The economic burden of excessive sugar consumption in Canada: should the scope of preventive action be broadened?

OBJECTIVE: Excessive sugar consumption is an established risk factor for various chronic diseases (CDs). No earlier study has quantified its economic burden in terms of health care costs for treatment and management of CDs, and costs associated with lost productivity and premature mortality. This information, however, is essential to public health decision-makers when planning and prioritizing interventions. The present study aimed to estimate the economic burden of excessive free sugar consumption in Canada. METHODS: Free sugars refer to all monosaccharides and disaccharides added to foods plus sugars naturally present in honey, syrups, and fruit juice. Based on free sugar consumption reported in the 2015 Canadian Community Health Survey-Nutrition and established risk estimates for 16 main CDs, we calculated the avoidable direct health care costs and indirect costs. RESULTS: If Canadians were to comply with the free sugar recommendation (consumption below 10% of total energy intake (TEI)), an estimated $2.5 billion (95% CI: 1.5, 3.6) in direct health care and indirect costs could have been avoided in 2019. For the stricter recommendation (consumption below 5% of TEI), this was $5.0 billion (95% CI: 3.1, 6.9). CONCLUSION: Excessive free sugar in our diet has an enormous economic burden that is larger than that of any food group and 3 to 6 times that of sugar-sweetened beverages (SSBs). Public health interventions to reduce sugar consumption should therefore consider going beyond taxation of SSBs to target a broader set of products, in order to more effectively reduce the public health and economic burden of CDs.

RéSUMé: OBJECTIF: La consommation excessive de sucre est un facteur de risque connu pour diverses maladies chroniques. Aucune étude antérieure n'en a chiffré le fardeau économique en termes de coûts de soins de santé pour le traitement et la prise en charge des maladies chroniques, et de coûts associés à la perte de productivité et à la mortalité prématurée. Ces informations sont pourtant essentielles aux décideurs de la santé publique pour planifier les interventions et gérer les priorités. Notre étude a cherché à estimer le fardeau économique de la consommation excessive de sucres libres au Canada. MéTHODE: Les sucres libres désignent tous les monosaccharides et disaccharides ajoutés aux aliments, plus les sucres naturellement présents dans le miel, les sirops et les jus de fruits. D'après la consommation de sucres libres constatée dans l'Enquête sur la santé dans les collectivités canadiennes ­ Nutrition de 2015 et les estimations du risque connues pour 16 grandes maladies chroniques, nous en avons calculé les coûts évitables directs (de soins de santé) et indirects. RéSULTATS: Si les Canadiens s'en tenaient à la consommation recommandée de sucres libres (soit moins de 10 % de l'apport énergétique total [AÉT]), il est estimé que 2,5 milliards de dollars (IC de 95 % : 1,5, 3,6) en coûts directs de soins de santé et en coûts indirects auraient pu être évités en 2019. Si la recommandation plus stricte (consommation inférieure à 5 % de l'AÉT) avait été respectée, les coûts évités se seraient chiffrés à 5 milliards de dollars (IC de 95 % : 3,1, 6,9). CONCLUSION: L'excès de sucres libres dans notre régime représente un fardeau économique énorme, supérieur à celui de tout autre groupe d'aliments et de 3 à 6 fois supérieur à celui des boissons édulcorées au sucre (BÉS). Il faudrait donc envisager des interventions en santé publique visant à réduire la consommation de sucre qui vont au-delà de la taxation des BÉS pour cibler un panier élargi de produits afin de réduire plus efficacement le fardeau sanitaire et économique des maladies chroniques.

Open-label randomized trial of titrated disease management for patients with hypertension: Study design and baseline sample characteristics.

Despite the availability of efficacious treatments, only half of patients with hypertension achieve adequate blood pressure (BP) control. This paper describes the protocol and baseline subject characteristics of a 2-arm, 18-month randomized clinical trial of titrated disease management (TDM) for patients with pharmaceutically-treated hypertension for whom systolic blood pressure (SBP) is not controlled (≥140mmHg for non-diabetic or ≥130mmHg for diabetic patients). The trial is being conducted among patients of four clinic locations associated with a Veterans Affairs Medical Center. An intervention arm has a TDM strategy in which patients' hypertension control at baseline, 6, and 12months determines the resource intensity of disease management. Intensity levels include: a low-intensity strategy utilizing a licensed practical nurse to provide bi-monthly, non-tailored behavioral support calls to patients whose SBP comes under control; medium-intensity strategy utilizing a registered nurse to provide monthly tailored behavioral support telephone calls plus home BP monitoring; and high-intensity strategy utilizing a pharmacist to provide monthly tailored behavioral support telephone calls, home BP monitoring, and pharmacist-directed medication management. Control arm patients receive the low-intensity strategy regardless of BP control. The primary outcome is SBP. There are 385 randomized (192 intervention; 193 control) veterans that are predominately older (mean age 63.5years) men (92.5%). 61.8% are African American, and the mean baseline SBP for all subjects is 143.6mmHg. This trial will determine if a disease management program that is titrated by matching the intensity of resources to patients' BP control leads to superior outcomes compared to a low-intensity management strategy.

Nutritional quality of children's school lunches: differences according to food source.

OBJECTIVE: To assess the nutritional quality of lunchtime food consumption among elementary-school children on Prince Edward Island according to the source of food consumed (home v. school). DESIGN: Students completed a lunchtime food record during an in-class survey. Dietary adequacy was assessed by comparing median micronutrient intakes with one-third of the Estimated Average Requirement; median macronutrient intakes were compared with the Acceptable Macronutrient Distribution Ranges. The Wilcoxon signed rank test was used to assess differences in nutrient intakes according to source of food consumed. SETTING: Elementary schools in Prince Edward Island, Canada. SUBJECTS: Grade 5 and 6 students (n 1980). RESULTS: Foods purchased at school were higher in nutrient density for ten micronutrients (Ca, Mg, K, Zn, vitamin A, vitamin D, riboflavin, niacin, vitamin B6 and vitamin B12) compared with packed lunch foods from home, which were higher in three micronutrients (Fe, vitamin C and folate). School lunches provided sufficient protein but were higher in sugar and fat than home lunches. Foods brought from home were higher in carbohydrates, fibre and Na than foods purchased at school. CONCLUSIONS: The overall nutritional quality of lunches was poor, regardless of source. A significant proportion of foods consumed by the students came from home sources; these were lower nutritional quality and were higher in Na than foods offered at school. Findings suggest that improving the dietary habits of school-aged children will require a collaborative effort from multiple stakeholders, including parents.

Implementing elementary school nutrition policy: principals' perspectives.

PURPOSE: We assessed principals' perceptions about the level of school nutrition policy (SNP) implementation in Prince Edward Island elementary schools, objectively evaluated how closely elementary schools are following SNP regulations for types and frequency of foods offered at school, and explored principals' beliefs about the key enablers and barriers to SNP implementation. METHODS: Phase I involved a cross-sectional survey of principals' assessment of perceived and actual adherence to SNP components. Phase II included in-depth interviews to explore principals' perceptions about factors influencing policy adherence. Descriptive statistics were generated. Thematic content analysis was used to identify themes. RESULTS: Forty-one (93%) principals participated in Phase I, and nine of these participated in Phase II. The level of implementation of SNP components varied. Seventy-four percent of all foods sold were categorized as allowed by the SNP; 68% of schools sold at least one "not allowed" food. Key barriers included lost revenue, a higher cost of healthy foods, and limited availability of policy-allowed foods. Enablers were a high level of community support, ready access to food suppliers, and active parent volunteers. CONCLUSIONS: While schools are making progress in implementing the SNP, challenges remain. Identifying and communicating strategies for healthy fundraising activities and finding ways to involve parents in SNP implementation are recommended.

Monitoring and evaluating school nutrition and physical activity policies.

Given the increase in the number of Canadian jurisdictions with school nutrition and/or physical activity policies, there is a need to assess the effectiveness of such policies. The objectives of this paper are to 1) provide an overview of key issues in monitoring and evaluating school nutrition and physical activity policies in Canada and 2) identify areas for further research needed to strengthen the evidence base and inform the development of effective approaches to monitoring and evaluation. Evaluation indicators, data sources and existing tools for evaluating nutrition and physical activity are reviewed. This paper has underscored the importance of identifying common indicators and approaches, using a comprehensive approach based on the WHO framework and ensuring that research capacity and funding is in place to facilitate high-quality evaluation efforts in the future.

A province-wide school nutrition policy and food consumption in elementary school children in Prince Edward Island.

OBJECTIVE: Although the majority of Canadian provinces have indicated that they have adopted new school nutrition policies, there have been few if any systematic evaluations of these policies. In Prince Edward Island, a nutrition policy for elementary schools was adopted province-wide in 2006. In the present study, we assessed the nutritional benefits of the new policy by examining changes in student food consumption prior to and one year following implementation of the policy. METHODS: We surveyed fifth and sixth grade children from 11 elementary schools in Prince Edward Island in 2001/02 (pre-policy implementation) and fifth and sixth grade children from the same 11 schools in 2007 (post-policy implementation). Food consumption was assessed using a self-administered validated food frequency questionnaire. We applied multilevel logistic regression to compare pre-/post-policy implementation differences in the proportion of students meeting Canada's Food Guide recommendations for vegetables and fruit (VF) and milk and alternatives (MA) and in the proportion of students consuming < 3 servings of low nutrient dense foods (LNDF) daily. RESULTS: Relative to students in 2001/02, students surveyed in 2007 were 2.14 (95% CI 1.62-2.82) times more likely to report consuming less than three daily servings of LNDF and were more likely to meet recommendations for VF (OR 1.44, 95% CI 1.00-2.07) and MA (OR 1.27, 95% CI 0.98-1.64). CONCLUSION: The present study is the first in Canada to show favourable changes in student food consumption that parallel the introduction of a school nutrition policy.

Knowledge translation case study: a rural community collaborates with researchers to investigate health issues.

INTRODUCTION: Knowledge translation implies the exchange and synthesis of knowledge between researchers and research users, employing a high level of communication and participation, not only to share the knowledge found through research, but also to implement subsequent strategies. Prince Edward Island, a rural province in Canada, provided the setting to exchange knowledge between researchers and a rural community on the health issues affecting children. METHODS: A case study reports census data, demographic trends, and information about health issues immediate to the community. These focus groups were held to plan solutions to the community's health priorities. The process was participatory, characterized by community involvement. RESULTS: Those participating in the focus groups were interested in research findings and literature to solve local problems. Parenting and mental health were determined to be priority issues requiring broader community engagement. The process of translating knowledge into action after the focus groups met lacked widespread involvement of the community. DISCUSSION: Although encouraged to do so, the larger rural community did not participate in examining research findings or in planning interventions. The parents in this community may not have perceived themselves as having influence in the process or goals of the project.

Nutritional concerns in aboriginal children are similar to those in non-aboriginal children in Prince Edward Island, Canada.

OBJECTIVE: To assess food consumption among aboriginal children living on Mi'kmaq reserves in Prince Edward Island, Canada. DESIGN: Data were collected as part of a larger study of health perceptions and behaviors in Mi'kmaq children and youth ages 1 to 18 years. Food consumption was assessed using a self-administered food frequency questionnaire during an in-home interview. SUBJECTS/SETTING: Fifty-five children living on a reserve (53% of total population) ages 9 to 18 years. STATISTICAL ANALYSES PERFORMED: The number of servings of milk products, vegetables and fruit, and snack foods/beverages was calculated by adding the responses to the frequency of consumption of foods assessed in each group. chi(2) analysis was used to assess differences in food consumption according to sex and age. RESULTS: Only one child reported consuming the recommended minimum of five vegetables and fruit daily (Canada's Food Guide to Healthy Eating, 1992) (mean [+/-standard deviation]=2.8+/-1.1 servings). Twenty-five (49%) of the children consumed three or more servings of milk products daily (mean=2.6+/-1.3 servings). Approximately half of the children had three or more snack foods/beverages daily (mean=3.1+/-2.2 servings). Younger children (grades 4 to 6) consumed more cereal, peanut butter, and yogurt than older children. There were no significant differences in food consumption between boys and girls. CONCLUSIONS: Our findings are consistent with past reports in aboriginal children. However, except for higher consumption of french fries, results are similar to recent surveys of other Prince Edward Island school children, suggesting a province-wide rather than cultural health issue.

Widespread micronutrient inadequacies among adults in prince edward island.

PURPOSE: The prevalence of micronutrient inadequacies was assessed among adult residents of Prince Edward Island (PEI) in the PEI Nutrition Survey. METHODS: A peer-reviewed protocol was used in this cross-sectional survey, in which 24-hour recalls were administered during in-home interviews. A stratified random sample of 1,995 adults aged 18 to 74 participated. Median nutrient intakes with and without supplements were calculated; intakes were adjusted for day-to-day variability. Chi-square testing was used to assess differences in prevalence of inadequacy by age and sex. RESULTS: Most of the sample (more than 90%) had folate intakes below the Estimated Average Requirement (EAR). Magnesium and vitamin C intakes were low in more than 50% of the sample. Iron intakes were adequate in all groups except women aged 19 to 50, 29% of whom had intakes below the EAR. Women were more likely than men to have inadequate intakes. Median calcium intakes fell below recommendations for all age and sex groups. Supplement use had little impact on dietary adequacy in this sample. CONCLUSIONS: This study underscores the need for public health interventions designed to reduce the very high prevalence of nutrient inadequacies in the PEI adult population. In addition, education is needed on the selection of appropriate vitamin and mineral supplements.

Determinants of healthy eating in children and youth.

This review outlines the state of knowledge and research gaps in the area of determinants of healthy eating among children and youth. The article is structured around individual and collective determinants that affect healthy eating in children and youth. We defined healthy eating as "eating practices and behaviours that are consistent with improving, maintaining and/or enhancing health." Relevant databases were searched for papers published between January 1992 and March 2003 that focussed on children or youth and reported at least one factor relevant to healthy eating. Among collective factors, familial factors and the nature of foods available in the physical environment, including at home, schools and in fast-food establishments, stand out as significant influences on healthy eating in children and youth. The media, particularly television, also have an enormous potential influence and can overshadow familial influences. Individual factors identified include knowledge, attitudes and food preferences; only the latter have been identified as a strong determinant of healthy eating in both children and adolescents. The results of the review identified a significant body of literature in the area of determinants of healthy eating in children and youth; however, very little of this research has taken place in Canada. Only a few determinants, such as economic factors and food security, the content of media nutritional messages, and the issue of flavours, neophobia and food preferences, have undergone some examination by Canadian researchers. Research priorities for Canada in the area of determinants of healthy eating and surveillance of eating behaviours are identified.

Symptom relief and adherence in the rotary diversified diet, a treatment for environmental illness.

CONTEXT: The rotary diversified diet, which involves food elimination and rotation of remaining allowed foods, is commonly used in the management of environmental illness. No studies have considered patient adherence while evaluating the effectiveness of the diet in controlling symptoms. OBJECTIVE: The study examined the severity of patients' perceived symptoms and dietary adherence during treatment with a rotary diversified diet. DESIGN: A prospective and exploratory study using purposive sampling and the following data collection methods: personal interviews, symptom severity questionnaires, and food records to assess dietary adherence. SETTING: Private clinic of a Toronto, Ontario physician specializing in environmental medicine. PATIENTS OR OTHER PARTICIPANTS: Twenty-five female residents of Toronto, Ontario (aged 25-67 years) diagnosed with environmental illness. INTERVENTION: Patients were treated with a rotary diversified diet for 16 weeks. MAIN OUTCOME MEASURES: Symptom severity and dietary adherence were assessed after 4, 10, and 16 weeks of treatment. Adherence was assessed by comparing food records to the diet prescription. RESULTS: At 16 weeks, patients reported a 50% decline in symptom severity for 5 of the 6 symptom categories assessed and for all categories combined. Those with closer elimination and rotation adherence reported a greater decline in gastrointestinal symptoms at 4 and 10 weeks of treatment, respectively. Improvement in total symptom severity was associated with closer rotation adherence at 10 weeks. Patients experienced difficulties in adhering to the diet. CONCLUSIONS: Results suggest that the diet, if followed, is beneficial, especially in improving gastrointestinal symptoms. Further evaluation of its effectiveness is limited by its complexity and the nature of environmental illness. Because the diet is difficult to follow over time, patients require extensive nutritional counseling and support.

Dietary adequacy of the rotary diversified diet as a treatment for "Environmental Illness".

The rotary diversified diet, used in the management of environmental illness, consists of eliminating prohibited foods from the diet and rotating remaining non-prohibited foods and their "food families" within a regular cycle. We assessed the adequacy of nutrient intakes in 22 women prescribed the diet, described the nature of supplement use, and assessed the relationship between adherence and nutrient intake levels. Except for calcium and folacin intakes, mean nutrient intakes met or exceeded recommended levels. No subjects had calcium intakes above the adequate intake for calcium; 72.7% had folate intakes below the estimated average requirement. Intakes of other nutrients, except thiamin and magnesium, were below the estimated average requirement in less than 25% of the sample; 31.8% and 45.5% of subjects, respectively, had thiamin and magnesium intakes at this level. Those who adhered more closely to the rotary diversified diet had higher intakes of vitamin C, vitamin B6, folate, and fibre than did those who followed the diet less closely. Supplements conferred some nutritional benefits; however, supplemental niacin and magnesium intakes exceeded tolerable upper intake levels. Those prescribed the rotary diversified diet require nutrition counselling from dietitians to cope with the complexity and restrictiveness of the diet.