Canadian Diabetes Association. Canadian Institute for Health Information Diabetes in Canada Second Edition has been. prepared primarily to inform Canadians …

Diabetes
in Canada
Second Edition

Diabetes in Canada
Second Edition

Center for Chronic Disease Prevention and Control Population and Public Health Branch Health Canada 2002

Acknowledgements
We would like to thank the following for their contributions to the production of this report Clarence Clottey, Health Canada Catherine Cook, Chair of the Aboriginal Diabetes Working Group Marielle Demers, Health Canada Sylvie Desjardins, Health Canada Peggy Dunbar, Diabetes Care Program of Nova Scotia Phillipe Dussault, Health Canada Valérie Emond, Institut de santé publique du Québec Hertzel C Gerstein, McMaster University Stewart Harris, University of Western Ontario Jan Hux, Institute for Clinical Evaluative Sciences Jeffrey Johnson, Institute of Health Economics Rhea Joseph, Community Health Consulting Lawrence Leiter, University of Toronto Ellen Bobet, Health Canada Fardosa Loyan, Health Canada Joan Canavan, Ontario Ministry of Health and Long-Term Care

Editorial Board
Health Canada Clarence Clottey, Geoffroy Scott, Frank Mo, Rebecca Stuart, Glenn Robbins and Bernard Choi Statistics Canada Cyril Nair, Helen Johansen University of Ottawa Yue Chen Canadian Institute for Health
Information Indra Pulcins Canadian Diabetes Association Donna Lillie

Contributors/Reviewers
Louise Aubrey, Health Canada

Diabetes in Canada

Richard Marcoux, Health Statistics Division, Statistics Canada Frank Mo, Health Canada Jeffrey Niles, Health Canada William Osei, Saskatchewan Health Poasie Peter, Inuit Tapariit Kanatami Robert Reid, University of British Columbia Kim Reimer, Ministry of Health, British Columbia Glenn Robbins, Health Canada Paul Sales and Paula Stewart, Douglas Consulting Geoffroy Scott, Health Canada Robert Semenciw, Health Canada Anita Stevens, Assembly of First Nations Julie Stokes, Health Canada Rebecca Stuart, Health Canada Larry Svenson, Alberta Health and Wellness Roslyn Tremblay, Health Canada Mark Vanderkloot, Health Canada Linda Van Til, Prince Edward Island Department of Health Social Services Bernard Zinman, University of Toronto

National Diabetes Steering Committee
All Provinces and Territories Assembly of First Nations Canadian Diabetes Association Canadian Institute for Health Information Canadian Institute of Health Research Clinical and Academic Representatives Inuit Tapirisat of Canada Metis National Council National Aboriginal
Diabetes Association Statistics Canada

Diabetes Council of Canada
Canadian Diabetes Association Canadian Institutes of Health Research Canadian National Institute for the Blind Canadian Pharmacists Association Diabète Québec Heart and Stroke Foundation of Canada Juvenile Diabetes Research Foundation National Aboriginal Diabetes Association The Kidney Foundation of Canada

Special Acknowledgements
Health Canada is grateful for the collaboration and partnership established with the following organizations in the production of the Diabetes in Canada Second Edition

Diabetes in Canada

Foreword
Diabetes in Canada Second Edition incorporates data from the National Diabetes Surveillance System NDSS as well as data from other sources The first edition was published in 1999 by Health Canada This second edition has been a collaborative effort between Health Canada and the many partner organizations acknowledged in this report Diabetes in Canada Second Edition has been prepared primarily to inform Canadians about the burden of diabetes It is also a resource for policy and program decisionmakers in government, the health care sector and volunteer organizations Its purpose is also to
raise awareness about diabetes and support the development of effective health care policies and programs across Canada If you have comments on this report, please contact: Centre for Chronic Disease Prevention and Control Population and Public Health Branch Health Canada The report is also available on the Web at Health Canada Website: wwwhc-scgcca

Diabetes in Canada

Highlights
Chapter 1 Diabetes
Diabetes is a chronic condition that results from the bodys inability to sufficiently produce and/or properly use insulin Insulin, a hormone secreted from beta cells in the pancreas, assists with the conversion of glucose into energy Without insulin, the cells of the body, primarily in muscle, fat, and liver tissue, cannot absorb sufficient glucose from the bloodstream Chronic high levels of blood glucose can result in longterm damage, leading to the dysfunction and failure of various organs, such as the kidneys, eyes, nerves, heart, and blood vessels Complications in these organs can lead to death Diabetes occurs in several forms: type 1, type 2, and gestational diabetes Type 1 and type 2 are the two most common forms of this chronic disease and represent about 10 and 90 of the
total diabetic population respectively

REPORT

Chapter 2 Prevalence and Incidence
Diabetes continues to be a significant health problem in Canada The administrative data from the NDSS, based on information from all provinces and territories with the exception of New Brunswick, Newfoundland and Labrador, Northwest Territories and Nunavut, identified a prevalence of physiciandiagnosed diabetes of 48 among people aged 20 years approximately 1,054,100 in 1998/99 The true prevalence may be significantly higher however, as it has been estimated that as many as one third of all cases of diabetes are undiagnosed in Canada Therefore, altogether, there may have been as many as 17 million Canadians with diabetes during 1998/99

Chapter 3 Risk Factors
The Canadian Diabetes Strategy has adopted a population health approach to prevent diabetes and improve its control This strategy will reduce the risk of diabetes

Diabetes in Canada

developing in individuals without the disease and reduce the risk of complications among those living with it This chapter presents data, derived from the National Population Health Survey NPHS, on the prevalence of risk factors for diabetes Risk factors for
type 2 diabetes remain very common in the general population In fact, the proportion of men who are overweight is increasing Unless this trend is reversed, it will have serious ramifications for the prevalence of diabetes in the future Although it is encouraging that both men and women are becoming more physically active, efforts to encourage regular physical activity must continue In individuals with diabetes, risk factors such as high blood pressure, smoking, being overweight, and physical inactivity, which are associated with poor blood sugar control and diabetesrelated complications, remain very common Because the complications of diabetes reduce both the life span and the quality of life, this requires action as a high priority

for children and youth with diabetes, who face the task of fitting in with their peers while coping with the demands of treatment In addition, the complications of diabetes can cause other serious health problems that may lead to disability or be life-threatening Individuals with diabetes are less likely than those without diabetes to report good health In addition, they more often report that they experience activity restriction The negative impact of
diabetes may be due to diabetes-related complications and/or the challenges associated with diabetes care The higher rate of mortality due to diabetes among men than women is consistent with the slightly higher prevalence of diabetes among men In addition, men tend to develop cardiovascular disease complications, which carry a high mortality rate, more often than women The levelling off of mortality rates may mislead health planners into thinking that the diabetes problem has stabilized In fact, it is projected that the number of deaths will increase in the future in both men and women because the population is aging These individuals will need a variety of health services in the acute, chronic, and home care sectors for many years before death Thus, coping with this increasing need for service requires immediate preparation, not only to address the current situation but also to be effective for the next 20 years

Chapter 4 Health Outcomes
Diabetes exerts a significant effect on the quality of life of those with the disease The continuous need to monitor intake in terms of timing, type, and amount of food, take medication whether pills or insulin injections, monitor blood glucose,
and anticipate and plan for activities that may affect diabetes control can put a severe strain on daily life This is a particular challenge

Diabetes in Canada

Chapter 5 Use of Health Services and Costs
Individuals with diabetes require a variety of health services, not only for the control of their disease but also for the diagnosis and treatment of associated complications Therapy for individuals with diabetes aims to control blood sugar, blood pressure, and blood lipids levels; to reduce symptoms and the risk of complications; and to enhance the quality of life Blood sugar levels can be controlled through diet and antihyperglycemic drugs taken orally and/or by injections of insulin combined with lifestyle modification healthy eating, active living, smoking avoidance/cessation, and stress management Pharmacologic interventions combined with these lifestyle modifications also form a necessary part of managing the complications of diabetes The data on medication use support the nature of type 2 diabetes: that it can be controlled early in the course of the disease in some circumstances without the use of insulin The increase in total units of hypoglycemic agents dispensed over
time may be due to their high use among seniors, a segment of the population that is growing over time This increase may also reflect the aggressive management of the disease with the use of medication to more closely control blood sugar, since type 2 diabetes is a progressive disease

The higher hospitalization rate among men than women may be a consequence of the higher rate of cardiovascular complications among men The lack of a decrease in hospitalization rates for diabetes in any age group contradicts the hospitalization rate in general, which has shown a steady decrease in the past several years This may signal that the level of serious health problems among individuals with diabetes has not decreased It also attests to continued pressure on hospital budgets In Canada, the economic burden of diabetes alone is estimated at 16 billion in 1998; 04 billion 25 in direct costs and 12 billion 75 in indirect costs This estimate is a very conservative one and does not include physician costs In addition, the hospital costs include only the leading cause of hospitalization, and this results in an underestimation of the real burden of diabetes, because the cost of the complications of
diabetes are not captured

Chapter 6 Diabetes in the Aboriginal Communities
The high prevalence of diabetes among Aboriginal peoples higher than in the general population, the greater severity at diagnosis and the high rates of complications are a few indicators of the importance of this issue to all Aboriginal communities

Diabetes in Canada

In addition, several risk factors have an enormous impact on diabetes in Aboriginal groups and have worsened the disease for a population already at risk The overall prevalence of diabetes among Aboriginals and the complications of the disease are expected to increase in future years and will represent a huge burden for health authorities A study conducted in Manitoba showed the magnitude of this problem It is estimated that between 1996 and 2016 there will be a 10-fold increase in the rate of cardiovascular disease, a 5-fold increase in strokes, 10 times as many dialysis starts, 10 times the rate of lower extremity amputations, and 5 times the rate of blindness Despite the lack of information on the precise costs of diabetes among Aboriginals, it is estimated that the costs are high as a result of both the high prevalence of diabetes and
the substantial utilization of health care services by people with diabetes Because of the serious consequences of diabetes for individuals and their communities, the prevention of diabetes is therefore imperative and is the key to reducing this epidemic Public health policies and especially community-based diabetes projects must be developed and implemented in order to reduce the burden of diabetes among Aboriginal peoples

A Final Word
A full understanding of the implications of diabetes on the lives of Canadians requires more data to differentiate between the types of diabetes More data will be needed in the following areas: incidence and prevalence; risk factors in children and youth; complications of diabetes; utilization of outpatient services; attendance at educational programs; economic impact of diabetes; and quality of life and impact on family, school and work The difficulties in obtaining accurate data on the prevalence and incidence of diabetes highlight the need for an ongoing comprehensive surveillance system The NDSS addresses the critical information gaps regarding diabetes in Canada The goal of the NDSS is to develop a national standardized database for
diabetes surveillance with long-term monitoring for diabetes-related complications and health services utilization However, other sources, such as the NPHS and the Canadian Community Health Survey CCHS will continue to provide important socio-economic data, and it is imperative that they be continued

Diabetes in Canada

Contents
Introduction 15 Chapter 1 Diabetes 19 Chapter 2 Prevalence and Incidence 25 Chapter 3 Risk Factors 31 Chapter 4 Health Outcomes 41 Chapter 5 Use of Health Services and Costs 49 Chapter 6 Diabetes in Aboriginal Communities 63 Appendix A Glossary 69 Appendix B List of Data Sources 73

TABLE OF

List of Figures
Chapter 2 Prevalence and Incidence Figure 2-1 Figure 2-2 Figure 2-3 Prevalence Rate of Diagnosed Diabetes by Age Group and Sex
27 Prevalence Rate of Diagnosed Diabetes by Province/Territory 27 Cumulative Incidence 28

Chapter 3 Risk Factors Figure 3-1 Figure 3-2 Figure 3-3 Proportion of Overweight Adults in Canada 32 Overweight Adults with Self-Reported Diabetes 33 Increases in Overweight with Age 33

Diabetes in Canada

Figure 3-4 Figure 3-5 Figure 3-6 Figure 3-7 Figure 3-8 Figure 3-9

Proportion of Physically Inactive Adults in Canada 34 Physically Inactive Adults with Self-Reported Diabetes 34 Increases in Physical Inactivity with Age 35 Proportion of Daily Smokers in Canada 35 Daily Smokers with Self-Reported Diabetes 36 Decreases in Daily Smoking with Age 36

Figure 3-10 Proportion of Adults with High Blood Pressure in Canada 37 Figure 3-11 High Blood Pressure with Self-Reported Diabetes 37 Figure 3-12 Proportion of Adults with High Blood Pressure in Canada
38 Chapter 4 Health Outcomes Figure 4-1 Figure 4-2 Figure 4-3 Figure 4-4 Figure 4-5 Figure 4-6 Figure 4-7 Figure 4-8 Self-Reported Health Among Men With and Without Diabetes 42 Self-Reported Health Among Women With and Without Diabetes 42 Self-Reported Health Among Men According to Age 43 Self-Reported Health Among Women According to Age 43 Trends in Diabetes Mortality Rates 44 Diabetes Mortality Rates in Males 45 Diabetes Mortality Rates in Females 45 Estimated Future Deaths from Diabetes 46

Chapter 5 Use of Health Services and Costs Figure 5-1 Figure 5-2 Figure 5-3 Figure 5-4 Figure 5-5 Figure 5-6 Figure 5-7 Figure 5-8 Figure 5-9 Patterns in the Use of Diabetes Medications 50 Blood Pressure Checks in Adults with Diabetes 51 Blood Pressure Checks in Adults, General Population 51 Eye Examination in Adults with Diabetes 52 Eye Examination in Adults, General Population 52 Home Care
for Adults with Diabetes 53 Home Care for Adults, General Population 53 Hospitalizations with a Diagnosis of Diabetes 54 Proportion of Hospitalizations with a Diagnosis of Diabetes 54

Figure 5-10 Trends in Hospitalizations with a Diagnosis of Diabetes Over Time 55 Figure 5-11 Other Health Conditions Associated with Diabetes 56 Figure 5-12 Other Health Conditions Associated with Diabetes, Males 57

Diabetes in Canada

Figure 5-13 Other Health Conditions Associated with Diabetes, Females 57 Figure 5-14 Economic Burden of Diabetes in Canada by Cost Component 58 Figure 5-15 Economic Burden of Diabetes in Canada by Sex and Cost Component 58 Chapter 6 Diabetes in Aboriginal Communities Figure 6-1 Crude Prevalence of Self-Reported Diabetes From the Aboriginal Peoples Survey 64

List of Tables
Table 1-1 Table 2-1 Table 4-1 Table 5-1 Diabetes Complications 23 Prevalence of Diagnosed Diabetes by Age Group and Sex 26
Deaths Due to Diabetes by Age Group and Sex 44 Hospitalizations Related to Diabetes 55

Diabetes in Canada

Introduction
Diabetes in Canada Second Edition brings together data on the prevalence and incidence of diabetes, risk factors, health outcomes, and use of health services Ideally, the report would include data specific to type 1 and type 2 diabetes and gestational diabetes Unfortunately, the available data sources do not differentiate between the three National Population Health Survey NPHS Statistics Canada Aboriginal Peoples Survey APS Statistics Canada IMS Health Dataset IMS Canadian Retail Pharmacies For a brief description of these data sources, see Appendix B List of Data Sources The first Diabetes in Canada report in 1999 highlighted the need for better data, in particular, data on the prevalence and incidence of diabetes, its complications, the use of health care services, and the effectiveness of prevention and control initiatives In response, the Diabetes Council of Canada took the lead in creating the NDSS This report includes the first published data from the NDSS from all participating provinces and
territories In addition, Statistics Canada introduced the Canadian Community Health Survey CCHS, a cross sectional survey that was

Data Sources
Several national data sources were accessed in the preparation of Diabetes in Canada Second Edition Hospital Morbidity Database HMDB Canadian Institute for Health Information Mortality Database Statistics Canada National Diabetes Surveillance System NDSS Health Canada National Longitudinal Survey of Children and Youth NLSCY Human Resource Development Canada HRDC

Diabetes in Canada

designed to address some of the weaknesses of the NPHS Unfortunately, the first results of this survey were unavailable to meet the deadline for this publication

In addition to the lack of differentiation between the various types of diabetes, other data gaps exist that inhibit the creation of a comprehensive picture of diabetes in Canada: data on the prevalence and risk factors in persons under the age of 20; complications of diabetes; utilization of outpatient services; attendance at educational programs; economic impact of diabetes; and quality of life and impact on family, school and work Fortunately there is the potential for both the NDSS
and the CCHS to significantly narrow the data gaps The NDSS has the potential to be able to provide additional information especially regarding the complications related to diabetes and health services utilization and the CCHS has the potential to provide improved information concerning risk factors and health determinants However, even with these important additions, it may still require additional data sources to develop a truly comprehensive picture of diabetes in Canada

Limitations of the Data
Those sources able to provide a national picture had some limitations: unable to differentiate between type 1 and type 2 diabetes and gestational diabetes; only persons 20 years and older are included The analyses of data from both the National Diabetes Surveillance System NDSS and the National Population Health Survey NPHS were restricted to age groups 20 years of age and older In the NDSS, the case definition has been validated only for those 20 years of age and older, and in the NPHS the sample of those 12-19 years of age with self-reported diabetes was too small to obtain reliable estimates Since type 1 diabetes occurs mainly in the juvenile population, specific information about
type 1 diabetes and related factors cannot be extracted from the data in its current form Note also that the data used were not always available over consistent time-frames; for example, some were available by fiscal year, and some by calendar year

Statistical Notes
Interpreting the Numbers
Throughout the document, the reader will notice differences in the results from the NPHS data for age groups, years, or provinces and territories These differences may not be

Diabetes in Canada

real, however, but simply artefacts due to sampling The NPHS includes only a sample of the population rather than the entire population; the resulting numbers, therefore, are only estimates of the true values for the population The 95 confidence intervals CIs of all estimates were calculated during the preparation of the report We can be 95 certain that the true value for the population lies somewhere in this range of values If the text reports a difference between two values and the 95 CIs of the values do not overlap, then one can be reasonably sure that a true difference exists If the text does not report on a difference in the values, then the reader should assume that none exists The
coefficient of variation CV indicates the quality of a population estimate A CV of 167-255 indicates moderate sampling variability A CV of 256-333 indicates high sampling variability Estimates with either a moderate or high CV should be interpreted with caution In some situations, the sample in the survey was too small to produce a reliable estimate; these numbers are not included in the report

development, who experiment with various health behaviours Those aged between 20 and 39 years are young adults, generally healthy and without serious health problems but in the process of establishing behaviours that will affect their health later in life The 40-59 year-old age group represents adults in their middle years, when serious health problems become more prevalent The 60-74 year-old age group may be described as young seniors, whose health problems become not only more frequent but also more serious The final age group consists of adults aged 75 years and older

Organization of Report
Each chapter in Diabetes in Canada Second Edition consists of an introduction, a summary of the available national data in tables and figures, and a discussion of the implications of the results The
chapters address the following questions: Chapter 1 Diabetes What is diabetes? Objective: To describe the various types of diabetes type 1, type 2 and gestational and the related complications Chapter 2 Prevalence and Incidence Who has diabetes now? Objective: To describe the frequency of the disease in Canada

Age Groups
Five age categories were selected for this report based on homogeneity of individuals in each age range The 0-19 year-old age group consists of children and youth in the period of greatest physical growth and

Diabetes in Canada

Chapter 3 Risk Factors Who is at risk of developing diabetes and diabetes complications? Objective: To describe several risk factors related to developing diabetes and its complications Chapter 4 Health Outcomes What happens to people with diabetes once diabetes sets in? Objective: To describe how diabetes and its complications affect the quality of life and contribute to early mortality Chapter 5 Use of Health Services and Costs What health services do people with diabetes use? What is the economic impact of the disease? Objective: To monitor the use of health services and to assess the burden of diabetes on the health care
system

Chapter 6 Diabetes in Aboriginal Communities How does diabetes affect the Aboriginal community? Objective: To give information on the frequency, risk factors, complications and the use of health services specific to Aboriginal communities As already noted, the report cannot provide comprehensive answers to these questions at this time However, the data sources continue to improve: Diabetes in Canada Second Edition is one more step in the evolution of a comprehensive diabetes surveillance and monitoring system

Diabetes in Canada

Diabetes
Introduction
Diabetes mellitus DM is a chronic condition that results from the bodys inability to sufficiently produce and/or properly use insulin Insulin, a hormone secreted from beta cells in the pancreas, assists in the conversion of glucose into energy Without insulin, the cells of the body, primarily in muscle, fat and liver tissue, cannot absorb sufficient glucose from the bloodstream Consistent high levels of blood glucose can result in longterm damage, leading to the dysfunction and failure of various organs, such as the kidneys, eyes, nerves, heart and blood vessels Complications in these organs can lead to death Diabetes
mellitus is not a single disease, it occurs in several forms: type 1, type 2 and gestational diabetes Type 1 and type 2 are the two most common forms of this chronic disease and represent about 10 and 90 respectively of the total diabetic population1

CHAPTER 1

Type 1 Diabetes
Type 1 diabetes, previously known as insulin-dependent diabetes mellitus IDDM, typically occurs in childhood or early adolescence, and treatment usually entails multiple daily injections of insulin for survival In type 1 diabetes, the immune system attacks the insulin-producing beta cells in the pancreas and destroys them As a result, the pancreas then produces little or no insulin Type 1 diabetes is not caused by obesity or by eating excessive sugar; rather, it is believed to be caused by a combination of genetic factors and environmental stressors Scientists do not know exactly what causes the bodys immune system to attack the beta cells, but they believe that both genetic factors and viruses are involved Even when insulin is injected regularly, type 1 diabetes usually results in a drastic reduction in the quality of life and shortens the average life span by 15 years2,3

Diabetes in Canada

Symptoms
of type 1 diabetes include increased thirst, frequent urination, constant hunger, weight loss, blurred vision and extreme tiredness If the condition is not diagnosed and treated in time with insulin, patients can lapse into a life-threatening coma The characteristics of type 1 are as follows4: It is one of the most serious chronic diseases, affecting young children and adolescents Insulin can help people with type 1 diabetes to maintain and balance their blood sugars, but it does not cure diabetes nor does it prevent its devastating comorbidity such as kidney failure, blindness, nerve damage, amputations, heart attack and stroke People with type 1 diabetes must take multiple daily insulin injections and test their blood sugar several times per day While trying to balance insulin injections with their amount of food intake, those with type 1 diabetes must constantly be prepared for potential hypoglycemic and hyperglycemic reactions, which can be life threatening A persons blood sugar can fluctuate with hormonal changes, periods of growth, physical activity, medications, illness/ infection and emotions Therefore, it is extremely challenging to manage type 1 diabetes, especially
among children

Type 2 Diabetes
Type 2 diabetes, previously known as non insulin-dependent diabetes mellitus NIDDM, is the most common form of diabetes It accounts for more than 90 of diagnosed diabetes Type 2 diabetes typically occurs after the age of 40 years and is found in a higher proportion of individuals who are considered overweight Individuals with type 2 diabetes are usually insulin resistant By losing weight, exercising, or taking medications orally, most people with type 2 diabetes can overcome this resistance to insulin; however, some require daily insulin injections2 Type 2 diabetes is now widely considered to be one component in a group of disorders called the metabolic syndrome, which includes insulin resistance, cholesterol and lipid disorders, obesity, high blood pressure, a high risk of blood clotting and disturbed blood flow to many organs1 Life expectancy is reduced by about 5 to 10 years among middle-aged adults with type 2 diabetes3 The mechanisms of type 2 diabetes are not fully understood, but some experts suggest that it may involve the following three stages4: 1 The first stage in type 2 diabetes is the condition called insulin resistance; although
insulin can attach normally to receptors on liver and muscle cells,

Diabetes in Canada

certain mechanisms prevent insulin from moving glucose blood sugar into these cells where it can be used Most type 2 diabetics produce variable, even normal or high, amounts of insulin, and in the beginning this amount is usually sufficient to overcome such resistance 2 Over time, the pancreas becomes unable to produce enough insulin to overcome resistance In type 2 diabetes, the initial effect of this second stage is usually an abnormal rise in blood sugar after a meal, called postprandial hyperglycemia This effect is considered to be particularly damaging 3 Eventually, the cycle of elevated glucose further impairs and possibly destroys beta cells, thereby stopping insulin production completely and causing full-blown diabetes This is evident in fasting hyperglycemia, a state of elevated glucose levels that is present during most of this stage

Children and Youth NLSCY, approximately 65 of women reported that they had received a diagnosis of gestational diabetes8 These women develop glucose intolerance that can be treated with diet and/or insulin However, if the glucose intolerance is not
well controlled, GDM can be associated with an increased incidence of fetal macrosomia big babies, pre-eclampsia, and Cesarean section, which affects both the health of the baby and the birth9 Some studies have shown perinatal mortality to be increased in untreated GDM10,11 GDM cannot be treated with pills that lower blood glucose as these medicines can cause harm to the baby The diagnosis of GDM is commonly based on the criteria of OSullivan and Mahan12 and the World Health Organization WHO13 The management strategy for GDM focuses on screening, patient education, glycemic control and perinatal surveillance

Gestational Diabetes
Gestational diabetes mellitus GDM occurs in some women during pregnancy In most cases, it ends after birth GDM is a very strong risk factor for the development of type 2 diabetes later in life: up to 40 of women with GDM may develop type 2 diabetes when they get older7 According to the 1996/97 National Longitudinal Study on

Diagnosis of Diabetes Mellitus
In 1997, the new criteria for diagnosis and classification terminology were developed All diabetes is diagnosed by one of three criteria: symptoms of diabetes fatigue, excessive thirst, excessive
urination and unexplained weight loss plus a casual plasma glucose value of 111 mmol/L, OR

Diabetes in Canada

a fasting no caloric intake for at least 6 hours plasma glucose test FPG of 70 mmol/L In 1998, the criterion was lowered from 78 to 70; this likely resulted in an increase in the number of individuals with a diagnosis of the disease, OR A plasma glucose value in the 2-hour sample 2hrPG of the oral glucose tolerance test OGTT 111 mmol/L12

The long-term complications of diabetes affect many parts of the body, decrease quality of life for the individual with diabetes and increase the use of health services Table 1-1 gives a description of the most common complications and their related outcomes Individuals with diabetes may face shortened life expectancy due to complications from the disease Life expectancy is influenced by the age at the onset of diabetes Good control of blood sugar, blood pressure and blood lipids through the adoption of a healthy diet, weight management, regular physical activity, and/or medication can decrease the risk of diabetes complications and increase life expectancy

Complications
The complications of diabetes are strongly related to
high blood sugar levels and are mostly correlated with the duration of diabetes Long-term complications may occur in both type 1 and type 2 diabetes Complications of diabetes may include microvascular changes, resulting in retinopathy, nephropathy and neuropathy After 20 years of diabetes, nearly all patients with type 1 diabetes and over 60 of patients with type 2 diabetes have some degree of retinopathy12

Diabetes in Canada

Table 1-1 Diabetes Complications Complication Type
Microvascular or peripheral vascular disease small blood vessel damage

Description
Small blood vessel damage that contributes to a decrease in blood circulation

Possible Outcomes
Retinopathy eye disease Nephropathy kidney disease that leads to renal failure requiring dialysis Periodontal disease

Macrovascular large blood vessel damage

Large blood vessel damage that contributes to a decrease in blood circulation

Cardiovascular disease Cerebrovascular disease Stroke Ischemic heart disease Lower limb amputation

Neuropathy nervous system disease

Diabetic neuropathy is a group of nerve diseases All these disorders affect the peripheral nerves There are three types of peripheral nerves: motor,
sensory, and autonomic Diabetic retinopathy is a general term for all disorders of the retina caused by diabetes There are two major types of retinopathy: nonproliferative and proliferative

Foot infections and ulceration Decreased sensation Increased sensitivity Muscle wasting Sexual dysfunction Glaucoma Cataracts and blindness

Retinopathy eye disease

2 The National Institute of Diabetes and Digestive and Kidney Diseases Wellconnected report: type 1 diabetes US 2002 3 Sasaki A Assessment of the new criteria for diabetes mellitus according to 10-year relative survival rates Diabetologia 1981;203:195-8 4 American Diabetes Association Clinical practice recommendations US 2000

Diabetes in Canada

5 OSullivan JB The Boston Gestational Diabetes Studies: review and perspectives In: Sutherland HW, Stowers JM, Pearson DWM, editors Carbohydrate metabolism in pregnancy and the newborn London: Springer-Verlag, 1989:
287-294 6 Human Resource Development Canada HRDC National Longitudinal Survey of Children and Youth NLSCY Ottawa, 1996-1997 7 Naylor CD, Sermer M, Chen E et al Selective screening for gestational diabetes mellitus N Engl J Med 1997;337:1591-96 8 Pettitt DJ, Knowler WC, Baird HR, Bennett PH Gestational diabetes: infant and maternal complications of pregnancy in relation to third trimester glucose tolerance in Pima Indians Diabetes Care 1980;3:458-64 9 Oats JN, Beischer NA Gestational diabetes Aust N Z J Obstet Gynaecol 1986;26:2-10 10 OSullivan JB, Mahan CM Criteria for the oral glucose tolerance test in pregnancy Diabetes 1964;13:278-85 11 World Health Organization Study Group Diabetes mellitus World Health Organ Tech Rep Ser 1985;727:13-14

12 Meltzer S, Leiter L, Daneman D, Gerstein H, Lau D, Ludwig S et al 1998 clinical practice guidelines for the management of diabetes in Canada Can Med Assoc J 1998;39 8:Suppl:S6 13 Health Canada Diabetes in Canada: national statistics and opportunities for improved surveillance, prevention, and control 1999 Ottawa: Health Canada, page 27

Diabetes in Canada

CHAPTER 2

Prevalence and Incidence
Introduction
The ability to determine the
extent of the disease on a national scale has been limited The National Population Health Survey NPHS has been conducted three times 1994/1995, 1996/1997, 1998/1999, but for the most part the sample size has made it difficult to produce statistically significant analysis for anything but a national analysis Therefore, these data are not particularly useful for provincial and territorial analysis and some other subpopulations To fill this void, a number of surveys have been conducted aimed at specific subpopulations, especially Aboriginal communities and also people with type 1 diabetes More recently, the National Diabetes Surveillance System NDSS has been implemented to address some of these limitations The National Diabetes Surveillance System NDSS, within the framework of the Canadian Diabetes Strategy, is still in its infancy but prevalence information was available for this report One of the significant strengths of the NDSS is that it is based on physician services data and hospitalization data and it does not rely on self-reporting of diabetes status The surveys or systems have not yet been able to differentiate between type 1 and type 2 diabetes Best estimates have shown
that about 10 of all people with diabetes mellitus have type 1 and about 90 have type 21 The NPHS is limited to those 12 years of age and over, and the NDSS data have been validated only for people aged 20 years and over, although work continues to improve this system In addition, because type 1 diabetes tends to occur mainly in younger people, it is difficult to give a comprehensive picture of this type of diabetes The frequency of a disease may be measured in two standard ways: Incidence is the number of new cases detected in the population at risk for the disease during a specific period

Diabetes in Canada

Prevalence is the total number of persons known to have had the disease at any time during a specific period It gives an idea of the importance/burden of disease at a given time, and it is widely used in public health monitoring and planning

According to the NDSS, the proportion of adults with diabetes increased with age and was higher among men than women Figure 2-1 The 1998/99 NDSS provided an estimate that 1,054,100 adults in Canada had diabetes diagnosed by a health professional and, of these, 406 were between the ages of 20 and 59 years Table 2-1 There is no
estimate of the younger age groups in NDSS, at this time The prevalence of diabetes by provinces and territories Figure 2-2 shows that Nova Scotia has the highest prevalence while Yukon has the lowest In addition, men have a higher prevalence of diabetes compared to women

Data
According to the NDSS, 48 of Canadians aged 20 years and older in the participating provinces/territories had diabetes 46 of women and 50 of men in 1998/99 Unfortunately, the data do not differentiate between type 1 and type 2 diabetes

Table 2-1 Prevalence of Diagnosed Diabetes by Age Group and Sex
Diagnosed diabetes among adults by age group and sex, Canada, 1998/99 Age Group
Years 20-39 40-59 60-74 75 All 20
95 CI

Women
Estimated no of Canadians

Men

95 CI Estimated no of Canadians

Total

95 CI Estimated no of Canadians

127
126 128

57,000 145,300 185,000 128,400 515,800

081
081 081

36,600 189,200 215,400 97,200 538,300

104
103 105

93,600 334,500 400,400 225,500 1,054,100

363
361 365

473
471 475

418
417 419

1077
1072 1082

1376
1371 1381

1219
1216 1223

1236
1230 1242

1535
1526 - 1544

1349
1344 1354

459
458 460

502
501 503

480
479 481

95 Confidence Interval

Numbers
are rounded to the nearest 100

Note: The sum of the age groups and or sexes may not equal the total due to rounding Source: Health Canada, National Diabetes Surveillance System

Diabetes in Canada

Figure 21: Prevalence Rate of Diagnosed Diabetes
Prevalence rate of diagnosed diabetes among adults aged 20 years in all provinces/territories excluding New Brunswick, Newfoundland and Labrador, Northwest Territories and Nunavut, by age group and sex, Canada 1998/99
20

Estimate of the number of Canadians with diabetes

From the eight provinces that reported to NDSS, 1,054,100 10 cases in Canadians 5 over 20 years of age 0 were reported The 20-39 years 40-59 years 60-74 years 75 years 20 years 459 1236 1077 363 127 Women number of cases in 502 1535 1376 473 081 Men Newfoundland and 480 1349 1219 418 104 Both New Brunswick were Age Group Source: National Diabetes Surveillance System, Centre for Chronic Disease Prevention and Control, Health Canada estimated using data from the NPHS National Population Health Survey A total Figure 22: Prevalence Rate of Diagnosed Diabetes Prevalence rate of diagnosed diabetes among adults aged 20 years of 57,400 cases were by provinces/territories
excluding New Brunswick, Newfoundland and estimated for residents Labrador, Northwest Territories and Nunavut, by sex, Canada 1998/99 over 20 in those two 6 provinces Using 4 information from NPHS and CCHS 2 Canadian Community Health Survey, it was 0 Nova SaskatManitoba Ontario Québec PEI Yukon BC Alberta calculated that there Scotia chewan were 1,700 Cases for Women 38 36 40 49 43 41 40 48 36 Men 45 42 48 53 51 50 51 56 34 the three Territories Both 41 39 44 51 47 45 45 52 35 The total number of Provinces and Territories Canadians under Source: National Diabetes Surveillance System, Centre for Chronic Disease Prevention and Control, Health Canada The data by gender is age-standardized, and the data for both is age and sex standardized 20 with diabetes was estimated using the American prevalence 2 of 019 multiplied by the total population of Canadians in this age group, to give
15 Percent

Percent

Numbers are rounded to the nearest 100

Diabetes in Canada

15,300 cases These Figure 23: Cumulative Incidence numbers were Four-years cumulative incidence of self-reported diabetes among adults aged 20 years by sex, Canada, from 1994 to 1998 summed to get a total of 1,128,500
diagnosed cases Women 13 of diabetes in 1998/99 It has been Men 16 estimated that one Women Men 14 third of all cases of diabetes are 00 05 10 15 20 Incidence per 100 undiagnosed in Source: Statistics Canada, National Population Health Survey Canada3,4, so the number of diagnosed cases among people aged 20 years were multiplied by 50 to account for approximately 1,054,100 The true this problem Altogether, there were prevalence may be significantly higher approximately 17 million Canadians however, as it has been estimated that as with diabetes during 1998/99 many as one third of all cases of diabetes Based on the NPHS Longitudinal Survey, between 1994 and 1998, 14 percent of adults developed diabetes Figure 2-3 The difference between men and women was not statistically significant Type 1 and type 2 diabetes are not differentiated in the NPHS results are undiagnosed in Canada Therefore, altogether, there may be as many as 17 million Canadians with diabetes during 1998-1999 The provincial/territorial administrative data indicate that the prevalence of diabetes increases with age and that the disease affects a higher proportion of men than women The aging of the population will
likely bring with it an increase in the number of seniors with diabetes This could have a serious impact on services for seniors, in part because of diabetic complications that increase with age Required services include not only acute care but also supportive services such as chronic care in hospital, home care, drug benefits, supportive housing and transportation

Summary of Findings
Diabetes continues to be a significant health problem in Canada The administrative data from the NDSS, based on information from all provinces and territories with the exception of New Brunswick, Newfoundland and Labrador, Northwest Territories and Nunavut, identified a prevalence of physician-diagnosed diabetes of 48

Diabetes in Canada

The cumulative incidence over four years showed that 14 percent of adults developed diabetes For comparison, the US Centers for Disease Control and Prevention report an annual incidence rate of approximately 29/1000 new cases of diabetes per year in the general population5 The NDSS will be able to provide an annual incidence rate in a few years The data presented in this chapter provide a snapshot of the prevalence and incidence of diabetes in Canada Monitoring
the impact of prevention programs will require data that are not only more comprehensive, but also of higher quality It is anticipated that the NDSS database will be a major source of both prevalence and incidence data Additional changes will require: the collection of data that differentiate between type 1 and type 2 diabetes; the collection of data on children and adolescents; and the expansion of the NDSS to all provinces and territories

References
1 Centers for Disease Control and Prevention National diabetes fact sheet: national estimates and general information on diabetes in the United States Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 1997 2 wwwcdcgov/diabetes/pubs/estimateshtm 3 Young Kue T, and Cameron A Mustard Undiagnosed diabetes: Does it matter? Can Med Assoc J 2001:1641:24-28 4 Harris MI, Flegal KM, Cowie CC et al Prevalence of diabetes, impaired fast glucose, and impaired glucose tolerance in US adults Diabetes Care 1998:214:518-524 5 Geiss LS, Herman WH, Goldschmid MG and al Surveillance for diabetes mellitus United States, 1980-1989 MMWR 1993;42SS-2: 1-20

Diabetes in Canada

Risk
Factors
Introduction
The Canadian Diabetes Strategy has adopted a population health approach to prevent diabetes and improve its control This strategy will help to reduce the risk of diabetes developing in individuals without the disease and the risk of complications among those living with it This chapter presents data, derived from the NPHS, on the prevalence of risk factors for diabetes and its complications Age: incidence increases with age throughout childhood and adolescence Genetic susceptibility: a family history of type 1 diabetes is associated with a slightly increased risk of developing type 1 diabetes

CHAPTER 3

Type 2 Diabetes
Weight and exercise are modifiable risk factors that can decrease the risk of developing type 2 diabetes among those at increased risk2 The prevalence of diabetes increases by 5 to 10 among adults for every 1 kg increase in population-measured body weight3,4

Type 1 Diabetes
No known modifiable risk factors exist for acquiring type 1 diabetes children and youth1 , a characteristic that limits the possibility of prevention Non-modifiable risk factors include the following: Race and ethnic background: in the United States, the prevalence is
higher among whites than among black or Hispanic people; as well, Scandinavian countries report higher rates

Complications of Diabetes
Diabetes has many complications for which there are a number of risk factors, such as cigarette smoking, dyslipidemia, and high blood pressure Therefore, the control of these risk factors for diabetes complications forms an essential part of a comprehensive

Diabetes in Canada

diabetes control program Since high blood pressure is associated with obesity and physical inactivity, maintaining a healthy weight and remaining physically active will protect against the complications of diabetes

population, the proportions were 128 and 225 respectively

Overweight
Diabetes is more common in individuals who are overweight The risk of developing type 2 diabetes increases with the amount of excess weight, the duration of the obesity, and the central deposition of fat Women who are overweight also have a greater risk of developing gestational diabetes Being overweight and gaining weight are strong predictors of diabetes6 The Body Mass Index BMI is a standard measure to determine weight status For the purpose of our analysis, we are using the World Health
Organizations WHO measure, which considers a person to be overweight who has a BMI equal to or greater than 250 kg/m2 According to the NPHS, the proportions of men and women who were overweight between 1994/95 and 1998/99 were similar Figure 3-1 Among men, the proportion who were overweight increased slightly between 1994/95 and 1998/99 The difference, however, was not statistically significant Women showed little change

Socio-Economic Determinants of Health
Socio-economic factors education and income heavily influence the adoption of healthy behaviours Individuals with lower income and less formal education are more likely to smoke and to be physically inactive and overweight5 Therefore, programs and policies must address these underlying determinants of health in a comprehensive program to prevent diabetes In the 1998/99 NPHS, 214 of individuals with diabetes reported low income, and 427 had not completed secondary school In the general

Figure 31: Proportion of Overweight Adults in Canada
Proportion of overweight1 adults aged 20-59 years in the general population, Canada 1994/95-1998/99
80

Percent

0 1994/95 Women Men 369 569 1996/97 354 569 Sex and
Year
1Overweight,

1998/99 380 597

BMI 250

Source:

Statistics Canada, National Population Health Survey

Diabetes in Canada

Figure 32: Overweight Adults with Self-Reported Diabetes
Proportion of overweight1 adults aged 20-59 years with self-reported diabetes, Canada 1994/95-1998/99
80

diabetes who were overweight remained similar throughout the three surveys Figure 3-2 In 1998/99, the tendency to be overweight increased with age among both men and women in the general population Figure 3-3 This tendency is similar to that in previous years

Percent

0 1994/95 Women Men 725 704 1996/97 708 712 Sex and Year
1Overweight,

1998/99 762 729

BMI 250

Source: Statistics Canada, National Population Health Survey

Figure 33: Increases in Overweight with Age
Proportion of overweight1 adults in the general population by age group and sex, Canada, 1998/99
80

Physical Inactivity
Physical inactivity leads to a higher risk for the development of diabetes The NPHS estimates energy expenditure during leisure time Individuals who expended 15 kilocalories/kg or less every day were classified as physically inactive

60 Percent

0 20-39 years Women Men 301 521 Sex and
Age Group
1Overweight,

40-59 years 437 662

BMI 250

Source: Statistics Canada, National Population Health Survey

Among individuals with self-reported diabetes, 743 were overweight in 1998/99 The proportion of women with

In the general population, more women than men reported inactivity in 1998/99 Figure 3-4 The proportions of

Diabetes in Canada

men and women who were physically inactive decreased between 1994/95 and 1998/99 Of those individuals with self-reported diabetes, women were more likely than men to be physically inactive Figure 3-5 The difference, however, was not statistically significant Overall in 1998/99, 554 of the general population reported that they were physically inactive Individuals with selfreported diabetes were more likely to be inactive 651

Figure 34: Proportion of Physically Inactive Adults in Canada
Proportion of physically inactive adults aged 20 in the general population, Canada, 1994/95-1998/99
80

60 Percent

0 1994/95 Women Men 647 582 1996/97 620 579 Sex and Year
Source: Statistics Canada, National Population Health Survey

1998/99 587 520

Figure 35: Physically Inactive Adults with Self-Reported Diabetes
Proportion of physically
inactive adults aged 20 years with self-reported diabetes, Canada, 1994/95-1998/99
80

60 Percent

Among men and 0 women in the general 1994/95 1996/97 1998/99 728 745 723 Women population, physical Men 610 624 591 inactivity appeared to Sex and Year increase with age The Source: Statistics Canada, National Population Health Survey difference, however, was not statistically significant Figure 3-6 This tendency is similar to that of previous years Cigarette smoking is a risk factor for the complications of diabetes A daily smoker

Smoking

Diabetes in Canada

Figure 36: Increases in Physical Inactivity with Age
Proportion of physically inactive adults in the general population by age group and sex, Canada, 1998/99
80

The proportion of men in the general population who smoked decreased between 1994/5 and 1998/99 Figure 3-7 The difference, however, is not statistically significant Although the proportion of men with diabetes who smoked appeared to decrease between 1994/95 and 1998/99 in a similar way to the general population, the trend is not statistically significant because of the small sample Figure 3-8

Percent

0 20-39 years Women Men 555 482 40-59 years
585 547 Age Group and Sex
Source: Statistics Canada, National Population Health Survey

60-74 years 592 534

75 years 754 582

Figure 37: Proportion of Daily Smokers in Canada
Proportion of daily smokers aged 20 years in the general population, Canada, 1994/95-1998/99
30

20 Percent

0 1994/95 Women Men 239 284 1996/97 221 277 Year and Sex
Source: Statistics Canada, National Population Health Survey

was defined in the NPHS as an individual who was smoking cigarettes on a daily basis at the time of the interview

In addition, almost one-quarter 241 of all Canadians aged 20 years smoked daily, 1998/99 according to the 220 1998/99 NPHS The 262 proportion of smokers among individuals with self-reported diabetes was much lower than in the general population 154; this may be due to a higher average age among diabetics than in the general population

Diabetes in Canada

In 1998/99, the proportion of men and women who smoked in the general population was highest among those aged between 20 and 39 years and decreased with increasing age Figure 3-9 The differences among men, however, may have resulted from sampling, as the confidence intervals of the estimates for the age groups
20-39 and 40-59 overlap This tendency is similar to that of the previous year

Figure 38: Daily Smokers with Self-Reported Diabetes
Proportion of daily smokers aged 20 years with self-reported diabetes, Canada, 1994/95-1998/99
30

Percent

0 1994/95 Women Men 133 205 1996/97 151 200 Sex and Year
CV 167 — 255
Source: Statistics Canada, National Population Health Survey

1998/99 145 162

Figure 39: Decreases in Daily Smoking with Age
Proportion of daily smokers in the general population by age group and sex, Canada, 1998/99
40

Percent

High Blood Pressure

High blood pressure is also considered a 10 risk factor for the complications of 0 diabetes An individual 20-39 years 40-59 years 555 585 Women is considered to have Men 482 547 high blood pressure Age Group and Sex when the physicianSource: Statistics Canada, National Population Health Survey assessed diastolic pressure is 90 mm Hg or systolic pressure is 160 mm Hg NPHS

60-74 years 592 534

75 years 754 582

Diabetes in Canada

Figure 310: Proportion of Adults with High Blood Pressure in Canada
Proportion of adults aged 20 in the general population with high blood pressure, Canada,
1994/95-1998/99
20

to have their blood pressure assessed The proportion showed little change among three surveys The sample of those with diabetes was too small to determine any trend in high blood pressure over time or between men and women Figure 3-11 In an overall picture, 137 in the general population reported having high blood pressure, whereas nearly one-half of individuals with selfreported diabetes 465 reported high blood pressure

Percent

0 1994/95 Women Men 132 100 1996/97 142 115 Sex and Year
Source: Statistics Canada, National Population Health Survey

1998/99 154 119

Figure 311: High Blood Pressure with Self-Reported Diabetes
Proportion of adults who have high blood pressure aged 20 years with self-reported diabetes, Canada, 1994/95-1998/99
60 50 Percent 40 30 20 10 0 1994/95 Women Men 451 329 1996/97 466 451 Sex and Year
Source: Statistics Canada, National Population Health Survey

In 1998/99, a higher proportion of women than men in the general population reported high blood pressure Figure 3-10 This may be because women are more likely

In 1998/99, among both men and women 1998/99 521 in the general 418 population, the prevalence of high blood pressure
increased with age Figure 3-12 This tendency is similar to that of the previous year

Diabetes in Canada

Summary of Findings

Figure 312: Proportion of Adults with High Blood Pressure in Canada
Proportion of adults aged 20 in the general population with high

blood pressure by age group and sex, Canada, 1998/99 Risk factors for type 2 50 diabetes remain very 40 common in both the 30 general population and 20 in people with diabetes 10 However, overweight and physical inactivity 0 20-39 years 40-59 years 60-74 years 75 years could be considered, in 25 120 407 441 Women Men 17 119 313 356 a general sense, as Age Group and Sex modifiable risk factors Source: Statistics Canada, National Population Health Survey for developing diabetes, and daily smoking and Over the three surveys, the proportion of high blood pressure could be seen mainly as men and women in the general population risk factors for diabetes complications who were daily smokers appeared to be Regarding overweight, the proportion of decreasing It is also encouraging that the men who are overweight seems to have proportion of smokers among individuals increased over time, and this may partially with diabetes is much
lower than in the explain the higher prevalence of diabetes general population However, this may be among men than women Unless this trend due to the fact that the diabetic population is reversed, it will have serious ramifications is older than the general population, and on the future prevalence of diabetes older Canadians are less likely to smoke

It is encouraging that both men and women are becoming more physically active in the general population However, efforts to encourage regular physical activity must continue so that Canadians, in general, become less sedentary Although physical inactivity is a risk factor for diabetes, it is also a risk factor for complications such as cardiovascular disease Therefore, the high proportion of people with diabetes who are physically inactive is a matter of great concern

Percent

The very high prevalence of reported high blood pressure among those with diabetes in all age groups is a cause for concern and at the same time a reassurance The concern is that many individuals with diabetes are at high risk of cardiovascular and other complications due to high blood pressure On the other hand, it is reassuring that those whose high blood
pressure is detected can be treated to reduce the risk The

Diabetes in Canada

effective control of high blood pressure can decrease the risk of cardiovascular disease complications7 Diabetes educational programs can assist individuals to adopt a healthy lifestyle with effective weight control, increased physical activity, and cessation of smoking Smoking is the only lifestyle factor that is less common among those with diabetes than in the general population Programs that encourage non-smoking and interventions by health providers may have made a significant impact on those with diabetes The lack of known modifiable risk factors for type 1 diabetes points to the need for further research in this area To date, no known effective methods for preventing type 1 diabetes exist Research is exploring the possibility of altering environmental factors in people who are genetically at risk by such methods as removing cows milk protein from infant feeds There is also research investigating the possibility of modifying the immune process in people with subclinical beta cell loss identified by positive screening tests, through the use of nicotinamide, oral insulin, and injected
insulin2

References
1 Fantus IJ, Delovitch TH, Dupré J Prevention of diabetes mellitus: goal for the twenty-first century, part two Diabetes Care 1997;214:184-206 2 Meltzer S, Leiter L, Daneman D, Gerstein H, Lau D, Ludwig S et al Clinical practice guidelines for the management of diabetes in Canada Can Med Assoc J 1998;39 8:Suppl:S8 3 Ford ES, Williamson DF, Liu S Weight change and diabetes incidence: findings from a national cohort of US adults Am J Epidemiol 1997; 146:214-22 4 Resnick H, Valsania P, Halter J, Lin X Relation of weight gain and weight loss on subsequent diabetes risk in overweight adults J Epidemiol Community Health 2000;54: 596-602 5 Statistics Canada Health care services recent trends Health Reports 2000;114:91-109 6 Pi-Sunyer FX Medical hazards of obesity Ann Intern Med 1993;119:655-60 7 Meltzer S et al S23

Diabetes in Canada

CHAPTER 4

Health Outcomes
Introduction
This chapter focuses on the health outcomes of diabetes, measured as the quality of life of individuals with diabetes and premature death due to the disease The concept of quality of life has multiple dimensions and could be related to physical well-being, social and economical stability, as
well as emotional well-being1 Diabetes exerts a significant effect on the quality of life of those with the disease The continuous need to monitor intake in terms of timing, type and amount of food, take medication whether pills or insulin injections, monitor blood glucose, and anticipate and plan for activities that may affect diabetes control can severely strain their daily lives This is a particular challenge for children and youth with diabetes, who face the task of fitting in with their peers while coping with the demands of treatment Without good control of blood sugar, diabetes can cause life-threatening events, such as severe hypoglycemia low blood sugar, hyperglycemia high blood sugar, ketoacidosis and even coma Selfmanagement education focusing on monitoring and interpreting bloo d sugar results, taking and adjusting medication as needed, and adopting a healthy lifestyle diet, physical activity, smoking cessation/ avoidance, and stress management plays a critical role in diabetes control In the short term, good metabolic control of sugars, lipids, and blood pressure will both enhance the quality of life and decrease the use of acute care services The long-term
complications of diabetes affect many parts of the body, decrease quality of life for individuals with diabetes, and increase their use of health services Those with diabetes may also face shortened life expectancy due to complications from the disease

Self-Reported Health
The measurement of self-reported health in this chapter comes from the NPHS, in which individuals were asked to self-rate their health on a five-point scale Responses in the categories excellent, very good and

Diabetes in Canada

good were grouped into a category called good or better According to the 1998/99 NPHS, 645 of individuals with diabetes reported their health as good or better The proportions were much lower than among those without diabetes 908 p 005 In 1998/99, the perception of good health was similar among both men and women with diabetes Figures 4-1 and 4-2 The apparent increase in reported good health among women with diabetes between 1994/95 and 1998/99 was not statistically significant because of the small sample

Figure 41: Self-Reported Health Among Men With and Without Diabetes
Self-ratings of good or better health among men aged 20 years with and without self-reported diabetes,
Canada, 1994/95-1998/99
100 80
94/95 96/97 98/99

Percent

60 40 20 0

Diab 651

Non 900

Diab 674

Non 902

Diab 650

Non 904

Good or better

Diab Individuals with self-reported diabetes
Source: Statistics Canada, National Population Health Survey

Non Individuals without diabetes

Figure 42: Self-Reported Health Among Women With and Without Diabetes
Self-ratings of good or better health among women aged 20 years with and without self-reported diabetes, Canada, 1994/95-1998/99
100 80
94/95 96/97 98/99

Percent

60 40 20 0

Diab 533

Non 873

Diab 599

Non 889

Diab 640

Non 890

Good or better

In 1998/99, perceived Diab Individuals with self-reported diabetes Non Individuals without diabetes Source: Statistics Canada, National Population Health Survey good health decreased with increasing age among 75 years without diabetes A much lower men in both the diabetic and non-diabetic proportion of men with diabetes aged populations Figure 4-3 The decrease 40-59 years reported good health, in appeared earlier among men with diabetes: comparison to their counterparts aged the proportion with perceived good health 20-39 years p 005 among men aged between 40 and 59 years was very
similar to that of men aged

Diabetes in Canada

Figure 43: Self-Reported Health Among Men According to Age
Self-ratings of good or better health among men with and without self-reported diabetes according to age, Canada, 1998/99

Activity Restriction
In 1998/99, individuals aged 20 years with diabetes reported at least one day of activity restriction in the previous year more frequently than those without diabetes 173 versus 111, p 005 This difference was statistically significant among individuals aged 40-59 years 223 versus 106, p 005 and aged 60-74 years 176 versus 113, p 005 The sample in the younger age group 20-39 years was too small to assess the difference between those with and without diabetes

20-39 years

40-59 years

60-74 years

75 years

100 80

Percent

60 40 20 0

Diab 880

Non 960

Diab 662

Non 912

Diab 615

Non 812

Diab 579

Non 681

Good or better

Diab Individuals with self-reported diabetes
Source: Statistics Canada, National Population Health Survey

Non Individuals without diabetes

Figure 44: Self-Reported Health Among Women According to Age
Self-ratings of good or better health among women with and without self-reported diabetes according to
age, Canada, 1998/99
20-39 years 40-59 years 60-74 years 75 years

100 80

Percent

60 40 20 0

Diab 880

Non 943

Diab 640

Non 893

Diab 647

Non 817

Diab 532

Non 752

Good or better

Diab Individuals with self-reported diabetes
Source: Statistics Canada, National Population Health Survey

Non Individuals without diabetes

In 1998/99, perceived good health decreased dramatically among women with diabetes over the age of 40 years p 005 Figure 4-4 The decrease in the nondiabetic population was more gradual

Diabetes in Canada

Mortality
Diabetes mortality data come from the Canadian Mortality File and only the leading cause of death has been considered Mortality rates attributed to diabetes increased among both men and women in the early 1990s and have remained steady since 1995 Figure 4-5

Figure 45: Trends in Diabetes Mortality Rates
Diabetes mortality rates per 100,000 for all ages by sex, Canada, 1988-1999 age-standardized to the 1991 Canadian population
Females Males Females Males

Rates per 100,000

20 15 10 5 0
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Year
Source: Centre for Chronic Disease Prevention and Control, Health Canada, using
Statistics Canada, Annual

In 1999, 6,137 deaths in Canadian Mortality File Canada were attributed to diabetes 26 of all as a result of diabetes, as did 580 between deaths Rates were higher among men than 40 and 59 years However, the actual women Table 4-1, Figures 4-6 and 4-7 number of deaths due to diabetes may be Rates of mortality due to diabetes were much higher The annual mortality file low among individuals under the age of compiled by Statistics Canada includes 60 years In spite of low mortality rates, only the underlying cause 70 people under the age of 40 years died Table 4-1 Deaths Due to Diabetes by Age Group and Sex, Canada 1999
Age Group years Females
No 0-19 20-39 40-59 60-74 75 All 3 29 178 758 2,104 3,072 Rate/100,000 01 06 43 429 2029 200 No 3 39 402 1,102 1,519 3,065

Deaths Due to Diabetes Rate/100,000 Males
Rate/100,000 01 08 98 689 2446 203

Females and Males
No 6 68 550 1,860 3,623 6,137 Rate/100,000 01 07 70 541 2185 201

Source: Centre for Chronic Disease Prevention and Control, Health Canada, using Statistics Canada Mortality File

Diabetes in Canada

Using data from other studies, the true mortality rate related to diabetes is as much as five times
higher than the rate calculated from the Statistics Canada mortality database2 Therefore, approximately 30,000 deaths 6,137 deaths in 1999 multiplied by 5 each year may be attributed to diabetes and diabetesrelated complications Between 2000 and 2050, the number of deaths directly attributed to diabetes is estimated to triple to almost 9,000 deaths per year among men and 8,500 among women Figure 4-8
Projections based on applying the 1996/97 five-year agespecific rates to population projections to the year 2050

Figure 46: Diabetes Mortality Rates in Males
Mortality rate for diabetes among males by age group, Canada, 1999
300 250 Rates per 100,000 200 150 100 50 0 0-19 years Males 01 20-39 years 08 40-59 years 98 Age Group
Source: Centre for Chronic Disease Prevention and Control, Health Canada, using Statistics Canada, Annual Canadian Mortality File

60-74 years 685

75 years 2445

Figure 47: Diabetes Mortality Rates in Females
Mortality rate for diabetes among females by age group, Canada, 1999
300 250 Rates per 100,000 200 150 100 50 0 0-19 years Females 01 20-39 years 06 40-59 years 43 Age Group
Source: Centre for Chronic Disease Prevention and Control, Health Canada, using
Statistics Canada, Annual Canadian Mortality File

60-74 years 428

75 years 2028

Diabetes in Canada

Figure 48: Estimated Future Deaths from Diabetes
Number of actual and projected deaths due to diabetes by sex, Canada, 1970-2050

10,000 9,000 8,000
Number

Females actual Males actual Males projected Females projected

7,000 6,000 5,000 4,000 3,000 2,000 1,000 0

1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050

Year
Source: Statistics Canada, Annual Canadian Mortality File

Summary of Findings
Individuals with diabetes are less likely than those without diabetes to report perceived good health In addition, they more often report that they experience activity restriction The negative impact of diabetes may be due to diabetes-related complications and/or the challenges associated with diabetes care The higher mortality rates associated with diabetes among men than women are consistent with the slightly higher prevalence of diabetes among men In addition, men

tend to develop cardiovascular disease complications, which carry a high mortality rate, more often than women Current mortality data compiled by Statistics Canada under-represent the
contribution of diabetes to mortality in Canada In a study by Statistics Canada of death certificates that mentioned diabetes, only 28 listed it as the underlying cause of death The remainder listed diabetes-related complications, such as kidney failure or heart disease or stroke, as the underlying cause of death and listed diabetes as a contributing cause

Diabetes in Canada

Mortality rates among those aged 75 years and over heavily influence the overall rates of diabetes mortality, as the rates in this age group are dramatically higher than among younger adults The stabilization of mortality rates in this age group among both men and women has resulted in a levelling off of the overall mortality rates Possible reasons for this trend include an increase in lifesaving procedures, advances in therapeutic and diagnostic technology, and a focus on reducing risk factors The levelling off of the mortality rate may signal that people are living longer with diabetes, but doesnt necessarily mean that they have a higher quality of life This levelling off of mortality rates may mislead health planners into thinking that the diabetes problem has stabilized In fact, the number of deaths
will likely increase in the future among both men and women because the population is aging These individuals will need a variety of health services in the acute, chronic and home care sectors for many years before death Thus, coping with this increasing need for service requires immediate preparation, not only to address the current situation but to be effective for the next 20 years as well

Full monitoring of the health outcomes or impact of diabetes on the lives of those with the disease will require additional data It is anticipated that the NDSS will be able to provide data on the complications of diabetes In addition, further refinement of existing data would enable analysis of health outcomes according to the type of diabetes type 1 and type 2 Population surveys could also seek information regarding the quality of life of both individuals with diabetes and their families, exploring such issues as the need for time away from work or school, activity restriction, and the ability to fulfil family and social roles

References
1 De Souza TT, Santini L, Wada SA, Vasco, CF, Kimura M The quality of life of diabetics Rev Esc Enferm USP 1997,3110:150-64 2 Health Canada Diabetes in
Canada: national statistics and opportunities for improved surveillance, prevention, and control Ottawa: Health Canada, 1999: 27

Diabetes in Canada

CHAPTER 5

Use of Health Services and Costs
Introduction
Individuals with diabetes require a variety of health services, not only for the control of their disease but also for the diagnosis and treatment of associated complications Therapy for individuals with diabetes aims to control blood sugar, blood pressure and blood lipids levels, to reduce symptoms and the risk of complications1, and to enhance the quality of life Blood sugar levels can be controlled through diet and oral hypoglycemic drugs and/or by injections of insulin, combined with lifestyle modification healthy eating, active living, smoking avoidance/cessation, and stress management Pharmacologic interventions combined with these lifestyle modifications also form a necessary part of managing the complications of diabetes Meeting these treatment goals requires a range of health care services, including primary health care, emergency, hospitalization and rehabilitation services, and home care: Central to the DHC [diabetes health care] team is the person with diabetes
and his/her family Also at the core are the primary care physician who may be a diabetes specialist, the diabetes medical specialist/endocrinologist/internist and diabetes educators nurses and dietitians If required, other professional and lay caregivers may be included in an expanded DHC team These may be medical specialists ophthalmologists, cardiologists, neurologists, nephrologists and obstetricians, other health professionals other nurses and dieticians, social workers, psychologists and other mental health workers, pharmacists, chiropodists, podiatrists and optometrists, community and public health agencies and other health organizations2

Diabetes in Canada

Primary health care services also have a central role in the early detection of individuals with diabetes It can take many years before a person develops symptoms sufficient to warrant a visit to a doctor for assessment specific to diabetes Therefore, screening all high-risk individuals such as those with a family history of diabetes, or those over the age of 45 years can result in early diagnosis and treatment that improves outcome3

Diabetes Association can help individuals make the necessary adjustments towards
improving the quality of their life

Medication Use
Over three-quarters of individuals with diabetes 760 use either insulin or oral anti-hyperglycemic agents OAAs pills to control their disease Early in the course of the disease, most are able to use pills rather than insulin Over time, however, as the disease progresses, treatment may require either insulin alone or insulin in combination with OAAs

Total Units Dispensed

Hospital services are required to treat the advanced stages of the complications of diabetes, which include heart disease, stroke, kidney disease, and foot, eye and nerve The total units of diabetes medications problems As a result, hospitalization data prescribed increased by 44 between 1996 provide a picture of the more severe aspects and 2000 Figure 5-1 This increase was of the disease Hospitalization data in this primarily due to the increased use of report include cases in which diabetes was biguanides and sulphonylureas reported as one of the first eight reasons for hospitalization This captures not only cases in which diabetes itself was the Figure 51: Patterns in the Use of Diabetes Medications Total Units of Diabetes Medications, by Year, dispensed
primary reason for the annually, Canada excluding the Territories, 1996-2000 hospital stay but also those 1,000,000 in which the complications 800,000 of diabetes were important 600,000 reasons for the stay
400,000 200,000 0
Total Units for Diabetes Sulphonylureas Biguanides Insulins Alpha-Glucosidase Inhibs Meglitinides Thiazolidinediones Others
Source: IMS HEALTH, Compuscript

Living with diabetes is challenging because it affects every part of a persons life Support from family, the multidisciplinary health care team, school, the workplace, and volunteer organizations such as the Canadian

1996 528,896 312,951 183,848 29,087 2,964 0 0 46

1997 594,227 335,868 219,107 30,914 8,209 0 0 130

1998 672,543 361,471 263,621 33,584 13,799 0 0 68

1999 756,958 383,962 318,370 35,094 18,395 1,034 0 103

2000 847,790 393,824 384,406 36,851 18,683 9,638 4,271 116

Diabetes in Canada

Figure 52: Blood Pressure Checks in Adults with Diabetes
Proportion of adults aged 20 years with self-reported diabetes who had their blood pressure checked in the previous year, Canada, 1994/951998/99
Women 100 80 60 40 20 0 1994/95 BP Checked 971 1996/97 967 1998/99 951 1994/95 941 Sex and Year
Source:
Statistics Canada, National Population Health Survey

Ambulatory Care Services
Blood Pressure Assessed
In 1998/99, according to the NPHS, almost all adults aged 20 years with diabetes 958 had had their blood pressure checked in the previous year A high proportion of both men and women continued to have their blood pressure checked This proportion remained steady between 1994/95 and 1998/99 Figures 5-2 and 5-3

Men

Percent

1996/97 937

1998/99 964

Figure 53: Blood Pressure Checks in Adults, General Population
Proportion of adults aged 20 years in the general population who had their blood pressure checked in the previous year, Canada, 1994/951998/99
Women 100 80 60 40 20 0 1994/95 BP Checked 781 1996/97 824 1998/99 823 1994/95 633 Sex and Year
Source: Statistics Canada, National Population Health Survey

Men

Percent

1996/97 707

1998/99 704

Diabetes in Canada

Eye Examination
Figure 54: Eye Examination in Adults with Diabetes

It is recommended that individuals with diabetes have their eyes assessed regularly Of all individuals with diabetes, 624 in 1998/99 reported having had an eye examination during the previous year By that year, a higher proportion of women than men
had had an annual examination Whether this was for refraction or as assessment for diabetic retinopathy eye disease that can lead to blindness is unknown In 1994/95-1998/99 in the general population, women seemed slightly more likely to have had an eye examination in the previous year than men

Proportion of adults aged 20 years with self-reported diabetes who had an eye examination in the previous year, Canada, 1994/95-1998/99
Women 80 70 60 Percent 50 40 30 20 10 0 1994/95 Eye Exam 575 1996/97 624 1998/99 700 1994/95 538 Sex and Year
Source: Statistics Canada, National Population Health Survey

Men

1996/97 628

1998/99 562

Figure 55: Eye Examination in Adults, General Population
Proportion of adults aged 20 years in the general population who had an eye examination in the previous year, Canada, 1994/95-1998/99
Women Men

50 40 Percent 30 20 10 0 1994/95 Eye Exam 377

1996/97 432

1998/99 401

1994/95 317

1996/97 381

1998/99 334

Sex and Year
Source: Statistics Canada, National Population Health Survey

Diabetes in Canada

Figure 56: Home Care for Adults with Diabetes
Proportion of adults aged 20 years with self-reported diabetes who had used home care in the previous
year, Canada, 1994/95-1998/99
Women 15 12 Percent 9 6 3 0 1994/95 Home Care 120 1996/97 124 1998/99 145 1994/95 100 Sex and Year
CV 167-255
Source: Statistics Canada, National Population Health Survey

Use of Home Care Services
According to the NPHS, a much higher proportion of individuals with diabetes used home care in the previous year than did the general population 125 compared with 28 The highest use of home care was in the 75 age group, in which 360 of those with diabetes used home care, as compared with 189 in the general population; in the 60-74 year-old age group the proportions were 100 versus 46 respectively Use of home care appeared to be more common among women than men with diabetes between 1994/95 and 1998/99 However, because of the small sample the differences were not statistically significant Figure 5-6

Men

1996/97 74

1998/99 108

Figure 57: Home Care for Adults, General Population
Proportion of adults aged 20 years in the general population who used home care in the previous year, Canada, 1994/95-1998/99
Women 40 35 30 Percent 25 20 15 10 05 00 1994/95 Home Care 33 1996/97 33 1998/99 35 Sex and Year
CV 167-255
Source: Statistics Canada, National
Population Health Survey

Men

1994/95 17

1996/97 17

1998/99 21

Diabetes in Canada

Hospitalization for Diabetes
Hospitalization data in this report include cases in which diabetes was reported as one of the first eight reasons for length of hospital stay This captures not only cases in which diabetes itself was the primary reason for the hospitalization but also those in which the complications of diabetes were important reasons for the hospitalization In 1999/2000, there were 279,653 admissions for diabetes in Canada Of all hospitalizations excluding pregnancies, 93 listed diabetes among the first eight reasons for length of hospital stay, an increase from 86 in 1998/99 Please note that a diagnosis of diabetes that had been recorded in a patients chart does not necessarily mean that diabetes was a significant factor in the hospitalization

Figure 58: Hospitalizations with a Diagnosis of Diabetes
Rates of hospitalization with a diagnosis of diabetes by age group and sex, Canada, 1999/2000
8000

Rate per 100,000

6000

4000

2000

0 0-19 years Females Males Females and Males 63 55 59 20-39 years 158 126 142 40-59 years 621 824 722 60-74 years 2,756 3,751 3,229 75 years 4,906
6,725 5,588 All ages 877 953 915

Age Group
Diabetes listed among the first eight reasons for length of hospital stay
Source: Centre for Chronic Disease Prevention and Control, Health Canada using data from Hospital Morbidity File, Canadian Institute for Health Information

Figure 59: Proportion of Hospitalizations with a Diagnosis of Diabetes
Hospitalizations with a diagnosis of diabetes as a proportion of all hospital admissions by age group and sex, Canada, 1999/2000
200

150

Percent

100

00 0-19 years Females Males Females and Males 14 12 13 20-39 years 12 35 17 40-59 years 79 113 96 60-74 years 166 177 172 75 years 142 154 147 All ages 78 114 93

Age Group
Diabetes listed among the first eight reasons for length of hospital stay, pregnancy excluded from the denominator
Source: Centre for Chronic Disease Prevention and Control, Health Canada using data from Hospital Morbidity File, Canadian Institute for Health Information

In 1999/2000, rates of hospitalization for diabetes increased with age Figure 5-8 Males aged 40 years and over had higher

Diabetes in Canada

Table 5-1 Hospitalizations Related to Diabetes
Age Group years
No 0-19 20-39 40-59 60-74 75 All 2,442
7,221 25,853 48,780 51,040 135,336

Hospitalizations related to diabetes as one of the first eight diagnoses by age group and sex, Canada, 1999/2000 rate/100,000 Females
Rate/100,000 63 158 621 2,756 4,906 877 No 2,248 5,901 34,065 60,131 41,972 144,317

Males
Rate/100,000 55 126 824 3,751 6,725 953

Females and Males
No 4,690 13,122 59,918 108,911 93,012 279,653 Rate/100,000 59 142 722 3,229 5,588 915

Source: Centre for Chronic Disease Prevention and Control, Health Canada, using data from Hospital Morbidity File, Canadian Institutes for Health Information

Rates per 100,000

rates of hospitalization than females Although the number of hospitalizations for diabetes was highest among those over the age of 60, 28 of diabetesrelated hospitalizations in 1999/2000 were for individuals under the age of 60 years Table 5-1

Figure 510: Trends in Hospitalizations with a Diagnosis of Diabetes Over Time
Rates of hospitalization for diabetes among adults by sex, Canada excluding the Territories, 1994/95-1999/2000 standardized to the 1991 Canadian population

Females

Males

Females Males

1,500 1,200 900 600

300 In a high proportion 0 of all hospitalizations of 1994 1995 1996 1997 1998
1999 individuals over the age Year Source: Centre for Chronic Disease Prevention and Control, Health Canada, using Statistics Canada, Annual of 40 years, diabetes was Canadian Mortality File listed among the first eight diagnoses Figure 5-9 decreased slightly while the rates among In 1999/2000, the contribution of diabetes males increased The net effect was little to hospitalization was highest in the change in the overall hospitalization rate 60-74 year age group 172 Figure 5-10 Between 1994 and 1999, rates of hospitalization for diabetes among females

Diabetes in Canada

Hospitalizations for Associated Conditions
Diabetes-related conditions include hypertension, cardiovascular disease, cerebrovascular disease, peripheral vascular disease, lower respiratory tract infection, renal disease, and skin disease In 1999/2000, the proportion of hospitalizations with these conditions was consistently higher among individuals with diabetes listed in the first eight diagnoses than among individuals without diabetes diabetes not listed in any of the diagnostic

fields Figure 5-11 The most common comorbid conditions were cardiovascular disease 435 and hypertension 370 Among individuals
with diabetes, cardiovascular disease and peripheral vascular disease were more common among males than females as diabetes-related conditions contributing to hospitalization rates Figures 5-12 and 5-13 Hypertension was more common among females than males as a diabetes-related complication 407 versus 336 These differences may be due to the different age structures of the respective populations

Figure 511: Other Health Conditions Associated with Diabetes
Proportion of hospitalizations with health-related conditions of diabetes among individuals with and without diabetes, Canada, 1999/2000

Skin disease Renal disease Lower respiratory tract infection Peripheral vascular disease Cerebrovascular disease Cardiovascular disease Hypertension Any of these 7 conditions

20 66 35 128 188 243 20 80 47 107 172 435 125 370 411

Non-diabetes Diabetes

769

40 Percent

Diabetes listed among the first eight reasons for length of hospital stay, pregnancy excluded from the denominator
Source: Centre for Chronic Disease Prevention and Control, Health Canada using data from Hospital Morbidity File, Canadian Institute for Health Information

Diabetes in
Canada

Figure 512: Other Health Conditions Associated with Diabetes, Males
Proportion of hospitalizations with health-related conditions among males with and without diabetes, Canada, 1999/2000

Skin disease Renal disease Lower respiratory tract infection Peripheral vascular disease Cerebrovascular disease Cardiovascular disease Hypertension Any of these 7 conditions

22 75 40 137 204 245 23 95 48 111 203 461 111 336 441

Non-diabetes Diabetes

778

40 Percent

Diabetes listed among the first eight reasons for length of hospital stay
Source: Centre for Chronic Disease Prevention and Control, Health Canada using data from Hospital Morbidity File, Canadian Institute for Health Information

Figure 513: Other Health Conditions Associated with Diabetes, Females
Proportion of hospitalizations with health-related conditions of diabetes among females with and without diabetes, Canada, 1999/2000

Skin disease Renal disease Lower respiratory tract infection Peripheral vascular disease Cerebrovascular disease Cardiovascular disease Hypertension Any of these 7 conditions

18 56 30 118 173 241 17 63 46 102 143 406 137 407 382

Non-diabetes
Diabetes

760

40 Percent

Diabetes in Canada

Economic Burden of Diabetes in Canada
In Canada, the economic burden of diabetes alone is estimated at 16 billion in 1998; 04 billion 25 in direct costs and 12 billion 75 in indirect costs4 The relative magnitude of the major cost components is illustrated in Figure 514

Figure 514: Economic Burden of Diabetes in Canada by Cost Component, 1998

Drug Expenditures 11 1810 Million

Mortality Costs 45 7328 Million

Hospital Expenditures 12 2035 Million

Long Term Morbidity Costs 32 5291 Million

Direct costs are defined as Figure 515: Economic Burden of Diabetes in Canada, by Sex and Cost Component, 1998 the value of goods and services for which 600 payment was made and resources used in 400 treatment, care and rehabilitation by 200 governments federal, provincial and territorial 0 as well as by individual Males Females Hospital
Expenditures Drug Expenditures Mortality Costs Long Term Morbidity Costs Canadians The direct cost Only 998 of drug expenditures could be distributed by sex estimate for diabetes includes only hospital care and drug expenditures, at value of lost production due to premature 2035 million, and 1810 million, mortality represents the largest indirect respectively cost at 7328 million The morbidity
Millions

Indirect costs refer to the dollar value of lost production due to illness, injury, disability or premature death In terms of the principal indirect cost components that are estimated for diabetes in 1998, the

costs due to long-term disability represent 5291 million Figure 515 illustrates the distribution of direct and indirect costs by sex and cost component Overall, males account for

Diabetes in Canada

almost 60 9632 million of the total cost of diabetes in Canada This is due to higher mortality and long-term disability costs for males as compared to females; 4263 million and 3313 million compared to 3064 million and 1978 million, respectively Seniors 65 years and individuals aged 35-64 years account for over 90 of the total diabetes cost This represents 8699 million and
6539 million, respectively Although the economic burden of diabetes appears to have increased in Canada in constant dollars since 19935, these costs estimates are still considered to be conservative for several reasons: the definition of diabetes used refers only to diabetes mellitus International Classification of Diseases, 9th revision 250; the direct cost does not include physician care and research expenditures as well as the cost borne by patients or other payers such as costs for transportation to health providers, and special diets; the indirect cost does not include morbidity costs due to short-term disability as well as the value of time lost from work and leisure activities by family members or friends who care for the patient; and all co-morbid effects are not taken into account

A brief review of US studies is useful for comparison purposes6 Four US studies during the 1980s estimated the cost of diabetes to range from 17 to 23 billion annually 1990 US dollars However, a 1992 US study published by the American Diabetes Association estimated costs at 918 billion annually when costs of illnesses associated with diabetes were included in the calculations7 For example,
since diabetes is a risk factor for heart disease, the costs for a proportion of those with heart disease were attributed to diabetes Given that the Canadian population is approximately one tenth the size of the US population and has roughly similar diabetes prevalence rates, the real economic cost of diabetes in Canada may be as high as 9 billion US annually ie 10 of 918 billion While the diabetes cost estimates presented in this report should be interpreted in the context of the methods, assumptions and limitations from which they were calculated4, they give an idea of the magnitude of the economic burden of diabetes in Canada

Summary of Findings
The potential for improving the health of individuals with diabetes and for decreasing the overall costs of the disease to the health care system and community lies in directing action towards better control of the disease

Diabetes in Canada

In the 1990s, diabetes care changed substantially with increased recognition of the importance of tight blood glucose control and diabetes self-management education Several provincial ministries of health made a commitment to support diabetes education centres, bringing greater attention to
the need to address risk factors such as high blood pressure and blood lipids, overweight/obesity, smoking, and stress The 1990s also saw the production of better insulin, new classes of oral antihyperglycemic agents and improved technology for supporting better management The data on medication use support the nature of type 2 diabetes: that it can be controlled early in the course of the disease in some circumstances without the use of insulin The increase in total units of hypoglycemic agents dispensed over time may be due to the high use among seniors, a segment of the population that is growing over time This increase may also reflect the aggressive management of the disease with the use of medication to more closely control blood sugar, since type 2 diabetes is a progressive disease The control of high blood pressure is one of the most important preventive measures for reducing the complications of diabetes The very high proportion of individuals with diabetes who have had their blood pressure checked in the past year is encouraging

Assessment is only the first step, however It must be followed by adequate treatment through lifestyle changes and, where necessary, medication
The higher use of home care services among seniors with diabetes compared with the general population of seniors attests to the disability that results from the complications of the disease As with hospitalizations, the aging of the population will increase the need for home care services in the future The higher hospitalization rate among men than women may reflect the higher rate of cardiovascular complications among men The lack of a decrease in hospitalization rates for diabetes in any age group contradicts the hospitalization rate in general, which has shown a steady decrease in the past several years This may signal that the level of serious health problems among individuals with diabetes has not decreased It also attests to continued pressure on hospital budgets Assessing the costs of diabetes still represents a major issue, and many challenges must be tackled In fact, the EBIC Economic Burden of Illness in Canada, 1998 estimate is a very conservative one and does not include physician costs In addition, the hospital costs include only the leading cause of hospitalization, and this results in an underestimation of the real burden of diabetes essentially because
the

Diabetes in Canada

complications of diabetes are not captured Further research is needed to fill the various gaps that exist in assessing the economic burden of diabetes in Canada Monitoring the use of health services by individuals with diabetes requires additional information As it matures, the NDSS will provide many of these data Additional information is also needed on the use of diabetes education centres

References
1 Meltzer S, Leiter L, Daneman D, Gerstein H, Lau D, Ludwig S et al 1998 clinical practice guidelines for the management of diabetes in Canada Can Med Assoc J 1998;39 8:Suppl:S9 2 Meltzer et al, S3 3 Meltzer et al, S8 4 Health Canada Economic Burden of Illness in Canada, 1998 Catalogue No H21-136/1998, Ottawa, 2002 5 Moore R, Mao Y, Zhang J, Clarke K Economic Burden of Illness in Canada, 1993 Ottawa: Canadian Public Health Association, 1997 6 National Institutes of Health Diabetes in America 2nd Edition MIM Publication No 95-1468 Bethesda, Maryland,1995 7 American Diabetes Association Direct and Indirect Costs of Diabetes in the United States in 1992 Alexandria, Virginia, 1993

Diabetes in Canada

CHAPTER 6

Diabetes in Aboriginal
Communities
Introduction
This chapter gives a summary of diabetes and its repercussions among Aboriginal people in Canada It is important to mention that many sub-populations are included in the Aboriginal communities and, in this report, they can be divided into four 4 groups: On-reserve First Nations, Off-reserve First Nations, Métis and Inuit We focus on all these groups, although limited data exists on Métis and Inuit people Much of the essential information presented in this chapter come however from the report Diabetes Among Aboriginal People in Canada: The Evidence1 Diabetes is a very important issue in the Aboriginal communities for a variety of reasons: High rate of disease and earlier onset; Late detection or diagnosis leading to greater severity at diagnosis; High rates of complications; Lack of accessible services; Increasing prevalence of risk factors for a population already at risk; Prevalence of diabetes among First Nations is now at least three times the national average; Most Aboriginal people with diabetes are women; Diabetes is now considered an epidemic in the Aboriginal communities

Prevalence
Many surveys have been conducted at the national level
since the 1990s but only two of them give an estimation of the prevalence of diabetes self-reported in each of the Aboriginal sub-populations

Diabetes in Canada

The Aboriginal Peoples Figure 61: Crude Prevalence of Self-Reported Diabetes from Survey APS 1991 is the the Aboriginal Peoples Survey, 1991 most recent comprehensive 100 survey across Canada 80 According to this survey Figure 6-1, the prevalence 60 of diabetes among native 40 groups in Canada is as 20 follows: 85 of North 00 Total On-Reserve Off-Reserve Total Métis Inuit American Indian peoples Aboriginal First Nations First Nations First Nations 55 19 Prevalence 60 85 53 64 on Indian reserves and settlements; 53 of North Note: Based on Statistics Canada 1993 report American Indian peoples off reserves; 55 of Métis people and 19 of Inuit Various local studies on the prevalence people Of the Aboriginal population of diabetes among Aboriginal people in represented in this survey, approximately Canada have also been conducted in the 783,980 identified as North American last two decades They have shown Indian, 212,650 as Métis and 49,255 as extremely high rates of diabetes, especially Inuit Approximately two-thirds of
the First among some specific First Nations Nations people with a diagnosis of diabetes communities For instance, rates among are women, which is different from the women age 35 were between 22 and overall trend of the general population2 48 in two Algonquin communities in Quebec and in Haida Gwaii BC, 17 The prevalence rate for all age groups from of adults over age 35 had type 2 diabetes3,4 the First Nations and Inuit Regional Health However, the methodologies used in these Survey FNIRHS 1997 are 20 greater studies varied considerably and no single than the Aboriginal Peoples Survey APS set of diagnostic criteria was identical Among First Nations on reserve, the overall prevalence is 12 and one in four individuals who are over the age of 45 have diabetes The age-standardized prevalence of diabetes for First Nations people is 3 to 5 times that of the general population5
Percent

Gestational diabetes is also an issue in the Aboriginal communities According to the First Nations and Inuit Regional Health Survey, about 30 of women with diabetes reported that their diabetes was first diagnosed during pregnancy5

Diabetes in Canada

Overall, diabetes among Aboriginal people at least
three times that of the population Prevalence is expected to increase over time as a function of incidence, survival of people with diabetes, and aging of the population5 Inuit people are the only exception and their prevalence rates are below the national average However, the latest indications are showing an increase of diabetes rates among this group6 Due to the self-reported nature of diabetes respondents were asked if they have been diagnosed with diabetes by a health physician and the non-inclusions of some reserves in the current surveys, the existing numbers probably understate the true prevalence of diabetes

diet high in energy, saturated fat and simple sugars, along with an increased tendency towards sedentary lifestyles and reduced activity, all of which leads to a rise in the prevalence of obesity and increased risk of diabetes1 Many studies have documented an increasing prevalence of obesity within Aboriginal communities over a few decades For example, among the community of St Theresa First Nations showed close to 50 of the children were clinically obese7 The First Nations and Inuit Regional Health Survey indicated that 36 of women and 26 of men in Labrador were
found to be overweight5 Lack of physical activity is an important risk factor for diabetes and the decline in physical activity often accompanies the transition to a more sedentary lifestyle8 Several studies show that Aboriginal people are less likely than non-Aboriginal people to exercise in a regular basis and are less likely to participate in leisure-time activity2,9

Risk Factors
Diabetes is a chronic disease with multifactorial causes involving the interactions of genetic susceptibility and environmental factors Many of the risk factors tend to be worse in the Aboriginal communities for a variety of reasons Aboriginal peoples are likely to be genetically predisposed to store energy from the diet very efficiently, due to the nomadic lifestyle of their ancestors Patterns of dietary change, from traditional food to a diet high in energy, saturated fat and simple sugars, have been observed in many Aboriginal communities1 Briefly, the problem can be summarized as the adoption of a market

Complications
Diabetes is associated with many severe complications, which are related to various chronic diseases These long-term complications seem to be more frequent in the Aboriginal
communities than in the general population and make diabetes an important public health problem in these communities

Diabetes in Canada

The following table summarizes important findings of the latest studies on complications among Aboriginal people However, more Type of complication
Heart problems

research is needed as gaps still exist in the literature about all types of complications

Main results
First Nations men and women on-reserve have approximately three times the rate of heart problems and hypertension compared to the general Canadian population5 A study at Kahnawake First Nations found that 13 of people with diabetes had strokes, versus just 3 of a comparable group of people without diabetes an odds ratio of 4510 The same study also found that half of those with diabetes had significant heart disease leading to heart attacks and coronary bypass surgery10

Lower limb amputations

In the Manitoba study of First Nations, 91 of all lower limb amputations among First Nations are among people with diabetes11 In a study done among Native Americans in Oklahoma, the mean age of first amputations was 66 years post diagnosis Also, the 5-year survival rate after first
amputation was only 4012

Diabetic nephropathy

The prevalence of diabetic nephropathy is much higher in First Nations than in the general population and the rates range from 25-60 following 15 to 20 years with diabetes13 Aboriginal people are at increased risk of developing end-stage renal disease ESRD and the risk of ERSD due to diabetes specifically was at least 3 times higher than Canadian nationally14 For those Aboriginal people who develop ESRD, the relative risk of being on dialysis is 65 times that of a non-aboriginal patients11

Disorders of the eyes

A study done by Ross and Fick 1991 identified a high prevalence of serious untreated diabetic retinopathy in both insulin-using and noninsulin-using Aboriginal patients in southern Alberta15 In the Kahnawake reserve First Nations, 25 of patients had retinopathy after 10 years of the disease10

Overall complications

A study among Mohawks with diabetes found that over 60 had at least one major complication In addition, the risk of having such complications was six 6 times that experienced by individuals without diabetes, even after adjusting for differences in age, sex, and the level of smoking, hypertension and
obesity10

Diabetes in Canada

Use of health services
According to the Aboriginal Peoples Survey APS 91, 67 of North American Indians, 72 of Métis and 47 of Inuit people saw a general practitioner in the previous year for all causes2 All of these rates are below the general population, which is an average of 82 The First Nations and Inuit Regional Health Survey FNIRHS 97 indicated that usually less than 40 attend diabetes clinics or receive diabetes education2 The availability of health services could have an impact on hospitalizations and health care utilization There is a lack of information on the cost of diabetes among Aboriginal people We found one study that addressed that issue and estimated the cost of diabetes among status Indians in Manitoba16 After adjusting for age, results indicated that the per-person annual cost for Status Indians with diabetes was 3,657, compared to 2,169 per person for the general population with diabetes In addition, it was estimated that the cost of providing health care services to the entire status Aboriginal population of Manitoba was 465 million

communities In addition, several risk factors have an enormous impact on diabetes among the
Aboriginals and worsens the disease for a population already at risk Diabetes is associated with many severe complications, which are related to various chronic diseases Such complications affect the circulatory system, eyes, kidneys, periodontal and nervous systems and may result in premature mortality, disability and compromised quality of life Among Aboriginals, the overall prevalence of diabetes and its complications are expected to increase in the next years and would represent a huge burden for health authorities A study done in Manitoba shows the magnitude of this problem It estimated that between 1996 and 2016, there will be a 10-fold increase in the rate of cardiovascular disease; a 5-fold increase in strokes, 10 times as many dialysis starts; 10 times the rate of lower extremity amputations; and 5 times the rate of blindness17 The difficulties in obtaining data on the prevalence and incidence of diabetes highlight the need for an on-going comprehensive surveillance system The National Diabetes Surveillance System addresses the critical information gaps regarding diabetes in Canada The goal of NDSS is to develop a national standardized database for diabetes surveillance
with longterm monitoring for diabetes-related complications

Discussion
The high prevalence of diabetes among Aboriginal, the greater severity at diagnosis and the high rates of complications are several reasons that show the importance of tackling diabetes in all Aboriginal

Diabetes in Canada

References
1 Health Canada 2000, Diabetes Among Aboriginal First Nations, Inuit and Métis People in Canada: The Evidence Health Canada 2 Statistics Canada 1993 1991 Aboriginal Peoples Survey : Language, Tradition, Health, Lifesyle and Social Issues Ottawa: Statistics Canada CatNo 89-533 3 Delisle, HF, Ekoé, JM 1993 Prevalence of non-insulin-dependant diabetes mellitus and impaired glucose tolerance in two Algonguin communities in Québec CMAJ, 148:41-47 4 Grams, G al 1996 Haida perspectives on living with non-insulin-dependent diabetes CMAJ, 155: 1563-8 5 First Nations and Inuit Regional Health Survey National Steering Committee 1999 First Nations and Inuit Regional Health Survey National Report ISBN 0-9685388-0-0 6 Centre for Chronic Disease Prevention and Control, Health Canada, using data from National Population Health Survey 1996-97, Statistics Canada 7 Dean, H 1998 NIDDM-Y in
first Nations children in Canada Clin Pediatr, 37: 89-96 8 Thouez, JP, Rannou, A, Foggin, P 1989 The other face of development: native population, health status and indicators of malnutrition the case of the Cree and Inuit in northen Quebec Soc Sci Med, 29: 965-74 9 Imrie R and Warren R 1988 Health promotion survey in the Northwest Territories Can J Public Health, 79: 16-24

10 Macauley, AC, Montour, LT, Adelson, N 1988 Prevalence of diabetic and atherosclerotic complications among Mohawk Indians of Kahnawake, PQ CMAJ 139: 221-4 11 Manitoba Health 1997 Epidemiology of diabetes in First Nations Epidemiology and Diabetes Units, Manitoba Health 12 Lee, J al 1993 Lower extremity amputation : incidence, risk factors, and mortality in the Oklahoma Indian Diabetes Study Diabetes, 42:876-82 13 Whiteside, C 1994 Diabetic nephropathy: successful treatment depends upon early diagnosis Diabetes News, 2:1-3,8 14 Young, TK al 1989 Excessive burden of end-stage renal disease among Canadian Indians: a national survey Am J Public Health, 79:756-758 15 Ross, AS Fick, GF 1991 Insulin as a risk factor for diabetes complications Diabetes, 40Suppl, 1: 333A Abstract 16 Jacobs, P 1998 Cost of diabetes
in the status Indian population of Manitoba, 1995/96 Draft document prepared for Medical Services Branch, Health Canada 17 Green, C Al 1997 Projecting future diabetes prevalence in Manitoba First Nations 4th International Conference on Diabetes and Aboriginal People, San Diego

Diabetes in Canada

Glossary
Activity Restriction In the NPHS, activity restriction is defined as at least one day of activity restriction in the previous year Age-Specific Rate The death or disease rate for a specified age group in a specified period Five-year age groups are commonly used Age-Standardized Rate An adjusted rate that represents what the crude rate would have been in the study population if that population had the same age distribution as the standard population, which in this report is the 1991 Canadian population However, because standardization produces a summary measure, it may obscure important differences in age-specific patterns Also, standardized rates can be compared with each other only when the same standard population has been used to obtain the rate Body Mass Index BMI Anthropometric measure, defined as weight in kilograms divided by the square of height in metres This
measure correlates closely with body density and thickness see Overweight Cardiovascular Disease ICD-9 codes 410-414, 428, 4292, 4293, 4299 Cerebrovascular Disease ICD-9 codes 430-438 Coefficient of Variation The coefficient of variation CV indicates the quality of a population estimate A CV of 167-255 indicates moderate sampling variability A CV of 256-333 indicates high sampling variability Estimates with either a moderate or high CV should be interpreted with caution In some situations, the sample in the survey was too small to produce a reliable estimate These numbers are not included in the report

APPENDIX A

Diabetes in Canada

Confidence Interval The 95 confidence intervals CIs of all estimates were calculated during the preparation of the report As a result, there is a 95 probability that the true value for the population lies somewhere in this range of values If the text reports a difference between two values, the 95 CIs of these estimates do not overlap, and one can be reasonably sure that a true difference exists If the text does not report on a difference found in the values, the reader should assume that none exists Cumulative Incidence The number or proportion
of a group who experience the onset of a health-related event during a specified time interval; this interval is generally the same for all members of the group, but, as in lifetime incidence, it may vary from person to person without reference to age Daily Smoker An individual who was smoking cigarettes on a daily basis at the time of the interview Deaths Projected Five-year age-specific mortality rates for 1996/97 were applied to the projected population structure to the year 2050, developed by Statistics Canada Diabetes Mellitus DM A chronic condition that results from the bodys inability to sufficiently produce and/or properly use insulin

Type 1 Diabetes Type 1, also known as insulin dependent diabetes, occurs mainly in childhood or early adolescence and requires daily insulin injections for survival The most common form is caused by the destruction of beta cells in the pancreas by the auto-immune system, leaving the pancreas unable to produce insulin Type 2 Diabetes Type 2, also known as non-insulin dependent diabetes, typically occurs after the age of 40 years A resistance to insulin develops, often exacerbated by excess weight, leaving the pancreas unable to produce enough
insulin to compensate Gestational Diabetes During pregnancy, some women develop glucose intolerance that can be treated with diet and/or insulin If the glucose intolerance is not well controlled, however, the fetus can develop macrosomia large size that affects both the health of the baby and the birth Health-related Conditions of Diabetes Diabetes-related conditions include hypertension, cardiovascular disease, cerebrovascular disease, peripheral vascular disease, lower respiratory tract infection, renal disease, and skin disease

Diabetes in Canada

High Blood Pressure High blood pressure, as defined by a physician, is usually considered to be a diastolic pressure of 90 mm Hg or systolic pressure of 160 mm Hg Hypertension also called High Blood Pressure ICD-9 codes 401-405 ICD-9 Codes International Classification of Disease, 9th edition Incidence Rate The rate at which new events occur in a population The numerator is the number of new events that occur in a defined period; the denominator is the population at risk of experiencing the event during this period, sometimes expressed as person-time Insulin A hormone secreted from beta cells in the pancreas, which assists with
the conversion of glucose into energy Life Expectancy Life expectancy is a summary measure of the health status of a population It is defined as the average number of years an individual of a given age is expected to live if current mortality rates continue to apply

Lower Respiratory Tract Infection ICD-9 codes 466, 480-487, 490-496, 500-519 Mortality Rate An estimate of the portion of a population that dies during a specified period The numerator is the number of people dying during the period; the denominator is the number in the population, usually estimated as the midyear population Mortality Data Mortality or death data are collected by the provincial registrar of vital statistics for people resident in that province or territory at the time of death and are sent to Statistics Canada for final editing The death registration covers all deaths of Canadians occurring in Canada and to some extent in the United States Deaths occurring in countries other than Canada and the United States are not covered Overweight Body Mass Index BMI equal to or greater than 25 kg/m2 for men and women Peripheral Vascular Disease ICD-9 codes 440, 443, 4598, 4599

Diabetes in Canada

Physical
Inactivity An energy expenditure equal to or below 15, a level considered equivalent to leisure activity Energy expenditure was calculated using the frequency and time per session of the physical activity as well as its MET value The MET is a value of metabolic energy cost expressed as a multiple of the resting metabolic rate, obtained from a table provided by Statistics Canada Thus, an activity of 4 METS, eg, bicycling, requires four times the amount of energy needed when the body is at rest EE kcal/kg/day x[Ni Di MET/365] where: N number of time respondents engaged in an activity i, over a 12month period; D the average duration in hours of the activity i; MET the energy cost of the activity, expressed as kilocalorie expended per kilogram of body weight per hour of activity, kcal/kg/h, divided by 365 to convert yearly data into daily data Prevalence Rate The rate of a disease in a given population The numerator is the number of people in the population with the disease at a given point of time and the denominator is the total population at risk at that given point in time

Renal Disease ICD-9 codes 580-587, 593 Sampling Variability The variability in the estimate of a
population characteristic due to sampling error Self-Reported Health Response to the question on the NPHS: In general, how would you say your health is? Responses in the categories Excellent, Very Good and Good were grouped into a category called Good or better Skin Disease ICD-9 codes 681-682, 707, 7854 Standard Population A population structure that is used to provide a constant age distribution, so that the rates of different study populations can be adjusted to it and can be properly compared see AgeStandardized Rates

Diabetes in Canada

APPENDIX B

List of Data Sources
Hospital Morbidity Database HMDB Canadian Institute for Health Information The Canadian Institute for Health Information maintains the HMDB, which covers hospital separations transfers, discharges, or deaths in Canada The hospital completes a record for each individual In addition to demographic and administrative information, the database contains up to 16 diagnostic codes and some procedure codes The HMDB contains separation records from general and allied special hospitals, including acute care, convalescence, and chronic facilities except in Ontario The tables presented exclude information on
newborns, out-of-province admissions, and a small number of records flagged as having serious errors Records are not available for the Ontario Chronic Care Patient System, which accounted for about 1 of admissions in fiscal year 1996/97 Mortality Database Statistics Canada Provincial and territorial offices of vital statistics submit information annually on all deaths from all vital statistics registries in Canada An informant, usually a relative of the deceased, completes the personal information portion of the death registration form The portion of the form comprising the medical certificate of death is completed by the medical practitioner last in attendance or by a coroner if an inquest or enquiry was held The database includes demographic information and the underlying cause of death as defined by the physician National Diabetes Surveillance System NDSS The NDSS uses provincial/territorial administrative databases to identify groups of individuals who are likely to have diabetes The medical diagnosis recorded on both the physician service claims data and hospitalization data are utilized in the determination of diabetes

Diabetes in Canada

status The initial data
available from the system has been able to show the prevalence number of existing cases of diabetes and as the system matures, it is expected to be able to be useful in assessing the incidence number of new cases In addition, the system has the potential to be able to compare groups of individuals who have diabetes to the general population in order to assess how health care services are being used National Longitudinal Survey of Children and Youth NLSCY Human Resource Development Canada HRDC The primary objective of the NLSCY is to develop a national database on the characteristics and life experiences of Canadian children as they grow from infancy to adulthood The survey collects cross-sectional information as well as longitudinal data Data collection began in 1994/1995 and will be repeated every 2 years to follow the children surveyed in 1994/1995 In subsequent years, a crosssectional sample will be added for age groups no longer covered by the longitudinal sample The NLSCY target population includes children in all provinces and territories, except children living in institutions, on Indian reserves, on Canadian Armed Forces Bases, and in some remote areas The survey collects
information on the child from the household member most knowledgeable about the child Up to four children per household are chosen

randomly The survey is designed primarily for analysis at the national, regional, and in some cases provincial/ territorial level Analysis of subpopulations is limited by insufficient sample sizes National Population Health Survey NPHS Statistics Canada The NPHS collects information related to the health of the Canadian population and related socio-demographic information The NPHS is composed of three components: the Household Survey, the Health Care Institution Survey and the Northern Territories Survey The NPHS Household Survey has two sections a longitudinal panel of individuals who are surveyed every 2 years 14,900 in 1996 and 14,200 in 1998 and a cross-sectional component 17,600 in 1994/95, 81,800 in 1996/97 and 17,200 in 1998/99 The data in this report come from the 1994/95, 1996/97, and 1998/99 crosssectional household component of the NPHS the Master File The NPHS household component includes household residents in all provinces/territories, with the exclusion of populations in Indian Reserves, Canadian Armed Forces Bases, and some remote
areas in Quebec and Ontario The first cycle of data collection began in 1994, and data will be collected every second year for approximately 20 years in total Three cycles of collection are now completed for each component: NPHS

Diabetes in Canada

Cycle 1 1994/1995, NPHS Cycle 2 1996/1997, and NPHS Cycle 3 1998/1999 Aboriginal Peoples Survey APS Statistics Canada The objective of the 1991 APS was to provide a unique source of comprehensive data on the employment, education, language, mobility, health, lifestyle, and housing characteristics of Canadas Aboriginal peoples The APS population defined through the 1991 Census includes those people who reported at least one Aboriginal origin ie North American Indian, Métis, Inuit, or other Aboriginal groups such as Cree or Inuvialuit for question 15 of the Census long questionnaire It includes individuals who had indicated either a single Aboriginal origin; multiple ethnic origins, that is Aboriginal in combination with at least one other non-Aboriginal origin eg English, Irish, etc; or multiple Aboriginal origins For each of the areas chosen for the survey, a list was compiled of people who had indicated Aboriginal origins and
those who reported being registered under the Indian Act on their 1991 Census long questionnaire A sample was selected from the list that allowed estimates to be made of the characteristics of Aboriginal people living on Indian reserves and settlements, in other Aboriginal communities, and in other areas in Canada

IMS Health Dataset Canadian Retail Pharmacies CompuScript measures the number of prescriptions dispensed by Canadian retail pharmacies Product information is presented according to therapeutic class and each individual product The data collected can be used to ascertain product prescription volume and share, for trending purposes, thereby providing a measure of product utilization By monitoring filled prescriptions as they pass into the hands of consumers, CompuScript can be used to evaluate education and information programs directed toward physicians, pharmacists, and consumers The CompuScript sample is drawn from the IMS prescription database panel, which now comprises over 4,400 pharmacies or nearly two-thirds of all retail pharmacies in Canada Over 2,100 stores are used in the CompuScript panel, each stratified by province, type chain or independent, and size large
or small Records are collected monthly from each of these pharmacies, by diskette from stores with independent computer systems or by an external software supplier for stores that are part of a data network system Sample data collected from this panel are projected to the universe in each province, and provincial totals are added together to provide a national estimate

Diabetes in Canada

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