Homelessness, Food Insecurity & Diabetes Care

Imagine how difficult it would be to have diabetes, even with an ideal support system around you. Now imagine being homeless, having diabetes and struggling to keep up with the necessary medical care needed to prevent negative outcomes of a complex disease. When you are homeless, your priorities become survival, when your next meal is or where you’re going to sleep. Medical appointments and regular health checks become secondary and you have very little autonomy over what you eat. Food banks and shelters can provide food resources, however, these meals are often high in sugary and starchy foods which diabetics need to avoid.

Over a decade of outreach Diabetes clinics at the Alex Community Health Centre 

Dr. Hanan Bassyouni saw the need to help address care gaps being experienced by this population, so over a decade ago she started outreach clinics at the Alex Community Health Centre: The Addictions and Youth Clinic and the Seniors Clinic. She has also provided care on the Alex Bus, travelling downtown to provide easier access to those who face barriers to attending clinic visits. Both Type 1 and Type 2 Diabetes are commonly seen in this population. Historically it has been difficult for those who are experiencing homelessness to attend specialist appointments, due to transportation and access issues. These outreach clinics are a multidisciplinary and collaborative effort between AHS and the Alex. A key member of the team in addition to Dr. Bassyouni, is Maureen Evans, RN. Maureen is a diabetes educator and experienced nurse. She offers education, insulin starts and supporting titration of medication on site. The clinic also has social work, physiotherapy and a pharmacy all built in – it makes things happen quickly for the population of this outreach clinic. Dr. Bassyouni holds a clinic every 3-4 months, as well as being available by phone for primary care doctors at the Alex.

Expansion of Endocrinology servies to the Mustard Seed 

When Dr. David Campbell was a resident, prior to starting his Endocrine Fellowship, he had the chance to attend clinics with Dr. Bassyouni. He was inspired by her approach, which helped to develop his current research interests and focus. One of Dr. Campbell’s first research projects was an environmental scan across Calgary, Ottawa, Toronto, Vancouver and Edmonton to see what similar programs existed – he was surprised to find that there was no specialists offering endocrine care to this particular population and Calgary was unique in having an endocrine outreach clinic. While the Alex has a fantastic program in place supporting underserved populations, not all homeless people in Calgary access programs at the Alex. In January 2022, Dr. Campbell decided it was time to introduce a similar program to the Mustard Seed, in conjunction with the University of Calgary Student Run Clinic. Specifically, Dr. Campbell provides outreach endocrinology consultations once per month at this student run clinic in the inner city.

Diabetes-Related screening clinics and connection to care at the Calgary Drop In Centre 

When a patient has Diabetes, they don’t just need a diagnosis – they also require ongoing screening for diabetes-related complications: specifically related to their eyes, feet, and kidneys – this adds an additional layer of complexity for people who are experiencing homelessness or facing social disadvantage. Sometimes it can be years between appointments due to access issues, which can negatively impact the health outlook for a patient with diabetes. Dr. Campbell started a once-per week diabetes-screening program at the Calgary Drop In Centre, also in January 2022. This service is provided by on-site nurses (Fatima Macavinta, LPN and Sara Scott, RN) checking feet, eyes, A1C (blood sugar levels) and kidney protein levels on the spot. This allows them to diagnose complications and immediately refer these patients to specialists. The Drop In Centre also helps with transportation to get the patients to the immediate care they need. For example: a patient with diabetic eye disease can be referred to a retina specialist the next week through expedited clinical care pathways, rather than waiting an extra 3-6 months. One particular patient had their eyes checked for the first time and had advanced proliferative diabetic retinopathy. Because of this program, the patient was diagnosed, referred, and treated, thereby slowing the progression of eye disease. Without this care the patient may have ended up blind. Another patient had no idea they had Kidney Disease. During the screening, it was established that they were nearing end stage Kidney Failure and the program was able to get them connected to a Kidney Specialist right away. It is evident that this program helps vulnerable community members access services that may be routine for the majority of the population, by making screenings and resources much more accessible.

Teaching the next generation of healthcare providers 

Through these initiatives, both Dr. Bassyouni and Dr. Campbell incorporate teaching to educate medical students and residents in providing care to these populations with unique needs. It is not just about clinical care, but also about teaching and training the next generation of internists who will serve this population. Dr. Campbell stated: “Dr. Bassyouni certainly influenced me and I hope I can pass this on to others” Dr. Bassyouni stated: “It is our duty as physicians to be educators and set good examples for our students and mentees”.

Research and clinical funding for these important initiatives 

Caring for this population is often challenging due to lengthy appointments and frequent no-shows. Furthermore, many people experiencing homelessness may have recently moved to the province or may not have health coverage but still need care. Funding through the AMHSP is what makes it possible for Dr. Campbell and Dr. Bassyouni to continue to provide this type of care in the community for this population. Dr. Bassyouni’s clinics are run in collaboration with The Alex Community Health Centre, who have graciously covered overhead expenses for this practice. Similarly, Dr. Campbell’s work has been generously supported by the Mustard Seed and the Student Run Clinic. Dr. Campbell’s research projects into homelessness and diabetes have been supported by the AHS Diabetes, Obesity and Nutrition Strategic Clinical Network, the Petro Canada Young Innovator Award, a seed grant from the Cumming School of Medicine’s Clinical Research Fund, the Cal Wenzel Cardiometabolic Fund, and the O’Brien Institute for Public Health. The Food Rx project is supported by research grants from Alberta Innovates (PRIHS), and CIHR Project Grants.

SPOTLIGHT: Community Based Particpatory Research & Food Insecurity 

At the end of Dr. Campbell’s training, he completed a post-doctoral fellowship in Toronto, at the MAP Centre for Urban Health Solutions based at St. Michaels Hospital. He wanted to understand the experiences of this community from their perspective through Community Based Participatory Research (CBPR). This involved recruiting members with lived experience in the community as researchers who were interviewed and trained to think like researchers to complete this CBPR project. This project has now moved to Calgary. One of the main issues raised by this CBPR project is that access to care, specialist and screening were all things that the community felt needed to be improved. While the screening and care are starting to be addressed in Calgary, the group also identified that accessing healthy food was a major challenge – even after people become housed. This spurred on another research project called Food Rx, which is a healthy food prescription program addressing food insecurity. Almost 600 adults experiencing food insecurity and persistent hyperglycemia are being recruited to take part in this study, and the team continues to recruit participants. For more information, check out: foodrxalberta.ca.