Diabetes Mellitus in New Brunswick

October 2016

Diabetes mellitus in New Brunswick

Diabetes mellitus is one of the most common chronic diseases in In this issue: New Brunswick, and its prevalence continues to increase.  Levels and trends of diabetes. Diabetes occurs when the pancreas does not produce enough  Relative burden of diabetes in insulin (a hormone that regulates blood sugar or glucose) or the New Brunswick. body cannot effectively use the insulin it produces to change the  Obesity and other contributing factors to diabetes. glucose from consumed food and drinks into energy, ultimately leading to high blood sugar levels (hyperglycemia). It can result in  Looking ahead. shortened life expectancy and fewer years lived in good health [1,2]. Diabetes is an important indicator of population health and kidney failure, vision loss, oral health system performance because of its increasing prevalence, disease, sexual dysfunction and association with preventable measures, and far-reaching leg or foot amputation (due to consequences [3,4]. nerve damage and poor blood There are three main types of diabetes: circulation). Conditions associated with type 2 diabetes,  Type 2, where the body makes insulin but cannot use it mainly through their association properly. Nine in 10 people with diabetes have this type. Being with similar risk factors, include 40 or older is an important risk factor for type 2 diabetes, but it arthritis, sleep and breathing is now increasingly appearing in children and youth. Being overweight or obese is another important risk factor. One of the fastest-growing diseases in Canada, type 2 diabetes can be prevented or postponed by making healthy lifestyle choices including dietary change, physical activity and weight management.  Type 1, where the body makes little or no insulin. This type of diabetes cannot be prevented based on current knowledge, and people living with it depend on daily doses of insulin for survival. It arises most often in children and youth.  Gestational diabetes, where the body does not properly use insulin during pregnancy. This type of diabetes usually goes away after the baby is born, although women who had gestational diabetes and their children are at increased risk of type 2 diabetes in the future.

Diabetes affects the nerves, blood vessels and various organs. A person with diabetes checks her blood glucose level as part of a personal care plan. Common long-term complications include heart disease, stroke, Image courtesy Centers for Disease Control and Prevention Key Points  Diabetes is a chronic condition characterized by hyperglycemia (high blood glucose) resulting from the body's inability to use blood glucose for energy. It is a complex disorder, associated with multiple genetic, lifestyle, social and environmental factors. The lifelong duration of types 1 and 2 diabetes can lead to other health complications, including problems with the heart, kidneys, nerves and eyes.  The diabetes and obesity epidemics, combined with longer life spans, have increased the prevalence of diabetes to one in 10 New Brunswickers. Each year an average of 5,620 residents are diagnosed with type 1 or type 2 diabetes. Many more have not yet been diagnosed but are at high risk of the disease.  Population aging is the most important demographic change affecting diabetes rates because the occurrence of diabetes increases with age. As with much of Canada, New Brunswick has experienced years of continued growth in diabetes, but there is potential to reverse this trend. People can help lower their chances of type 2 diabetes and its preventable complications by maintaining a healthy weight, exercising regularly, eating a healthy diet, not smoking and keeping their blood glucose in check.  Socio-economic conditions, such as lower income, are also associated with higher rates of diabetes. Actions to improve rates of diabetes and its underlying determinants at the population level are likely to have a positive impact on other prevalent health conditions. disorders, depression and some The prevalence of diabetes in incidence rose from 6.2 to 8.1 cancers. New Brunswick has been per 1,000 population between growing steadily in recent years 2001-02 and 2013-14. The rate Although there is no cure for [5,6]. decreased by about seven per diabetes, the risk of developing cent in the last two years, but it complications can be reduced Diabetes is widely recognized is too early to consider the by managing blood sugar levels as an enormous global, national implications of such small through administration of oral and provincial public health decreases at this point. medication and/or insulin as challenge, but there is a well as by lifestyle choices. potential to reverse this trend. As more people are being diagnosed and are living longer The World Health Organization Levels and trends of with diabetes, the prevalence (WHO) estimates the number of (or total number of cases) diabetes adults living with diabetes has continues to increase. almost quadrupled worldwide during the last three decades, Chronic disease surveillance One in 10 New largely due to the rise in factors data indicate the incidence, or Brunswickers has diabetes driving type 2 diabetes, new diagnoses, of diabetes has including overweight and experienced some year-to-year In 2007-08, one in 13 New obesity [2]. fluctuations during the past Brunswickers one year and decade or so, but has generally older was living with diagnosed In Canada, diabetes is a increased in New Brunswick diabetes, and it was projected leading cause of death and (Figure 1). In 2013-14, there that the ratio would rise to one diabetes-related costs to the were 5,620 new cases of in 10 in five years [5]. health-care system – such as physician-diagnosed diabetes laboratory tests, physician (types 1 and 2 combined), New data confirm that one in 10 services and kidney analysis – compared to 4,505 in 2001-02. New Brunswickers one year amount to $15.6 billion This represents an increase of and older (74,740 individuals) annually, or $430 for every 25 per cent over 12 years. now has this lifelong condition man, woman and child [4]. (Figure 2). Taking into account population growth, the rate of diabetes

Diabetes mellitus in New Brunswick – Page 2 Figure 1: Trends in the incidence of diagnosed diabetes, by gender, New Brunswick, 2001-02 to 2013-14

Counts Rates 8,000 12

Males Females

8.8 6,000 5620 9 5390 Males 8.2 8.0 8.1 5090 7.6 Total 7.3 4505 6.8 7.4Females 7.1 6.2 6.6 4,000 6 5.7 Number of new cases new of Number 2,000 3 Rate per 1,000 population 1 year and older and year 1 population 1,000 per Rate

0 0

Note: Data on physician-diagnosed diabetes mellitus (types 1 and 2 combined) among New Brunswick residents one year and older based on tracking of individuals’ interactions with the healthcare system integrating various health administrative databases. Source: New Brunswick Department of Health, using the Canadian Chronic Disease Surveillance System infrastructure and case definitions.

Figure 2: Trends in the prevalence of diagnosed diabetes, by gender, New Brunswick, 2001-02 to 2013-14

Counts Rates 80,000 120 74,740

Males 103 Males Females 98 61,490 Total 60,000 90 Females 85 93

53,350 81 74 78 71 38,740 68 40,000 60 53 51 50 Total number cases of number Total

20,000 30 Rate per 1,000 population 1 year and older and year 1 population 1,000 per Rate

0 0

Diabetes mellitus in New Brunswick – Page 3 This represents a 25-per-cent (Figure 3). One in four seniors One of the challenges with the increase in the numbers from now has the disease (270 per provincial data sources for five years earlier, and a 90-per- 1,000 population), compared to surveillance of diabetes is the cent increase compared to 12 fewer than one in five 12 years inability to identify whether years earlier. earlier (190 per 1,000 persons have type 1 or type 2 population). diabetes. It is reasonable to Diabetes prevalence assume, at least for now, that increases substantially While prevalence increases the vast majority of children and with advancing age with age, one-half (48 per cent) youth are diagnosed with type 1 of New Brunswickers living with diabetes. Because diabetes is a chronic diabetes are of working age, disease, the proportion of between 20 and 64 years of Canada has higher rates of type people with diagnosed diabetes age. 1 diabetes in children than most tends to increases with age. other countries with developed The sharpest increase occurs Slightly increasing diabetes market economies [7]. While after 40 years, as the body's prevalence is observed in the type 1 accounts for only some ability to produce and use youngest age groups. In 10 per cent of all diabetes insulin begins to deteriorate. 2013-14, 640 New cases, incidence rates are Brunswickers 1 to 19 years old rising fast in some countries, Between 2002-03 and 2013-14, were living with diabetes (4.4 possibly attributable to the greatest increase in per 1,000), up from 550 in changing environments and prevalence was seen among 2002-03 (3.2 per 1,000) infant and maternal diets [7]. persons 65 and older (Figure 4).

Figure 3: Trends in the prevalence of diabetes by age group, New Brunswick, 2002-03 to 2013-14

350

300 2013-14 An estimated 1 in 10 New Brunswickers 250 2007-08 has been diagnosed with diabetes. 200 2002-03

150

100

specific rate per 1,000 populationperrate 1,000 specific - 50 The disease is Age more common in older age groups. 0 Among those 65 and older, 1 in 4 has diabetes. Age group Note: Data on diagnosed diabetes mellitus (types 1 and 2 combined) among New Brunswick residents one year and older. Source: New Brunswick Department of Health, using the Canadian Chronic Disease Surveillance System infrastructure and case definitions.

Diabetes mellitus in New Brunswick – Page 4 Figure 4: Trends in the prevalence of diabetes among children and detected in three to five per cent youth under 20, New Brunswick, 2002-03 to 2013-14 of pregnancies [1,5]. Its occurrence increases with age. 1,000 5

4.4 In pregnancy, diabetes is Rate associated with health risks for 3.9 800 4 both the mother (complications in labour and delivery) and the fetus

19 years 19 3.2 640 - 620 (high birth weight and congenital 600 3 550 anomalies leading to increased risk of death).

400 2 Although gestational diabetes is a

Number of personsNumberof temporary condition, about 20 per cent of women 20 to 39 years when first diagnosed with 200 1 Rate per 1,000 population 1 1,000populationperRate gestational diabetes will develop type 2 diabetes within nine years [5]. 0 0 2002-2003 2007-2008 2013-2014 Blood tests identify Note: Data on diagnosed diabetes mellitus among New Brunswick residents one to 19 years. increasing numbers of Source: New Brunswick Department of Health, using the Canadian Chronic Disease Surveillance System infrastructure and case definitions. hyperglycemic conditions

Many long-term complications of

diabetes are linked to sustained Men overall have higher rates of diabetes than women high blood glucose causing damage to the blood vessels in While women generally live longer, diabetes is more common the body, which in turn affects the among men. The incidence rate of diabetes (types 1 and 2) is heart, kidneys, eyes, nerves and some 15 per cent higher among New Brunswick males compared feet. Clinical tests for to females (8.8 versus 7.4 per 1,000 population in 2013-14), a hyperglycemia identify individuals pattern that has remained relatively stable (Figure 1). who have, or are at risk of, diabetes and its preventable Given the years of higher diabetes incidence among males, complications. Since diabetes considerably more males are now living with the condition than develops over time, different or females (103 versus 93 per 1,000 population in 2013-14). The repeat tests are typically used to gender gap in diabetes prevalence is growing over time tell when overall blood glucose (Figure 2). levels are becoming too high.

Male excess in diabetes has been found in many populations with Laboratory measurement of higher type 2 incidence, possibly due to sex-related differences in glycosylated hemoglobin (also insulin sensitivity, consequences of obesity and regional body fat known as A1c testing), as an deposition, and other contributing factors such as high blood indicator of the degree of control pressure, tobacco smoking and alcohol intake [8,9]. of glucose metabolism, helps to diagnose, prevent and manage This does not include gestational diabetes, a type of diabetes that type 2 diabetes [2,10]. The higher develops only in pregnant women. Gestational diabetes is the A1c level, the higher the

Diabetes mellitus in New Brunswick – Page 5 average concentration of future chronic complications them at substantial risk of glucose in the blood during the associated with diabetic diabetes complications such as preceding three months, and glycemic levels in the general heart disease and eye disease the higher the risk of diabetes population [11]. (diabetic retinopathy), complications. An A1c level regardless of diagnosis status. below 5.7 per cent is generally Increasing numbers of persons Of these, more than 10 per cent considered in the healthy range. with poor blood sugar control had severe hyperglycemia (A1c have been identified in New value of 9.0 per cent or higher). Other blood glucose Brunswick since the measurements (fasting plasma introduction of A1c testing in Another 51,210 individuals (69 glucose, random plasma 2000 (Figure 5). per 1,000 population one year glucose and oral glucose and older) had recorded A1c tolerance tests) are also used to In 2015-16, 46,875 New levels between 6.0 and 6.4 per diagnose and manage types 1 Brunswickers (63 per 1,000 cent; i.e., impaired glucose and 2 and gestational diabetes, population one year and older) tolerance among those who in conjunction with a review of were detected to have had have not yet been diagnosed risk factors and symptoms. elevated glucose with diabetes, also referred to There is increasing evidence concentrations (A1c value of A1c is a better predictor of 6.5 per cent or higher), putting

Figure 5: Trends in the population with increased A1c values classified at risk of diabetes and its preventable complications, New Brunswick, 2005-06 to 2015-16

Counts Rates 120,000 150 Intermediate hyperglycemia (6.0-6.4%) Intermediate hyperglycemia (6.0-6.4%)

Diabetic hyperglycemia (6.5-8.9%) Diabetic hyperglycemia (6.5-8.9%) 100,000 Severe diabetic hyperglycemia (≥9.0%) 125 Severe diabetic hyperglycemia (≥9.0%)

80,000 100

60,000 75

Number persons of Number 40,000 50

20,000 25 Rate per 1,000 population 1 year and older and year 1 population 1,000 per Rate

0 0

Note: Data on average blood glucose levels as measured in a hemoglobin A1c test, regardless of diagnosis status. An A1c result of 6.5 per cent or greater indicates elevated blood glucose associated with diabetes and its complications (although diagnosis in a clinical setting necessitates confirmation with a second measurement unless there are clear symptoms of diabetes and in consideration of certain conditions known to interfere with test results). A result of 9.0 per cent or greater indicates severe diabetic hyperglycemia detected in the reporting period. A result between 6.0 and 6.4 per cent indicates controlled diabetic glycemic levels, or prediabetes in the absence of previous diagnosis. Glycemic targets for diabetes management should be individualized based on age and other patient characteristics, and balanced against risk of inducing hypoglycemia. Source: New Brunswick Department of Health, using the regional health authorities’ A1c/LDL lab services databases.

Diabetes mellitus in New Brunswick – Page 6 as prediabetes. Prediabetes, notably hypoglycemia, a diagnosed diabetes (types 1 which usually has no potentially life-threatening and 2) has been significantly symptoms, increases the risk of emergency that can arise when higher in New Brunswick than type 2 diabetes heart disease glycemic levels are too low [10]. the Canadian average, but the and stroke – although this can gap is essentially attributable to be prevented or delayed by Relative burden of differences in the population diet, exercise and weight loss. diabetes in New age structure (Figure 6) [16]. The cumulative number of Brunswick After adjusting for differences in persons with metabolic markers age distribution among the for diabetes and prediabetes Because diabetes is strongly provinces and territories, the (98,085) is twice that observed related to age, provinces and diabetes incidence rate in New 10 years earlier, attributable in territories with Brunswick has been similar to large part to more widespread disproportionately older the Canadian average in recent A1c testing in the province. This populations are expected to years (no significant difference number excludes those who have higher diabetes rates. in 2008-09 and 2009-10) have been diagnosed with (Figure 6) [16]. New Brunswick’s population is diabetes but have not had an older than the national average: A1c test as part of their care When population aging is taken (20 versus 17 per cent 65 years plan for reducing the risk of into account, the increase in of age and older) [14], so New complications. National data New Brunswick’s diabetes Brunswick’s crude (unadjusted) suggest 20 per cent of adults prevalence rate between diabetes rate is expected to be with diabetes do not receive 2007-08 and 2013-14 was 15 higher. The proportion of A1c tests annually [12]. per cent, or one-half as quickly seniors is growing faster than as the 25-per-cent increase Laboratory-based data do not any other age group, a result of observed in the crude rate. include results from self- longer life expectancy, declining monitoring of blood glucose, fertility rates and aging of the The diabetes prevalence rate, i.e., when persons with diabetes baby boom cohort, exacerbated influenced by the incidence and collect information about their in New Brunswick by negative by the duration of the condition, glucose levels at various time interprovincial migration [15]. has nonetheless remained points using home blood significantly higher in New Higher diabetes rates in glucose meters. Depending on Brunswick compared to New Brunswick are the patient population, self- nationally during the previous associated with population decade (Figure 7). The testing may be associated with aging improvements in glycemic province’s higher diabetes prevalence is largely a control [13]. Self-monitoring of National chronic disease reflection of an older population blood glucose can also serve surveillance data show the and of significantly higher for other measures of glycemia, crude incidence rate of

For more information on diabetes prevention and management, New Brunswickers may access the following resources:  In person: speak to a health-care provider  Telephone: Tele-Care at 811 (24 hours a day)  Web: Government of New Brunswick, A Comprehensive Diabetes Strategy for New Brunswickers (www.gnb.ca/0053/phc/diabetes-e.asp)  Web: Government of Canada – Public Health Agency of Canada (www.phac-aspc.gc.ca/cd- mc/diabetes-diabete)

Diabetes mellitus in New Brunswick – Page 7 disease incidence 10 years Newfoundland and Labrador prevalence observed through earlier. and in Nova Scotia) [17]. surveillance data.

Data from the Canadian The survey data also indicate Growing awareness among Community Health Survey no significant difference in the health-care professionals and (CCHS) on self-reported age-adjusted diabetes rates the public combined with diabetes status confirm the between New Brunswick and broader diagnostic criteria could pattern of higher crude the Canadian average in recent lead to increased detection of prevalence rate in New years (similar annual rates from diabetes cases identified. For Brunswick compared to the 2012 to 2014) [18]. example, changes in the national average (8.4 per cent recommendations for type 2 versus 6.7 per cent of the In addition to demographic diabetes screening and population 12 and older in changes, clinical and lifestyle localized screening campaigns 2014), and higher than in seven factors may influence trends in may influence observed rates other provinces (except in diabetes incidence and across each province and territory [1].

Figure 6: Trends in diabetes incidence rates, New Brunswick and Canada, 2001-02 to 2013-14

Crude Age-standardized 10 10

New

8 7.6* Brunswick 8 7.3*

Canada 6.6* 6.2* 6.7 6.6 5.9 New 6 6 5.7* Brunswick 6.1 5.9 Canada 5.7 5.5

4 4 Rate per 1,000 population 1,000 per Rate

2 2

0 0

Note: * = statistically different from the national rate (p<0.05). Data on diagnosed diabetes mellitus (types 1 and 2 combined) using population-based health administrative databases. Age standardized rates are adjusted against the1991 Canadian Census population structure to allow for meaningful comparisons across population groups and over time. Source: New Brunswick Department of Health and Public Health Agency of Canada, using data from the Canadian Chronic Disease Surveillance System.

Diabetes mellitus in New Brunswick – Page 8 Figure 7: Trends in diabetes prevalence rates, New Brunswick and Canada, 2001-02 to 2013-14

Crude Age-standardized 120 120

New

90 Brunswick 90 81*

71* Canada 72 New 61* Brunswick 60 60 56* 51* 63 Canada 58 44* 53 46 41 Rate per 1,000 population 1,000 per Rate 30 30

0 0

Note: * = statistically different from the national rate (p<0.05). Data on diagnosed diabetes mellitus (types 1 and 2 combined) using population-based health administrative databases. Age standardized rates are adjusted against the 1991 Canadian Census population structure to allow for meaningful comparisons across population groups and over time. Source: New Brunswick Department of Health and Public Health Agency of Canada, using data from the Canadian Chronic Disease Surveillance System.

International data indicate Deaths from diabetes are population in 2005 to 2.8 per diabetes prevalence among declining, but often go 10,000 in 2014 (Figure 8) adults, as measured by raised underreported [21,22]. This is likely due to fasting blood glucose, is lower better and earlier treatment of in Canada (age-standardized Diabetes is the sixth leading the disease, given that the rates of 48 per 1,000 females cause of death in Canada and prevalence of diabetes and 62 per 1,000 males) New Brunswick [20], and the continues to increase [4]. compared to the regional eighth worldwide [2]. It was the average for the Americas (81 direct cause of 215 deaths New Brunswick’s diabetes per 1,000 females and 85 per among New Brunswickers in mortality rate is higher than the 1,000 males) [19]. This may be 2014 – slightly more men than Canadian average, but the gap related to reductions in smoking women (111 versus 104) – narrows considerably when and better management of representing 3.2 per cent of all taking into account the diabetes compared to many deaths in the province [21]. province’s older demographics low- and middle-income (Figure 8) [22]. While the numbers have countries in the region. fluctuated from year to year, Looking at data on diabetes as generally speaking the mortality the cause of death may obscure burden of diabetes has declined the true burden of this disease. in New Brunswick during the Diabetes is not itself usually last decade, down from a peak reported as cause of death, but rate of 3.6 deaths per 10,000

Diabetes mellitus in New Brunswick – Page 9 Figure 8: Trends in mortality rates due to diabetes, New Brunswick and Canada, 2002 to 2014

Crude Age-standardized 6 6

4 4 3.6

3.1 2.8 2.8 New 2.6 Brunswick 2.4 2.5 2.2 2 Canada 2 1.7 New 2.0 2.1 1.9 Brunswick Rate per 10,000 population 10,000 per Rate 1.4 Canada

0 0

Note: Data on underlying cause of death among New Brunswick residents tabulated according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision: ICD-10 codes E10-E14 (diabetes mellitus, types 1 and 2 combined). The underlying cause of death is defined as the disease or injury which initiated the train of events leading directly to death, as listed on the medical certificate of cause of death. Source: Statistics Canada and Service New Brunswick, Vital Statistics.

many of its complications (e.g., Contributing factors to as age, genetics and ethnicity – heart disease, stroke, kidney diabetes are not modifiable. Others, such disease) are associated with as being overweight or obese, premature death and are often A number of lifestyle, genetic, unhealthy diet, insufficient listed as the underlying cause social, economic and physical activity and smoking, on death certificates rather than environmental factors have are modifiable through diabetes [1]. important effects on the levels behavioural and environmental and patterns of diabetes in the changes. Risk factors of Globally, WHO estimates population. developing gestational diabetes diabetes causes 1.5 million are similar. deaths each year, with another The risk factors for type 1 2.2 million deaths attributable to diabetes are still not well Since type 2 is the most high blood glucose resulting in understood but studies suggest common type of diabetes, increased risks of genetic factors and assessing the risk factors for cardiovascular and other environmental triggers are type 2 diabetes is critical to diseases [2]. involved. There is no conclusive informing clinical and public evidence for interventions to health-care strategies for prevent or delay the onset of reducing problems associated type 1 diabetes. with this disease.

The key risk factors for type 2 diabetes are well known [2,10]. Some of these factors – such

Diabetes mellitus in New Brunswick – Page 10 Increasing rates of The most widely used indicator increased by 12 per cent overweight and obesity to assess the health risks of between 2003 and 2014. It is linked to rising diabetes overweight and obesity in a significantly higher than the population is based on body national average (64 versus 54 The causes of diabetes are mass index (BMI), a measure per cent in 2014) [17]. The complex. While its development that examines weight in relation pattern holds when controlling cannot be explained by any to height [24,25]. for differences in population age single factor, overweight and structure (age-standardized rate obesity are the strongest risk Based on the CCHS, nearly of 61 versus 52 per cent in exposures linked to rising two-thirds of New Brunswickers 2014) [18]. diabetes prevalence worldwide 18 and older, roughly 355,960 [2]. About 80 to 90 per cent of adults, report height and weight The rate of overweight and people with type 2 diabetes are that classify them as overweight obesity among children and overweight or obese [10]. In or obese (Figure 9) [17]. The youth 12 to 17 years old has Canada, adults who are obese rate is considerably higher decreased somewhat since are nearly three times more among men than women (70 2005 and remained relatively likely than those who are not versus 58 per cent in 2014) stable in New Brunswick in obese to report that they had [17]. recent years (Figure 9). The been diagnosed with diabetes provincial rate is no longer The provincial rate of adult (14.6 versus 5.2 per cent in statistically different from the overweight and obesity 2014) [23]. national average [17].

Figure 9: Trends in the rate of overweight and obesity among adults and youth, New Brunswick and Canada, 2005 to 2014

Adults 18 and older Children and youth 12-17 80 80

New Brunswick 64* 61* 59* 60 57* 60

53 54

51 49 Canada

40 40 Percent New 27* 28 25 Brunswick 23

20 20 22 23 19 19 Canada

0 0

Note: * = statistically different from the national rate (p<0.05). Data based on self-reported height and weight and classified according to health risk using internationally accepted cut-off points for body mass index (excluding pregnant women). Source: Statistics Canada, Canadian Community Health Survey.

Diabetes mellitus in New Brunswick – Page 11 Still, nearly one-quarter of Socio-demographic factors, Tobacco smoking is also youth in the province – some including lower income, associated with an increased 10,630 boys and girls – are at belonging to certain ethnic risk of type 2 diabetes and its greater risk of type 2 diabetes groups and living in rural areas, complications, particularly and other chronic conditions in are generally associated with cardiovascular disease. While the future associated with higher rates of type 2 diabetes smoking rates have been having excess weight in [1]. declining in New Brunswick childhood. over the last several years, New Brunswickers living in they remain twice as high International data indicate the lower income households are among those in the lowest prevalence of overweight and significantly more likely to versus highest household obesity among adults and report having been diagnosed income group (Figure 10) [27]. among children are among the with diabetes than those living highest in Canada compared to in higher-income households Some communities may be other countries with developed (Figure 10) [27]. more vulnerable to adverse market economies [26]. health outcomes. While current Concurrently, levels of data are unable to distinguish Overweight and obesity results unhealthy eating and physical the relative risk related to First when people consume far more inactivity – which are fuelling Nations identity in developing calories than they use. This the obesity epidemic – are diabetes in New Brunswick, imbalance has been attributed significantly higher in national data indicate diabetes to a variety of changes in lower-income households. prevalence is three to five times society, work and leisure have higher among Aboriginal The rate of unhealthy eating, as affected activity and eating populations compared to the assessed through inadequate patterns, such as a shift toward non-Aboriginal average [1]. daily consumption of less physically demanding This pattern can be attributed vegetables and fruits, is highest work, increased use of to their socio-economic among persons in the least automated transport, passive disadvantage compared to the affluent households compared leisure activities and increased rest of the population. intake of foods that are high to the most affluent households energy-dense but nutrient-poor (73 versus 62 per cent). This It is estimated that if all New (often high in sugar and pattern is attributed in part to Brunswickers experienced the saturated fats). differences in gaining access to same diabetes prevalence rate health literacy, food security as those in the highest income Social inequalities and other societal resources. level, there would be one- contribute to diabetes quarter (24 per cent) fewer Physical activity is important for persons living with diabetes both diabetes prevention and There is growing evidence that across the province [28]. the social and cultural management, inhibiting the conditions in which people are progression of the disease by born, grow and age are increasing sensitivity to important determinants of insulin. In New Brunswick, the health. Obesity prevention can rate of physical inactivity during If all New Brunswickers reduce a large proportion of the leisure-time drops from 57 to had the same low diabetes rate as those in the highest diabetes burden, notably by 40 per cent across the least to the most affluent group. income level, there would acting on the underlying be about 1 in 4 fewer cases determinants that contribute to of diabetes. obesogenic environments.

Diabetes mellitus in New Brunswick – Page 12 Figure 10: Rates of self-reported diabetes and modifiable risk factors by household income group, New Brunswick

Diabetes Risk factors 20 100 Inadequate vegetable and fruit consumption Physically inactive

Daily smoker

15 75 73*

12* 62 57*

10 50 40

26* 5 5 25

13 Percent of the population 12 and olderand12of populationthePercent

0 0 Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5 Least affluent → Most affluent Least affluent → Most affluent

Note: * = statistically different from the Q5 rate (p<0.05). Household income groups based on income quintiles adjusted to the household and community size, with quintile 1 (Q1) representing the least affluent households and quintile 5 (Q5) the most affluent. Data on diabetes based on self- reports of having been diagnosed by a health professional with type 1 or type 2 diabetes, or gestational diabetes among females 15 and older. Inadequate vegetable and fruit consumption indicates the person reports usually eating vegetables and fruits fewer than five times per day. Physically inactive based on an index of average daily physical activity during leisure time. Daily smoker indicates the person reports currently smoking cigarettes every day. Source: New Brunswick Department of Health, using data from the Canadian Community Health Survey 2011-2012 (two-year period estimates).

Inequalities by income are also increasing chronic conditions in Diabetes prevalence is reflected in diabetes Canada and New Brunswick. likely to continue to management. The Canadian One in 10 New Brunswickers increase in the near future Diabetes Association estimates one year and older is living with people with diabetes average diagnosed diabetes, mostly The aging of the population has over $1,500 in out-of-pocket type 2. Many more individuals been one of the main factors expenses for medications, may not yet have been contributing to the increase in devices and supplies needed diagnosed. the number of New for self-managing their disease, Brunswickers with diabetes. leaving many lower income Diabetes exerts important Taking into account shifts in the Canadians with diabetes at risk impacts on physical, mental and population age structure, the of not being able to comply with social health. Nearly two-fifths incidence rate of diabetes has their prescribed therapy due to (39 per cent) of Canadian remained relatively stable, costs [29]. adults who report having although prevalence has been diabetes rate their health as steadily increasing given the "fair" or "poor," compared to greater longevity of individuals Looking ahead one-tenth of the adult living with the disease (due to population without diabetes (10 advancements in clinical and Diabetes mellitus is one of the per cent) [1]. preventive care). most common and rapidly

Diabetes mellitus in New Brunswick – Page 13 As the population ages, the [1,5]. Those with diabetes are number of New Brunswickers hospitalized three to four times living with diabetes is likely to more often with a heart attack, continue to increase in the near eight to 12 times more often future [4]. While the diabetes with renal failure, and 12 to 20 prevalence rate has been more often with a lower limb higher in New Brunswick amputation. compared to the national It has been estimated that if A male with diabetes and a health-care average, given the contracted professional talk about managing his disease, incidence gap, it is uncertain diabetes was eliminated from including blood sugar monitoring and related whether the pattern of higher the population, the rate of heart factors such as diet and physical activity. Image courtesy WHO prevalence in the province will attacks would decrease by 19 prevail in the longer term. per cent among women and by 10 per cent among men Other contributors to the worldwide [30]. combination of diet, physical increase in the number of cases activity, weight management of diabetes are rising rates of Keeping type 2 diabetes from and, if necessary, medication overweight and obesity, occurring in the first place, and and/or insulin therapy. It also increasingly sedentary lifestyles preventing the complications means controlling the risk and the global nutrition and premature deaths that can factors associated with transition. result from all types of diabetes, cardiovascular disease (blood are critical to reducing the pressure and lipids) and regular Reducing diabetes would problems associated with this screening for other common positively affect other disease. Reducing the burden complications (damage to the chronic diseases of diabetes will also likely have eyes, kidneys and feet). a positive impact on other People with diabetes often have chronic diseases. Slowing the rise in diabetes has additional serious health been identified as a global, problems, known as comorbid Evidence-based actions to national and provincial priority conditions. prevent and manage [2,31]. Preventive measures diabetes have the potential including targeted interventions Canadians and New to reverse current trends for healthy lifestyle choices Brunswickers with diabetes are among individuals at high risk twice as likely to be hospitalized For those with diabetes, early for type 2 diabetes (e.g., those with a stroke than individuals diagnosis can help improve with prediabetes), as well as without diabetes, and two to health outcomes. Living well population-wide strategies for four times more likely to be with diabetes means blood reducing rates of overweight hospitalized with heart disease glucose control, through a and obesity and addressing the

For information and resources for individuals, families, health professionals and organizations on healthy body weights, visit:  It’s your health: Obesity (Health Canada): hc-sc.gc.ca/hl-vs/iyh-vsv/life-vie/obes-eng.php  Childhood Obesity: www.healthycanadians.gc.ca/healthy-living-vie-saine/obesity-obesite/index-eng.php  Our Health Our Future: A national dialogue on healthy weights: ourhealthourfuture.gc.ca  Clinical practice guidelines on the management and prevention of obesity in adults and children (Canadian Medical Association): www.cmaj.ca/cgi/content/full/176/8/S1/DC1  Healthy Eating Physical Activity Coalition of New Brunswick: hepac.ca

Diabetes mellitus in New Brunswick – Page 14 underlying determinants, are balance may be programmed, About the data likely to have the greatest is an investment in the health of Measures of incidence and prevalence impact [2,10,32]. New Brunswickers. Everyone of diabetes mellitus in New Brunswick has a role to play to collectively were calculated using diagnostic Evidence-based approaches to reduce the impact of all forms of information from the provincial reduce the rates and costs of diabetes. physician billing and hospital discharge diabetes include policies and abstract databases drawing on practices across populations Canadian Chronic Disease Surveillance System (CCDSS) and within specific settings infrastructure, privacy protocols and An aging population and an (schools, homes, workplaces, case definitions [33]. New Brunswick health-care settings, during important rise in obesity has a universal single-payer health- times of leisure, etc.) that place New Brunswickers at care system that covers all physician increased risk of developing contribute to good health for and hospital services for residents. diabetes. One in 10 New Full-time members of the Canadian everyone, regardless of Brunswickers has diabetes, Forces and people in federal whether they have diabetes, and about 5,600 new cases correctional facilities are not included such as exercising regularly, are diagnosed annually. in the provincial databases. eating healthily and avoiding New Brunswick’s The CCDSS identifies people with smoking [2,10]. diagnosed diabetes using an algorithm Comprehensive Diabetes validated through a collaborative No single policy or intervention Strategy outlines the network supported by the Public Health can ensure this happens. A province’s road map to Agency of Canada (PHAC). range of policies, legislation and address the growing Information from the discharge abstract changes to the environment are challenge of diabetes. This database includes clinical diagnoses includes improved for acute-care hospital stays, coded needed to address prevention, screening, health using the International Classification of systematically the factors that coaching, access to Diseases and Related Health influence health risks and affordable medications and Conditions (ICD-10-CA). Data from the physician billing database are based outcomes at the necessary supplies, and support for the on search patterns for “diabetes” and scale, including removing management of diabetes and related nomenclature, including all fee- barriers to healthy lifestyles for its risk factors. for-service payments for services those living in poverty. rendered as well as alternate payment Read more at: structures using shadow-billing claims. Twenty years from now, in www.gnb.ca/0053/phc/diabet 2036, 30 per cent of New es-e.asp The quality of surveillance information on diabetes in Canada has increased Brunswickers will be 65 or older substantially during the last decade [1]. [15] and at high risk for type 2 However, diabetes rates estimated diabetes. Despite some limited from administrative data may be data that the incidence of affected by changes in data characteristics or collection methods diabetes may be plateauing, such as coding/classification systems, diabetes prevalence remains clinical practices, billing methods or high and continues to increase. patient factors. Comparisons with rates previously published by the Investing in supportive built and Department of Health or PHAC must social environments to mitigate be made with caution; rates in this report are definitive should a the risks of overweight and discrepancy exist. obesity during the life-course, beginning in childhood when The surveillance system cannot eating and physical activity distinguish between type 1 and type 2 diabetes. Because type 2 diabetes habits are formed and when the accounts for about 90 to 95 per cent of long-term regulation of energy the cases of diagnosed diabetes in

Diabetes mellitus in New Brunswick – Page 15 adults, trends in diabetes observed in Brunswickers of 10.3 per cent (95% CI: 6. New Brunswick Department of the data are likely to be reflective of 10.2-10.4%) and among females 9.3 Health and Wellness, Diabetes in true trends in type 2 diabetes in the per cent (95% CI: 9.2-9.4%), based on New Brunswick: Prevalence, adult population. It is less certain how some 74,740 observed cases among incidence, mortality and selected well the data reflect true trends in type individuals one and older. co-morbidities, 1997/98 to 2001/02. Fredericton, 2005. 1 diabetes (previously known as juvenile diabetes), since type 2 For all sources, descriptions of 7. Organisation for Economic diabetes is being increasingly diabetes incidence and prevalence Cooperation and Development, diagnosed in children and youth as a exclude undiagnosed cases in the Health at a Glance 2013. Paris, result of obesity. The data do not population. According to data obtained 2013. identify other (relatively uncommon) from blood samples, up to 20 per cent 8. Gale EA, Gillespie KM, “Diabetes types of diabetes caused by specific of diabetes cases in Canada are and gender.” Diabetologia, 2001; genetic conditions or from surgery, undiagnosed [1]. Important efforts 44(1):3-15. medications, infections, pancreatic within the health-care system to 9. Meisinger C et al., “Sex differences improve chronic disease detection and disease or other illnesses, which in risk factors for incident type 2 together account for less than five per management means the number of Diabetes Mellitus: The MONICA cent of all diagnosed cases. individuals who are unaware of their Augsburg Cohort Study.” Archives condition is likely decreasing. of Internal Medicine, 2002; 162(1): Data from population health surveys, 82-89. laboratory testing and vital statistics 10. Canadian Diabetes Association provide additional information on Clinical Practice Guidelines Expert diabetes, its risk factors and impacts. References Committee, “Clinical Practice Since this report uses multiple data Guidelines for the Prevention and sources, estimates may be reported for 1. Public Health Agency of Canada, Diabetes in Canada: Facts and Management of Diabetes in different reference periods and age figures from a public health Canada.” Canadian Journal of groups, and definitions may vary perspective. Ottawa, 2011 Diabetes, 2013: 37(suppl 1):S1- depending on the source. Specific (http://www.phac-aspc.gc.ca/cd- S212 (http://guidelines.diabetes.ca, conventions are used to distinguish mc/publications/diabetes- accessed Aug. 25, 2016). between different reference periods of diabete/facts-figures-faits-chiffres- 11. Bonora E, Tuomilehto J, “The Pros data collection. The format “20XX-YY” 2011/index-eng.php, accessed and Cons of Diagnosing Diabetes indicates a fiscal year running from Sept. 12, 2016). with A1C.” Diabetes Care, 2011; April 1, 20XX, to March 31, 20YY; data 2. World Health Organization, Global 34(Supplement 2): S184-S190. spanning more than a year are Report on Diabetes. Geneva, 2016 12. Canadian Institute for Health reported as “20XX–20YY.” (http://www.who.int/diabetes/global- Information, Diabetes Care Gaps report, accessed Sept. 12, 2016). and Disparities in Canada. Ottawa, For key measures, 95 per cent 2009. confidence intervals were calculated to 3. Statistics Canada, Health Status: Diabetes. Ottawa ascertain the degree of variability 13. Canadian Agency for Drugs and (http://www.statcan.gc.ca/pub/82- Technologies in Health, Systematic associated with the rates and help in 229-x/2009001/status/dia-eng.htm, Review of Use of Blood Glucose reaching conclusions about whether accessed Sept. 12, 2016). Test Strips for the Management of the observed differences reflect a true Diabetes Mellitus. Optimal Therapy pattern, rather than an effect driven by 4. Conference Board of Canada, Mortality Due to Diabetes. Ottawa, Report, Ottawa, 2009. sampling variability, coincidence or 2012 chance. 14. Statistics Canada, “Table 051- (http://www.conferenceboard.ca/hc 0001: Estimates of population, by p/details/health/mortality- age group and sex for July 1, Each data source has its strengths and diabetes.aspx , accessed Sept. 12, Canada, provinces and territories.” limitations, and reported diabetes rates 2016). CANSIM [online database]. Ottawa may vary by data source because of 5. New Brunswick Department of (http://www5.statcan.gc.ca/cansim, differences in methodologies. For accessed Sept. 30, 2016). example, according to results from the Health, Diabetes in New Brunswick, 1998-2007. Fredericton, 2014 CCHS, the prevalence of self- 15. Statistics Canada, Population 2010 projections: Canada, the provinces reported diabetes among male New (http://www.gnb.ca/0051/pub/pdf/20 and territories, 2013 to 2063. Brunswickers 12 and older was 9.0 per 10/diabetes_report_1998-2007- Ottawa, 2014. cent (95% CI: 7.0-11.0%) and among e.pdf, accessed Sept. 30, 2016). females 7.8 per cent (95% CI: 6.2- 16. Public Health Agency of Canada, 9.4%), based on a sample yielding Chronic Disease Infobase some 255 cases. In comparison, (http://infobase.phac- aspc.gc.ca/cubes/data-cubes- CCDSS data indicate a prevalence of eng.html, accessed Aug. 25, 2016). diagnosed diabetes among male New

Diabetes mellitus in New Brunswick – Page 16 17. Statistics Canada, “Table 105- 24. Statistics Canada, Overweight and 33. Public Health Agency of Canada, 0501: Health indicator profile, obese adults (self-reported), 2014. Surveillance: Canadian Chronic annual estimates, by age group Ottawa, 2015 Disease Surveillance System. and sex, Canada, provinces, (http://www.statcan.gc.ca/pub/82- Ottawa (http://www.phac- territories, health regions (2013 625-x/2015001/article/14185- aspc.gc.ca/surveillance-eng.php, boundaries).” CANSIM [online eng.htm, accessed Sept. 12, 2016). accessed Sept. 12, 2016). database]. Ottawa (http://www5.statcan.gc.ca/cansim, 25. Statistics Canada, Overweight and obese youth (self-reported), 2014. accessed July 18, 2016). Ottawa, 2015 18. Statistics Canada, “Table 105- (http://www.statcan.gc.ca/pub/82- 0503: Health indicator profile, age- 625-x/2015001/article/14186- standardized rate, annual eng.htm, accessed Sept. 12, 2016). estimates, by sex, Canada, provinces and territories.” CANSIM 26. Canadian Institute for Health [online database]. Ottawa Information, Learning From the Best: Benchmarking Canada’s (http://www5.statcan.gc.ca/cansim, accessed July 18, 2016). Health System. Ottawa, 2011. 19. World Health Organization, “Raised 27. New Brunswick Department of fasting blood glucose (≥7.0 mmol/L Health, Health Inequities in New or on medication).” Global Health Brunswick. Fredericton, 2016 Observatory data repository [online (http://www2.gnb.ca/content/dam/g database]. Geneva nb/Departments/h- (http://apps.who.int/gho/data/view. s/pdf/en/Publications/HealthInequiti main.2469, accessed Aug. 30, esNewBrunswick2016.pdf). 2016). 28. Canadian Institute for Health Information, Health Inequalities 20. Statistics Canada, “Table 102- 0563: Leading causes of death, Interactive Tool: Diabetes total population, by sex, Canada, (https://www.cihi.ca/en/factors- provinces and territories.” CANSIM influencing-health/socio- [online database]. Ottawa economic/health-inequalities- (http://www5.statcan.gc.ca/cansim, interactive-tool-diabetes-combined, accessed Aug. 30, 2016). accessed Aug. 10, 2016). 21. Service New Brunswick, Vital 29. Canadian Diabetes Association, Statistics: Annual Statistics. The Burden of Out-of-Pocket Costs Fredericton for Canadians with Diabetes. (http://www.snb.ca/e/1000/1000- Toronto, 2011. 01/e/annual-e.asp, accessed Aug. 30. Anand SS, Islam S, Rosengren A 12, 2016). et al., “Risk factors for myocardial 22. Statistics Canada, “Table 102- infarction in women and men: 0552: Deaths and mortality rate, by insights from the INTERHEART selected grouped causes and sex, study.” European Heart Journal, Canada, provinces and territories.” 2008; 29(7), 932-940. CANSIM [online database]. Ottawa 31. New Brunswick Department of (http://www5.statcan.gc.ca/cansim, Health, A Comprehensive Diabetes accessed May 10, 2016). Strategy for New Brunswickers, 23. Statistics Canada, Diabetes, 2014. 2011-15. Fredericton, 2011. Ottawa, 2015 32. Eriksson J, Lindström J, Tuomilehto (http://www.statcan.gc.ca/pub/82- J, “Potential for the prevention of 625-x/2015001/article/14180- type 2 diabetes.” British Medical eng.htm, accessed Sept. 12, 2016). Bulletin, 2001: 60(1): 183-199.

New Brunswick Department of Health PO Box 5100, Fredericton, NB E3B 5G8 www.gnb.ca/health

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