Diabetes in Nova Scotia

• Among Nova Scotians (1):
  •  33% live with diabetes or prediabetes, and
  • 12% live with diagnosed diabetes, a figure that climbs to 17% when cases of undiagnosed type 2 diabetes are included.
• Diabetes complications are associated with premature death (3). Diabetes can reduce lifespan by five to 15 years (3). It is estimated that the all-cause mortality rate among Canadians living with diabetes is twice as high as the all-cause mortality rate for those without diabetes (4).
• People with diabetes are over three times more likely to be hospitalized with cardiovascular disease, 12 times more likely to be hospitalized with end-stage renal disease, and almost 20 times more likely to be hospitalized for a non-traumatic lower limb amputation compared to the general population (3).
• The prevalence of clinically relevant depressive symptoms among people living with diabetes is approximately 30% (6). Individuals with depression have a 40% – 60% increased risk of developing type 2 diabetes (6).
• Diabetic retinopathy is the leading cause of vision loss in people of working age (7). Vision loss is associated with increased falls, hip fractures, and a 4-fold increase in mortality (7). The prevalence of diabetic retinopathy is approximately 25.1% in Canada (8).
• Foot ulceration affects an estimated 15%–25% of people with diabetes in their lifetime (9). One-third of amputations in 2011–2012 were performed on people reporting a diabetic foot wound (10).
• The risk factors for type 1 diabetes are not well understood, but interaction between genetic and environmental factors are likely involved (11). Type 2 diabetes is caused by a combination of individual, social, environmental, and genetic factors (11).
  • Certain people are at higher risk of developing type 2 diabetes, such as those of African, Arab, Asian, Hispanic, Indigenous, or South Asian descent, those who are older, have a lower level of income or education, are physically inactive, or are living with overweight or obesity (11).
  • The rate of diabetes is 2.2 times higher in the Métis population than in the non-Indigenous population, a situation compounded by barriers to care for Indigenous peoples (12,13). In addition to the risk factors that impact all people in Canada, the ongoing burden of colonization continues to influence Indigenous Peoples’ health.
  • The prevalence of diabetes among adults in the lowest income groups is 7.7 times that of adults in the highest income group (13).
  • Adults who have not completed high school have a diabetes prevalence 7.2 times that of adults with a university education (13).
• For many Canadians with diabetes, adherence to treatment is affected by cost. The majority of Canadians with diabetes pay more than 3% of their income or over $1,500 per year for prescribed medications, devices, and supplies out-of-pocket (2,14).
• Among Canadians with type 2 diabetes, 33% do not feel comfortable disclosing their disease to others (2).
• Hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) may affect mood and behaviour, and can lead to emergency situations if left untreated (11).

• In progress: Updates to the Guidelines for Supporting Students with type 1 Diabetes (and other diabetes requiring insulin).
• In 2019, Pharmacare revised the Special Authorization form to help remove barriers to access diabetes medications.   
• In April 2015, the insulin pump program was enhanced to include eligible individuals with type 1 diabetes under age 26 years.
• The Diabetes Care Program of Nova Scotia is mandated to standardize and improve the quality of care provided through Nova Scotia’s 38 Diabetes Centres (DCs). Originally a Department of Health program, the DCPNS now reports to the Nova Scotia Health Authority.
• The government produces an annual report for district health authorities on diabetes epidemiology and health services utilization using the National Diabetes Surveillance System. The DCPNS Registry allows for a review of process and outcome measures in diabetes centres that use the Registry onsite, as well as longitudinal tracking of newly diagnosed referrals, including those with prediabetes, and key self and clinical indicators of care, including lower-extremity amputation data, hypertension rates, and retinopathy screening rates.

Nova Scotia faces unique challenges in reducing risk of type 2 diabetes and meeting the needs of those living with diabetes:

• Non-modifiable risk factors of type 2 diabetes include age, sex, and ethnicity (11).
  • The median age in Nova Scotia is 45.5 years (15). 19.9% of Nova Scotians are over 65 years old (15). The risk of developing type 2 diabetes increases with age (11). Older adults living with diabetes are more likely to be frail and progressive frailty has been associated with reduced function and increased mortality (16).
  • Adult men are more at risk of type 2 diabetes compared to adult women (11).
  • Approximately 7% of Nova Scotians self-identify as being of African, Arab, Asian, Hispanic, or South Asian descent (15). These groups are at increased risk of developing type 2 diabetes (11).
  • There are 51,495 Indigenous Peoples in Nova Scotia, who face significantly higher rates of diabetes and adverse health consequences than the overall population (17).
• Nova Scotia has high rates of individual-level modifiable risk factors (18):
  • 40.5% of adults and 48.1% of youth are physically inactive; 
  • 37.1% of adults are living with overweight and 35.8% of adults are living with obesity;
  • 80.8% of adults are not eating enough fruits and vegetables; and
  • 13.2% of adults are current tobacco smokers.
  • Factors related to the social determinants of health and that can influence the rate of individual-level modifiable risk factors among Nova Scotians include income, education, food security, the built environment, social support, and access to health care (3).
    • Nova Scotia has one of the highest rural populations among the provinces. For people with diabetes, accessing care is more challenging in rural areas across Canada than in urban areas (19).
    • The median after-tax family income in Nova Scotia is among the lowest among the provinces (20).

1. Implement Diabetes 360°

• Implement a provincial diabetes strategy that aligns with the Diabetes 360° framework.
• Support the F/P/T process to establish a nationwide diabetes framework.

2. Expand access: Put patients at the centre of policy decisions

• Eliminate barriers, including age discrimination, to access evidence-based, personalized diabetes treatments, including diabetes medications, devices, and supplies.
• Provide equitable access to continuous glucose monitoring systems (isCGM & rtCGM) according to Diabetes Canada’s reimbursement recommendations.  

3. Protect students with diabetes

• Implement a mandatory standard of care for students with diabetes that aligns with Diabetes Canada’s Guidelines for the Care of Students Living with Diabetes at School.

4. Prevent amputations

• Implement health policies that support the prevention and management of diabetes foot complications and reduce the risk of lower limb amputations.