Photo of Northern lights in Nunavut, unknown photographer
The Canadian Chronic Disease Surveillance System (CCDSS) is used to estimate and report on the current burden and trend of chronic illnesses within Canada. It is also the culmination of 10 provincial and 3 territorial surveillance systems across Canada. Data collected from approximately 97% of the Canadian Population is supported by the Public Health Agency of Canada (PHAC). The CCDSS initially provided diabetes surveillance, but has since expanded to include obtaining data on other chronic illnesses such as hypertension, mental illness, mood and anxiety disorders, COPD, heart factures, stroke, arthritis, and neurological conditions, and more.
As a matter of professional interest as a registered nurse in Ontario, I am interested to learn more about the similarities and differences experienced between Ontario and Nunavut, to better understand the healthcare landscape in two dynamically different regions of Canada. The following comorbidities in relation to mental health and addictions will be: (1) Diabetes (DM); (2) Cardiovascular disease (CV); and (3) Respiratory conditions (COPD).
The way in which individuals experience mental illness can increase their susceptibility of developing poor physical health and chronic physical condition(s). We know that disproportionately, individuals living with mental illness often encounter higher rates of poverty, unemployment, precarious housing, and social isolation. The absence of these favorable determinants of health increases the individual’s propensity to develop a chronic condition. There is evidence to support that the more symptomatic the chronic condition, the more likely it is that the individual will also experience mental illness. Consequently, it stands to reason that individuals with a chronic condition often self report poor mental health (Canadian Mental Health Association, CMHA, n.d.). Previous reviews indicate that individuals with a psychotic disorder experience a higher incidence of “several chronic physical health conditions, including HIV, diabetes mellitus (DM), as well as gastrointestinal, cardiovascular, and respiratory diseases” (Rodrigues, Wiener, Stranges, Ryan, & Anderson, 2021). Additionally, individuals who are receiving pharmacological treatment and use second generation antipsychotic medication are at an increased risk of “cardiometabolic side effects such as weight gain and impaired glucose metabolism” (Rodrigues, et. al., 2021).
1. Diabetes
For individuals who have a mental illness, particularly depression or schizophrenia, the rate of developing diabetes (DM) type 2 is significantly greater than in individuals without a mental illness. Individuals who have a mental illness experience other side effects which would predispose them to DM, including obesity and high cholesterol levels. Additionally, antipsychotic medications used to treat an array of mental illnesses, have been shown to increase an individual’s weight; obesity rates are 3.5 times higher in individuals with a mental illness as compared to the general population (CMHA, n.d.). Interestingly, individuals with DM experience 2 times the rate of diagnosed mental illness as compared to their counterparts who do not have DM. 40% of individuals with DM exhibited symptoms of anxiety. The impact of this on one’s mental health is enormous and can lead to poor management of DM, thus exacerbating symptoms of anxiety or depression, and ultimately contribute to worsening mental and physical health (CMHA, n.d.).
In previous generations for Indigenous communities, diabetes was unheard of. However, for the “Inuit of Northern Canada, sukaqaluartuq or timi siuraujaartuqaluartug, meaning “too much sugar within the body” is not commonplace” (Rotem, 2015). Despite affecting fewer Indigenous peoples compared to the 10 million Canadians living with diabetes, it is known that Nunavut is experiencing a “rapid rate of growth, reaching 110% by far exceeding the 30% for the rest of Canada (Rotem, 2015). Reasons for this swelling rate has to do with food insecurity, poverty, a shift from traditional Indigenous lifestyle, the negative impact of pollution and animal rights campaigns on key food systems (Rotem, 2015).
Fast Facts (PHAC, 2017)
· 1 in 9 Canadians live with diabetes
· 11% of Canadian adults over 20 years of age live with diabetes
· 1 in 333 (0.3%) of children between the ages of 1-19 live with diabetes
· 1 in 10 pregnant women will be diagnosed with diabetes, either pre-existing or gestational (during pregnancy only)
· There are 549 new cases of diabetes diagnosed in Canada each day
Risk Factors (PHAC, 2017)
· Diabetes is more common amongst men, 11.8% compared to 10.0% for women
· 55% of Canadians with diabetes are over the age of 65
· Overweight or obese
· Hypertension
· High cholesterol
Protective Factors (Rotem, 2015)
· Consumption of seal meat has been found to have preventative measures against diabetes, likely due to the high level of fatty acids
· Raw fish has the highest retained level of fatty acids compared to cooked fish
· Meats and fish protein take longer for the body to breakdown, thus providing a longer and healthier source of energy
· Arctic char has less pollutants than beluga, pilot whales, and narwhal – and health officials encourage pregnant women to eat char as a means of lowering mercury levels in their bodies as mercury can harm the fetus and cause developmental disabilities and permanent brain damage
Surveillance (PHAC, 2017)
· Trends suggest that the prevalence of Canadians who are living with diabetes went up by an average of 3.3%. These numbers are expected to continue to increase incrementally since Canadians are living longer than historically
· National Diabetes Surveillance System (NDSS) committee was formed in 1997, and then established in 1999.
· The NDSS expands to the Canadian Chronic Disease Surveillance System (CCDSS) which now includes other chronic illnesses such as hypertension, mood and anxiety disorders, mental health, respiratory conditions, cardiovascular condition, and more
Prevention (PHAC, 2017)
· Making healthy lifestyle choices like eating well, exercising regularly, maintaining a healthy weight
· For individuals who already have type 1 DM, medication can help prevent the progression to type 2 DM
Management (PHAC, 2017)
· It is possible to maintain healthy and well despite having DM, but treatment plans must be based upon the individual’s unique needs. All plans, however, seek to avoid short term risks of high or low blood sugar levels
· Together with medication, healthy changes made to diet, exercise and weight are cornerstones for maintenance and management
2. Hypertension
Individuals with mental illness often experience (HTN) hypertension and an increased levels of adrenaline, thus increasing heartrate. It has been shown that antipsychotic medication is linked to the development of an irregular heart rhythm. The impact physically, is that there are changes with the cardiovascular function which unfortunately increase the risk of developing heart disease when compared to individuals without a mental illness. Also, those individuals living with mental illness have higher rates for many other risk factors for heart disease, they include poor or inadequate nutrition, lack of preventative screening measures, and obesity. It has been found that women with depression are 80% more likely to experience heart disease than women without depression. Unfortunately, due to biological and social factors, individuals with mental illness experience up to 3 times the likelihood of having a stroke (CMHA, n.d.).
According to the Government of Canada’s surveillance of heart diseases and conditions, a whopping 2.4 million Canadian adults live with heart disease, with approximately 9.8% of males and 7.1% of women, all over the age of 20 years (Government of Canada, 2020). Astonishingly, heart disease is the second leading cause of death in Canada, behind cancer. In 2014, over 51000 Canadians died due to heart disease (Government of Canada, 2020). In Nunavut, approximately 2200 individuals live with hypertension. The prevalence for hypertension accounts for about 1/3 of cases in 25% of adults. (Canadian Pharmacists Association, n.d.).
Please see below, the differences in the prevalence rate for hypertension in individuals 20 years of age and older, between Ontario and Nunavut from the Public Health Agency of Canada, 2018.
Risk Factors (Government of Canada, 2020)
· Diabetes
· Smoking
· High cholesterol
· Poor diet (not enough fruits and vegetables, too much fat and processed food)
· Sleep apnea
· History in family of heart diseases
· Overweight/obesity
· Men who are older than 45, and women who are older than 55
· Risk is higher for women who: take oral contraceptive pill, already have high blood pressure, and have gone through menopause
· People with lower incomes are more likely to develop heart diseases, due to social disadvantages such as diabetes, smoking, and resultant high blood pressure
· Some ethnic groups have a higher rate of heart disease, this is in part due to family history and cultural mores. Indigenous, African, Chinese, Hispanic, and South Asian individuals are at a greater risk
Prevention (Government of Nunavut, n.d.)
· Maintain a healthy weight
· Avoid salt and salty food – make healthier eating choices – follow the Eating Well with Canada’s Food Guide
· Be active – most days, or often
· Reduce or quite smoking
· Limit alcohol and reducing stress (through reading a book, visiting a friend, exercising, etc.)
3. Chronic Obstructive Pulmonary Disease
Individuals who experience serious and persistent mental illnesses, are predisposed to developing a vast range of chronic respiratory conditions, including chronic obstructive pulmonary disease (COPD), chronic bronchitis, and asthma. As we all know, there is a strong link between smoking and COPD, but is this a modifiable risk factor? Given what we know of the social determinants of health (SDOH), simply quitting smoking it not so easily done. When we consider the individual and their choice to smoke, or not smoke, there are competing rewards that offset the benefit of quitting smoking. For instance, we know that “people with mental illness have high smoking rate, due in part of historical acceptability of smoking in the psychiatric institutions, the dependency of nicotine, the positive social aspects of smoking” (CMHA, n.d.). However, we must also consider that unmodifiable risk factors regarding smoking, such as “poverty, precarious housing, loss of job or reduction in hours, and social exclusion with one’s peers, and how this has an impact on their mental health and wellbeing.
The PHAC (2018) reports that COPD is “characterized by shortness of breath, cough and sputum production”, and that symptoms do not typically present in individuals who are younger than 55 years of age. The onset is insidious, and with frequent bouts of exacerbating symptoms while ultimately cause further decreases in airflow and ultimately, premature death.
An overwhelming “2.0 million are living with COPD, which adversely impacts the individual’s ability to breath, participate fully in daily life, school, work, and social activities” – and there is also an impact on the Canadian economy because of loss of productivity from individuals who have COPD (PHAC, 2018). Additionally, COPD is more likely to occur as a comorbidity in individuals who have other chronic illnesses, including diabetes, hypertension, mood and anxiety disorders, or asthma (PHAC, 2018). Statistics Canada reports that deaths related to respiratory diseases, such as COPD account for more than 11,000 deaths (PHAC, 2018).
Undeniably, COPD is both a public health concern and economic burden. It is well established that smoking (tobacco), the largest and most significant modifiable risk factor, has also been recognised by the Federal Tobacco Control Strategy (FTCS) which specifically targets smoking reduction and cessation in youth and adults (PHAC, 2018). The FCTS’s main tenet is prevention of smoking initiation, specifically with children and youth; aiding people in quitting; assisting Canadians to protect themselves against passively smoking (second-hand smoking); and regulating the manufacturing, labeling, and selling of tobacco (PHAC, 2018).
Please see below, the differences in the prevalence rate for individuals 35 years of age and older, between Ontario and Nunavut from the Public Health Agency of Canada, 2018.
Fast Facts (PHAC, 2018):
· 2 million Canadians over 35 years of age live with COPD
· Number of Canadians 35 years of age and older living with COPD increased by 82% between 2000-2001 and 2012-2013, this increase has been driven by the aging population
· The likelihood of having COPD increases with age
· In younger age groups, women and men are equally likely to have COPD; however, in older age groups, men are more likely to be affected by COPD
· The prevalence of COPD in Ontario in 2012 was 9.5%
· The prevalence of COPD in Nunavut in 2012 was 22.1%
· The national prevalence in 2012 was 9. 6%
· 15% of respondents to the CCDSS reported their mood as “fair or poor"
Risk Factors (PHAC, 2018)
· Smoking is an underlying cause of COPD cases
· Primary smoking is very well established but the contribution of exposure to second-hand smoke, or passive smoking, also plays a huge role in COPD
· Other contributing factors to COPD include occupational exposure (dust); outdoor air position; repeated respiratory infections in childhood; and
· A genetic deficiency of an anti-protease which protects the lungs from damage
Surveillance:
· Education, particularly with adolescents and young adults – highlighting the addictive and harmful repercussions of smoking (Nunavut News, 2021)
· Initiative to reduce visibility of tobacco products, such as banning advertising signage – like an out of sight, out of mind approach
· Nunavut has the Tobacco Control and Smoke Free Places Act (TCSFPA), which is the main law in Nunavut, informing where tobacco can be used, who can purchase it, and how retailers sell it to individuals (Government of Nunavut, n.d.).
· There is a federal tobacco law; the Canada Tobacco Act that impacts the sales and usage in Nunavut, as it mandates health advisories on the packaging of tobacco products (Government of Nunavut, n.d.)
· Furthermore, there is a Tobacco Retailer Permit that retails must have to sell tobacco products, it is registered through the Department of Finance and retailers receive an education and outreach visit to ensure retailers are enforcing checks of ID (must be 19 and older) of customers; that the store has a tobacco policy; that proper signage is in place; and that all employees of the retail store receive the same training before sell tobacco (Government of Nunavut, n.d.)
Management (PHAC, 2018)
· Early detection is paramount; this is done through pulmonary function tests like a spirometer, and 84% of respondents reported they have undergone testing
· No cure for COPD, however, the symptoms may be managed with use of medications to slow down the progression of the diseases
· Good healthcare is key to managing COPD
· Management includes medication, oxygen therapy, influenza vaccinations, education, and reduction in exposure to environmental triggers to help manage COPD
Nunavut and Tobacco use (Government of Nunavut, n.d.)
· Smoking tobacco results in heart disease and stroke; contributes to transmission of tuberculosis throughout the community
· 1/5 deaths in Nunavut are caused by smoking (Government of Nunavut, Department of health, n.d.).
· As of October 2018, 74% of Nunavut residents over the age of 16 reported using tobacco products
· Youth, aged 12-19 years of age who use tobacco are the highest in the nation, at 51% (more than 6x the rate of Canada at 7.7%
· Reportedly, adults buy their underage children snuff
References
Canadian Legal Information Institute. (CandLII). (2013, May 16). Tobacco Control and Smoke-Free Places Act (TCSFPA). From https://canlii.org/en/nu/laws/stat/snu-2003-c-13/latest/snu-2003-c-13.html
Canadian Legal Information Institute. (CanLII). (2019, November 9). Tobacco and vaping products act. From https:// www.canlii.org/en/ca/laws/stat/sc-1997-c-13/latest/sc-1997-c-13.html
Canadian Mental Health Association (CMHA). (n.d.). The relationship Between Mental Health, Mental Illness, and Chronic Physical Conditions. From https://ontario.cmha.ca/documents/the-relationship-between-mental-health-mental-illness-and-chronic-physical-conditions/
Canadian Pharmacists Associations. (n.d.). Improving health and lowering cost: Benefits of pharmacist care in hypertension in Nunavut. From https://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/Benefits%20of%20pharmacist%20care%20in%20hypertension_NU.pdf#:~:text=Hypertension%20in%20Nunavut%20In%20Nunavut,%20around%202,200%20people,from%20the%20US%20suggests%20that%20by%202030,%20hypertension
Government of Canada. (2020). The Canadian chronic disease surveillance system – an overview. From http://www.canada.ca/en/public=health/services/publications/canadian-chronic-disease-surveillence-system-factsheet.html
Government of Canada. (2018, May 1). Chronic Obstructive Pulmonary Disease (COPD) in Canada. From https:// health-infobase.canada.ca/data lab/copd-blog.html
Government of Canada. (2021, March 4). Canada’s Food Guide. From https://food-guide.canada.ca/en/
Government of Canada. (2020, January 10). Canada’s Tobacco Strategy. From https://Canada's Tobacco Strategy - Canada.ca
Government of Canada. (2020, August 07). Public health infobase. From https://health-infobase.canada.ca/?search=copd&sortType=2
Government of Nunavut, Department of Health. (n.d.). Inuusittiaringniq Living Well Together. From https://livehealthy.gov.nu.ca/en/health-topics/tobacco
Government of Nunavut. (n.d.). Hypertension: Healthy living. From https:// livehealthy.gov.nu.ca/en/health-topics/chronic-diseases/high-blood-pressure
Government of Nunavut. (n.d.). Tobacco has no place here. Tobacco Facts. Retrieved March 8, 2021 from https://nuquits.gov.nu.ca/tobacco-facts/tobacco-and-law
Nunavut News. (2021, January 18). Nunavut updating smoking legislation to combat highest rates in the country. From https://www.nunavutnews.com/nunavut-news/nunavut-updating-smoking-legislation-to-combat-highest-rates-in-the-country/
Public Health Agency of Canada (PHAC). (2018). Asthma and Chronic Obstructive Pulmonary Disease (COPD) in Canada, 2018. From https://www.canada.ca/en/public-health/services/publications/diseases-conditions/asthma-chronic-obstructive-pulmonary-disease-canada-2018.html
Public Health Agency of Canada (PHAC). (2017). Diabetes in Canada: highlights from the Canadian chronic disease surveillance system. From https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/diabetes-canada-highlights-chronic-disease-surveillance-system/diabetes-in-canada-eng.pdf
Public Health Agency of Canada (PHAC). (2018). Prevalence of chronic diseases in Canada. [Infographic]. From http://www.canada.ca/content/dam/phac-aspc/documents/services/chronic-diseases/prevalence-canadian-adults-infographic-2019-eng.pdf
Public Health Ontario. (2019). The Burden of Chronic Diseases in Ontario Key Estimates to Support Efforts in Prevention July 2019. From http://www.publichealthontario.ca/-/media/documents/c/2019/cdburden-overview.pdf?la=en
Rodrigues, M., Weiner, J.C., Stranges, S., Ryan, B.L., & Anderson, K.K. (2021). The risk of physical comorbidity in people with psychotic disorders: A systematic review and meta-analysis. Journal of Psychosomatic Research, 140. From https://doi.org/10.1016/j.jpsychores.2020.110315
Rotem, T. (2015, December 15). Diabetes in Northern Canada: the case for a culturally appropriate, realistic solution. Feeding Nunavut. From https://www.feedin gnunavut.com/diabetes-in-northern-canada/
Comments