Upstream: Toward a Provincial Strategy on Obesity Prevention

We have heard that Saskatchewan has a financial deficit of about $1 billion.  We know that a large proportion of our Saskatchewan budget, perhaps 40 percent, is devoted to what is called “health care” although more correctly it should be called illness care and treatment. A significant portion of that cost is what the provincial government pays for treatment of diabetes and other obesity-related illnesses. We also know that prior to 1960, diabetes of type II was relatively rare in Saskatchewan whereas now it is considered an epidemic.

What is called for here is real “transformational change,” not just continuing the current treatment approach, but an upstream approach, a prevention approach, dealing with causes, and gradually reducing treatment costs over time.

In this submission we claim that obesity is preventable, and with it, many obesity-related illnesses, such of diabetes and the complications associated with diabetes. We claim that in our society we presently have the knowledge and skill to prevent obesity but we are not putting a sufficient priority on prevention. We claim that increasing the current health promotion and disease prevention budget to 3 percent from the current 1.4 percent of total health expenditures by Saskatchewan Health would have a major impact in reducing obesity and reducing overall “health care” costs. We suggest that the following claim be pondered, at least briefly, rather than dismissed as outrageous:

“…if all residents of Saskatchewan had healthy weights (BMI = 20 to 24.9) the province would save up to $260 million a year… If all Saskatchewan residents had healthy weights and did not smoke, the province could save up to $570 million a year.” (Colman 2001: 20)

Finally we claim, if we do not increase substantially the current efforts at prevention, that obesity, diabetes and related costs shall continue to climb dramatically, with major negative impacts on all Saskatchewan residents.

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“Widespread increases in physical inactivity and caloric intake have led to a global epidemic of overweight, obesity and diabetes. The reasons for these trends are multifaceted and complex. However, major drivers include the ubiquity of high-calorie, low-cost convenience foods, increased portion sizes, and a way of life that encourages sedentary behaviour, such as sitting at computers, in front of television screens, and in cars” (Booth 2015).

For the first time, in 1997, the World Health Organization (WHO) referred to obesity as a “global epidemic.”  For the first time in human history, the number of overweight people in the world now equals the number of underfed people, with 1.1 billion in each group (Colman 2001).

Obesity and diabetes have reached epidemic proportions in Canada. Obesity is a major risk factor for diabetes and many other chronic diseases, all of which place major costs on the health care system and the economy as well as the individual and family involved. For example, obese Canadians are four times more likely to have diabetes than those with healthy weights. Obesity was not a problem several decades ago. Obesity is preventable. A cost-effective strategy must take an “upstream” approach, aiming at prevention of obesity, focussing primarily on adequate physical activity and a healthy diet from an early age and secondarily on the physical environment.

Obesity is a sensitive subject. Our intent here is not to cast blame, to make overweight people feel bad about themselves, or to allow healthy weight people to feel smug. “On the contrary, it is to suggest that Saskatchewan could take the lead in turning around a highly destructive global trend, and to encourage communities, schools, policy makers, health professionals and ordinary individuals to work together to improve the health and well-being of all our citizens” (Colman 2001). Pursuing healthy weights should not be viewed as simply a purely individual responsibility but a challenge calling for a “whole-of-society” approach (Obesity in Canada, Canada Senate Report, 2016:18).

 

Extent of Obesity and Diabetes

The extent of obesity in Canada is “high and rising:” even more alarming is the recent increase among children and youth. Two-thirds of Canadian adults are overweight (BMI= 25.0 to 29.9) or obese (BMI=>30.0), (where BMI or Body Mass Index = weight in kg/height in cm squared). This has increased dramatically over the past 25 years, roughly doubling in adults. One quarter of Canadian adults and 8.6 percent of children and youth aged 6-17 are obese according to measured height and weight data from 2007-2009 (Obesity in Canada, p. 4). Another source states that in the period 1985 to 2011 obesity tripled from 6 percent to 18 percent of the Canadian population.

Other sources show similar findings: obese Canadians are 20.2 % of the population; overweight and obese men are 62 % and women 46 %. Another source shows that among non-aboriginals, age 18 and over, 2009-2010 data, the percentage who are overweight or obese is 51.9%; among First Nations on-reserve  it is 74.4%; among First Nations off-reserve it is 62.5%, 2008-2010 data (Public Health Agency of Canada, 2011).

In Saskatchewan, nearly two-thirds of residents have an unhealthy weight, second only to New Brunswick (Colman 2001). In Saskatchewan, approximately 57 percent of adults and 20 percent of youth are either overweight or obese. Regarding diabetes, it is estimated that the number of people living with diabetes in Saskatchewan will grow to 100,000 in 2017, up from 97,000 in 2016, and will increase by 35 percent in the next decade. In addition, a further 176,000 are expected to be living with pre-diabetes and another 43,000 living with undiagnosed diabetes (Canadian Diabetes Association, 2017??). Not only is the number of people with diabetes growing, but so are the serious complications they experience such as heart attack, stroke, kidney failure, blindness and limb amputation, all of which incur serious costs on the individuals, families and the province.

 

Impacts

Obesity is a risk factor in many chronic diseases. Obesity significantly increases the risk of Type 2 diabetes, cardiovascular disease, hypertension (high blood pressure), high cholesterol, osteoarthritis and certain types of cancer. In turn, diabetes leads to serious complications as listed above. Estimates of the cost of obesity in Canada range from $4.6 billion to $7.1 billion annually (2006). For diabetes alone the cost in 2000 was $2.5 billion a year (Diabetes in Canada, p. 47).

In Saskatchewan obesity is the second-leading preventable cause of death after cigarette smoking. It is estimated that more than 960 Saskatchewan residents die prematurely each year due to obesity-related illness, compared to 1,200 deaths due to tobacco and about 100 road accident deaths.

Obesity-related illnesses cost the Saskatchewan health care system an estimated $120 million dollars annually, or 7.3% of total direct health care costs. When productivity losses due to obesity, including premature death, absenteeism and disability are added, the total cost of obesity to the Saskatchewan economy was estimated at between $230 million and $260 million a year, equal to 1% of the province’s Gross Domestic Product. If present trends continue, these costs could surpass the direct and indirect costs of tobacco smoking, currently about $311 million a year (Colman 2001).

A recent study indicates that diabetes alone costs Saskatchewan’s health care system $99.8 million a year in direct costs including hospitalization, doctor visits, dialysis and inpatient medications.

Although obesity represents a burden for some, it is a boon to economic growth and the GDP. The obesity epidemic is a boon for the pharmaceutical industry. New factories need to be built to produce more insulin and other anti-diabetic drugs to meet the skyrocketing demand from those with diabetes, as global incidence of diabetes is expected to double to 300 million people by the year 2015. Like war, crime and pollution, illness can make the economy grow more rapidly than peace, health and a clean environment. In the USA, liposuction is the leading form of cosmetic surgery; diet and weight loss industries contribute $33 billion to the U.S. economy annually (Colman 2001: 23).

 

Causes 

Obesity involves a wide and interactive range of behavioural, biological/genetic, and societal factors. Health behaviours or lifestyle factors, primarily eating healthy food and having adequate physical activity, are themselves influenced by deeper societal factors like stress and work patterns.

Poor eating habits (including low consumption of fruits and vegetables and high consumption of refined carbohydrates and sweetened beverages (Bray 2003), particularly high-sugar, high-salt, fast food, show a strong association with the prevalence of obesity. Eating habits, healthy and unhealthy, are learned at an early age, like developing a taste for vegetables or for foods with sugar and salt: much food marketed as baby food has considerable levels of salt and sugar. Access to healthy food also is important: low income and distance from a food store may lead to more use of closer convenience stores with poorer food choices. For those with higher incomes, sedentary lifestyles, longer work hours, rising stress levels, may all contribute to increasing unhealthy weights. In Saskatchewan residents eat out more often than they used to and one quarter experience high levels of chronic stress (Colman 2001).

The food industry contributes $30 billion in advertising to the U.S. GDP (Gross Domestic Product), more than any other industry does, and much of it promotes the very foods that cause obesity: much of it targets children and youth. In Canada, current support for education or information programs aimed at nutritional illiteracy is infinitesimal in comparison: it appears that we are simply leaving this topic to the food industry.

Physical inactivity also has a strong association with obesity for both men and women. In the USA, which does not have universal Medicare, some HMOs (Health Management Organizations), finding that people who are more active use fewer medications, encourage their clients to participate in physical activity by subsidizing gym fees,

Less than half of Saskatchewan residents exercise regularly (three or more times a week), the second lowest rate of activity in Canada, and a quarter either never exercise or exercise less than once a week. Saskatchewan residents watch an average of 3.25 hours of television each day (Colman 2001). Television watching often begins at an early age, followed by video games and smart phones.

Although lifestyle is the major risk factor for obesity, societal factors such as family history, ethnic background and socioeconomic status, as well as the physical environment also play a significant part. Obesity is correlated with low educational level, poverty and rural residence; obesity also is generally higher in Aboriginal (37.8%) than non-Aboriginal people. Climbing obesity rates are less the fault of individuals and more a consequence of changes in the food environment (e.g. a huge increase in fast food outlets) and a decrease in physical activity demands in daily living, resulting in an “obesogenic environment” making it too easy to eat poorly and remain sedentary (Obesity in Canada, Senate Report, 2016:8)

A more recent consideration regarding obesity that is gaining momentum among public health officials, at least in urban areas, is the potential to design or redesign the built environment in which we live—including buildings, parks, transportation systems and overall communities—to promote active, healthy living. Numerous studies have suggested a link between neighbourhood characteristics – including urban design, the presence of recreational spaces and “foodscapes” –and the physical activity and dietary patterns of local residents. Thus there is growing evidence from large, observational studies that neighbourhoods that provide more opportunities for walking and cycling have lower rates of obesity and diabetes. Collectively, this evidence suggests that population interventions targeting the built environment may have long-term health benefits (Booth 2015).

Suggested Interventions

Saskatchewan Ministry of Health

1. That the Ministry increase the health promotion and disease prevention budget to 3% from the current 1.4% of total health expenditures (currently 98.6% of Saskatchewan’s “health care” budget is actually comprised of illness-treatment expenditures. Currently we spend substantial amounts to make Saskatchewan roads safer and reduce the likelihood of about 100 road accident deaths annually: a fraction of that invested in nutritional literacy and physical education programs might yield significant dividends both in lives saved and in reducing the annual quarter billion dollar drain on the Saskatchewan economy due to obesity-related illness (currently about 960 lives lost yearly).
2. That the Ministry develop performance indicators that reflect upstream preventative measures as well as downstream treatment measures like wait times.
3. Encourage improved training for physicians regarding diet and physical activity.
4. Promote the use of physician counseling, including the use of prescriptions for exercise.
5. That public funding be increased for treatment of obese adults and youth: counselling, medication and surgery.

Saskatchewan Ministry of Education: Children and Youth

1. Mandating and funding school boards to implement the existing policy that children and youth engage in 30 minutes of moderate to vigorous physical activity daily at school. (Inspiring Movement 2010). This is not necessarily the same as
2. Monitoring to what extent school boards have implemented the 2010 policy on physical activity.
3. Limiting foods and drinks sold in schools to healthy choices: these should provide healthy meals as well as educational opportunities for children to participate in meal planning and preparation.
4. Nutritional education.

Other Public Policy

1. Regulation of marketing to children particularly of the energy-dense, nutrient-poor foods and beverages
2. Warning labels and taxes on unhealthy foods and beverages (akin to current anti-tobacco strategies)
3. Community planning that promotes active commuting and recreational physical activities
4. Financial incentives, similar to the Children’s Fitness Tax Credit, for low income adults and seniors affected with chronic conditions, to attend a fitness centre that provides supervised physical activity.
5. Dependable funding for programs such as ParticipAction.

General

1. In view of the correlation between stress, long work hours, poor dietary habits and gains in overweight, consider creating jobs by reducing work hours as European countries have done (Colman 2001)

 

Questions

1. How much currently is spent by government and non-governmental organizations like the Canadian Diabetes Association on prevention?
2. What research has been done on the possible cost-effectiveness of prevention measures such as those suggested here?
3. Why do Saskatchewan governments of all political stripes continue to spend so little on prevention?
4. How much could we save in the cost of anti-diabetic medications with a nation-wide pharmacare plan involving bulk purchases?
5. How much attention is given in Saskatchewan schools to (a) learning healthy eating practices, cooking, and vegetable gardening? (b) physical activity? (c) community alternatives to school bussing?
6. What lessons have been learned from the reasonably successful anti-smoking campaign in Canada?

References

Beveridge, Angelina. Resolution by Saskatchewan Registered Nurses Association (SRNA) at Annual General Meeting 2008

Beveridge, Angelina. Resolution by Saskatchewan Registered Nurses Association (SRNA) at Annual General Meeting 2008

Beveridge, Angelina. Toward a Provincial Strategy on Obesity Prevention and Management, SRNA Newsletter, August 2013

Booth, Gillian. Lifestyle, the built urban environment and social engineering. International Diabetes Federation Conference, Vancouver 2015.

Bray, GA. Low CHO diets and realities of weight loss, JAMA 2003, 289. pp.1853-1855.

Canadian Diabetes Association. The Cost of Diabetes in Saskatchewan: the Saskatchewan Diabetes Cost Model. (from CDA, An Economic Tsunami: the Cost of Diabetes in Canada, 2009)

Canadian Diabetes Association/Diabetes Educator Section, Saskatchewan Newsletter, Update for members, Winter 2017, “New 2017 – Saskatchewan Diabetes Rates Rising, Report indicates urgent changes needed”

Colman, R. Cost of Obesity in Saskatchewan. Glen Haven, NS: GPI Atlantic, Jan. 2001. Retrieved 2013/08/12, http://www.gpiatlantic.org/pdf/health/obesity/sask-obesity.pdf

Obesity in Canada: A Joint Report from the Public Health Agency of Canada and the Canadian Institute for Health Information, 2011. http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/oic-oac/assets/pdf/oic-oac-eng.pdf

Obesity in Canada: A Whole-of-Society Approach for a Healthier Canada. Report of the Standing Senate Committee on Social Affairs, Science and Technology, 2016. Retrieved 2017/01/30, https://sencanada.ca/content/sen/committee/421/SOCI/Reports/2016-02-25_Revised_report_

Diabetes in Canada 2011: Facts and figures from a public health perspective. Public Health Agency of Canada, Ottawa, 2011. http://www.phac-aspc.gc.ca/cd-mc/publications/diabetes-diabete/facts-figures-faits-chiffres-2011

Saskatchewan Ministry of Education, Inspiring Movement: Towards Comprehensive School

Community Health: Guidelines for Physical Activity in Saskatchewan Schools. Feb. 2010. http://www.education.gov.sk.ca/inspiring-movement

Saskatchewan Ministry of Education, Nourishing Minds: Towards Comprehensive School Community Health: Nutrition Policy Development in Saskatchewan Schools. Oct. 2009. http://www.education.gov.sk.ca/nourishing-minds

 

Angelina Beveridge is a retired diabetes nurse educator with the Regina Qu’Appelle Health Region. Daniel Beveridge is a retired University of Regina professor. 

Contact:

Daniel M. Beveridge  danmbeveridge@gmail.com

Angelina Beveridge  Angelina.Beveridge@gmail.com