Diabetes and prediabetes in Canada: 29% of Canadians affected today
In 2015, 3.4 million Canadians (9.3%) have been diagnosed with diabetes. Another one million have diabetes, but don’t know it because they have not been diagnosed. An additional 5.7 million Canadians have prediabetes.[i],[ii] So today, of 37 million Canadians, more than 10 million have diabetes or prediabetes.
Even more alarming is the fact that the number of Canadians with diagnosed diabetes will rise to 5 million people (12%) by 2025. While 29% of Canadians now have diabetes, undiagnosed diabetes, or prediabetes, this will rise to 33% by 2025 if current trends continue.[iii]
Diabetes costs us all
Diabetes is a leading cause of blindness, end-stage renal disease (ESRD) and lower limb non-traumatic amputation in Canadian adults. Individuals with diabetes are 2 to 4 times more likely to die of cardiovascular disease (CVD) than people without diabetes. People with diabetes are over 3 times more likely to be hospitalized with CVD, 12 times more likely for ESRD, and over 20 times more likely for a non-traumatic lower limb amputation compared to the general population.[iv]
Diabetes will cost our health-care system and economy $14 billion in 2015, and $16 billion annually by 2020. Unless we take action, diabetes threatens not only more Canadians, but also the viability of our health-care system and our economic prosperity. Complications account for 80% of diabetes costs.[v]
No region or population of Canada is immune to diabetes. While the greatest burden is in Atlantic Canada, provinces with the lowest prevalence have the highest rates of growth of diabetes. Aboriginal people, immigrants, people with specific ethnic backgrounds, and people living with a low-income experience diabetes at a higher rate.[vi]
Diabetes also costs those living with the disease. In addition to the physical and emotional burden of diabetes, the disease also has a financial toll. Affordability and access to diabetes medications, devices and supplies vary depending on where you live in Canada and available public programs and services. Out-of-pocket costs continue to be a major challenge for many with diabetes.
The Diabetes Charter for Canada: the role of government
Diabetes Canada released the Diabetes Charter for Canada on April 7, 2014. The guiding principles of Diabetes Canada in developing this Charter were to:
Ensure that people who live with diabetes are treated with dignity and respect.
Advocate for equitable access to high quality diabetes care and supports.
Enhance the health and quality of life for people who live with diabetes and their caregivers.
Under the Charter, governments have the responsibility to:
Form comprehensive policies and plans for the prevention, diagnosis, and treatment of diabetes and its complications.
Guarantee fair access to diabetes care, education, prescribed medications, devices, and supplies to all Canadians, no matter what their income or where they live.
Address the unique needs and disparities in care and outcomes of vulnerable populations who experience higher rates of diabetes and complications and significant barriers to diabetes care and support.
A call-to-action: a strong federal role to stem the tsunami of diabetes
While all levels of government must play an integral role in improving the health of those with diabetes or those at risk of diabetes, federal leadership is essential in guaranteeing that all Canadians with diabetes or prediabetes have equitable access to support, high quality care and services.
Diabetes Canada urges all federal parties to commit to:
A tax on sugar-sweetened beverages (SSBs) given evidence of the link between excessive consumption of these drinks and type 2 diabetes
Establish a national pharmacare program to ensure access to needed medications for people with diabetes and related complications
Expand the disability tax credit (DTC) to include people with type 1 diabetes
Priority #1: Federal parties should commit to introducing a tax on sugar-sweetened beverages and use the revenues generated to promote the health of Canadians.
Overweight and obesity are risk factors for the development of prediabetes, type 2 diabetes and gestational diabetes.[vii] Approximately 60% of adult Canadians[viii] and one-third of children and youth aged 5 to 17 years are overweight or obese.[ix] Children who are obese are at increased risk of remaining overweight or obese as adults.[x] Type 2 diabetes is being diagnosed earlier than ever before, and more frequently in children.[xi]
Sugar consumption has risen across the globe from an average of 218 kilocalories per person per day in 1960 to over 280 kilocalories per person per day in 2013. Assuming a food wastage rate of 30%, these calories exceed the recommended daily upper limit of 150 kilocalories per man and 100 kilocalories per woman by the American Heart Association. Much of this is in the form of high fructose corn syrup within SSBs; however, added sugar is found throughout the food supply.[xii]
While a direct association with intake of sugars and the risk of developing type 2 diabetes has not been established, large amounts of free sugars are often found in highly processed, high energy, high calorie foods. Excessive calorie consumption often occurs with these high-free-sugars foods, leading to weight gain. Given the established relationship between type 2 diabetes with overweight and obese, as well as the relationship between excess calories and weight gain, sugar consumption must be duly considered by all people trying to manage their weight and their risk for diabetes.
“The Committee shares the fears of many experts who predict that today’s children will be the first generation for some time to have poorer health outcomes and a shorter life expectancy than their parents …
… Children are consuming too many calories. The link between obesity and the increased consumption of sweetened drinks is particularly disturbing. It has been estimated that sugary drinks may be responsible for as much as one pound per month weight gain in adolescents.”
- Healthy Weights for Healthy Kids. Report of the Standing Committee on Health, March 2007
Sugar-sweetened beverages (SSBs) include soft drinks and other beverages such as sports drinks, fruit drinks, lemonade, blended coffee drinks and iced tea. They contain large amounts of added sugar and are nutrient poor. A single serving of soft drink (e.g., non-diet pop) contains approximately 40 grams (about 10 teaspoons) of sugar.
Many researchers have investigated the impact of SSBs and the incidence of type 2 diabetes. While a direct association with intake of sugars and the risk of developing type 2 diabetes has not been established, there is now substantial credible evidence for an association between high SSB consumption and the risk of developing type 2 diabetes.[xiii] ,[xiv], [xv], [xvi]There is also some preliminary evidence concerning the consumption of SSBs and the risk of gestational diabetes.[xvii]
Internationally, some governments have used policy levers to influence SSB consumption. Mexico, France, regions in the U.S. and Europe, have applied taxes on sugar-sweetened beverages (SSBs) as a means to deter consumption and redirect revenues toward health promoting initiatives. Preliminary results from the Mexico experience, which added a 10% tax to non-dairy and non-alcoholic drinks with added sugar, demonstrate a 6% decline in purchases in 2014 compared to pre-tax trends. These results were observed across socio-economic groups and occurred in tandem with an increase in water consumption.
“Habitual consumption of sugar sweetened beverages was associated with a greater incidence of type 2 diabetes,” [independently of body fat]…
… “The current consumption of sugar-sweetened beverages was estimated to cause approximately 2 milliion excess events of type 2 diabetes in the USA and 80,000 in the UK over 10 years. This could cost nearly £12bn in the USA and £206m in the UK.”
- British Medical Journal, July 2015
Priority #2: Diabetes Canada recommends the establishment of a national pharmacare program to ensure access to needed medications for people with diabetes and related complications, and save public funds.
Equal and timely access to medications is an important issue for the 16 million Canadians with a chronic condition,[xviii] including diabetes and related complications (e.g., cardiovascular disease, stroke, kidney failure, amputation, blindness and depression). This is because 90% of Canadians with these conditions take at least one prescription drug, and 54% take four or more.[xix]
Since pharmaceuticals outside of those not administered in hospitals are not covered by the Canada Health Act, Canadians with chronic disease without specific forms of public coverage (e.g. social assistance, benefits to seniors, etc.) or private insurance (employers or other sources) can have high out-of-pocket costs. These costs can be a significant barrier to compliance with prescribed drug therapy: while about 10% of Canadians overall skipped medications due to cost, 23% of those with a chronic disease did.[xx] While one in 10 Canadians has difficulty paying for medications even if they have insurance, this rises to one in four for those without coverage. Those with the most difficulty have chronic conditions with recurring drug costs.[xxi]
“Because I now have a daughter to look after I am willing to pay the extra financial burden because I want to be around for her. If I don't pay those out-of-pocket costs I am robbing her of a mother later on.“
- Diabetes Advocate Stacey Livitski, July 2015
These costs are particularly onerous for people with diabetes and complications: most have catastrophic drug costs (>$1,500 or 3% of individual annual income). As a result, many do not comply with prescribed therapies, compromising their diabetes management and leaving them vulnerable to complications.[xxii]
While provinces have enhanced coverage for those on low incomes or with high drug costs, there is no nationally coordinated plan.[xxiii] The result is “a jumbled assortment of public and private plans in which individual coverage is no longer based on patients’ needs, but subject to where people live and work, as well as on each person’s and family’s financial means.”[xxiv]
Over the last decade, rates of the major complications of diabetes such as heart attack, amputation and kidney failure have been cut in half. That improvement is attributed almost entirely to the use of evidence-based medicines.[xxv] Unfortunately, not all Canadians stand to benefit from these advances because about 24% have no drug coverage and about two-thirds of households must spend out-of-pocket for prescriptions.[xxvi]
A recent study estimated that a national pharmacare program can both meet the needs of Canadians for access to medications and save public as well as private sector funds. Except for Canada, every developed country with a universal health-care system also has universal drug coverage, including Britain, France, Germany, Australia, New Zealand, Norway and Sweden. Public and private spending on prescription drugs could be reduced by $7.3 billion annually. Savings would be achieved through lower costs because of economies of scale in price negotiations.[xxvii]
“I live with type 2 diabetes and have required insulin for the past several years. I’m blessed with a comfortable income, and have paid a premium to enhance the already-good drug coverage from my employer. This coverage helps to control costs related to my diabetes management.
However, every time I pay the co-pay amount on refills of the prescriptions I need to keep me healthy, I’m reminded of the financial burden this disease would be without my health plan. And I’m more fortunate than the many thousands of Canadians who have to choose daily between feeding their children and buying life-saving medications. No Canadian should ever be left in this position.”
- Diabetes Advocate Rob Beck, July 2015
Priority #3: Diabetes Canada urges all federal parties to commit to expanding the disability tax credit (DTC) for people dependent on insulin as a life-sustaining therapy by extending the credit to all Canadians living with type 1 diabetes.
When a person is diagnosed with type 1 diabetes, usually at a young age, the life-long management regimen begins, with activities directly related to determining each dosage of insulin as a life-sustaining therapy, including frequent blood sugar monitoring, dose calculation and insulin administration. The complexity, effort and time required to perform diabetes self-management activities are often underestimated. Managing type 1 diabetes can involve as many as 600 steps every day, with the insulin injection process alone involving about 40 steps.[xxviii]
The inclusion of insulin as a life-sustaining therapy within the eligibility criteria for the DTC is intended to provide financial relief to insulin-dependent individuals. However, significant inequities exist in accessing the DTC among people with type 1 diabetes. Eligibility criteria state that individuals on insulin therapy may be eligible if a physician certifies that their patient requires therapy at least 3 times a week, with an average of at least 14 hours per week spent on activities related to determining the dosage of insulin required each time it is administered, multiple times a day. However, the following activities are the only activities currently permitted to be counted towards the 14 hours criteria: monitoring and maintaining a log book of blood glucose levels; preparing and administering insulin; and calibrating equipment.
Currently, most adults with type 1 diabetes do not qualify for the DTC because the time required to conduct the additional activities related to managing their insulin therapy is not permitted in this calculation. Most children with type 1 diabetes up to age 18 qualify for the DTC, as the Income Tax Act permits the time that parents spend on the permitted activities to be counted toward the 14 hours criteria. Qualifying for the DTC also allows eligibility for a Registered Disability Savings Plan (RDSP). However, as the permitted activities related to insulin therapy within the eligibility criteria for the DTC do not adequately capture the activities or the time required to administer multiple daily injections of insulin, adults then fail to qualify, even if they qualified as children. As a result, families who have invested in an RDSP to save for their children’s future living with the burden of managing a chronic illness and its complications are seeing their plans terminated when their children turn 18. People with type 1 diabetes spend well over 14 hours a week on activities related to their insulin therapy beyond the activities currently permitted. This restriction related to insulin therapy results in inequitable access to the DTC.
Inclusion of all activities related to insulin therapy within the DTC criteria would be consistent with its spirit and intent to relieve some of the burden of requiring a life-sustaining therapy. The estimated cost is $100-150 million for 2015, however, this pales compared to the cost of the diabetes in Canada of almost $14 billion in 2015.[xxix] This tax credit will also provide financial relief and fairness for people with diabetes to optimally self-manage their disease.
“A review of this cancellation policy and required repayment of government contributions could go a long way in supporting individuals living with type 1 diabetes that are looking to a potential future of living with serious complications including heart attack, stroke, limb amputation, blindness and kidney failure and therefore hopeful that the RDSP will assist them when they need it.”
- January 14, 2015 letter to the Hon. Joe Oliver, Minister of Finance, by James Rajotte, MP, Chair of the House of Commons Standing Committee on Finance
[ii] A condition when blood glucose is elevated, but not as high as type 2 diabetes About 50% of Canadians with prediabetes develop type 2 diabetes in their lifetime.
[iv] Canadian Diabetes Association. Clinical Practice Guidelines for the Prevention and Management of Diabetes. Canadian Journal of Diabetes, 2013; http://guidelines.diabetes.ca/.
[v] Canadian Diabetes Cost Model. See: Diabetes: Canada at the Tipping Point – Charting a New Path.
[vii] 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada.
[ix] Roberts KC, Shields M, de Groh M, Aziz A, Gilbert J. Overweight and obesity in children and adolescents: Results from the 2009 to 2011 Canadian Health Measures Survey. Health Reports 2012;23(3):3-7.
[x] Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Preventive Medicine 1993;22(2):167-77.
[xi] 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada/
[xii] Basu S, Yoffe P, Hills N, Lustig RH. The relationship of sugar to population-level diabetes prevalence: an econometric analysis of repeated cross-sectional data. PLoS One 2013; 8:e57873.
[xiii] A meta-analysis by Wang and colleagues who estimated the increased risk of diabetes associated with high of SSBs is 1.30 times that for low consumption (95% CI 1.12 to 1.39). This risk persisted after adjustment for BMI. See: Coleman-Jensen, A., Nord, M., Andrews, M., Carlson, S. (2011). United States Department of Agriculture: Household Food Security in the United States in 2010.
[xiv] Evidence from the European Prospective Investigation into Cancer (EPIC)-InterAct study funded by the European Union, which included eight European countries, across 26 research centres also showed that in adjusted models, one 336 g (12 oz) sugar-sweetened soft drink daily was associated with hazard ratio (HR) for type 2 diabetes of 1.22 (95% CI 1.09 to 1.38). After further adjustment for energy intake and BMI, the association of sugar-sweetened soft drinks with type 2 diabetes persisted (HR 1.18, 95% CI 1.06 to 1.32). See: InterAct consortium Consumption of sweet beverages and type 2 diabetes incidence in European adults: results from EPIC-InterAct. Diabetologia. 2013;56(7):1520–30.
[xv] Imamura and colleagues recently prospectively examined the association between consumption of SSBs and type 2 diabetes and estimated the population attributable fraction in the United States and United Kingdom. Higher consumption of SSBs were associated with a greater incidence of type 2 diabetes by 18% and 13% per serving per day before and after adjustment of adiposity respectively. See: Imamura F; O’Connor L; Ye Z; Mursu J; Hayashino,Y; Bhupathiraju S; Forouhi NG. BMJ 2015;351:h3576.
[xvi] See also Malik, VS, SCD;Popkin, BM, Bray, GA, Després, JP; Willett. Sugar-Sweetened Beverages and Risk of Metabolic Syndrome and Type 2 Diabetes: A meta-analysis Diabetes Care; Nov 2010; 33(11): 2477-2483; and Sonestedt E, Øverby N, Laaksonen, D, BirgisdottirB. Does high sugar consumption exacerbate cardiometabolic risk factors and increase the risk of type 2 diabetes and cardiovascular disease? Food & Nutrition Research 2012. 56: 19104
[xvii] Chen et al. reported results from the Nurses Health Study II which evaluated the impact of SSBs on gestational diabetes. This large prospective study found that cola was significantly and positively associated with GDM risk, after adjustment of known risk factors for GDM including age, family history of diabetes, parity, physical activity, smoking status, alcohol intake, BMI, and Western dietary pattern. Compared with women who consumed <1 serving/month, those who consumed ≥5 servings/week of sugar-sweetened cola had a 22% greater GDM risk. See: United States Department of Agriculture. (2009). Access to Affordable and Nutritious Food: Measuring and Understanding Food Deserts and Their Consequences.
[xxi] Law, M. R., Cheng, L., Dhalla, I. A., Heard, D., Morgan, S. G. “The Effect of Cost on Adherence to Prescription Medications in Canada,” Canadian Medical Association Journal, (184) 3 (2012): pp. 297-302.
[xxvi] See notes xxi and xxiv..
[xxvii] According to this study, universal public drug coverage would reduce total spending on prescription drugs in Canada by $7.3 billion (worst-case scenario $4.2 billion, best-case scenario $9.4 billion). The private sector would save $8.2 billion (worst-case scenario $6.6 billion, best-case scenario $9.6 billion). Costs to government would increase by about $1.0 billion (worst-case scenario $5.4 billion net increase, best-case scenario $2.9 billion net savings). Most of the projected increase in government costs would arise from a small number of drug classes. Steven G. Morgan, Michael Law, Jamie R. Daw, Liza Abraham, Danielle Martin. Estimated cost of universal public coverage of prescription drugs in Canada, CMAJ March 16, 2015; http://www.cmaj.ca/content/early/2015/03/16/cmaj.141564.
[xxviii] Coffen, R. D. (2009). The 600-step program for type 1 diabetes self-management in youth: The magnitude of the self-management task. Postgraduate Medicine, 121(5), 119-139.