Environmental stewardship in diabetes care: actionable insights for pharmacists

IntroductionIt is estimated that approximately 4.6% of Canada’s total greenhouse gas (GHG) emissions are attributable to the health sector, with the vast majority arising in supply chains; pharmaceuticals account for roughly one-quarter of health-care life-cycle emissions.1 Currently, ~4.1 million Canadians are diagnosed with diabetes (90–95% type 2), a figure projected to rise substantially by 2033; moreover, surveys suggest about one-fifth of adults with diabetes are undiagnosed, indicating true prevalence is materially higher than counts of diagnosed cases alone.2 Taken together, these figures mean the climate and diabetes stories are intertwined: because most health-sector emissions arise in supply chains—and medicines are a substantial share—rising diabetes prevalence pulls emissions upward via greater demand for drugs, devices, and testing; in Canada, antidiabetic medicines’ market share nearly doubled to 7.9% (2012–2021), signalling a growing medication-embedded footprint.3 At the same time, the climate crisis worsens diabetes risk and outcomes4 —heatwaves are associated with ~18% higher diabetes mortality and ~10% higher morbidity, and long-term exposure to fine particulate matter (PM₂.₅ ) contributes meaningfully to the global burden of type 2 diabetes. This creates a vicious cycle in which climate impacts drive disease and complications that, in turn, expand high-emission care.5 Pharmacists are uniquely positioned to help break this cycle: they are the most accessible clinicians (about 95% of Canadians live within 5 km of a community pharmacy). They are supported by Canadian guidance and emergency-coverage policies to safeguard continuity of care and deliver climate-conscious counselling (heat/smoke advisories, safe storage) alongside sustainable product choice.6Diabetes, heat, and the health-system footprintPeople with diabetes are especially vulnerable to heat. Peripheral and autonomic neuropathy can blunt sweating and skin blood-flow responses, impair thermoregulation and raising the risk of heat illness.7 Heat also perturbs glucose–insulin dynamics—altering insulin action and counter-regulation—while hyperglycemia drives osmotic diuresis, worsening dehydration.8Warmer ambient temperatures are linked to worse outcomes across the diabetes continuum. In population studies, higher temperatures are associated with increased gestational diabetes risk, and heatwaves are tied to higher diabetes morbidity and mortality.9 Common comorbidities (cardiovascular and kidney disease, depression) and several widely used drugs compound the heat risk. For example, beta-blockers and diuretics can impair heat loss or volume status, and ACE inhibitors/ARBs can heighten susceptibility to heat-related kidney injury.10 Heat-related infectious threats also grow as climates warm, while diabetes itself increases infection susceptibility due to immune dysfunction.11 Finally, the downstream care for heat-exacerbated diabetes complications contributes to health-sector emissions, particularly in the most emissions-intensive aspects. Within complication care, dialysis stands out as one of the most carbon-intensive services.12Air quality, wildfire smoke and diabetesWildfire smoke and urban air pollution increase cardiometabolic strain and are associated with higher type 2 diabetes risk. Global burden estimates suggest that a meaningful share of diabetes in 2019 was attributable to PM₂.₅, with cohort and meta-analytic data linking higher long-term PM₂.₅ exposure to increased diabetes incidence and prevalence.13Air quality and wildfire smoke pose parallel risks for people with diabetes; the Air Quality Health Index (AQHI) offers a practical framework for patient counselling and service planning on days with poor air quality. Pharmacists can integrate AQHI-based advice during smoke events, pair it with indoor-air strategies and appropriate respirator use, and confirm temperature-sensitive medication storage during outages.14 The following points align with Canadian AQHI and wildfire-smoke guidance and standard diabetes storage advice:Show patients how to check and interpret AQHI (1–10+) and adjust activity on higher-risk days.14During smoke alerts, reduce outdoor exertion, relocate to cleaner-air spaces, and consider portable air purifiers/HEPA to lower indoor PM₂.₅.14If outdoor time is unavoidable, recommend a well-fitting NIOSH-certified N95 (or KN95/KF94) respirator to reduce particulate exposure (not gases).14Reinforce insulin and device storage during heat and power disruptions (e.g., keep within labelled temperature ranges; follow emergency insulin guidance).14Prioritize proactive outreach to higher-risk groups—including people with diabetes—before and during smoke episodes.14 Climate-smart pharmacy in diabetes careSlowing the progression of diabetes is associated with reduced carbon emissions.12,15 The CASCADES Canada Network has developed a practical, evidence-based framework outlining mitigation and adaptation strategies to support sustainable pharmacy practice.16 While not exhaustive, the following “actionable areas” highlight key intersections between sustainable pharmacy, diabetes, and climate change.Mitigation strategies1) Switch to lower-impact products16Switching from higher- to lower-impact options, where clinically appropriate, is essential. For example:Reusable insulin delivery: Replacing single-use insulin syringes or disposable pens with reusable cartridge pens can reduce emissions (e.g., ~30%) and substantially cut plastic waste.17–21Concentrated formulations: Switching from standard insulin to more concentrated formulations can yield similar reductions.18Within-class differences: Carbon impacts may vary between drugs in the same class (e.g., canagliflozin [100–300 mg tablets] vs. dapagliflozin [5–10 mg]).222) Improve medication adherence and device use16Targeted education on proper administration improves adherence and outcomes.16 One study found that people who achieved glycemic control with first-line oral therapy (e.g., metformin) had lower associated carbon impacts than those requiring third-line agents or insulin.12 Pharmacists can also reinforce right-sized self-monitoring for type 2 diabetes to reduce unnecessary strips and device waste.233) Ensure proper disposal of medical waste16Advances in diabetes technology carry environmental costs.21,24–26 Most supplies—test strips, lancets, and many monitors—are not recyclable; patients should be counselled to collect and return biohazardous sharps (insulin syringes, pen needles, lancets) and unused medications to participating pharmacies or as directed by local public-health guidance.20,21,25 Adaptation strategies1) Educate patients during heatwaves16Prepare patients for heat, especially regarding medications that can exacerbate heat-related illness.27 Use brief, point-of-care messages and proven communication strategies—one review found that discussing near-term extreme-weather risks is more engaging than distant climate messaging.28 In practice, raise this during routine pickups31:“Do you worry more about your health on hot days?”“How do you store your medications when the power goes out?”Patients should also know that some medications increase heat risk (e.g., beta-blockers in cardiovascular disease); heatwaves have been linked to higher myocardial infarction risk in exposed groups. 27,30,33 Use the “SAD MANS” acronym (Sulfonylureas, ACE inhibitors, Diuretics/direct renin inhibitors, Metformin, ARBs, NSAIDs, SGLT2 inhibitors) to guide temporary holds during acute illness or dehydration.23,30,34 2) Safe storage of medications and supplies16Extreme heat can reduce the efficacy of insulin and damage supplies (e.g., strips, sensors, monitors).10 Advise patients to:Avoid exposing medication to hot environments (cars, direct sunlight).Use a cooler for transport, but do not place insulin directly on ice or allow it to freeze. 353) Review disaster preparedness plansHeatwaves increase the likelihood of power outages and wildfires, which may cause unexpected pharmacy closures.36 A formal plan helps maintain continuity of care. A scoping review from the U.S. reported pharmacy closures, difficulty contacting prescribers, and insurance issues interrupting care after extreme weather events.36 Preparedness should include:Awareness of emergency coverage policies (e.g., in Ontario, early or emergency refills/renewals may be permitted under specific conditions).37,38Remote access to pharmacy systems.38Back-up power for cold-chain storage.38An adequate supply of life-sustaining medications such as insulin.35,38,39System-level levers: social prescribing, partnerships and advocacyBeyond patient-level actions, pharmacy teams can leverage system-level tools—social prescribing, community partnerships, and advocacy—to strengthen resilience and reduce emissions at scale.37Social prescribing pathways (link workers/referral workflows) to connect patients to cooling centres, clean-air spaces, food and activity supports; use Canadian tools (CISP; CEP).41Public-health partnerships for AQHI/heat alerts and coordinated messaging (use Health Canada pharmacist guidance).42Safe disposal infrastructure (HPSA meds/sharps take-back) codified in your SOPs and patient materials. 43Team training & advocacy using the CASCADES Pharmacy Playbook (climate-resilient, low-carbon practice) and related action areas.16 Conclusion: climate-conscious diabetes careThe intersection of climate change and diabetes care presents both a growing challenge and a critical opportunity. People living with diabetes face heightened risk from climate-related hazards—especially extreme heat—which is linked to increased diabetes morbidity and mortality.27 At the same time, health care contributes materially to the problem: Canada’s health system accounts for roughly 4.6% of national greenhouse gas emissions, consistent with estimates of the sector’s global footprint.44Integrating climate-conscious approaches into routine diabetes management—sustainable medication and device practices, targeted patient education, and preparedness for heat and other disruptions—can lower emissions while supporting better outcomes.40 Action at the pharmacy level is practical and necessary to safeguard continuity of care in an increasingly unstable climate, with Canadian guidance and post-disaster evidence underscoring pharmacists’ pivotal role.30 ReferencesVogel L. Canada’s health system is among the least green. 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Environmental stewardship in diabetes care: actionable insights for pharmacists

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