Health trends in Canada 1990-2019: An analysis for the Global Burden of Disease Study.

OBJECTIVE: Monitoring trends in key population health indicators is important for informing health policies. The aim of this study was to examine population health trends in Canada over the past 30 years in relation to other countries. METHODS: We used data on disability-adjusted life years (DALYs), years of life lost (YLL), years lived with disability, life expectancy (LE), and child mortality for Canada and other countries between 1990 and 2019 provided by the Global Burden of Disease Study. RESULTS: Life expectancy, age-standardized YLL, and age-standardized DALYs all improved in Canada between 1990 and 2019, although the rate of improvement has leveled off since 2011. The top five causes of all-age DALYs in Canada in 2019 were neoplasms, cardiovascular diseases, musculoskeletal disorders, neurological disorders, and mental disorders. The greatest increases in all-age DALYs since 1990 were observed for substance use, diabetes and chronic kidney disease, and sense organ disorders. Age-standardized DALYs declined for most conditions, except for substance use, diabetes and chronic kidney disease, and musculoskeletal disorders, which increased by 94.6%, 14.6%, and 7.3% respectively since 1990. Canada's world ranking for age-standardized DALYs declined from 9th place in 1990 to 24th in 2019. CONCLUSION: Canadians are healthier today than in 1990, but progress has slowed in Canada in recent years in comparison with other high-income countries. The growing burden of substance abuse, diabetes/chronic kidney disease, and musculoskeletal diseases will require continued action to improve population health.

RéSUMé: OBJECTIF: La surveillance des tendances des indicateurs clés de la santé de la population est importante pour éclairer les politiques de santé. Dans cette étude, nous avons examiné les tendances de la santé de la population au Canada au cours des 30 dernières années par rapport à d'autres pays. MéTHODES: Nous avons utilisé des données sur les années de vie ajustées en fonction de l'incapacité (DALY), les années de vie perdues (YLL), les années vécues avec un handicap, l'espérance de vie (LE) et la mortalité infantile pour le Canada et d'autres pays entre 1990 et 2019, fournies par l'Étude mondiale sur le fardeau de la maladie. RéSULTATS: L'espérance de vie, les YLL ajustées selon l'âge et les DALY ajustées selon l'âge ont tous connu une amélioration au Canada entre 1990 et 2019, bien que le taux d'amélioration se soit stabilisé depuis 2011. Les cinq principales causes des DALY pour tous les âges au Canada en 2019 étaient les néoplasmes, les maladies cardiovasculaires, les affections musculosquelettiques, les affections neurologiques et les troubles mentaux. Les plus fortes augmentations des DALY pour tous les âges depuis 1990 ont été observées pour l'usage de substances, le diabète et les maladies rénales chroniques, ainsi que les troubles des organes sensoriels. Les DALY ajustées selon l'âge ont diminué pour la plupart des conditions, à l'exception de l'usage de substances, du diabète et des maladies rénales chroniques, ainsi que des troubles musculosquelettiques, qui ont augmenté de 94,6 %, 14,6 % et 7,3 % respectivement depuis 1990. Le classement mondial du Canada pour les DALY ajustées selon l'âge est diminué de la 9ième place en 1990 à la 24ième place en 2019. CONCLUSION: Les Canadiens sont en meilleure santé aujourd'hui qu'en 1990, mais les progrès se sont ralentis ces dernières années par rapport à d'autres pays à revenu élevé. La croissance du fardeau lié à l'abus de substances, au diabète/maladies rénales chroniques et aux affections musculosquelettiques exigera des actions continues pour améliorer la santé de la population.

Higher Neighborhood Drivability Is Associated With a Higher Diabetes Risk in Younger Adults: A Population-Based Cohort Study in Toronto, Canada.

OBJECTIVE: Car dependency contributes to physical inactivity and, consequently, may increase the likelihood of diabetes. We investigated whether neighborhoods that are highly conducive to driving confer a greater risk of developing diabetes and, if so, whether this differs by age. RESEARCH DESIGN AND METHODS: We used administrative health care data to identify all working-age Canadian adults (20-64 years) who were living in Toronto on 1 April 2011 without diabetes (type 1 or 2). Neighborhood drivability scores were assigned using a novel, validated index that predicts driving patterns based on built environment features divided into quintiles. Cox regression was used to examine the association between neighborhood drivability and 7-year risk of diabetes onset, overall and by age-group, adjusting for baseline characteristics and comorbidities. RESULTS: Overall, there were 1,473,994 adults in the cohort (mean age 40.9 ± 12.2 years), among whom 77,835 developed diabetes during follow-up. Those living in the most drivable neighborhoods (quintile 5) had a 41% higher risk of developing diabetes compared with those in the least drivable neighborhoods (adjusted hazard ratio 1.41, 95% CI 1.37-1.44), with the strongest associations in younger adults aged 20-34 years (1.57, 95% CI 1.47-1.68, P < 0.001 for interaction). The same comparison in older adults (55-64 years) yielded smaller differences (1.31, 95% CI 1.26-1.36). Associations appeared to be strongest in middle-income neighborhoods for younger residents (middle income 1.96, 95% CI 1.64-2.33) and older residents (1.46, 95% CI 1.32-1.62). CONCLUSIONS: High neighborhood drivability is a risk factor for diabetes, particularly in younger adults. This finding has important implications for future urban design policies.

Trends in glucose testing among individuals without diabetes in Ontario between 2010 and 2017: a population-based cohort study.

BACKGROUND: Early identification of people with diabetes or prediabetes enables greater opportunities for glycemic control and management strategies to prevent related complications. To identify gaps in screening for these conditions, we examined population trends in receipt of timely glucose testing overall and in specific clinical subgroups. METHODS: Using linked administrative databases, we conducted a retrospective cohort study of people aged 40 years and older without diabetes at baseline. Our primary outcome was up-to-date glucose testing, defined as having received testing at least once in the 3 years before each index year from 2010 to 2017, using linked administrative databases of people residing in Ontario, Canada. We calculated rates of up-to-date testing by age group, sex, ethnicity (South Asian, Chinese, general population) and comorbidities (hypertension, hyperlipidemia, cardiovascular disease). RESULTS: Over the 8-year study period, up-to-date glucose testing rates were stable at 67% for men and 77% for women (both relative risk 1.00 per year; 95% confidence interval 1.00-1.00). Testing rates were significantly lower in men than in women (all age groups p < 0.001) and lower in younger than older age groups (except those aged ≥ 80 yr). South Asian people had the highest testing rates, although among people aged 70 years or older, testing was highest in the general population (p < 0.001). Among people with hypertension, hyperlipidemia and cardiovascular disease, annual testing rates were also stable, but only 58% overall among people with hypertension. INTERPRETATION: We found lower glucose testing rates in younger men and people with hypertension. Our findings reinforce the need for initiatives to increase awareness of glycemic testing.

Development of a neighborhood drivability index and its association with transportation behavior in Toronto.

BACKGROUND: Car driving is a form of passive transport that is associated with an increase in physical inactivity, obesity, air pollution and noise. Built environment characteristics may influence transport mode choice, but comprehensive indices for built environment characteristics that drive car use are still lacking, while such an index could provide tangible policy entry points. OBJECTIVE: We developed and validated a neighbourhood drivability index, capturing combined dimensions of the neighbourhood environment in the City of Toronto, and investigated its association with transportation choices (car, public transit or active transport), overall, by trip length, and combined for residential neighbourhood and workplace drivability. METHODS: We used exploratory factor analysis to derive distinct factors (clusters of one or more environmental characteristics) that reflect the degree of car dependency in each neighbourhood, drawing from candidate variables that capture density, diversity, design, destination accessibility, distance to transit, and demand management. Area-level factor scores were then combined into a single composite score, reflecting neighbourhood drivability. Negative binomial generalized estimating equations were used to test the association between driveability quintiles (Q) and primary travel mode (>50% of trips by car, public transit, or walking/cycling) in a population-based sample of 63,766 Toronto residents enrolled in the Transportation Tomorrow Survey (TTS) wave 2016, adjusting for individual and household characteristics, and accounting for clustering of respondents within households. RESULTS: The drivability index consisted of three factors: Urban sprawl, pedestrian facilities and parking availability. Relative to those living in the least drivable neighbourhoods (Q1), those in high drivability areas (Q5) had a significantly higher rate of car travel (adjusted Risk Ratio (RR): 1.80, 95%CI: 1.77-1.88), and lower rate of public transit use (RR: 0.90, 95%CI: 0.85-0.94) and walking/cycling (RR: 0.22, 95%CI: 0.19-0.25). Associations were strongest for short trips (<3 km) (RR: 2.72, 95%CI: 2.48-2.92), and in analyses where both residential and workplace drivability was considered (RR for car use in high/high vs. low/low residential/workplace drivability: 2.18, 95%CI: 2.08-2.29). CONCLUSION: This novel neighbourhood drivability index predicted whether local residents drive or use active modes of transportation and can be used to investigate the association between drivability, physical activity, and chronic disease risk.

Forecasting Diabetes Cases Prevented and Cost Savings Associated with Population Increases of Walking in the Greater Toronto and Hamilton Area, Canada.

Promoting adequate levels of physical activity in the population is important for diabetes prevention. However, the scale needed to achieve tangible population benefits is unclear. We aimed to estimate the public health impact of increases in walking as a means of diabetes prevention and health care cost savings attributable to diabetes. We applied the validated Diabetes Population Risk Tool (DPoRT) to the 2015/16 Canadian Community Health Survey for adults aged 18-64, living in the Greater Toronto and Hamilton area, Ontario, Canada. DPoRT was used to generate three population-level scenarios involving increases in walking among individuals with low physical activity levels, low daily step counts and high dependency on non-active forms of travel, compared to a baseline scenario (no change in walking rates). We estimated number of diabetes cases prevented and health care costs saved in each scenario compared with the baseline. Each of the three scenarios predicted a considerable reduction in diabetes and related health care cost savings. In order of impact, the largest population benefits were predicted from targeting populations with low physical activity levels, low daily step counts, and non active transport use. Population increases of walking by 25 min each week was predicted to prevent up to 10.4 thousand diabetes cases and generate CAD 74.4 million in health care cost savings in 10 years. Diabetes reductions and cost savings were projected to be higher if increases of 150 min of walking per week could be achieved at the population-level (up to 54.3 thousand diabetes cases prevented and CAD 386.9 million in health care cost savings). Policy, programming, and community designs that achieve modest increases in population walking could translate to meaningful reductions in the diabetes burden and cost savings to the health care system.

Universal Drug Coverage and Socioeconomic Disparities in Health Care Costs Among Persons With Diabetes.

OBJECTIVE: To examine whether neighborhood socioeconomic status (SES) is a predictor of non-drug-related health care costs among Canadian adults with diabetes and, if so, whether SES disparities in costs are reduced after age 65 years, when universal drug coverage commences as an insurable benefit. RESEARCH DESIGN AND METHODS: Administrative health databases were used to examine publicly funded health care expenditures among 698,113 younger (20-64 years) and older (≥65 years) adults with diabetes in Ontario from April 2004 to March 2014. Generalized linear models were constructed to examine relative and absolute differences in health care costs (total and non-drug-related costs) across neighborhood SES quintiles, by age, with adjustment for differences in age, sex, diabetes duration, and comorbidity. RESULTS: Unadjusted costs per person-year in the lowest SES quintile (Q1) versus the highest (Q5) were 39% higher among younger adults ($5,954 vs. $4,270 [Canadian dollars]) but only 9% higher among older adults ($10,917 vs. $9,993). Adjusted non-drug costs (primarily for hospitalizations and physician visits) were $1,569 per person-year higher among younger adults in Q1 vs. Q5 (modeled relative cost difference: 35.7% higher) and $139.3 million per year among all individuals in Q1. Scenarios in which these excess costs per person-year were decreased by ≥10% or matched the relative difference among seniors suggested a potential for savings in the range of $26.0-$128.2 million per year among all lower-SES adults under age 65 years (Q1-Q4). CONCLUSIONS: SES is a predictor of diabetes-related health care costs in our setting, more so among adults under age 65 years, a group that lacks universal drug coverage under Ontario's health care system. Non-drug-related health care costs were more than one-third higher in younger, lower-SES adults, translating to >$1 billion more in health care expenditures over 10 years.

Neighborhood walkability and pre-diabetes incidence in a multiethnic population.

INTRODUCTION: We examined whether adults living in highly walkable areas are less likely to develop pre-diabetes and if so, whether this association is consistent according to immigration status and ethnicity. RESEARCH DESIGN AND METHODS: Population-level health, immigration, and administrative databases were used to identify adults aged 20-64 (n=1 128 181) who had normoglycemia between January 2011 and December 2011 and lived in one of 15 cities in Southern Ontario, Canada. Individuals were assigned to one of ten deciles (D) of neighborhood walkability (from lowest (D1) to highest (D10)) and followed until December 2013 for the development of pre-diabetes. RESULTS: Overall, 220 225 individuals in our sample developed pre-diabetes during a median follow-up of 8.4 years. Pre-diabetes incidence was 20% higher among immigrants living in the least (D1) (adjusted HR 1.20, 95% CI 1.15 to 1.25, p<0.0001) versus most (D10, referent) walkable neighborhoods after accounting for age, sex, and area income. Findings were similar among long-term residents and across sexes. However, susceptibility to walkability varied by ethnicity where D1 versus D10 adjusted HRs ranged from 1.17 (95% CI 1.02 to 1.35, p=0.03) among West Asian and Arab immigrants to 1.32 (95% CI 1.19 to 1.47, p<0.0001) in Southeast Asians. Ethnic variation in pre-diabetes incidence was more marked in low walkability settings. Relative to Western Europeans, the adjusted HR for pre-diabetes incidence was 2.11 (95% CI 1.81 to 2.46, p<0.0001) and 1.50 (95% CI 1.27 to 1.77, p<0.0001) among Sub-Saharan African and the Carribean and Latin American immigrants, respectively, living in the least walkable (D1) neighborhoods, but only 1.24 (95% CI 1.08 to 1.42, p=0.002) and 1.00 (95% CI 0.87 to 1.15, p=0.99) for these same groups living in the most walkable (D10) neighborhoods. CONCLUSIONS: Pre-diabetes incidence was reduced in highly walkable areas for most groups living in Southern Ontario cities. These findings suggest a potential role for walkable urban design in diabetes prevention.

Ethnic variation in the conversion of prediabetes to diabetes among immigrant populations relative to Canadian-born residents: a population-based cohort study.

OBJECTIVE: The aim of this study was to compare absolute and relative rates of conversion from prediabetes to diabetes among non-European immigrants to Europeans and Canadian-born residents, overall, and by age and level of glycemia. RESEARCH DESIGN AND METHODS: We conducted a retrospective cohort population-based study using administrative health databases from Ontario, Canada, to identify immigrants (n=23 465) and Canadian born (n=1 11 085) aged ≥20 years with prediabetes based on laboratory tests conducted between 2002 and 2011. Individuals were followed until 31 December 2013 for the development of diabetes using a validated algorithm. Immigration data was used to assign ethnicity based on country of origin, mother tongue, and surname. Fine and Gray's survival models were used to compare diabetes incidence across ethnic groups overall and by age and glucose category. RESULTS: Over a median follow-up of 5.2 years, 8186 immigrants and 39 722 Canadian-born residents developed diabetes (7.1 vs 6.1 per 100 person-years, respectively). High-risk immigrant populations such as South Asians (HR: 1.72, 95% CI 1.55 to 1.99) and Southeast Asians (HR: 1.65, 95% CI 1.46 to 1.86) had highest risk of converting to diabetes compared with Western Europeans (referent). Among immigrants aged 20-34 years, the adjusted cumulative incidence ranged from 18.4% among Eastern Europeans to 52.3% among Southeast Asians. Conversion rates increased with age in all groups but were consistently high among South Asians, Southeast Asians and Sub-Saharan African/Caribbeans after the age of 35 years. On average, South Asians converted to diabetes 3.1-4.6 years earlier than Western Europeans and at an equivalent rate of conversion to Western Europeans who had a 0.5 mmol/L higher baseline fasting glucose value. CONCLUSIONS: High-risk ethnic groups converted to diabetes more rapidly, at younger ages, and at lower fasting glucose values than European populations, leading to a shorter window for diabetes prevention.

Ethnic differences in prediabetes incidence among immigrants to Canada: a population-based cohort study.

BACKGROUND: Prediabetes appears to be increasing worldwide. This study examined the incidence of prediabetes among immigrants to Canada of different ethnic origins and the age at which ethnic differences emerged. METHODS: We assembled a cohort of Ontario adults (≥ 20 years) with normoglycemia based on glucose testing performed between 2002 and 2011 through a single commercial laboratory database (N = 1,772,180). Immigration data were used to assign ethnicity based on country of origin, mother tongue, and surname. Individuals were followed until December 2013 for the development of prediabetes, defined using either the World Health Organization/Diabetes Canada (WHO/DC) or American Diabetes Association (ADA) thresholds. Multivariate competing risk regression models were derived to examine the effect of ethnicity and immigration status on prediabetes incidence. RESULTS: After a median follow-up of 8.0 years, 337,608 individuals developed prediabetes. Using definitions based on WHO/DC, the adjusted cumulative incidence of prediabetes was 40% (HR 1.40, CI 1.38-1.41) higher for immigrants relative to long-term Canadian residents (21.2% vs 16.0%, p < 0.001) and nearly twofold higher among South Asian than Western European immigrants (23.6%; HR 1.95, CI1.87-2.03 vs 13.1%; referent). Cumulative incidence rates based on ADA thresholds were considerably higher (47.1% and 32.3% among South Asians and Western Europeans, respectively). Ethnic differences emerged at young ages. South Asians aged 20-34 years had a similar prediabetes incidence as Europeans who were 15 years older (35-49 years), regardless of which prediabetes definition was used (WHO/DC 14.4% vs 15.7%; ADA 38.0% vs 33.0%). CONCLUSION: Prediabetes incidence was substantially higher among non-European immigrants to Canada, highlighting the need for early prevention strategies in these populations.

Neighbourhood walkability and the incidence of diabetes: an inverse probability of treatment weighting analysis.

BACKGROUND: People living in highly walkable neighbourhoods tend to be more physically active and less likely to be obese. Whether walkable urban design reduces the future risk of diabetes is less clear. METHODS: We used inverse probability of treatment weighting to compare 10-year diabetes incidence between residents living in high-walkability and low-walkability neighbourhoods within five urban regions in Ontario, Canada. Adults (aged 30-85 years) who were diabetes-free on 1 April 2002 were identified from administrative health databases and followed until 31 March 2012 (n=958 567). Within each region, weights reflecting the propensity to live in each neighbourhood type were created based on sociodemographic characteristics, comorbidities and healthcare utilisation and incorporated into region-specific Cox proportional hazards models. RESULTS: Low-walkability areas were more affluent and had more South Asian residents (6.4%vs3.6%, p<0.001) but fewer residents from other minority groups (16.6%vs21.7%, p<0.001). Baseline characteristics were well balanced between low-walkability and high-walkability neighbourhoods after applying individual weights (standardised differences all <0.1). In each region, high walkability was associated with lower diabetes incidence among adults aged <65 years (overall weighted incidence: 8.2vs9.2 per 1000; HR 0.85, 95% CI 0.78 to 0.93), but not among adults aged ≥65 years (weighted incidence: 20.7vs19.5 per 1000; HR 1.01, 95% CI 0.91 to 1.12). Findings were consistent regardless of income and immigration status. CONCLUSIONS: Younger adults living in high-walkability neighbourhoods had a lower 10-year incidence of diabetes than similarly aged adults living in low-walkability neighbourhoods. Urban designs that support walking may have important benefits for diabetes prevention.

Evolving Trends in the Epidemiology, Risk Factors, and Prevention of Type 2 Diabetes: A Review.

Currently, the global prevalence of diabetes is 8.8%. This figure is expected to increase worldwide, with the largest changes projected to occur in low- and middle-income countries. The aging of the world's population and substantial increases in obesity have contributed to the rise in diabetes. Global shifts in lifestyles have led to the adoption of unhealthy behaviours such as physical inactivity and poorer-quality diets. Correspondingly, diabetes is a rapidly-increasing problem in higher- as well as lower-income countries. In Canada, the prevalence of diabetes increased approximately 70% in the past decade. Although diabetes-related mortality rates have decreased in Canada, the number of people affected by diabetes has continued to grow because of a surge in the number of new diabetes cases. Non-European ethnic groups and individuals of lower socioeconomic status have been disproportionately affected by diabetes and its risk factors. Clinical trials have proven efficacy in reducing the onset of diabetes in high-risk populations through diet and physical activity interventions. However, these findings have not been broadly implemented into the Canadian health care context. In this article we review the evolving epidemiology of type 2 diabetes, with regard to trends in occurrence rates and prevalence; the role of risk factors including those related to ethnicity, obesity, diet, physical activity, socioeconomic status, prediabetes, and pregnancy; and the identification of critical windows for lifestyle intervention. Identifying high-risk populations and addressing the upstream determinants and risk factors of diabetes might prove to be effective diabetes prevention strategies to curb the current diabetes epidemic.

Identifying mechanisms for facilitating knowledge to action strategies targeting the built environment.

BACKGROUND: In recent years, obesity-related diseases have been on the rise globally resulting in major challenges for health systems and society as a whole. Emerging research in population health suggests that interventions targeting the built environment may help reduce the burden of obesity and type 2 diabetes. However, translation of the evidence on the built environment into effective policy and planning changes requires engagement and collaboration between multiple sectors and government agencies for designing neighborhoods that are more conducive to healthy and active living. In this study, we identified knowledge gaps and other barriers to evidence-based decision-making and policy development related to the built environment; as well as the infrastructure, processes, and mechanisms needed to drive policy changes in this area. METHODS: We conducted a qualitative thematic analysis of data collected through consultations with a broad group of stakeholders (N = 42) from Southern Ontario, Canada, within various sectors (public health, urban planning, and transportation) and levels of government (federal, provincial, and municipalities). Relevant themes were classified based on the specific phase of the knowledge-to-action cycle (research, translation, and implementation) in which they were most closely aligned. RESULTS: We identified 5 themes including: 1) the need for policy-informed and actionable research (e.g. health economic analyses and policy evaluations); 2) impactful messaging that targets all relevant sectors to create the political will necessary to drive policy change; 3) common measures and tools to increase capacity for monitoring and surveillance of built environment changes; (4) intersectoral collaboration and alignment within and between levels of government to enable collective actions and provide mechanisms for sharing of resources and expertise, (5) aligning public and private sector priorities to generate public demand and support for community action; and, (6) solution-focused implementation of research that will be tailored to meet the needs of policymakers and planners. Additional research priorities and key policy and planning actions were also noted. CONCLUSION: Our research highlights the necessity of involving stakeholders in identifying inter-sectoral solutions to develop and translate actionable research on the built environment into effective policy and planning initiatives.

Association of Neighborhood Walkability With Change in Overweight, Obesity, and Diabetes.

IMPORTANCE: Rates of obesity and diabetes have increased substantially in recent decades; however, the potential role of the built environment in mitigating these trends is unclear. OBJECTIVE: To examine whether walkable urban neighborhoods are associated with a slower increase in overweight, obesity, and diabetes than less walkable ones. DESIGN, SETTING, AND PARTICIPANTS: Time-series analysis (2001-2012) using annual provincial health care (N ≈ 3 million per year) and biennial Canadian Community Health Survey (N ≈ 5500 per cycle) data for adults (30-64 years) living in Southern Ontario cities. EXPOSURES: Neighborhood walkability derived from a validated index, with standardized scores ranging from 0 to 100, with higher scores indicating more walkability. Neighborhoods were ranked and classified into quintiles from lowest (quintile 1) to highest (quintile 5) walkability. MAIN OUTCOMES AND MEASURES: Annual prevalence of overweight, obesity, and diabetes incidence, adjusted for age, sex, area income, and ethnicity. RESULTS: Among the 8777 neighborhoods included in this study, the median walkability index was 16.8, ranging from 10.1 in quintile 1 to 35.2 in quintile 5. Resident characteristics were generally similar across neighborhoods; however, poverty rates were higher in high- vs low-walkability areas. In 2001, the adjusted prevalence of overweight and obesity was lower in quintile 5 vs quintile 1 (43.3% vs 53.5%; P < .001). Between 2001 and 2012, the prevalence increased in less walkable neighborhoods (absolute change, 5.4% [95% CI, 2.1%-8.8%] in quintile 1, 6.7% [95% CI, 2.3%-11.1%] in quintile 2, and 9.2% [95% CI, 6.2%-12.1%] in quintile 3). The prevalence of overweight and obesity did not significantly change in areas of higher walkability (2.8% [95% CI, -1.4% to 7.0%] in quintile 4 and 2.1% [95% CI, -1.4% to 5.5%] in quintile 5). In 2001, the adjusted diabetes incidence was lower in quintile 5 than other quintiles and declined by 2012 from 7.7 to 6.2 per 1000 persons in quintile 5 (absolute change, -1.5 [95% CI, -2.6 to -0.4]) and 8.7 to 7.6 in quintile 4 (absolute change, -1.1 [95% CI, -2.2 to -0.05]). In contrast, diabetes incidence did not change significantly in less walkable areas (change, -0.65 in quintile 1 [95% CI, -1.65 to 0.39], -0.5 in quintile 2 [95% CI, -1.5 to 0.5], and -0.9 in quintile 3 [95% CI, -1.9 to 0.02]). Rates of walking or cycling and public transit use were significantly higher and that of car use lower in quintile 5 vs quintile 1 at each time point, although daily walking and cycling frequencies increased only modestly from 2001 to 2011 in highly walkable areas. Leisure-time physical activity, diet, and smoking patterns did not vary by walkability (P > .05 for quintile 1 vs quintile 5 for each outcome) and were relatively stable over time. CONCLUSIONS AND RELEVANCE: In Ontario, Canada, higher neighborhood walkability was associated with decreased prevalence of overweight and obesity and decreased incidence of diabetes between 2001 and 2012. However, the ecologic nature of these findings and the lack of evidence that more walkable urban neighborhood design was associated with increased physical activity suggest that further research is necessary to assess whether the observed associations are causal.

The evidence base of primary research in public health emergency preparedness: a scoping review and stakeholder consultation.

BACKGROUND: Effective public health emergency preparedness and response systems are important in mitigating the impact of all-hazards emergencies on population health. The evidence base for public health emergency preparedness (PHEP) is weak, however, and previous reviews have noted a substantial proportion of anecdotal event reports. To investigate the body of research excluding the anecdotal reports and better understand primary and analytical research for PHEP, a scoping review was conducted with two objectives: first, to develop a thematic map focused on primary research; and second, to use this map to inform and guide an understanding of knowledge gaps relevant to research and practice in PHEP. METHODS: A scoping review was conducted based on established methodology. Multiple databases of indexed and grey literature were searched based on concepts of public health, emergency, emergency management/preparedness and evaluation/evidence. Inclusion and exclusion criteria were applied iteratively. Primary research studies that were evidence-based or evaluative in nature were included in the final group of selected studies. Thematic analysis was conducted for this group. Stakeholder consultation was undertaken for the purpose of validating themes and identifying knowledge gaps. To accomplish this, a purposive sample of researchers and practicing professionals in PHEP or closely related fields was asked to complete an online survey and participate in an in-person meeting. Final themes and knowledge gaps were synthesized after stakeholder consultation. RESULTS: Database searching yielded 3015 citations and article selection resulted in a final group of 58 articles. A list of ten themes from this group of articles was disseminated to stakeholders with the survey questions. Survey findings resulted in four cross-cutting themes and twelve stand-alone themes. Several key knowledge gaps were identified in the following themes: attitudes and beliefs; collaboration and system integration; communication; quality improvement and performance standards; and resilience. Resilience emerged as both a gap and a cross-cutting theme. Additional cross-cutting themes included equity, gender considerations, and high risk or at-risk populations. CONCLUSIONS: In this scoping review of the literature enhanced by stakeholder consultation, key themes and knowledge gaps in the PHEP evidence base were identified which can be used to inform future practice-oriented research in PHEP.

Physical health and gender as risk factors for usage of services for mental illness.

BACKGROUND: People with comorbid mental and physical illness (PI) experience worse health, inadequate care and increased mortality relative to those without mental illness (MI). The role of gender in this relationship is not fully understood. This study examined gender differences in onset of mental health service usage among people with physical illness (COPD, asthma, hypertension and type II diabetes) compared with a control cohort. METHODS: We used a unique linked dataset consisting of the 2000-2001 Canadian Community Health Survey and medical records (n=17 050) to examine risk of onset of MI among those with and without PI among Ontario residents (18-74 years old) over a 10-year period (2002-2011). Adjusted COX proportional survival analysis was conducted. RESULTS: Unadjusted use of MI medical services in the PI cohort was 55.6% among women and 44.7% (p=0.0001) among men; among controls 48.1% of the women and 36.7% of the men used MI medical services (p=0.0001). The relative risk of usage among women in the PI group relative to controls was 1.16. Among men, the relative risk was 1.22. Women were 1.45 times more likely to use MI medical services relative to men (HR=1.45, CI 1.35 to 1.55). Respondents in the PI cohort were 1.32 times more likely to use MI medical services (HR=1.32, CI 1.23 to 1.42) relative to controls. Women in the PI cohort used MI medical services 6.4 months earlier than PI males (p=0.0059). In the adjusted model, women with PI were most likely to use MI medical services, followed by women controls, men with PI and men controls. There was no significant interaction between gender and PI cohort. CONCLUSIONS: Further, gender-based research focusing on onset of usage of MI services among those with and without chronic health problems will enable better understanding of gender-based health disparities to improve healthcare quality, delivery and public health policy.

Density, destinations or both? A comparison of measures of walkability in relation to transportation behaviors, obesity and diabetes in Toronto, Canada.

The design of suburban communities encourages car dependency and discourages walking, characteristics that have been implicated in the rise of obesity. Walkability measures have been developed to capture these features of urban built environments. Our objective was to examine the individual and combined associations of residential density and the presence of walkable destinations, two of the most commonly used and potentially modifiable components of walkability measures, with transportation, overweight, obesity, and diabetes. We examined associations between a previously published walkability measure and transportation behaviors and health outcomes in Toronto, Canada, a city of 2.6 million people in 2011. Data sources included the Canada census, a transportation survey, a national health survey and a validated administrative diabetes database. We depicted interactions between residential density and the availability of walkable destinations graphically and examined them statistically using general linear modeling. Individuals living in more walkable areas were more than twice as likely to walk, bicycle or use public transit and were significantly less likely to drive or own a vehicle compared with those living in less walkable areas. Individuals in less walkable areas were up to one-third more likely to be obese or to have diabetes. Residential density and the availability of walkable destinations were each significantly associated with transportation and health outcomes. The combination of high levels of both measures was associated with the highest levels of walking or bicycling (p<0.0001) and public transit use (p<0.0026) and the lowest levels of automobile trips (p<0.0001), and diabetes prevalence (p<0.0001). We conclude that both residential density and the availability of walkable destinations are good measures of urban walkability and can be recommended for use by policy-makers, planners and public health officials. In our setting, the combination of both factors provided additional explanatory power.