Preventing diabetes complications such as amputations begins with reducing the risk of developing type 2 diabetes and ensuring that all forms of diabetes are detected promptly. 

Primary care is an important setting for people to regularly access diabetes prevention interventions, including programs for smoking cessation, cardiovascular risk reduction, physical activity, weight loss and healthy behaviour interventions. Most screenings for type 2 diabetes also take place in primary care. Screening is recommended every 3 years starting at age 40, or earlier if the patient is at high risk.Reference2

Surveillance activities, public health promotion and policy development also play a critical role in the prevention and early detection of diabetes. These efforts facilitate interventions that increase awareness of risk factors for diabetes, promote healthier environments (e.g., walkable neighbourhoods to support regular physical activity, improved access to healthier foods) and make screening for diabetes more widely available.Reference3

Understanding inequalities in diabetes risk factors, access to primary care and early detection is a first step for developing targeted risk reduction interventions. 

• 2% of people in Canada are living with undiagnosed diabetes,Reference4 leading to missed opportunities for early intervention. 
• Many people in Canada struggle to access a regular health care provider. Some groups, including men and people with a lower household income or lower educational attainment, are less likely to have a regular primary care provider in Canada.Reference5 Reference6
• A study of primary care settings in Alberta found that diabetes screening guidelines were met less often for men than for women. Adherence to the guidelines was lowest for young men.Reference7
• Smoking, poor nutrition, food insecurity and low physical activity are among the risk factors for developing type 2 diabetes.Reference1 Reference3 These circumstances are more common for those with lower income.Reference1 Smoking prevalence is also higher among men, people with lower educational attainment and people living in remote areas.Reference1 Reference8
• Smoking cessation attempts are less successful among people with lower socio-economic status (SES). Compared with people with higher SES, they face greater systemic barriers to quitting, including higher levels of stress.Reference9 ������ϱ� systems can increase rates of cessation through more consistent delivery of evidence-based treatment, including pharmacotherapy and counselling, in primary care settings. Clinicians have cited barriers to delivering these kinds of treatments, including the lack of time, training and practice supports for delivering accessible smoking cessation interventions.Reference10

For the 3.7 million people diagnosed with diabetes in Canada, the delivery of high-quality health care services and self-management education for diabetes is supported by national and international guidelines and resources. These guidelines and resources cover areas such as foot care (including annual checks by a health care provider), glycemic (blood sugar) management, cardiovascular risk management, smoking cessation supports and patient education.Reference11 Reference12 Reference13 Reference4

Primary care physicians, nurses, diabetes educators and other health professionals aim to provide coordinated services that support patients to live a healthy life with their condition (i.e., self-management) and reduce the risk of short- and long-term diabetes complications.

Accessing guideline-aligned health care services and adhering to diabetes care plans may be challenging for populations with lower income, lower educational attainment or limited social support. 

• People diagnosed with diabetes were about 5% less likely to report having a regular care provider if they lived in neighbourhoods with the lowest income or high school completion levels compared with the highest levels.Reference15
• Performing regular foot checks and other self-care practices at home, as well as accessing health care services, may be especially challenging for those living alone or with less social support. Survey data from New Brunswick, Ontario and the Northwest Territories in 2015 shows that about 40% of people with diabetes did not see a health care professional for their annual foot check.Reference16 More recent and comprehensive data is needed on measures of diabetes care, including foot checks.Reference17
• Individuals with lower educational attainment are more likely to experience challenges with finding, understanding and using health information and services for diabetes management.Reference18 A diabetes management program that addresses literacy, such as by using techniques that enhance comprehension, may be particularly beneficial for improving clinical outcomes for patients with low literacy.Reference19
• Only 54% of patients with diabetes who were hospitalized reported receiving enough information about what to do if they were worried about their condition or treatment after discharge.Reference20 This finding highlights that patients may experience a knowledge gap when leaving the hospital. Exploring opportunities to enhance discharge practices may be a worthwhile quality improvement initiative for this population.

Cost barriers affect diabetes management for people living with the condition.

• In 2015, 25% of Canadians with diabetes reported that adhering to their treatments was affected by cost. In some cases, people needed to choose between basic expenses and buying their medications.Reference21
• Estimated out-of-pocket costs in 2022 varied across Canada’s provinces and territories. The costs were as high as $18,300 per year for people living with type 1 diabetes and as high as $10,000 per year for those living with type 2 diabetes.Reference22 Although government programs may cover or partly cover the costs of medications, devices and/or supplies for some people, lower-income adults were still estimated to spend the most out of pocket relative to their family income.Reference22
• The Government of Canada is working toward making a range of diabetes medications free, as part of a first phase of national universal pharmacare.Reference23

I [had] wounds [on my foot] and then I worked on them. I used to be a superintendent in an automotive factory... I was on my feet in steel-toed boots all the time... I couldn't really afford to go off work. Footnotei — Matt Anderson, patient partner of Our Voices Our Stories initiative

The lifetime risk of developing a foot ulcer is about 15% to 25% among those with diabetes; Reference24 however, data for Canada is lacking. Access to integrated specialized care and supplies for these patients is critical to prevent worsening complications. 

Patients can face challenges accessing the specialist services and interventions required to prevent or to heal diabetic foot ulcers (DFUs), such as special footwear, insoles or devices that redistribute and offload pressure under the foot. Reference24 Some offloading devices such as casts need customization and repeated visits to trained professionals with expertise in foot care.Reference24 Although coverage varies across Canada, public funding is limited for visits to foot specialists such as podiatrists and chiropodists, and for the costs of offloading devices, prosthetics and other mobility devices.Reference25 Total contact casts, custom braces and other devices can improve outcomes for patients with a DFU but are not widely used due to affordability issues.Reference26 Economic analyses indicate that public funding for offloading devices could increase use of these devices by patients and lead to net cost savings for the health care system.Reference26

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With an infected foot ulcer, you can go to a hospital and receive the required antibiotics, surgical debridement, revascularization and, if required, amputation, all covered by publicly funded health care services. What you may not have received up to this point is care that could have prevented the tissue breakdown which led to the ulcer, infection and amputation. That requires the skills of practitioners like chiropodists or podiatrists, orthotists, pedorthists and more, which are seldom publicly funded. They are sometimes covered by private insurance, which people at greatest risk rarely have. — Tom Weisz, patient partner with Diabetes Action Canada, retired chiropodist/podiatrist, and former social services worker

Patients with a higher level of risk (e.g., active infection, critical ischemia) require immediate access to vascular services for potential revascularization and tissue preservation.Reference13 Reference27 For example, delays between receiving a diagnosis of limb-threatening ischemia (impaired blood flow) and receiving endovascular revascularization have been shown to increase the risk of leg amputation.Reference28 The phrase “time is tissue” highlights that timely intervention and access to specialists are critical for limb preservation. 

If you want to run a wound care clinic, and you want to heal wounds, you need to employ every discipline in the same clinic so that you can heal the wound together. Footnotei — Matt Anderson, patient partner of Our Voices Our Stories initiative

For patients with complex care needs, including a history of a DFU, access to a multidisciplinary diabetes foot care team is a well-established method to support limb preservation efforts.Reference24 Reference26 Patients who receive care from a multidisciplinary team have better outcomes, such as fewer amputations.Reference29 Improving access to multidisciplinary teams would help address gaps in treatment of diabetes foot complications in Canada.Reference25 Reference27

• Continuum of care
• Primary care
• Canadian Patient Experiences Survey — Inpatient Care