Appendix B: The Chief Public Health Officer's Report on the State of Public Health in Canada 2013 – The health and well-being of Canadians

Appendix B: The Health and Well-Being of Canadians

• Who we are
• Our health
• Behavioural, social and economic factors influencing health
• Summary
• References

Presented below is an overview of the demographics of the Canadian population, including their life expectancy and patterns of ill health, disability and mortality. Also discussed are determinants that influence health–income, employment, education, health behaviours and access to healthcare. Although some health challenges can be related to our genetic make-up, evidence shows that income, education, employment and other social determinants of health can cause or influence the health outcomes of individuals and communities.

Who we are

As shown in Table B.1, the Canadian population was 34.9 million in 2012, of which an estimated 1.4 million were Aboriginal (61% First Nations, 32% Métis and 4% Inuit) and an estimated 6.8 million were foreign-born.^{Footnote 2-Footnote 5} Approximately 84% of Canadians lived in population centres^{Who we are - Footnote *} in 2011.^{Footnote 7, Footnote 8}

The life expectancy of Canadians has increased dramatically over the past century to the point where a person born in Canada today has an estimated life expectancy of 81 years.^{Footnote 9} While Canadian women continue to experience greater longevity, having an estimated life expectancy of 83 years compared to 79 years for men, between 1992 to 1994 and 2007 to 2009 the difference in life expectancy at birth between them decreased from 6.1 years to 4.5 years.^{Footnote 9}

Our health

This section explores the current health status of Canadians including mental health, physical health, health behaviours and other influential factors (see Table B.3 for a list of indicators). According to the 2011 Canadian Community Health Survey (CCHS), the majority of Canadians 12 years and older reported their health as either very good or excellent (60%).^{Footnote 10} Despite relatively high rates of very good or excellent perceived health and mental health, not all years are spent in good health.^{Footnote 10-Footnote 12} The health-adjusted life expectancy (HALE) from 2005 to 2007 shows that, of their 78.3 years of expected life, males spend the equivalent of 68.9 years in full health.^{Footnote 12} During the same period, females with a life expectancy of 83.0 years had a HALE of 71.2 years.^{Footnote 12}

Chronic conditions

The proportion of Canadians living with specific diseases and health conditions varies across the population. Although chronic health conditions are most often experienced by–and associated with–older members of the population, more than one-half (56%) of Canadians 12 years and older reported living with at least one of a number of chronic health conditions in 2011.Footnote 13, Footnote 14

More specifically, chronic health conditions such as asthma, diabetes and cancer affect many people. Asthma, which is characterized by coughing, shortness of breath, chest tightness and wheezing, was reported by 9% of the population aged 12 years and older in 2011.^{Footnote 10, Footnote 15} Early onset of asthma has been linked to low birth-weight, exposure to tobacco smoke (including second-hand smoke and parental smoking) and family history, whereas later onset has been linked to genetic predisposition, obesity and increased exposure to allergens and environmental factors such as pollution.^{Footnote 15-Footnote 18} According to the 2008/2009 Canadian Chronic Disease Surveillance System, close to 2.4 million Canadians aged one year and older were living with diagnosed diabetes.^{Footnote 19} Although both type 1 and type 2 diabetes have been linked to genetic anomalies, type 2 diabetes is also associated with being overweight or obese.^{Footnote 19-Footnote 21} About 186,400 new cases of cancer were expected to be diagnosed in 2012.^{Footnote 22} Cancers of the breast, lung, colon/rectum and prostate were expected to account for more than one-half (53%) of all cancers diagnosed in the same year.^{Footnote 22}

Sexually transmitted infections

Rates of sexually transmitted infections (STIs) officially reported to the Canadian Notifiable Disease Surveillance System (CNDSS) increased in the overall Canadian population over the past 15 years.^{Footnote 23} Untreated STIs, whether symptomatic or not, can have long-lasting effects on health. STIs have been linked to pelvic inflammatory disease, infertility, ectopic pregnancies, miscarriages and low birth-weight babies as well as genital warts and various types of cancers including cervical, anal and penile.^{Footnote 24, Footnote 25}

In 2010, young women between 20 and 24 years had the highest reported rate of chlamydia infections (2,005.5 cases per 100,000 population), more than seven times the overall national rate (277.6 cases per 100,000) and more than five times the overall female rate (363.8 cases per 100,000 population).^{Footnote 23} In the same year, the highest rates of reported gonococcal infections (147.0 cases per 100,000 population) were among young women between 15 and 19 years, more than four times the overall national average (33.4 cases per 100,000 population).^{Footnote 23} Unlike chlamydia and gonorrhea, reported rates of infectious syphilis in 2010 were higher in males than in females in all age groups.^{Footnote 23} Young men between 30 and 39 years had the highest reported rate with 16.2 cases per 100,000 population, which is more than three times the overall national average (5.2 cases per 100,000 population).^{Footnote 23}

An estimated 71,300 people were living with HIV infection at the end of 2011.^{Footnote 26} More than three-quarters (77%) of all new HIV infections reported in 2011 were among men, with the highest proportion of all new cases being among men between 30 and 39 years (29%).^{Footnote 26} In 2011, men who have sex with men accounted for the largest proportion of new positive test reports (49%).^{Footnote 26} Women represent an increasing proportion of those with positive HIV test reports in Canada, and represented 23% of all new cases reported in 2011.^{Footnote 26} Among women, heterosexual contact was the most reported exposure category (65%) followed by intravenous drug use (30%) in 2011.^{Footnote 26}

Healthy weights

Less healthy eating, including over-consumption, combined with inadequate physical activity can lead to increased body weight.Footnote 27, Footnote 28 Body mass index (BMI) is a common measure based on height and weight that is used to determine healthy and unhealthy weights. As measured in the 2009 to 2011 Canadian Health Measures Survey (CHMS), 26% of Canadians 18 years and older were obese and 34% were overweight based on their measured height and weight.Footnote 29 Obesity is not only a problem for adult Canadians; measured heights and weights of Canadian children in the same period showed that 9% of 6- to 17-year-olds were obese and 17% were overweight.Footnote 29

While BMI is considered an adequate measure for portions of the population, standard BMI categories may not accurately reflect the rate of overweight and obesity in all populations.^{Footnote 30-Footnote 34} Using BMI in conjunction with waist circumference, as suggested by the World Health Organization (WHO), can more clearly identify populations who are at increased risk of ill health related to obesity and waist circumference.^{Footnote 35, Footnote 36} Using measured values from the 2009 to 2011 CHMS, it is estimated that more than one-half (56%) of Canadians between 20 and 69 years were, at minimum, at increased risk of obesity-related ill health (see Table B.2).^{Footnote 29, Footnote 37} Obesity is a risk factor for many chronic health conditions including high blood pressure, type 2 diabetes, gallbladder disease, coronary artery disease, osteoarthritis and certain types of cancer.^{Footnote 27, Footnote 35, Footnote 36}

Mental health and mental illness

Mental health is an important aspect of the overall health and well-being for all Canadians.Footnote 38 Mental health and mental illness can affect many lives and influence health throughout the lifecourse. A considerable body of scientific research supports the idea that mental health and mental illness are not on opposite ends of a single continuum with mental health increasing only as mental illness decreases.Footnote 39 Rather mental health and mental illness are best conceived as existing on two separate but related continua; therefore, mental health is more than the absence of mental illness.Footnote 40 Mental illness can affect people of all ages, cultures, education and income levels.Footnote 39, Footnote 41 However, those with a family history of mental illness, substance abuse issues, certain chronic health conditions or who have experienced stressful life events are more at risk.Footnote 41

It is difficult to accurately determine the mental health state or rates of mental illness because data are limited. Nevertheless, the data available through surveys, studies and databases provide us with some understanding of the mental health of Canadians. According to the 2011 CCHS, the majority of Canadians 12 years and older reported their mental health as very good or excellent (73%).^{Footnote 10} Rates of mental illness in Canada may be underestimated as many people remain undiagnosed and those with severe conditions may not be captured at all.^{Footnote 39}

The most commonly self-reported mental health conditions in 2011 were mood disorders such as depression, bipolar disorder, mania or dysthymia.^{Footnote 13, Footnote 14} The overall percentage of Canadians 15 years and older who reported having been diagnosed with a mood disorder was 7.3%.^{Footnote 13, Footnote 14} A greater percentage of females (9.5%) than males (5.2%) reported mood disorders, overall and within different age groups.^{Footnote 13, Footnote 14} Older adults between 55 and 64 years old had the highest reported rates (9.4%) in the same year.^{Footnote 13, Footnote 14}

Approximately 6.5% of Canadians 15 years and older reported having an anxiety disorder, such as a phobia, obsessive-compulsive disorder or a panic disorder, in 2011.^{Footnote 13, Footnote 14} As with mood disorders a greater percentage of females (8.2%) than males (4.7%) reported anxiety disorders, overall and within different age groups.^{Footnote 13, Footnote 14} Persons between 20 and 54 years reported having the highest rates of anxiety (7.2%).^{Footnote 13, Footnote 14}

Causes of death

In 2009, cancers were the leading overall cause of death in Canada (30%), followed by circulatory diseases (29%) and respiratory diseases (9%).Footnote 42-Footnote 61 Since population distributions are not identical, age-standardized mortality rates (ASMR) provide a better indication of mortality risk within a population. Between 2000 and 2009, the ASMR have decreased for each of these diseases: cancers from 185.4 to 163.8 per 100,000 population; circulatory diseases from 212.3 to 140.9 per 100,000 population; and respiratory diseases from 49.2 to 44.2 per 100,000 population.Footnote 4, Footnote 42-Footnote 44 During the same period, deaths from infectious diseases increased from 9.0 to 10.7 per 100,000 population.Footnote 4, Footnote 45

While knowing the number of deaths due to a particular disease or condition is important to understanding the health of the Canadian population, so too is knowing the age at which those deaths occur. Measuring the number of potential years of life lost (PYLL) to premature death provides a better sense of the impact a given disease or condition has on the health of the population. For example, if a Canadian dies of cancer at age 45 years, he or she has potentially lost 30 years of life (conservatively assuming a life expectancy of 75 years at birth, as is commonly done in these calculations).^{Footnote 62} In 2009, most years of lost life were due to premature deaths associated with cancers (1,504 years per 100,000 population), circulatory diseases (755 years per 100,000 population) and unintentional injuries (546 years per 100,000 population).^{Footnote 63}

Behavioural, social and economic factors influencing health

Individual behaviours, such as physical inactivity, tobacco use, high-risk drinking, and drug misuse, can have negative health effects. Education and income are key determinants of health across the lifecourse.^{Footnote 64, Footnote 65} While behaviours are individual choices that people make, the physical, social and economic environments where individuals live, work and learn influence these choices.^{Footnote 66, Footnote 67} In general, an improvement in any of these can produce an improvement in both health behaviours and outcomes at the individual, group or population level (see Table B.4 for a list of indicators).

Physical activity

While many factors can affect a person's health, research studies report that people who are the most physically active are at a lower risk for poor health.Footnote 68, Footnote 69 Physical inactivity is a modifiable risk factor for a wide range of chronic health conditions including coronary heart disease, stroke, hypertension, colon cancer, breast cancer, type 2 diabetes and osteoporosis.Footnote 68, Footnote 70

In order to maximize the health benefits associated with being physically active, World Health Organization (WHO) and Canadian guidelines suggest that adults should accumulate at least 150 minutes of moderate-to-vigorous physical activity per week; 60 minutes of moderate-to-vigorous physical activity every day is recommend for children and youth between 5 and 17 years.Footnote 71-Footnote 74 According to the 2007 to 2009 CHMS, only 17% of males and 14% of females between 20 and 79 years achieved this level of physical activity.Footnote 71 While only 7% of children and youth (9% of boys and 4% of girls) attained the suggested level of activity at least six days a week, 44% (53% of boys and 35% of girls) were engaged in at least 60 minutes of moderate-to-vigorous physical activity at least three days a week.Footnote 72

Smoking, alcohol consumption and drug use

The effects of smoking on health and well-being are well documented and remain a leading cause of preventable disease and premature death.^{Footnote 75, Footnote 76} Smoking and exposure to second-hand smoke have been linked to an increased risk of developing a number of diseases and conditions that can affect the cardiovascular system and respiratory systems as well as being a known carcinogen.^{Footnote 76, Footnote 77} Smoking can also interfere with various drug therapies, causing medications, including antidepressants, to be less effective.^{Footnote 78, Footnote 79} While the overall smoking rate has declined since 1985, 17% of Canadians aged 15 years and older reported being current smokers (15% of females and 20% of males) in 2011.^{Footnote 80, Footnote 81}

Alcohol is the psychoactive substance used by the highest proportion of Canadians.Footnote 82 Alcohol intoxication can lead to a variety of risks including harmful effects on physical and mental health, personal relationships, work and education; in extreme cases, it can even cause death.Footnote 83-Footnote 85 In 2011, guidelines for low-risk alcohol drinking in Canada were released defining short- and long-term effects of alcohol consumption for men and women.Footnote 85 In 2011, 78% of Canadians ages 15 years and older reported drinking in the past year.Footnote 82 Of those who consumed alcohol, 19% exceeded the guidelines for long-term effects (e.g. increased risk of liver diseases and certain cancers) and 13% exceeded guidelines for short-term effects (e.g. increased risk of injury and overdose).Footnote 82

Short- and long-term effects of illicit drug use vary. Short-term effects of cannabis use, for example, can include an increase in heart rate and decrease in blood pressure.Footnote 86, Footnote 87 It can interfere with concentration, depth perception and reaction time, affecting driving, among other things.Footnote 86, Footnote 87 Cannabis use may also trigger psychosis in vulnerable individuals and may aggravate the course of psychiatric diseases such as schizophrenia.Footnote 86, Footnote 88 Long-term use of cannabis can lead to respiratory distress and increased risk of cancer and may cause impaired memory and information processing.Footnote 86-Footnote 89 Other illicit drugs–cocaine, hallucinogens and ecstasy–have been linked to various health and social problems including panic attacks, hallucinations, psychosis, paranoia and risky or violent behaviour.Footnote 87, Footnote 90-Footnote 93 Physical effects associated with these drugs include convulsions, increased blood pressure and increased heart rate, all of which have the potential to be fatal.Footnote 90-Footnote 93 Over the long-term, and depending on the substance, harmful effects can include impaired brain function affecting memory, and lung and nasal tissue damage.Footnote 90-Footnote 95 The use of illicit drugs (i.e. abuse, misuse or dependence) can affect performance at school and work, and in extreme cases even cause death.Footnote 90-Footnote 93

The illicit drug most commonly used by Canadians in 2011 was cannabis.^{Footnote 82, Footnote 96} Nearly one-in-ten Canadians aged 15 years and older (12% of males and 6% of females) reported having used cannabis in the past year.^{Footnote 82, Footnote 96} The prevalence of cannabis use among Canadians 15 years of age and older has been in decline since 2008.^{Footnote 97} Other than cannabis, the illegal drugs most commonly used in 2011 were hallucinogens (0.9%), crack/cocaine (0.9%) and ecstasy (0.7%).^{Footnote 96} Pharmaceutical drugs prescribed for therapeutic purposes, including opioid pain relievers, stimulants, tranquillizers and sedatives, may also be abused due to their psychoactive properties.^{Footnote 82} In 2011, 1.5% of those who used psychoactive pharmaceutical drugs did so to get high.^{Footnote 82}

Education, employment and income

Between the 1990/1991 and 2010/2011 school years, the percentage of Canadians between 20 and 24 years who had completed high school increased from 81% to 90%.^{Footnote 98} Men, however, continue to have consistently higher non-completion rates when compared with women, with 89% versus 92% completing high school in 2011.^{Footnote 98} Between the 1990/1991 and 2010/2011 school years, the percentage of Canadians between 25 and 34 years who had completed a post-secondary education increased from 44% to 68%.^{Footnote 98}

Unemployment and a stressful or unsafe workplace have been associated with poorer health outcomes.Footnote 65, Footnote 99 People who have more control over their work and fewer stress-related demands tend to be healthier with increased longevity than those in more stressful or riskier work environments.Footnote 65, Footnote 99 In 2012, the unemployment rate was highest (14.3%) among young Canadians between 15 and 24 years; the lowest rates (4.6%) were among those aged 65 years and older.Footnote 100

Canadians have seen an overall increase in personal income (adjusted for inflation) over time, but increases have not been consistent for everyone. In fact, the gap between those with the highest and lowest income has widened significantly between 1976 and 2010.^{Footnote 101, Footnote 102}

Although women face living in low income more often than do men, the difference in these rates has decreased considerably over time. As of 2010, the low income rates stood at 8.7% for men and 9.3% for women.^{Footnote 101, Footnote 103} The number of children under the age of 18 years living in low income households has declined from a peak of 18.4% in 1996 to 8.2% in 2010.^{Footnote 101, Footnote 103} The 5.3% of Canadian seniors living in low income (3.4% of men and 6.8% of women) in 2010 was also a large decrease from 30.4% in 1977.^{Footnote 101, Footnote 103}

Summary

Although the health of Canada's population is considered to be very good, a closer inspection of differing rates of death, disease and disability among various groups shows that some Canadians experience worse health and a lower quality of life than do others. Many factors influence these outcomes, including the aging of the population, increasing survival rates for potentially fatal conditions and changes in personal choices about eating, physical activity and the use of substances such as drugs, tobacco and alcohol. These are not the only factors at play; evidence shows that income, education, employment and working conditions can affect individual health behaviours and outcomes.