Download in Newfoundland and Labrador

2016 Report on Diabetes
in Newfoundland and Labrador
2016 Report on Diabetes
in Newfoundland and Labrador
ABOUT THE CANADIAN DIABETES ASSOCIATION
The Canadian Diabetes Association (CDA) is a registered charity that helps the 11 million
Canadians living with diabetes or prediabetes. We lead the fight against diabetes by helping
those affected by diabetes to live healthy lives, preventing the onset and consequences of
diabetes, and discovering a cure.
Dr. Charles Best, co-discoverer of insulin, helped create the Diabetic Association of Ontario
in the 1940s—which became the CDA in 1953.
The CDA’s Diabetes Charter for Canada sets out a vision that all Canadians with diabetes
have the supports needed to achieve their full health potential.1
O
• CARE • E
The guiding principles of the Canadian Diabetes Association
in developing this Charter are to:
I TY
SUPP
RT
QU
The vision of the Canadian Diabetes Association for the
Diabetes Charter for Canada is a country where people with
diabetes live to their full potential.
• Ensure that people who live with diabetes are treated with dignity and respect.
• Advocate for equitable access to high quality diabetes care and supports.
• Enhance the health and quality of life for people who live with diabetes and
their caregivers.
Canadians Living with Diabetes* Have the Right to:
• Affordable access to insurance coverage.
• Be treated with respect, dignity, and be free from stigma
and discrimination.
• Fully participate in daycare, pre-school, school and extracurricular
activities, receiving reasonable accommodation and assistance
if needed.
• Affordable and timely access to prescribed medications, devices,
supplies and high quality care, as well as affordable and adequate
access to healthy foods and recreation, regardless of their income
or where they live.
• Timely diagnosis followed by education and advice from an
interprofessional team which could include the primary care
provider, diabetes educator, nurse, pharmacist, dietitian and
other specialists.
• Supportive workplaces that do not discriminate and make
reasonable accommodation as needed.
• Appropriate and seamless transitional care that recognizes the
progression of the disease.
Canadians Living with Diabetes Have
the Responsibility to:
• Guarantee fair access to diabetes care, education, prescribed
medications, devices, and supplies to all Canadians, no matter what
their income or where they live.
• Address the unique needs and disparities in care and outcomes
of vulnerable populations who experience higher rates of diabetes
and complications and significant barriers to diabetes care
and support.
• Implement policies and regulations to support schools and
workplaces in providing reasonable accommodation to people with
diabetes in their self-management.
• Self-manage to the best of their abilities and personal
circumstances, including a healthy diet, exercise, following care
plans and attending appointments.
Health Care Providers Have the Right to:
• Emotional and mental health support, as well as support for their
caregivers if needed.
• Be an active partner in decision making with their health
care providers.
• Be honest and open with health providers about their current state
of health so that the most suitable care plans can be created.
• Have access to their medical records and other health information
when requested, and have it easily understood.
• Actively seek out education, information and support to live well
with diabetes.
• Work in well-coordinated teams, either at the same location or
virtually where support from specialists who provide diabetes care
can be obtained within a reasonable time.
• Diabetes information, education and care that take into
account a person’s age, culture, religion, personal wishes, language
and schooling.
• Respect the rights of other people with diabetes and health
care providers.
• Have their eyes, feet, kidneys, blood glucose control,
cardiovascular risk factors and mental health checked as
often as recommended by current clinical practice guidelines.
• Form comprehensive policies and plans for the prevention,
diagnosis, and treatment of diabetes and its complications.
* and their informal caregivers where relevant
CARE
EQUITY
SUPPORT
Governments Have the Responsibility to:
• Collect data on diabetes burden, such as costs and complications,
and to regularly evaluate whether progress is being made.
CARE
EQUITY
• Ongoing training, funding and tools needed to provide high quality
diabetes care.
Health Care Providers Have the Responsibility to:
Schools, Pre-schools, and Daycares Have the
Responsibility to:
• Ensure staff and the child’s peers have accurate information about
diabetes, provide a safe environment for diabetes self-management
and protect children with diabetes from discrimination.
Workplaces Have the Responsibility to:
• Create an environment where people can reach their full potential
by providing accommodation and eliminating discrimination
against people with diabetes.
The Canadian Diabetes Association Has
the Responsibility to:
• Strongly advocate for the rights of people living with diabetes on
behalf of Canada’s diabetes community.
• Raise public awareness about diabetes.
• Work to ensure the accuracy of information about diabetes in
the public domain.
• Treat people with diabetes as full partners in their own care.
• Partner with researchers to improve the planning, provision and
quality of diabetes care by promoting and applying research.
• Learn and apply up-to-date evidenced-based clinical practice
guidelines when caring for people with diabetes.
• Advocate for equitable access to diabetes care, education,
medications, devices, and supplies.
• Diagnose people living with diabetes as early as possible.
• Help people with diabetes and their caregivers navigate the
health care system.
SUPPORT
CARE
EQUITY
SUPPORT
www.mydiabetescharter.ca
CARE
EQUITY
diabetes.ca | 1-800 BANTING
SUPPORT
The report was supported by an unrestricted grant from Novo Nordisk Canada.
Suggested citation: Canadian Diabetes Association. (2016). Report on Diabetes in Newfoundland and
Labrador 2016. Toronto, Ontario: CDA.
www.mydiabetescharter.ca
diabetes.ca | 1-800 BAN
TABLE OF CONTENTS
Executive Summary
2
Methods and data sources
Introduction
3
4
Diabetes in Newfoundland and Labrador
Chapter 1: Access to supports
Jackie’s story
5
6
7
Insulin pump coverage
9
Transition to adult care
9
Chapter 2: Cost of diabetes
10
Dawn’s story
11
Cost of diabetes management
Chapter 3: Patient needs
Dr. Joshi’s story
13
14
15
Risk factors among Newfoundland and Labrador residents
Prevention of complications
Chapter 4: CDA’s recommendations
Conclusion
19
References
20
diabetes.ca/charter
16
17
18
1
EXECUTIVE SUMMARY
Newfoundland and Labrador has the highest
prevalence of diabetes and prediabetes among
Canadian provinces. Today, approximately 179,000
Newfoundland and Labrador residents, or 35 per
cent of the population, are living with diabetes or
prediabetes. In the next decade, the diabetes rate
in this province is predicted to increase by 38 per
cent. Uncontrolled diabetes puts people at higher
risk of serious and costly complications, including
heart attack, stroke, vision loss, kidney disease
and amputation. Every year, diabetes is costing the
provincial health-care system an estimated $54
million.
The rising diabetes prevalence is largely due to the
rapidly aging population. Meanwhile, the province
also has high rates of many modifiable risk factors
that contribute to the increasing type 2 diabetes
burden. Approximately 67 per cent of adults and
47 per cent of youth are overweight or obese. More
than one in five people smokes cigarettes, half of the
provincial population are deemed physically inactive,
and over 70 per cent do not eat enough fruits and
vegetables.
Financial constraints limit people’s ability to effectively
manage their diabetes. Many Newfoundland
and Labrador residents with diabetes can’t afford
2 | 2016 Report on Diabetes in Newfoundland and Labrador
prescription medications and supplies. Public
coverage for diabetes supports is available, but to
varying degrees based on income and age, and not
to everyone that needs it. Without private insurance,
many people may have to shoulder high out-of-pocket
costs associated with diabetes management..
Diabetes care gaps create another barrier to effective
management. A significant percentage of people with
diabetes are not receiving tests recommended by
the Canadian Diabetes Association’s Clinical Practice
Guidelines, such as A1C tests and foot exams, and
those who are often don’t receive them as frequently
as they should. Some families with children with
diabetes reported difficulty transitioning from
pediatric care to adult care.
The Auditor General of Newfoundland and Labrador
has identified areas for improvement in diabetes
care to tackle the burden of diabetes, including poor
coordination of primary health care and wellness
efforts, lack of screening for diabetes complications,
limited diabetes surveillance, and the need for a
provincial strategy for chronic disease. The Auditor
General’s recommendations from the 2010 report
have yet to be addressed.
Based on findings presented in this report, the CDA
urges the Government to introduce a Provincial
Diabetes Strategy that consists of the following
components:
• A diabetes registry or database
• Increased support for self-management of diabetes
• Enhanced access to diabetes medications, devices
and supplies, particularly insulin pumps, pump
supplies and test strips
• Coordinated diabetes care and access to interprofessional teams
• Wellness programs to support type 2 diabetes
prevention
METHODS AND DATA SOURCES
Data provided in this report were drawn primarily
from Statistics Canada and CDA estimates based
on national diabetes surveillance data. The CDA
estimated out-of-pocket costs for people with type
1 and type 2 diabetes living in Newfoundland and
Labrador based on composite case studies. The CDA
also developed a model that estimates diabetes
prevalence, cost and projections for the province
diabetes.ca/charter
based on data from the Public Health Agency of
Canada and Statistics Canada.
This report includes the most recent available data
that describe the burden of diabetes. The risk factors
are presented in age-standardized rates for ease of
comparison with Canadian rates. It is important
to note that on-reserve First Nations Peoples are
excluded from national surveys administered by
Statistics Canada; so are people without a fixed
address. Also note that Statistics Canada estimates
presented in this report are self-reports, which may
be subject to reporting bias, especially for socially
undesirable behaviours. Hence, these data likely
underestimate the burden of diabetes and modifiable
risk factors in the province.
To facilitate a deeper understanding of how diabetes
impacts everyday lives of Newfoundlanders and
Labradorians with the disease, we included personal
stories from people with diabetes, their family
members and health-care providers who experience
the challenges and successes in managing diabetes.
3
INTRODUCTION
Diabetes is increasing at an alarming rate across
Canada, affecting millions of people and their
families, and contributing to the ever-increasing
health budgets across the country. Every year,
diabetes contributes to about 30 per cent of strokes,
40 per cent of heart attacks, 50 per cent of kidney
failure (that requires dialysis) and 70 per cent of
non-traumatic amputations in hospitals. Diabetes
currently costs the provincial health-care system $54
million a year in hospitalizations, doctor visits and
medications.
Effective diabetes management can prevent or delay
these devastating and potentially life-threatening
complications. But not all people with diabetes in
this province have the financial resources to pay for
prescribed medications, devices, supplies or other
supports to avoid complications. For these people,
diabetes management may mean choosing between
rent and medications, or stretching their use of
supplies so they can last longer (e.g. blood glucose test
strips and pen needles)
4 | 2016 Report on Diabetes in Newfoundland and Labrador
The 2016 Report on Diabetes in Newfoundland and
Labrador presents the most recent data available on
the risk and burden of diabetes in this province, as
well as lived experiences as described by a health-care
provider and Newfoundland and Labrador residents
living with diabetes. In the final chapter of the report,
we offer the Government our recommendations on
priorities that require urgent attention in order to
bend the impact curve of diabetes in the province.
The Diabetes Charter for Canada released by the CDA
in 2014 outlines a vision: all people with diabetes
in Canada deserve affordable and timely access to
medications, devices, supplies, high quality care,
healthy foods and other supports needed to effectively
manage their diabetes, regardless of their income, or
where they live. This is our vision for all people with
diabetes in Newfoundland and Labrador. All people
with diabetes in Newfoundland and Labrador have
the right to needed supports to achieve their full
health potential. This report acts as a tool to guide the
way to achieve this vision.
DIABETES IN NEWFOUNDLAND
AND LABRADOR
Government sources found that in 2010,
Newfoundland and Labrador had the highest
prevalence of diabetes among all jurisdictions in
Canada.2 The CDA estimates that in 2016, 12 per
cent of people in Newfoundland and Labrador have
diabetes (diagnosed), the highest prevalence among
all provinces. We estimate that diabetes prevalence
has increased by 68 per cent over the last decade, and
will continue to increase by another 38 per cent over
the next ten years.3
While diabetes prevalence is high, this does not
represent the full burden of diabetes, as many people
with diabetes have not been diagnosed or live with
prediabetes, a precursor to type 2 diabetes. With
undiagnosed diabetes and prediabetes factored in,
an estimated 179,000 people (35% of population) are
currently living with diabetes or prediabetes in the
province.3
diabetes.ca/charter
Work remains to be done to better capture the
prevalence and burden of diabetes in this province.
In 2011, the Auditor General of Newfoundland and
Labrador reported that the province did not have
a diabetes registry or database to capture patient
data such as demographic information, diabetes
type, treatments, co-existing conditions, and test
results. The prevalence as reported by National
Diabetes Surveillance System (now known as Chronic
Disease Surveillance System) was also believed to
be understated, as this information did not include
data from salaried physicians serving the majority of
Indigenous Peoples with diabetes, who have much
higher diabetes prevalence than non-Indigenous
Peoples.2
5
CHAPTER 1:
Access to supports
6 | 2016 Report on Diabetes in Newfoundland and Labrador
Jackie’s story
Jackie Rice’s son Mark has been managing his type 1
diabetes successfully with an insulin pump.
Now, as he gets older and ages out of the provincial
insulin pump program, Jackie is worried about the
high pump costs and the lack of care for her son,
who will also soon transition out of pediatric care.
When Mark Rice was diagnosed with type 1 diabetes
at the age of 10, he had to grow up fast. “Right from
the beginning, he took charge of his diabetes. He
gave himself his very first insulin injection,” says
his mother, Jackie. But now, growing up—or rather,
growing older—will soon present problems for
20-year-old Mark. When he turns 25, the government
will no longer cover any costs associated with his
insulin pump, and once he graduates from Memorial
University, he will not be eligible for the partial
coverage that he now enjoys under his father’s private
insurance plan. “That will be a very big expense. It
is definitely a concern,” says Jackie. Forty children
received insulin pumps the same year that Mark did
and will age out of the program at the same time.
“What will happen to those 40 kids when they can’t
afford a pump anymore? Will the government end
up paying for hospitalizations and complications like
blindness and kidney failure down the road because
their diabetes wasn’t well managed?” she wonders.
The first two years after Mark’s diabetes diagnosis,
his blood sugars were persistently dangerously high,
landing him in hospital three times. Although his
physician recommended an insulin pump, the family
didn’t have private insurance at the time and could
not afford the $6,000 expense. They got him the
device as soon as the province introduced coverage,
when Mark was 12, and within 24 hours on the
insulin pump his blood sugar levels normalized. He
now also uses a continuous glucose monitor, which
sounds an alarm if Mark’s blood sugar goes too high
or too low (the latter is particularly serious if he is
driving or sleeping). Although the cost of the monitor,
which Jackie calls “a godsend”, is covered along with
his pump, the $50 sensors, which last less than two
weeks, are not.
Even with this expense, Jackie recognizes that her
family is among the lucky few. Her 67-year-old
mother was diagnosed with type 2 diabetes three
years ago and has no private health insurance.
“Her blood sugars are always way too high, but an
insulin pump just isn’t in the cards for her because
she wouldn’t be able to afford the $6,000 for pump
plus $900 for supplies, insulin and test strips every
month,” says Jackie. As it is, her mother’s insulin, test
strips and medication for other health conditions now
add up to more than her monthly income. As a result,
Jackie says her mother often skips testing her blood
sugar and sometimes cuts back on her medication.
“It’s pretty sad when you work your whole life and it
comes to that.”
Jackie is also concerned about how difficult it is to
access diabetes care in the province, especially as
children transition to adult care. “There just aren’t
enough diabetes specialists available. This needs to be
addressed urgently,” she says. Although Mark received
excellent pediatric care in St. John’s, he has been able
to get only one appointment with a diabetes specialist
since transitioning to the adult system 18 months
ago. “I’ve been calling and calling for him and getting
nowhere,” says Jackie with audible frustration.
“We have such a high rate of diabetes in
Newfoundland and Labrador, but the government
isn’t covering people’s expenses and care is getting
harder to find,” she says. “It’s just crazy.”
7
8 | 2016 Report on Diabetes in Newfoundland and Labrador
INSULIN PUMP COVERAGE
An insulin pump costs about $6,000–$7,000 and
needs to be replaced every five years. In its 2007
budget, the Newfoundland and Labrador government
introduced a pediatric insulin pump program which
would fund the cost of pumps and supplies for
eligible children and youth up to age 17. In 2010, the
government allotted extra funding of $797,700 to
allow for expansion of this coverage to include eligible
people with type 1 diabetes between 18 and 24.4
Administered by Eastern Health, the adult insulin
pump program is available to people with type 1
diabetes between 18 and 24 years old who live in
the province; have completed an insulin pump
education program; perform blood glucose tests at
least four times per day and record their results; have
regular attendance at diabetic clinics; have sick day
knowledge and management and have not had more
than one diabetic ketoacidosisi in the previous six
months; and have an ongoing support system in place.5
Each jurisdiction across Canada now offers financial
assistance to help people with type 1 diabetes pay
for their insulin pump therapy. However, the level of
coverage varies. Some programs have age limits, and
not everyone with type 1 diabetes can access these
programs.
i Ketoacidosis is an acute and severe complication of diabetes that is the
Table 1: Overview of coverage for insulin pumps and supplies
inhigh
Canada,
ageglucose
thresholds
result of
levels of blood
and ketones. It is often associated
PROVINCE/TERRITORY
with poor control of diabetes or occurs as a complication of other
illnesses. It can be life threatening and requires emergency treatment.
INSULIN PUMPS
PUMP SUPPLIES
British Columbia
25 and under
All ages
Alberta
All ages
All ages
Saskatchewan
25 and under
25 and under
Manitoba
17 and under
17 and under
Ontario
All ages
All ages
Quebec
17 and under
17 and under
New Brunswick
18 and under
18 and under
Nova Scotia
25 and under
25 and under
Prince Edward Island
18 and under
18 and under
Newfoundland and Labrador
24 and under
24 and under
Yukon/Nunavut/Northwest Territories
All ages
All ages
Non-Insured Health Benefits program
All ages
All ages
TRANSITION TO ADULT CARE
The transition from childhood to adulthood is not
only a phase of life but a transition from the pediatric
health system to the adult health-care system. This
is a critical time when young adults start taking
responsibility for their diabetes self-management
and interactions with the health-care system but also
when they become more independent, potentially
moving out of their parents’ home to attend university
or begin employment.
Between 25 and 65 per cent of young adults have
no medical follow-up during the transition from
pediatric to adult diabetes care services. These gaps in
diabetes care can result in inadequate blood glucose
control, increased occurrence of acute complications
such as diabetic ketoacidosis and the beginning of
chronic complications.6
i Ketoacidosis is an acute and severe complication of diabetes that is the result of high levels of blood glucose and ketones. It is often associated with poor control
of diabetes or occurs as a complication of other illnesses. It can be life threatening and requires emergency treatment.
diabetes.ca/charter
9
CHAPTER 2:
Cost of diabetes
10 | 2016 Report on Diabetes in Newfoundland and Labrador
Dawn’s story
Dawn Gallant has type 2 diabetes. She is also a nurse
caring for people with diabetes. Her daughter Kelly,
who has type 1 diabetes, is not eligible for the government’s
insulin pump program due to her age. Dawn shared
with us the challenges of managing diabetes in her family.
As a nurse with more than 40 years’ experience,
Dawn Gallant is a big believer in patient empowerment. Give people the information they need to take
care of their health, and if something isn’t working,
then explore new options. Her advice is the same for
government decision-makers. “We need universal
access to the tools and information that will allow
people to self-manage their diabetes and live a healthy
life,” Dawn says from a hotel in Ottawa where she
has been advocating to the federal government for
improved access to disability tax credits for people
with type 1 diabetes. “Changes need to be made
on all levels to slow the diabetes epidemic, improve
the way it is managed, and prevent diabetes-related
complications so that the health-care system will save
money in the long run.”
Diabetes has affected Dawn’s life on multiple fronts.
For the first two decades of her nursing career, she
cared for many patients who suffered with long-term
complications of the disease. Her daughter, Kelly, was
diagnosed with type 1 diabetes in 1997 when she
was nine years old. One year later—ironically, while
she was volunteering as a nurse at a summer camp
for children with diabetes—Dawn discovered that
she herself has type 2 diabetes. Her sister also has the
disease.
In the early years of dealing with diabetes personally,
Dawn’s biggest challenge was learning to overcome
her perceptions of the disease based on her
professional experiences. Having seen some of the
worst possible outcomes in her patients, Dawn was
careful to ensure she and Kelly carefully managed
their diabetes. She is grateful that both she and her
daughter have received good care over the years and
that the family has been able to afford the medications
and devices they need to stay healthy.
At the same time, she recognizes that not everyone
is as fortunate. “My husband and I both have private
insurance, but my diabetes-related medications and
supplies still cost about $100 a month out of pocket,”
she says. People who don’t have private insurance
often have to go without medications that are not on
the provincial formulary because they simply can’t
afford the expense.
Insulin pumps are also prohibitively expensive for
many people. Kelly has been unlucky in the timing
of her insulin pump purchases and the availability of
government programs that cover the cost of insulin
pumps. She started using a pump when she was
16, before the introduction of the province’s insulin
pump plan, and the family had to pay $5,500 for the
device at the time. She required a second pump at age
21 before the pump program was expanded to people
aged 24 and under, which they paid for out of pocket.
Now at age 28, Kelly is too old for government
coverage, so she will have to come up with $6,500 or
more for her next pump. Until recently starting a new
job with medical insurance, Kelly had to pay $150
each month for private insurance in order to partially
cover her monthly diabetes-related expenses of $450.
With private insurance, she still pays $100 to $150 a
month out of pocket.
“The bottom line is that all diabetes medications and
devices should be equally available to everyone in
Canada who needs them regardless of age, income or
where they live,” says Dawn.
11
12 | 2016 Report on Diabetes in Newfoundland and Labrador
COST OF DIABETES MANAGEMENT
In Newfoundland and Labrador, public coverage
for drug therapy to treat diabetes varies based on a
person’s income level, age and prescribed therapy—
the level of coverage impacts out-of-pocket costs. The
CDA has estimated out-of-pocket costs for people
with diabetes in Newfoundland and Labrador who do
not have private insurance.
A person with type 1 diabetes taking insulin through
multiple daily injections may spend an estimated
$1,000–$3,200 a year to manage diabetes. Insulin
pump therapy may cost $1,000–$6,300 a year,
depending on whether the individual is eligible for
public coverage and their income. While people with
type 1 diabetes are eligible for some government
assistance for management costs (more for low
income earners), people with type 2 diabetes,
diabetes.ca/charter
including seniors, need to pay the full cost for their
prescribed treatment at an estimated $2,000 per year
if they do not have private insurance. Only seniors
qualifying for a Guaranteed Income Supplement may
have the majority of their expenses covered by the
government.
Even with private insurance, cost may still be a
struggle to those with diabetes, due to incomplete
coverage or difficulty in obtaining insurance.
Insurance plans are not always accessible to those
with diabetes: 15 per cent of people with diabetes
residing in Atlantic Canada said they had difficulty
obtaining insurance due to their diabetes, and 21
per cent said the cost of diabetes impacted their
adherence to treatment.7 The impact was most
significant for lower income earners.
13
CHAPTER 3:
Patient needs
14 | 2016 Report on Diabetes in Newfoundland and Labrador
Dr. Joshi’s story
Dr. Joshi is concerned about the burden of
type 2 diabetes in the province. From his perspective,
prevention is the best medicine, including better supports
for diabetes patients to prevent serious complications.
Dr. Pradip Joshi has been practicing as an internist in
St. John’s for 36 years. In recent years, he has become
increasingly concerned by not just the rising numbers
of people being diagnosed with type 2 diabetes but
also the younger age of these patients. “I am seeing
more and more young adults with type 2 diabetes—
people 20 to 25 years of age. I have even seen it in
youth as young as 15 and 16,” he says.
Dr. Joshi is encouraged by the province’s moves to
ban sugar-sweetened beverages in schools and to
make physical education a mandatory course in
high school. “It is so important to give children and
adolescents a healthy start in terms of nutrition and
physical activity,” he says. “Initiatives that target
diabetes prevention in youth will make the biggest
impact from a public health perspective.”
Dr. Joshi’s practice is not unique. Currently, about
63,000 people in Newfoundland and Labrador have
been diagnosed with diabetes. At more than 12 per
cent of the population, this province’s diabetes rates
are the highest in Canada. By 2026, Newfoundland
and Labrador’s rate of diabetes is expected to increase
to 17 per cent of the population, representing 86,000
people. “That’s a huge increase,” he says.
A diabetes registry, which Dr. Joshi hopes to see roll
out soon, will help demonstrate the effectiveness
of these and other wellness initiatives. Analysing
data from the registry, researchers will be able to
spot trends across the province, to see whether any
communities have particularly high or low rates of
diabetes and what factors may be influential. “It’s
important to know which initiatives are making
an impact. The registry will help us to allocate our
resources more efficiently and more cost-effectively,”
he says.
Only part of this increase can be attributed to the
aging of our population. The more significant driving
factor is obesity, says Dr. Joshi. Across the country,
60 per cent of Canadians are overweight or obese.
In the Atlantic provinces, almost a third of teens are
already at an unhealthy weight. While the causes of
obesity are extremely complex, socioeconomics have
a lot to do with what people eat. A healthy diet rich
in fresh fruits and vegetables is expensive; high-fat,
nutrient-poor junk food, on the other hand, is often
much more affordable. Exercise—or rather, the lack
of—also plays an important role in the development
of type 2 diabetes.
He encourages the government to make decisions
based on sound clinical considerations, a practice
that would emphasize prevention. “Right now, the
government will approve a second bypass surgery
for a patient with diabetes but not a drug that would
have prevented that patient from developing heart
disease in the first place,” he says with frustration. “If
they were more forward thinking, they would put our
money where it would give us the best return. “
15
RISK FACTORS AMONG
NEWFOUNDLAND AND
LABRADOR RESIDENTS
to the rest of Canada. Statistics Canada estimated
that close to one in five residents in the province is
a senior in 2016.8 By 2038, the province is projected
to have the highest proportion of senior population
(aged 65 and over) in Canada, which will be 32–36
per cent of the provincial population.9
The rapidly aging demographic is a key driver
for the rising diabetes burden in this province.
Newfoundland and Labrador along with other
Atlantic provinces have older populations compared
Table 2: Median age and percentage of people aged 65 and older, by province & territory, 2016
Median
age
65+
CANADA
B.C.
ALTA.
SASK.
MAN.
ONT.
QUE.
N.B.
N.S.
P.E.
N.L.
Y.T.
N.W.T.
NVT.
40.6
42.1
36.3
36.9
37.5
40.6
42.1
45
44.6
43.9
45.3
39.5
33.3
26.1
16.5%
17.9%
11.9%
14.8%
15%
16.4%
18.1%
19.5%
19.4%
18.9%
19.1%
11.6%
7.1%
4%
Source: Statistics Canada projections based on 2011 Census.
In addition to age, risk factors such as ethnicity,
gender and family history also contribute to higher
risk of type 2 diabetes. While these factors are
out of individuals’ control, risk factors related to
health behaviours can be “modified” to reduce the
risk of developing type 2 diabetes and improve the
management of diabetes. In this report, we focus on
unhealthy diet, physical inactivity and tobacco use.
The most current data on overweight and obesity are
also presented.
Many people in Newfoundland and Labrador are
inactive and do not eat enough fruits and vegetables.
In 2014, 73 per cent of people consumed fruits and
vegetables less than five times a day, and 50 per cent
said they were inactive during leisure time; these
rates were the second highest among all provinces
and territories (after Nunavut).10 Almost every year
between 2003 and 2014, Newfoundland and Labrador
reported higher rates of inadequate consumption of
fruits and vegetables and physical inactivity than the
Canadian average rates.
Physical activity and a healthy diet are important
for general health, particularly for people at risk of
type 2 diabetes and those living with the disease.
Physical activity has been shown to improve blood
glucose control, reduce insulin resistance, and
16 | 2016 Report on Diabetes in Newfoundland and Labrador
increase cardiorespiratory fitness and energy; it
also helps maintain weight loss and reduces blood
pressure. Physical activity combined with a healthy
diet can contribute to weight loss, and a moderate
weight loss (5–10 per cent of body weight) can
substantially improve blood glucose control, and
reduce the risk of cardiovascular disease and type 2
diabetes.
Corresponding to the low level of physical activity
and fruits and vegetables consumption are high rates
of overweight and obesity. In 2014, 67 per cent of
Newfoundland and Labrador residents were reported
to be overweight or obese, and 30 per cent were
found to be obese; both rates were the highest among
all jurisdictions. In fact, in most years between 2003
and 2014, Newfoundland and Labrador consistently
reported higher rates in overweight and obesity rates
than the rest of Canada.10 In youth, over 12,000
(47 per cent) of those aged 12–17 were found to be
overweight or obese.11
Tobacco use is linked to increased risk for diseases
such as lung cancer, heart attack and stroke. It is
also an independent risk factor for type 2 diabetes—
people who smoke 25 or more cigarettes daily have
double the risk for diabetes than non-smokers,
regardless of whether they have other risk factors
for diabetes.12 13 14 Smokers are also at high risk of
developing metabolic syndrome, a common condition
characterized by a cluster of risk factors occurring
together, which puts people at higher risk for chronic
diseases such as type 2 diabetes and cardiovascular
disease; these risk factors include high fasting blood
glucose, abdominal obesity, high triglycerides, low
HDL-C (high-density lipoprotein cholesterol) and
high blood pressure.15
Clinical Practice Guidelines recommend the following
screening tests as part of optimal care people with
diabetes should receive:
In 2014, 22 per cent of Newfoundland and Labrador
residents aged 12 and older reported that they used
tobacco daily or occasionally, a rate higher than
the Canadian average, and second highest among
provinces (after Nova Scotia).10
• Dilated eye exam (to check for retinopathy): every
one to two yearsiii 6
PREVENTION OF COMPLICATIONS
Regular screening for complications and comorbidities,
and assessment of glycemic control are essential in
diabetes care and management. The CDA’s 2013
• A1C test: every 3 months, or every 6 months for
those who have consistently achieved targets
• Foot exam: every year
• Urine protein test (to screen for kidney disease):
every year ii
A high percentage of people with diabetes in the
province were not receiving these key screening
tests in 2007—in fact, Newfoundland and Labrador
had the lowest percentage of people with diabetes
that reported receiving all four tests among all
jurisdictions in Canada.
Table 3: Percentage of Newfoundland and Labrador residents and Canadians with diabetes who reported
having received recommended care components, 2007
RECOMMENDED SCREENING TEST
NEWFOUNDLAND AND LABRADOR
CANADA
A1C test in the past 12 months
75%
81%
Urine protein test in the past 12 months
73%
74%
Dilated eye exam (ever received)
49%
66%
Feet check by health-care professionals in
the past 12 months
41%
51%
All four exams as per recommendations
21%
32%
ii The initial urine protein test should be done at diagnosis for type 2 diabetes, and five years after diagnosis for type 1 diabetes. The test should be repeated yearly.
iii A dilated eye exam should be done at diagnosis for type 2 diabetes with rescreening every 1-2 years, and five years after diagnosis for type 1 diabetes (15 years
and older) with annual rescreening.
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CHAPTER 4: Canadian Diabetes
Association’s recommendations
Across Canada, the CDA advocates to all levels of
government to improve care and health outcomes
for people with diabetes and to prevent diabetes and
associated complications. These include government
policies and guidelines to protect children with diabetes
in school in every province and territory; adoption of
our recommendations to prevent foot problems and
amputation; improved access to diabetes supports such
as medications, devices, supplies and healthy foods;
enhanced diabetes care and screening; reduction in
stigma and discrimination related to diabetes; making
disability tax credit available to all people with type 1
diabetes; restricting marketing of foods and beverages
to children; and implementation of a tax on sugarsweetened beverages. The CDA’s Diabetes Charter for
Canada identifies many of these important aspects.
Currently in Newfoundland and Labrador, there is a
lack of coordinated diabetes care and limited capacity
for diabetes surveillance, as observed by the provincial
Auditor General. To better organize care for people
with diabetes, the CDA recommends using a chronic
care model and inter-professional care teams, which
have shown to improve both the quality of care and
health outcomes.6 In adults with type 2 diabetes,
the interdisciplinary chronic care model has been
associated with improvements in A1C levels, blood
pressure, lipids and care processes compared to
care that is delivered by a specialist or primary care
physician alone. 16 17 18 19 20 A reduction in the number
of preventable, diabetes-related emergency room
visits has been noted when the care team includes a
specifically trained nurse who follows detailed treatment
algorithms for diabetes care.21
According to the provincial Auditor General, between
2000 and 2006, the province created nine primary
health care sites consisting of physicians, nurse
18 | 2016 Report on Diabetes in Newfoundland and Labrador
practitioners, public health officials, social workers and
other health-care providers, with federal funding aimed
at renewing provincial primary health care systems. A
Primary Health Care Office at the Department of Health
and Community Services was also created to coordinate
services including prevention and management of
diabetes. However, when the funding ended in 2006,
the government discontinued funding for the Primary
Health Care Office and thereby ended its coordinating
role of primary health care in the province.2
In order to stem the tide of increasing diabetes burden,
the CDA urges the Government to develop and
implement a Provincial Diabetes Strategy that would
address the serious gaps in preventing and managing
diabetes in the province. The strategy should include
the following key components in order to successfully
reduce the burden of diabetes:
• A diabetes registry or database, to track diabetesrelated statistics and ensure up-to-date and evidencebased decision making for diabetes initiatives
• Better coordination of diabetes care at the provincial
level, delivered using a model that focuses on interprofessional team care
• Better access to diabetes medications, devices and
supplies, including expanded coverage for insulin
pumps, pump supplies and blood glucose test strips
• Increased support for self-management of diabetes,
through enhanced commitment to fund public
awareness campaigns and education programs that
promote lifestyle modification
• Wellness programs to support diabetes prevention,
through sustained and increased funding
commitments
CONCLUSION
Stories from Newfoundland and Labrador residents whose lives have been affected by diabetes speak to
the urgent need for government action on diabetes. Diabetes in Newfoundland and Labrador will continue
to grow at an alarming rate. The level of support for diabetes management must be enhanced to keep pace
with the increasing demands of diabetes on the provincial health-care system. With concerted efforts
and strong leadership from the Government, in close collaboration with key stakeholders in the diabetes
community, we reduce the impact of diabetes and significantly improve the lives of those with diabetes
and all Newfoundland and Labrador residents.
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