Lifetime risk of diabetes among First Nations and non–First Nations people

Tanvir Chowdhury Turin MBBS PhD, Nathalie Saad MD, Min Jun PhD, Marcello Tonelli MD, Zhihai Ma MSc,Cheryl Carmelle Marie Barnabe MD, Braden Manns MD, Brenda Hemmelgarn MD
Competing interests: None
This article has been peer
Accepted: May 2, 2016
Online: Sept. 19, 2016
Correspondence to: Tanvir
Chowdhury Turin, turin.
CMAJ 2016. DOI:10.1503/
Background: Lifetime risk is a relatively straightforward
measure used to communicate disease
burden, representing the cumulative risk of an
outcome during the remainder of an individual’s
life starting from a disease-free index age.
We estimated the lifetime risk of diabetes
among men and women in both First Nations
and non–First Nations populations using a
cohort of adults in a single Canadian province.
Methods: We used a population-based cohort
consisting of Alberta residents from 1997 to
2008 who were free of diabetes at cohort
entry to estimate the lifetime risk of diabetes
among First Nations and non–First Nations
people. We calculated age-specific incidence
rates with the person-year method in 5-year
bands. We estimated the sex- and index-age–
specific lifetime risk of incident diabetes, after
adjusting for the competing risk of death.
Results: The cohort included 70 631 First
Nations and 2 732 214 non–First Nations people
aged 18 years or older. The lifetime risk of
diabetes at 20 years of age was 75.6%
among men and 87.3% among women in the
First Nations group, as compared with 55.6%
among men and 46.5% among women in the
non–First Nations group. The risk was higher
among First Nations people than among
non–First Nations people for all index ages
and for both sexes. Among non–First Nations
people, men had a higher lifetime risk of diabetes
than women across all index ages. In
contrast, among First Nations people, women
had a higher lifetime risk than men across all
index ages.
Interpretation: About 8 in 10 First Nations
people and about 5 in 10 non–First Nations
people of young age will develop diabetes in
their remaining lifetime. These populationbased
estimates may help health care planners
and decision-makers set priorities and
increase public awareness and interest in the
prevention of diabetes.
1148 CMAJ, November 1, 2016, 188(16)
Study population
All residents of the province of Alberta are eligible
for insurance coverage by Alberta Health,
and more than 99% participate in this coverage.
We included 2 897 299 residents aged 18 years
or older (1 436 324 men and 1 460 975 women)
who were registered with Alberta Health
between Apr. 1, 1997, and Mar. 31, 2008. Each
person’s first encounter date with Alberta Health
was considered the study entry date. We
excluded those who had diabetes at cohort entry.
Classification of First Nations status
We determined participants’ First Nations status
from an indicator variable in the Alberta Health
Registry file, which identifies people registered
with Aboriginal Affairs and Northern Development
Canada under the Indian Act. A person
with a First Nations identifier at any time during
the study period was classified as First Nations;
all other participants were classified as non–First
Nations people.12 Aboriginal people in Alberta
who were not registered within the Indian Act
(e.g., unregistered First Nations and Metis) were
included in the non–First Nations group.
According to the 2011 census, about 52% of the
Alberta Aboriginal population is registered First
After Ontario and British Colombia, Alberta
has the third largest First Nations population
among the provinces and territories of Canada.14
About half of the population lives on Indian
reserves.15 More than half of First Nations people
in Alberta are under 25 years of age, and less
than 5% are over 64 years old; the median age is
23 years.15 Great cultural diversity exists within
the Albertan First Nations communities, including
a broad range of spoken languages, the most
common being Blackfoot, Cree, Chipewyan,
Dene, Sarcee and Stoney.15
Outcome measure
Participants were followed for the development
of diabetes after their study entry. The diagnosis
of diabetes was based on the previously validated
National Diabetes Surveillance System definition.16
The case definition required 2 or more
physician service claims for diabetes (International
Classification of Diseases, 9th Revision
[ICD-9] code 250) within 2 years, or 1 or more
hospital admissions with ICD-9 code 250 (before
Mar. 31, 2002) or the equivalent ICD-10 (International
Statistical Classification of Disease and
Related Health Problems, 10th Revision) codes
E10–14 (after Mar. 31, 2002),16 selected from all
available diagnostic codes from the administrative
data sources.17 This case definition has been
reported to have 86% sensitivity, 97% specificity
and 80% positive predictive values for identifying
individuals with diabetes through administrative
data sources.16 Death was determined from
the Alberta Health Registry file. Participants were
followed from their study index date to the occurrence
of the study outcome, death, out-migration
from Alberta or the end of the study period
(Mar. 31, 2009).
Measurement of cohort characteristics
Socioeconomic status was categorized based on
Statistics Canada 2001 and 2006 census data.
Median neighbourhood household income (in
quintiles) and residency (rural or urban) were
identified based on census data closest to the
study entry date of the participants.18 A diagnosis
of hypertension was determined based on previously
validated criteria.19 We identified other
comorbid conditions among physician claims and
hospital admission records using validated coding
algorithms based on the Deyo adaptation
(ICD-9, Clinical Modification [ICD-9-CM] data)
and the Quan validation (ICD-10 data) of the
Charlson Comorbidity Index.20
Statistical analysis
We used age (in years) as the time scale. The
index age categories started at age 20 years and
increased by decade to age 60. Risk estimation
began at an index age; participants who were
younger than the index age of interest at the
beginning of the study period entered the analysis
when they reached the required age. For example,
for risk estimation at an index age of 20
years, participants aged 20 years and older were
included; those who were less than 20 years old
at cohort entry began contributing to the risk estimation
when they attained the age of 20.
We estimated the cumulative incidence of
diabetes conditional on survival to ages 20, 30,
40, 50 and 60 years. We estimated lifetime risk
of diabetes accounting for the competing risk of
death. We calculated index-age–specific incidence
of diabetes and the lifetime risk estimates
using a modified technique of survival analysis,21
as in prior reported analyses.22,23 In contrast to
the conventional Kaplan–Meier survival analysis
(which considers individuals who die as censored
observations), this modified approach considers
death as a competing event.
All statistical analyses were performed using
SAS version 9.1 (SAS Institute).
Ethics approval
The Conjoint Health Research Ethics Board of
the University of Calgary approved the study.
CMAJ, November 1, 2016, 188(16) 1149
The study cohort included 2 802 845 participants
without a history of diabetes, 70 631 (2.5%) of
whom had First Nations status (Figure 1). The
mean follow-up period was 8.71 (standard deviation
3.84) years. The First Nations participants
were younger, generally had a higher prevalence
of comorbid conditions and were more likely to
be in a lower income quintile (Table 1). During a
total follow-up of 23 362 108.3 person-years for
the participants 20 years and older during the
study, diabetes developed in 160 549 participants.
The number of person-years of follow-up and the
number of events (diabetes and death) across all
age groups are presented in Appendix 1 (available
Table 2 presents the lifetime risk of diabetes
as well as the risk over 10-, 20-, 30- and 40-year
time horizons among First Nations and non–First
Nations men by index age. The lifetime risk of
diabetes adjusted for competing risk of death
among 20-year-old men was 75.6% in the First
Nations group and 55.6% in the non–First Nations
group. As expected, there was a graded increase
in the risk of diabetes over longer time horizons
for all index ages in both First Nations and
non–First Nations groups. For example, among
20-year-old First Nations men, the risk of diabetes
was 1.4%, 6.0%, 15.4%, 31.5%, 51.7% and
68.6% over the 10-, 20-, 30-, 40-, 50- and 60-
year time horizons, respectively.
Table 3 presents the short, intermediate and
lifetime risks of diabetes among women in the
First Nations and non–First Nations groups.
Among 20-year-old women, the adjusted lifetime
risk was 87.3% in the First Nations group
and 46.5% in the non–First Nations group. The
lifetime risk of diabetes was lower among
women than among men in all index age categories
in the non–First Nations group. In contrast,
First Nations women had a higher lifetime risk
of diabetes than First Nations men in all index
age categories (Tables 2 and 3). Again, a graded
increase in diabetes risk with increasing time horizon
was consistently observed among women
in both the First Nations and non–First Nations
groups (Figure 2).
The lifetime risk estimates of diabetes among
men and women by location of residence (urban
or rural) are presented in Appendix 2 (available
.150787/-/DC1). The estimates among First Nations
men and women were consistently higher
than those among their non–First Nations counterparts
across both urban and rural locations. In
the First Nations group, the lifetime risk of diabetes
was notably higher among those living in
Non–First Nations
n = 2 732 214
First Nations
n = 70 631
Alberta residents = 18 yr
n = 2 897 299
Excluded n = 94 454
(history of diabetes)
Included in study cohort
n = 2 802 845
Figure 1: Selection of the study cohort.
Table 1: Baseline characteristics of study participants by First Nations status
% of participants*
First Nations
n = 70 631
Non–First Nations
n = 2 732 214
Age, yr, mean ± SD 34.5 ± 12.6 40.7 ± 16.3
Sex, female 49.9 49.5
Comorbid condition
Hypertension 3.9 7.5
Cerebrovascular disease 0.7 1.0
Peripheral vascular disease 0.2 0.6
Congestive heart failure 0.8 1.1
Cancer 1.0 1.8
COPD 17.6 9.2
Dementia 0.2 0.5
Myocardial infarction 0.5 0.9
Peptic ulcer disease 4.8 1.9
Rheumatic disease 1.2 0.6
Location of residence
Rural 47.7 19.3
Urban 52.3 80.7
Unknown 0.0 0.01
Income quintile
1 (lowest) 42.5 21.6
2 14.7 19.6
3 10.5 18.3
4 7.9 18.0
5 (highest) 9.4 17.8
Unknown 15.1 4.71
Note: COPD = chronic obstructive pulmonary disease, SD = standard deviation.
*Unless stated otherwise.
1150 CMAJ, November 1, 2016, 188(16)
rural locations than among those in urban areas.
This difference was strikingly prominent among
women. For example, 20-year-old First Nations
women in rural areas had a lifetime risk of
94.2%, as compared with 80.4% among their
counterparts in urban locations. In contrast, non–
First Nations men and women in urban locations
had slightly higher lifetime risks of diabetes than
their rural counterparts.
We estimated the lifetime risk of diabetes among
First Nations and non–First Nations people in a
population-based cohort of nearly 3 million people
from a provincial health registry. The observed
probabilities suggest that about 5 in 10 non–First
Nations men and women of young age will develop
diabetes in their lifetime. The lifetime risk
was much higher in the First Nations population
(about 7 in 10 men and 9 in 10 women).
In our study, men had a higher lifetime risk of
diabetes than women of similar age strata in the
non–First Nations group. In contrast, women had a
higher lifetime risk than men in the First Nations
group. This observation likely reflects the fact that
the incidence of diabetes is higher among First
Nations women than among First Nations men in
Canada.24 That women in First Nations communities
are more likely to be overweight or obese than
the men, and at a younger age,25 would explain this
disparity to some extent. Also, there are high rates
of gestational diabetes among pregnant Aboriginal
women who develop type 2 diabetes later in life.26
Irrespective of urban or rural location of residence,
we observed a higher lifetime risk of diabetes
among First Nations people than among
non–First nations people. However, in the First
Nations group, the lifetime risk was higher
among those living in rural communities than
among those in urban areas. This difference was
striking among First Nations women. Access to
care and geographic factors, which have been
identified as important determinants of health for
indigenous people,27 may be contributing to the
higher observed risk.28
We also observed that the First Nations group
reached a higher risk of diabetes at a much
younger age than the non–First Nations group. The
cumulative risk of diabetes among young First Nations
men overtook the lifetime risk among non–
First Nations men by about 20  years earlier.
Among First Nations women, this happened about
30 years earlier. These findings coupled with the
observations that younger people had a higher lifetime
risk of diabetes than their older counterparts
indicates the importance of early mobilization of
preventive measures against the development of
diabetes among First Nations people.
Reports of a similar nature were limited to
studies in the United States11 and Australia.9
However, the methodologic differences across
these studies hinder direct comparison of the estimates
with our results. In the US study, Narayan
and associates11 used incidence rates and mortality
derived from different sources and a Markov
chain model to estimate the lifetime risk of diabetes.
The authors estimated that the lifetime risk of
diabetes among people 40 years of age was about
3 in 10.11 They defined diabetes based on selfreported
disease status, which might have underestimated
true diabetes rates.
In the Austrialian study, Magliano and associates9
used the approach of building a multistate
life table to estimate the lifetime risk of diabetes
in an epidemiologic cohort of 5842 adults.9
authors reported that the lifetime probability of
Table 2: Age- and sex- specific risk estimates for diabetes among First Nations
and non–First Nations men, by index age
age, yr Time horizon
Risk estimate, % (95% CI)
First Nations Non–First Nations
20 10 yr 1.4 (1.2–1.7) 0.6 (0.6–0.7)
20 yr 6.0 (5.6–6.4) 2.5 (2.4–2.6)
30 yr 15.4 (14.7–16.1) 7.4 (7.3–7.5)
40 yr 31.5 (30.3–32.8) 18.1 (17.9–18.3)
50 yr 51.7 (49.9–53.6) 33.5 (33.3–33.8)
60 yr 68.6 (66.0–71.0) 47.8 (47.5–48.1)
Lifetime 75.6 (72.6–78.5) 55.6 (55.3–55.9)
30 10 yr 4.7 (4.3–5.0) 1.9 (1.9–1.9)
20 yr 14.3 (13.6–15.0) 6.8 (6.7–6.9)
30 yr 30.8 (29.6–32.1) 17.6 (17.4–17.7)
40 yr 51.5 (49.6–53.4) 33.1 (32.9–33.4)
50 yr 68.6 (66.1–71.2) 47.5 (47.2–47.8)
Lifetime 75.9 (72.9–78.9) 55.3 (55.0–55.7)
40 10 yr 10.0 (9.3–10.6) 4.9 (4.9–5.0)
20 yr 27.1 (25.8–28.3) 15.8 (15.7–16.0)
30 yr 48.5 (46.6–50.4) 31.5 (31.3–31.7)
40 yr 66.3 (63.6–68.9) 46.0 (45.7–46.3)
Lifetime 73.8 (70.6–76.9) 53.9 (53.6–54.3)
50 10 yr 18.0 (16.8–19.3) 11.1 (10.9–11.2)
20 yr 40.7 (38.7–42.7) 27.0 (26.8–27.3)
30 yr 59.5 (56.7–62.2) 41.8 (41.5–42.1)
Lifetime 67.4 (64.0–70.7) 49.9 (49.5–50.2)
60 10 yr 24.8 (22.8–26.9) 16.7 (16.4–16.9)
20 yr 45.4 (42.3–48.5) 32.0 (31.7–32.3)
Lifetime 54.1 (50.4–57.8) 40.4 (40.1–40.8)
Note: CI = confidence interval.
CMAJ, November 1, 2016, 188(16) 1151
diabetes among people 26 years of age was about
3 in 10.9
They recognized the potential limitation
of using a single oral glucose tolerance test to
define diabetes in their study and acknowledged
the possibility of underestimation of the true risk.
Our analysis used a cohort of nearly 3 million
people from a single Canadian province,
and diabetes was defined using administrative
data sources. We used a survival analysis
approach to estimate the lifetime risk of diabetes,
with a special focus on the difference in
risk between First Nations by non–First Nations
people. We did not identify prior reports that
compared estimates of lifetime risk in an
Aboriginal population and a contemporaneous
non-Aboriginal counterpart.
Although the lifetime risk of diabetes was high
in both First Nations and non–First Nations
groups, it was higher in the former. These findings
are consistent with population-based diabetes
reports showing higher incidence and prevalence
of diabetes among First Nations people than
among non–First Nations people.24,29,30 Dyck and
associates24 reported that the incidence and prevalence
of diabetes were more than 4 times higher
among First Nations women than among non–
First Nations women, and more than 2.5 times
higher among First Nations men than among non–
First Nations men. The reasons that have been
attributed to these differences include genetic susceptibility,31–34
dietary acculturation,34,35 adoption
of sedentary lifestyle34,36 and increasing prevalence
of obesity and metabolic syndrome.37–39 Overall,
the First Nations populations in Canada, and similarly
other indigenous groups worldwide, are vulnerable
to developing diabetes. It also appears that
inequities in the social, cultural, historical, economic
and political determinants of health, lack of
access to nutritionally adequate food and barriers
Table 3: Age- and sex- specific risk estimates for diabetes among First Nations
and non–First Nations women, by index age
age, yr Time horizon
Risk estimate, % (95% CI)
First Nations Non–First Nations
20 10 yr 2.8 (2.5–3.2) 1.2 (1.1–1.2)
20 yr 9.2 (8.6–9.7) 3.5 (3.4–3.6)
30 yr 19.4 (18.6–20.2) 7.1 (7.0–7.2)
40 yr 38.6 (37.3–40.0) 14.7 (14.6–14.9)
50 yr 60.8 (58.7–62.9) 26.0 (25.8–26.2)
60 yr 79.2 (76.3–82.2) 38.0 (37.8–38.3)
Lifetime 87.3 (83.7–90.8) 46.5 (46.2–46.8)
30 10 yr 6.4 (6.0–6.9) 2.4 (2.3–2.4)
20 yr 16.8 (16.0–17.6) 6.0 (5.9–6.1)
30 yr 36.2 (34.8–37.6) 13.6 (13.5–13.7)
40 yr 58.6 (56.5–60.7) 24.9 (24.7–25.1)
50 yr 77.3 (74.3–80.3) 37.0 (36.7–37.3)
Lifetime 85.4 (81.8–89.0) 45.4 (45.1–45.7)
40 10 yr 10.6 (9.9–11.3) 3.6 (3.6–3.7)
20 yr 30.5 (29.1–31.8) 11.3 (11.2–11.4)
30 yr 53.5 (51.3–55.6) 22.6 (22.4–22.8)
40 yr 72.5 (69.5–75.6) 34.8 (34.5–35.1)
Lifetime 80.9 (77.2–84.5) 43.3 (43.0–43.6)
50 10 yr 20.6 (19.3–21.9) 7.7 (7.6–7.9)
20 yr 44.5 (42.2–46.7) 19.2 (19.0–19.4)
30 yr 64.3 (61.0–67.5) 31.5 (31.2–31.8)
Lifetime 72.9 (69.1–76.8) 40.1 (39.8–40.4)
60 10 yr 25.5 (23.2–27.7) 11.8 (11.6–12.0)
20 yr 46.6 (43.1–50.1) 24.4 (24.2–24.7)
Lifetime 55.8 (51.6–60.0) 33.2 (32.9–33.6)
Note: CI = confidence interval.
20 30 40 50 60 70 80 Life
40 50 60 70 80 Life
Cumulative risk of diabetes,
Attained age, yr Attained age, yr
FN men
FN women
Non-FN men
Non-FN women
A: Index age 20 yr B: Index age 40 yr
Figure 2: Cumulative risk of diabetes with advancing age among First Nations and non–First Nations men and women at the index age
of (A) 20 years and (B) 40 years. FN = First Nations.
1152 CMAJ, November 1, 2016, 188(16)
to proper health care play major roles in the diabetes
epidemic in indigenous populations.40–43
The increase we observed in the cumulative
risk of diabetes across the time horizons for all index
age categories among both men and women
reflected the contribution of the age time scale that
has been reported for other chronic diseases.44–48
We also observed that the lifetime risk decreased
by increasing index age, which is consistent with
reports of lifetime risk estimation for other diseases.44–48
The decrease in lifetime risk of diabetes
with increasing age reflects the shorter life expectancy
and period at risk among older participants.
Also, at older ages, competing causes of death
will increase in importance because older people
may not live long enough to develop diabetes,
and people susceptible to diabetes might have developed
the disease at an earlier age.
From the perspective of public health education,
the lifetime risk estimates are beneficial
because they are more intuitive than conventional
epidemiologic measures such as incidence, prevalence
and relative risk.49 Problems with statistical
numeracy or low quantitative literacy are not
uncommon.50 Furthermore, innumeracy and difficulties
understanding proportions, ratios and relative
risks seem to be general barriers to knowledge
translation across all user communities in Canada.
Indeed, one study found that patients preferred
their health risks to be presented in absolute terms
and that their lifetime estimate of risk be given in
an “X in 100” format.51 In addition, merits of
reporting lifetime risk estimates have been
observed. For instance, the widely publicized lifetime
risk of breast cancer among American
women (estimated to be 1  in 8 [12.6%])52 is
believed to have influenced the increase in screening
mammography for early disease detection.53
Although lifetime risk lacks the detail and precision
needed for individual clinical consultation,
the lifetime estimates presented in our study offer
a useful and understandable summary of risk in a
population. This will be particularly relevant to
help researchers and policy-makers appreciate the
population burden of diabetes.
The strengths of our study include the use of a population-based
cohort and data that encompassed
diabetes and mortality. However, our reported estimates
need to be interpreted in light of the limitations
of this type of methodology.47,52,54–57 First, lifetime
risk estimates are population based and reflect
average individuals in a population. Although they
serve as general guidelines, lifetime risk estimates
therefore have only restricted prognostic utility at
the patient level, where the lifetime risk would be
influenced by individual risk factors for diabetes.
Second, lifetime risk estimates assume a fixed
age and demographic structure for the general
population, as well as stable diabetes incidence
rates and mortality. Because studies suggest that
the incidence and prevalence of diabetes is
increasing over time, the lifetime risk of diabetes
may be even higher than reported here. Moreover,
the temporal trends in life expectancy, sensitivity
of diagnostic tests and the prevalence of risk factors
could also alter the lifetime risk estimates of
diabetes. Also, our results are based on population-based
data from Alberta; they may not be
generalizable to other provinces in Canada.
Third, it was not possible for us to recognize
unregistered First Nations people, which may
caused misclassification of some individuals in
the non–First Nations group. Nonetheless,
given that most of the First Nations population
in Alberta is registered and given the size of the
non–First Nations population in our study, we
expect this potential misclassification to have
minimal impact on the study estimates.
Fourth, we did not differentiate between
type 1, type 2 and gestational diabetes. However,
the major form of diabetes in the population
is type 2 diabetes, which accounts for
90%–95% of diabetes cases in Canada.6
The observed probabilities indicate that 75.6%
of First Nations men and 87.3% of First Nations
women of young age will develop diabetes in
their lifetime. The corresponding risk among
non–First Nations people is about 55.6% and
46.5%, respectively. These measures can be used
both in assisting health care planners and decision-makers
to set priorities and in increasing
public awareness and interest in primary prevention
initiatives against diabetes.
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Affiliations: Department of Family Medicine (Turin),
Department of Community Health Sciences (Turin, Manns,
Hemmelgarn), Institute of Public Health (Turin, Manns,
Hemmelgarn) and Department of Medicine (Saad, Jun,
Tonelli, Ma, Barnabe, Manns, Hemmelgarn), University of
Calgary, Calgary, Alta.
Contributors: Tanvir Turin and Brenda Hemmelgarn contributed
to the study concept and design. Tanvir Turin and
Zhiha Ma performed the data analysis. Tanvir Turin, Marcello
Tonelli, Braden Manns and Brenda Hemmelgarn interpreted
the results. Nathalie Saad, Min Jun and Cheryl Barnabe
contributed to the interpretation and contextualization of
the results. Tanvir Turin drafted the manuscript, and Nathalie
Saad, Min Jun, Cheryl Barnabe, Marcello Tonelli, Braden
Manns, Zhihai Ma and Brenda Hemmelgarn revised it critically
for important intellectual content. All of the authors
approved the final version to be published and agreed to act
as guarantors of the work.
Acknowledgement: This study is based in part on data provided
by Alberta Health and Alberta Health Services. The
interpretation and conclusions are those of the researc

and do not represent the views of the Government of Alberta

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