2016 Report on Diabetes. in Newfoundland and Labrador

Transcription

1 2016 Report on Diabetes in Newfoundland and Labrador

2 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 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 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. SUPPORT CARE EQUI TY The guiding principles of the Canadian Diabetes Association in developing this Charter are to: 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: Be treated with respect, dignity, and be free from stigma and discrimination. 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. 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. Have access to their medical records and other health information when requested, and have it easily understood. Diabetes information, education and care that take into account a person s age, culture, religion, personal wishes, language and schooling. Have their eyes, feet, kidneys, blood glucose control, cardiovascular risk factors and mental health checked as often as recommended by current clinical practice guidelines. *and their informal caregivers where relevant Affordable access to insurance coverage. Fully participate in daycare, pre-school, school and extracurricular activities, receiving reasonable accommodation and assistance if needed. 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: Self-manage to the best of their abilities and personal circumstances, including a healthy diet, exercise, following care plans and attending appointments. Be honest and open with health providers about their current state of health so that the most suitable care plans can be created. Actively seek out education, information and support to live well with diabetes. Respect the rights of other people with diabetes and health care providers. Governments Have the Responsibility to: Form comprehensive policies and plans for the prevention, diagnosis, and treatment of diabetes and its complications. Collect data on diabetes burden, such as costs and complications, and to regularly evaluate whether progress is being made. 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. Health Care Providers Have the Right to: Ongoing training, funding and tools needed to provide high quality diabetes care. 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. Health Care Providers Have the Responsibility to: Treat people with diabetes as full partners in their own care. Learn and apply up-to-date evidenced-based clinical practice guidelines when caring for people with diabetes. Diagnose people living with diabetes as early as possible. Help people with diabetes and their caregivers navigate the health care system. 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. Partner with researchers to improve the planning, provision and quality of diabetes care by promoting and applying research. Advocate for equitable access to diabetes care, education, medications, devices, and supplies. diabetes.ca BANTING CARE EQUITY SUPPORT CARE EQUITY SUPPORT CARE EQUITY SUPPORT CARE EQUITY 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 Toronto, Ontario: CDA.

3 TABLE OF CONTENTS Executive Summary 2 Methods and data sources 3 Introduction 4 Diabetes in Newfoundland and Labrador 5 Chapter 1: Access to supports 6 Jackie s story 7 Insulin pump coverage 9 Transition to adult care 9 Chapter 2: Cost of diabetes 10 Dawn s story 11 Cost of diabetes management 13 Chapter 3: Patient needs 14 Dr. Joshi s story 15 Risk factors among Newfoundland and Labrador residents 16 Prevention of complications 17 Chapter 4: CDA s recommendations 18 Conclusion 19 References 20 diabetes.ca/charter 1

4 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 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

5 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 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. diabetes.ca/charter 3

6 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) 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 Report on Diabetes in Newfoundland and Labrador

7 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 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 diabetes.ca/charter 5

8 CHAPTER 1: Access to supports Report on Diabetes in Newfoundland and Labrador

9 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

10 Report on Diabetes in Newfoundland and Labrador

11 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 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 ketoacidosis i 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 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. PROVINCE/TERRITORY INSULIN PUMPS PUMP SUPPLIES Table 1: Overview of coverage for insulin pumps and supplies in Canada, age thresholds 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

12 CHAPTER 2: Cost of diabetes Report on Diabetes in Newfoundland and Labrador

13 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

14 Report on Diabetes in Newfoundland and Labrador

15 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, 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. diabetes.ca/charter 13

16 CHAPTER 3: Patient needs Report on Diabetes in Newfoundland and Labrador

17 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 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. 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. 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. 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. 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

18 RISK FACTORS AMONG NEWFOUNDLAND AND LABRADOR RESIDENTS 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 to the rest of Canada. Statistics Canada estimated that close to one in five residents in the province is a senior in By 2038, the province is projected to have the highest proportion of senior population (aged 65 and over) in Canada, which will be per cent of the provincial population. 9 Table 2: Median age and percentage of people aged 65 and older, by province & territory, 2016 CANADA B.C. ALTA. SASK. MAN. ONT. QUE. N.B. N.S. P.E. N.L. Y.T. N.W.T. NVT. Median age % 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 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 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 Report on Diabetes in Newfoundland and Labrador

19 for diabetes 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 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 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 Clinical Practice Guidelines recommend the following screening tests as part of optimal care people with diabetes should receive: 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 Dilated eye exam (to check for retinopathy): every one to two years iii 6 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. diabetes.ca/charter 17

20 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 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 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 Report on Diabetes in Newfoundland and Labrador

21 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. diabetes.ca/charter 19

22 REFERENCES 1 Canadian Diabetes Association. (2014). The Diabetes Charter for Canada. Toronto, ON: CDA. Available at Auditor General of Newfoundland and Labrador (January 2011). Annual report, Part 2.9. Retrieved from ag.gov.nl.ca/ag/annualreports/2010annualreport/2.9%20-%20diabetes%20in%20nl.pdf 3 Canadian Diabetes Association. (2013). Canadian Diabetes Cost Model. 4 Government of Newfoundland and Labrador. Budget Eastern Health Newfoundland and Labrador. (2014). Newfoundland and Labrador Adult Insulin Pump Program [pamphlet]. Retrieved from (accessed: October 14, 2016) 6 Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2013). Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of diabetes in Canada. Can J Diabetes, 37(Suppl 1):S1-S Canadian Diabetes Association Survey of people with diabetes and without diabetes. Unpublished. 8 Statistics Canada. Table Estimates of population, by age group and sex for July 1, Canada, provinces and territories, annual (persons unless otherwise noted), CANSIM (database). (accessed: October 14, 2016) 9 Statistics Canada. (2014). Population projections: Canada, the provinces and territories, 2013 to Retrieved from 10 Statistics Canada. Table Health indicator profile, age-standardized rate, annual estimates, by sex, Newfoundland and Labrador, occasional, CANSIM (database). (accessed: June 17, 2016) cansim/a26?lang=eng&retrlang=eng&id= &pattern=health+indicator+profile&tabmode=datatable&srchl an=-1&p1=1&p2=-1 (accessed: May 31, 2016) 11 Statistics Canada. Table Health indicator profile, annual estimates, by age group and sex, Canada, provinces, territories, health regions (2013 boundaries) and peer groups, occasional, CANSIM (database). (accessed: October 12, 2016) 12 Rimm, E.B., Chan, J., Stampfer, M.J., et al. (1995). Prospective study of cigarette smoking, alcohol use, and the risk of diabetes in men. BMJ, 310, Shi, L., Shu, X., Li, H., et al. (2013). Physical activity, smoking, and alcohol consumption in association with incidence of type 2 diabetes among middle-aged and elderly Chinese men PLoS One, 8(11), e Zhang, L., Curhan, G.C., Hu, F.B., et al. (2011). Association between passive and active smoking and incident type 2 diabetes in women. Diabetes Care, 34, Alberti, K., Eckel, R.H., Grundy, S.M., et al. (2009). Harmonizing the metabolic syndrome. A joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation, 120(16), Retrieved from ahajournals.org/content/120/16/1640.long Report on Diabetes in Newfoundland and Labrador

23 16 Borgermans, L., Goderis, G., Van Den Broeke, C., et al. (2009). Interdisciplinary diabetes care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: findings from the Leuven Diabetes Project. BMC Health Serv Res, 9, vanbruggen, R., Gorter, K., Stolk, R., et al. (2009). Clinical inertia in general practice: widespread and related to the outcome of diabetes care. Fam Pract,26, 428e Davidson, M.B., Blanco-Castellanos, M., Duran, P. (2010). Integrating nurse-directed diabetes management into a primary care setting. Am J Manag Care, 16, 652e6. 19 Saxena, S., Misra, T., Car, J., et al. (2007). Systematic review of primary healthcare interventions to improve diabetes outcomes in minority ethnic groups. J Ambul Care Manage,30,218e Willens, D., Cripps, R., Wilson, A., et al. (2011). Interdisciplinary team care for diabetic patients by primary care physicians, advanced practice nurses and clinical Pharmacists. Clin Diabetes, 29,60e8. 21 Davidson, M.B., Blanco-Castellanos, M., Duran, P. (2010). Integrating nurse-directed diabetes management into a primary care setting. Am J Manag Care,16, 652e6. diabetes.ca/charter 21

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