
and non-First Nations people was the age at which most new ductive years, and there were more diabetes cases among
diabetes cases occurred. Those peaked in the 40–49 year age non-First Nations men than women, particularly during mid-
group for both First Nations men and women, while most dle age and older. Finally, although peak age-
new cases among non-First Nations people were in the oldest specific diabetes incidence and incident case counts both

First Nations women

25
First Nations men
Non-First Nations women
Non-First Nations men
Diabetes Incidence/1000 people

20

15

10

0
80

82

84

86

88

90

92

94

96

98

00

02

04

05
19

19

19

19

19

19

19

19

19

19

20

20

20

20
Year

Figure 1: Age-standardized diabetes incidence by ethnic background and sex.

First Nations women

0.25 First Nations men
Non-First Nations women
Non-First Nations men

0.2
Diabetes prevalence

0.15

0.1

0.05

0
80

82

84

86

88

90

92

94

96

98

00

02

04

05
19

19

19

19

19

19

19

19

19

19

20

20

20

20

Year

Figure 2: Age-standardized diabetes prevalence by ethnic background and sex.

252 CMAJ • FEBRUARY 23, 2010 • 182(3)

 Research

occurred in the oldest non-First Nations group (≥ 70), there period reported for a Canadian jurisdiction. We found distinct
was a 20-year difference between the peak in new diabetes differences between populations that extend beyond known
cases (ages 40–49) and incidence (ages 60–69) among First disparities in the rates of diabetes. Thus, diabetes is a disease
Nations people. of young First Nations adults with a marked predilection for
Figure 4 shows that, with few exceptions, there was a pro- women. In contrast, diabetes is a disease of aging non-First
gressive increase in the age-specific diabetes prevalence over Nations adults that is more common among men. These
time in all groups. The largest increases occurred after age observations suggest fundamental differences between popu-
40 among First Nations people and after age 50 among non- lations in the mechanisms underlying diabetes; this has wide-
First Nations people. Among First Nations adults, the preva- spread implications that are probably also relevant to other
lence of diabetes was highest between ages 60 and 75. In indigenous and developing populations.1
contrast, the prevalence was highest after age 80 among non- Our findings are consistent with reports that used similar
First Nations adults. By 2005, almost 50% of First Nations methods8,9 to show higher prevalence of diabetes among
women and more than 40% of First Nations men aged 60 and First Nations people than among non-First Nations people in
older had diabetes, compared with the highest levels of less neighbouring provinces. This difference appears to be at
than 25% observed among non-First Nations people aged 80 least partly because of higher rates of overweight and obe-
or older. sity among First Nations people.3,19,20 Because of a longer
study duration and the inclusion of more detailed incidence
Interpretation data, we have now shown that First Nations people also
have markedly different trends and patterns of diabetes than
This study describes the epidemiology of diabetes among non-First Nations people. Among non-First Nations people,
First Nations and non-First Nations adults over the longest the prevalence of diabetes was identical among men and

400 40 4000 40
First Nations women Non-First Nations women
350 35 3500 35

Incidence/1000 people
300 30 3000 30
Case counts

250 25 2500 25

200 20 2000 20

150 15 1500 15

100 10 1000 10

50 5 500 5

0 0 0 0
20–29 30–39 40–49 50–59 60–69 ≥ 70 20–29 30–39 40–49 50–59 60–69 ≥ 70

400 40 4000 40
First Nations men Non-First Nations men
350 35 3500 35

300 30 3000 30

Incidence/1000 people
Case counts

250 25 2500 25

200 20 2000 20

150 15 1500 15

100 10 1000 10

50 5 500 5

0 0 0 0
20–29 30–39 40–49 50–59 60–69 ≥ 70 20–29 30–39 40–49 50–59 60–69 ≥ 70

Age, yr Age, yr

1981–1985 1991–1995 1988–1992 incidence

1986–1990 1996–2000 1998–2002 incidence
2001–2005

Figure 3: Age-specific diabetes incident case counts and incidence by period.

CMAJ • FEBRUARY 23, 2010 • 182(3) 253

Research

women in 1980, but it was substantially higher among men Despite very low rates of type 1 diabetes in North Ameri-
by 2005. This corresponded to a divergence in the incidence can Aboriginal people,18,22 most incident cases of diabetes
of diabetes between the sexes, which is possibly related to a occurred in young First Nations adults. Furthermore, the con-
greater increase in BMI observed in Canadian men than sistently higher rates of diabetes among First Nations women
women during this period.21 Among First Nations people, than among First Nations men was related to an excess bur-
the prevalence of diabetes was almost twice as high among den of diabetes in women aged 20–49. What could account
women as it was among men in the early 1980s, and a large for this striking sex difference? One possibility is the higher
absolute difference has persisted. Although there was con- rates of overweight and obesity among First Nations
siderable annual variation in the incidence (probably partly women.19,23 Another factor may be the high rates of gestational
because of small numbers), the incidence was consistently diabetes that were present before the significant occurrence of
higher among First Nations women. Differences in inci- type 2 diabetes in northern First Nations communities;23 ges-
dence between the sexes have diminished over time, how- tational diabetes is strongly linked to pre-pregnancy over-
ever, and it is possible that the large decrease in diabetes weight and obesity.24 Because gestational diabetes is a predic-
incidence among women in the late 1980s was accentuated tor for type 2 diabetes in affected women, 25 female
by the passage of Bill C-31 in 1985. This primarily re- populations with high rates of prepregnancy overweight and
instated young urban First Nations women to the Indian obesity and gestational diabetes could experience a resultant
Registry and would have increased the corresponding study intragenerational increase in the rate of type 2 diabetes.
denominators.13 Gestational diabetes has also been implicated in an inter-

0.6 0.6
First Nations women Non-First Nations women
0.5 0.5
Diabetes prevalence

0.4 0.4

0.3 0.3

0.2 0.2

0.1 0.1

0 0
2 3 4 ≥ 20 2 3 3 4 4 5 5 6 6 7 7 ≥
20 3 4 5 5 6 6 7 7
–2 5–2 0–3 5–3 0–4 5–4 0–5 5–5 0–6 5–6 0–7 5–7 80 –2 5–2 0–3 5–3 0–4 5–4 0–5 5–5 0–6 5–6 0–7 5–7 80
4 9 4 9 4 9 4 9 4 9 4 9 4 9 4 9 4 9 4 9 4 9 4 9

0.6 0.6
First Nations men Non-First Nations men

0.5 0.5
Diabetes prevalence

0.4 0.4

0.3 0.3

0.2 0.2

0.1 0.1

0
0
20 2 3 3 4 4 5 5 6 6 7 7 ≥ 20 2 3 3 4 4 5 5 6 6 7 7 ≥
–2 5–2 0–3 5–3 0–4 5–4 0–5 5–5 0–6 5–6 0–7 5–7 80 –2 5–2 0–3 5–3 0–4 5–4 0–5 5–5 0–6 5–6 0–7 5–7 80
4 9 4 9 4 9 4 9 4 9 4 9 4 9 4 9 4 9 4 9 4 9 4 9
Age, yr Age, yr
1980 1990 2005

Figure 4: Age-specific diabetes prevalence in 1980, 1990 and 2005.

254 CMAJ • FEBRUARY 23, 2010 • 182(3)

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generational “vicious cycle”26 by increasing the risk of type 2 criteria between First Nations and non-First Nations people.
diabetes among the offspring.22,26 This is supported by the However, a decrease in diagnostic fasting plasma glucose was
early appearance of gestational diabetes among First Nations widely instituted in 199733 and was followed by an expected
people23 and its association with increasing rates of high birth rise in diabetes incidence in all study groups.
weight,27 a predictor of diabetes among First Nations peo- Limitations of the study included an inability to identify
ple.28 A recommendation from the Fifth International Work- Aboriginal people other than First Nations, reducing the true
shop on Gestational Diabetes was to clarify the intergenera- differences between First Nations and non-First Nations peo-
tional diabetogenic role of gestational diabetes.29 We believe ple. Second, identifying cases using administrative data is
that it is equally important to clarify its intragenerational likely to underestimate the incidence and prevalence of dia-
impact and are currently attempting to gain insights into the betes.8,16 Third, we could not differentiate between type 1 and
relative contribution of each through the use of simulation type 2 diabetes. However, less than 3% of all non-First
modelling.30 Nations diabetes incident cases occurred among people aged
The contrasting demographic features of diabetes in First 20–29, the adult group most likely to develop type 1 diabetes.
Nations and non-First Nations people have different implica- Furthermore, type 1 diabetes is very uncommon among First
tions for prevention, screening, management and allocation Nations people, including children.18,21,22 Thus, inclusion of
of health care resources. We highlight three examples. First, type 1 diabetes cases would have only marginally increased
with respect to screening and primary prevention initiatives the rates of diabetes among non-First Nations people and
for First Nations people, our findings support an emphasis on would have likely reduced the true differences between First
children and young adults.31 We believe that there is suffi- Nations and non-First Nations people.
cient evidence for both an intra- and intergenerational dia- Fourth, some prevalent cases of diabetes may have been mis-
betogenic role of gestational diabetes to focus primary pre- classified as incident cases at the beginning of the study because
vention initiatives on the time before and during the of delayed diagnosis or limitations of the algorithm. This could
reproductive years of First Nations women. Programs have contributed to the initial decline in diabetes incidence
designed to prevent gestational diabetes, ensure universal observed in all groups. Finally, we were not able to determine
gestational diabetes screening, optimize management of dia- the rate of diabetes by location. However, the rates are currently
betic pregnancies and provide follow-up initiatives for higher in rural areas34 and are consistently lower among northern
women who have experienced gestational diabetes have the compared with southern First Nations people.5,8,9
potential to reduce the rate of type 2 diabetes in mothers and
their offspring. Conclusion
Second, the large difference in the age of diabetes onset This study shows marked differences in the epidemiology of
between First Nations and non-First Nations people could type 2 diabetes between First Nations and non-First Nations
contribute to distinct patterns of chronic complications people. Whether this is because of relative differences in the
because of differential mortality and differential exposure to genetics of energy balance interacting with other differences
the metabolic effects of diabetes. Although speculative, the in the environmental determinants of obesity and carbohy-
duration of exposure to diabetes and its interaction with other drate intolerance is still uncertain. Complicating this further is
variables (e.g., quality of diabetes management) might be an the emerging possibility that epigenetic phenomena may play
important determinant in the relative likelihood of developing a role.35 What is clear is that the rapid appearance of type 2
specific diabetic complications such as diabetic end-stage diabetes particularly among First Nations people and other
renal disease.32 This should also be a priority area for future indigenous and developing populations has been precipitated
research. by environmental rather than genetic factors. Its long-term
Finally, the trends reported here indicate that the preva- solution will require effective primary prevention initiatives
lence of diabetes among both First Nations and non-First that are population-based and driven by public health and
Nations people is likely to continue increasing in the foresee- community initiatives.
able future, particularly as the large cohort of children and
teenagers that make up about half of the First Nations popu- This article has been peer reviewed.
lation enter young adulthood. In addition, an earlier “baby Competing interests: None declared.
boom” among non-First Nations people is approaching the
Contributors: Roland Dyck conceived and designed the study, acquired,
age during which it will also be at the highest risk of dia- analyzed and interpreted the data, and drafted the article. Mary Rose Stang
betes. We are now beginning a period in which two helped design the study and acquired the data. Nathaniel Osgood analyzed
markedly different cohorts will simultaneously experience an and interpreted the data. Ting Hsiang Lin and Amy Gao analyzed the data.
increase in diabetes. Nathaniel Osgood, Ting Hsiang Lin, Mary Rose Stang and Amy Gao revised
the manuscript critically for important intellectual content. All of the authors
gave final approval of the version submitted for publication.
Strengths and limitations
Acknowledgement: This study is based in part on nonidentifiable data pro-
The strengths of this study included its duration, use of a vali- vided by the Saskatchewan Ministry of Health. The interpretations and con-
dated algorithm to identify diabetes cases,7,16 the use of data clusions of this article do not necessarily represent those of the Government
for total populations, and the ability to subdivide the popula- of Saskatchewan or the Saskatchewan Ministry of Health.
tion by ethnic background. We are not aware of systematic Funding: There was no external funding for this study. The Saskatchewan
differences in strategies for diabetes screening or diagnostic Ministry of Health did not provide funding for this study.

CMAJ • FEBRUARY 23, 2010 • 182(3) 255

Research

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