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More on diet and population health

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 08 January 2013
in CHNET-Works!

A recent posting featured two important research syntheses on overweight and obesity. Another, especially useful for non-specialist audiences, appeared as a special report on “The big picture” in the December 15 issue of The Economist.

Commendably, the report does not sugar-coat the difficult politics of reducing overweight and obesity. It notes, for example, that “while lots of people remain fat, the associated ailments represent big business for the drug companies.”  It is candid about the role of companies like soft-drink manufacturers and fast-food chains in contributing to the epidemic of overweight, and the conflicts of interest that can arise in partnerships like one between Nestlé and the International Diabetes Federation, or the “Responsibility Deal” between food and alcohol companies and Britain’s Department of Health. (In negotiations about the action plan that emerged from the UN Summit on non-communicable diseases in September 2011, Canada was among the countries pressing for removal of text that mentioned such conflicts.) And it presents a succinct overview of efforts to deal with overweight and obesity through taxation and regulation. So far, those efforts have met with modest success, although that may be a consequence of modest ambition rather than of limitations intrinsic to the available policy instruments.

Unfortunately, the report is not open-access, although non-subscribers will be able to read part of it online. Unfortunately as well, the report pays insufficient attention to connections between the built environment and overweight, or to the cost of a healthy diet. Nevertheless, it is a refreshing signal that approaches going beyond the usual health promotion nostrums are moving into the policy mainstream.

Shortly before the Economist report appeared, Britain’s Department of Environment, Food and Rural Affairs released its annual Family Food Survey for the year 2011. Among the survey’s disturbing findings: fruit and vegetable purchases were 10 percent lower in 2011 than in 2007, with an even larger decline among the bottom fifth of Britain’s income distribution. Households in the lowest tenth of the income distribution were spending 17 percent more on food in 2011 than in 2007. A report in The Guardian quoted the director of the consumer protection organization Which? as saying: “One in six people say rising food prices are making it difficult to eat healthily,” and the preceding month a report in the same newspaper warned of a “nutrition recession” - this in a country where benefit caps planned for 2013 will cut the incomes of many people in full-time jobs as well as those who cannot find work. 

Closer to home, Ottawa's deparment of public health released the lastest issue of an annual calculation showing that if you are living on social assistance and paying market rents in the city, it is arithmetically impossible - as it is much of the rest of the province- to pay for the diet recommended by Ontario's Public Health Standards. In the capital of a weathly G7 country, 48,000 people a month turn to food banks. Against the background of ongoing concern about health care spending and areport recommending an immediate increase in Ontario social assistance rates to " the lower rate category, single adults receiving Ontario Works, as a down payment on adequacy while the system undergoes transformation," it may be worth asking`just how does making healthiy diets unaffordable contribute to a healthier population and lower health system costs down the road?

Our big fat complicated population health problem: Perspectives from both sides of the Atlantic

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Friday, 30 November 2012
in CHNET-Works!

 Overweight and obesity contribute directly to a variety of adverse health outcomes, as pointed out in a recent Lancet series.  At least in high-income countries, these conditions exhibit a pronounced socioeconomic gradient, and therefore present both a challenge and an opportunity.  A challenge, because of the complex etiology of overweight and obesity; an opportunity, because of the tremendous improvements in health that can be anticipated from any population-wide shift toward healthy weights.

Two recent syntheses of research findings offer useful insights, and also a few (intentional and unintentional) warnings, about how best to address overweight and obesity. A report by a committee of the US Institute of Medicine got the diagnosis absolutely right, from a health equity perspective: “If a community has no safe places to walk or play, lacks food outlets offering affordable healthy foods, and is bombarded by advertisements for unhealthy foods and beverages, its residents will have less opportunity to engage in physical activity and eating behaviors that that allow them to achieve and maintain a healthy weight.” Unfortunately this valuable analysis was not, in the end, used to arrive at system-level recommendations appropriate to the scale of the problem. The committee described its approach in terms of “large-scale transformative approaches,” but in its proposed responses it drifted back into behavioural nostrums like “mak[ing] physical activity and integral and routine part of life” and “mak[ing] schools a national focal point for obesity prevention” – an example of the phenomenon Jennie Popay and colleagues have described as “lifestyle drift.” 


Some environments are far more supportive of maintaining healthy weights than others.


A recent literature review on policy interventions to tackle the obesogenic environment produced by the Scottish Collaboration for Public Health Research and Policy, a research unit headed by expat Canadian John Frank, is more effective at avoiding what I have come to think of as the lifestyle trap. Focused on the situation of working-age adults, the review is organized using a framework called ANGELO (Analysis Grid for Environments Linked to Obesity): a simple four-by-two matrix in which four aspects of the environment – physical, economic, political or legislative, and sociocultural – are each analyzed at two levels, micro (the household or community) and macro (the region, province or nation). The authors make a point that has broad applicability in other population health contexts: “[M]any strategies aimed at obesity prevention may not be expected to have a direct impact on BMI, but rather on pathways that will alter the context in which eating, physical activity and weight control occur. Any restriction on the concept of a successful outcome … is therefore likely to overlook many possible intervention measures that could contribute to obesity prevention.”


 The authors of the review are candid about the difficulties facing large-scale interventions that are expensive or challenge vested interests, yet do not shrink from asking tough questions about the need for these, noting (for example) that the transport mode split in urban areas is 84% by car versus 9 percent walking in the United States, while it’s 36% by car versus 39% walking in Sweden. “Suffice it to say, it has been a concerted combination of infrastructure provision, integrated transport planning and disincentives for private cars which has helped to bring about the higher active travel rates,” which include a much larger role for cycling as well. And they argue that because of the relatively high price elasticity of soft drink taxation, it should be considered as a promising intervention along with price reductions of healthy foods like fruit and vegetables. (As an aside on a related point, I once heard a leading aboriginal health researcher wonder why Ontario can ensure that a bottle of whisky costs the same in the province’s far north as in downtown Toronto, but can’t or won’t do this for a carton of milk or a bag of apples.)


A further step in the Scottish review was to create another matrix classifying potential interventions on two criteria: certainty of effectiveness and potential population impact. Here a sugared beverage tax scored high on both criteria, as did healthy eating advocacy campaigns backed with supportive regulation, although curiously none of the policies that have been adopted to increase the costs of car travel scored similarly high, despite the authors’ extensive documentation of the role of public policy and their warning about defining successful outcomes too narrowly. But this is a minor disagreement with an important research synthesis on a complex problem that also provides a methodological template for reviews in other areas. It should be read by everyone concerned with social determinants of health, even if not specifically with overweight. Health policy analysis has joined other, more familiar high quality products for which Scotland is justifiably known far beyond its borders.  

 Blog-overweight 2

 Not the only quality product of Scotland.




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So you think you have free health care?

Posted by guest blogger Sarah Giles
guest blogger Sarah Giles
Sarah Giles is a family physician with an interest in remote and rural medicine.
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on Tuesday, 09 October 2012
in CHNET-Works!

Many doctors do not openly discuss the social determinants of health. It's the dirty little secret of Canadian medicine: income makes a huge difference to your health. In the land of "free" health care, living in poverty is still going to have the biggest effect on a patient's health.

At the recent Canadian Medical Association annual meeting in Yellowknife, doctors finally seemed to acknowledge the poverty=poor health situation. Why has it taken so long for doctors to acknowledge the problem? A cynic might say that it is because the vast majority of doctors come from privileged backgrounds, have an income in the top 5% of Canadians, and generally don't care about or understand the poor. A more forgiving person might argue that, coming from such privileged backgrounds and having little to no formal teaching on the subject, many doctors are unaware of the devastating impact of poverty on their patients. And, in fairness, some doctors do not get much exposure to the poor.

A wise physician once told me: "If you don't know your patient's financial situation, you don't know your patient." Truer words have never been uttered. Yesterday I saw a wheezing little boy in clinic. He is a known asthmatic who had not taken his puffers in 3 months. It would have been easy to dismiss the mother as lazy and "non-compliant". Instead, the aunt (who recently gained custody of the little boy), explained to me that she was now looking after 4 children and could not afford the insurance co-pay on these potentially life-saving medications. She didn't qualify for income support and she had insurance – but she still couldn't afford the medications. So much for universal health care.

Patients with low socioeconomic status face a number of challenges within our system. For the homeless, the first challenge is getting a health card. You need a fixed address to get one and then the organizational skills to hold on to it and renew it every few years. Small wonder that the homeless go to the ER more than almost any population – that's the only place they will be seen without a health card.

Let's say that you are on income support or disability. Your health should be good, right? You likely have housing, get your meds covered, and can even access some allied health resources. But can you afford to eat? Studies show that, actually, in Ontario you can't afford to eat a healthy diet on income support. And, even if you could, you likely live in an area where there are lots of expensive "convenience" stores but very few places to buy fresh produce or healthy foods with a short shelf-life. It's much easier to buy crappy food than anything with nutritional value. So, you put on some weight and develop diabetes. Your meds are covered but since your family doctor isn't part of one of those fancy health teams that you get in rich neighbourhoods, you can't access a dietitian because you Community Health Centre hasn't been able to fill the position and all of the other dietitians charge $70 per hour to tell you what you already know – eat better (more expensive and inaccessible) food.

giles-guest-blog-pic-1 giles-guest-blog-pic-2
Healthy foods are available in some low-income neighbourhoods,
but often "it's much easier to buy crappy food."
Photos: T. Schrecker

Now let's pretend that you have developed crippling insomnia. You can't sleep. You got fired from your last job for falling asleep during the day because you couldn't sleep at night. You are now on income support but that's going to run out soon. You are sure you could get back into the work force if you could just sleep six hours per night. You have tried trazodone and amitriptyline – the infamously ineffective sleep aids – but they didn't work. Your doctor now gives you an option: try zopiclone – a sleep aid that works and has little addictive potential – or try clonazepam – a highly addictive benzodiazepine that requires higher and higher doses as your body becomes habituated to it and a drug with considerable street value. The choice is obvious, you want zopiclone. Unfortunately, the provincial formulary will only cover the highly addictive medication with a street value. Zopiclone will cost you at least a dollar a day – a dollar you don't have.

Nobody ever claimed that life was fair. It is intuitively obvious that the more money you have, the more access you have to goods and services. But should money make such a difference that it can determine how healthy you will be or how long you will live? If we, as Canadians, want to continue to be proud of our "universal" health care, we need to make some changes.

Provincial and non-insured health benefits (NIHB) formularies are set by a bunch of experts sitting in a room. The formulary, to those of us in practice, seems to be arbitrary. There is no explanation as to why one drug is covered and another is not. Recent drug shortages have made life even more difficult as drugs that I would commonly substitute in for a short drug are often not on formulary (for instance, amitriptyline is covered but we couldn't get any; gabapentin is not covered for anything other than seizures so I had nothing to give my patients with neuropathic pain). I'm not sure why we need ten drugs in one category covered when we could have three instead, buy in bulk, and use those savings to incorporate other drugs into the formulary.

Provincial and NIHB formularies need to help doctors decrease addictions to opioids and benzodiazepines. They could do this by covering medications that are currently believed to be less addictive. For instance, I can prescribe OxyNeo (the new version of Oxycontin) until the cows come home but prescribing a long fentanyl patch or long acting codeine requires special forms. Doctors can prescribe massive doses of narcotics but need a special license to prescribe the meds required to help people break their addictions (Suboxone and methadone). Certain non-steroidal anti-inflammatory drugs (NSAIDs) require special permission but massive doses of benzodiazepines don't raise flags in the system. Private insurance fills these gaps for many patients, but creates a two-tiered system.

When poor people get injured their lack of access to out patient allied health services (such as physiotherapy) and non-addictive medications decreases their chances of returning to the work force. If outpatient allied health services were easily available to patients, they would be able to get off of income support faster and be less likely to remain in chronic pain.

Imagine if the thousands of people off work for mental health reasons were able easily to access free psychological help? In Ottawa, the going rate for a psychologist is $160/hr. I know of very few people who can afford this. If they could afford it, many people could remain in the work force or stay off of the streets. Instead, we rely on NGOs to provide care that should really be universally available.

In short, I'm sick of being a doctor who sees such discrepancies in the availability of care, medication, and overall health status between the poor and the rich. I am glad that the CMA is finally taking note of the problem – but how are we going to address it? Having the current Canadian government pull the social safety net out from under those who have the most precarious balance is not going to help matters. Is it only a matter of time before I recommend that patients find a way to get sent to jail so that they can get the medication, rehab, and care they require? There has got to be a better way.

Diabetes in Canada: Parts of the story

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Wednesday, 04 January 2012
in CHNET-Works!

Shortly before this past Christmas, with minimal publicity, the Public Health Agency of Canada released a valuable collection of facts and figures on Diabetes in Canada. It points out (for instance) that in the decade after 1998/99, the prevalence of diabetes among Canadians increased by 70 percent (to 2.4 million), with a predicted increase in prevalence to 3.7 million by 2018/19. Further, "although only 3.1% of all deaths in Canada were attributed to diabetes in 2007, more than a quarter (29.9% of individuals who died had diabetes in 2008/09. Diabetes itself does not typically lead directly to death, but the complications associated with diabetes do." Thus, prevalence figures substantially understate its overall contribution to the burden of illness borne by Canadians; that contribution includes cardiovascular disease (the most frequent complication), eye disease, kidney disease, increased infection from minor injuries and a variety of other conditions.

Diabetes-posting-pic-1Healthy food choices: not always availableThe report's importance in drawing attention to the magnitude of the diabetes-related burden of illness is beyond question, yet its contribution to understanding that burden from a health equity perspective is limited. For the most part the authors adopt a conventional risk factor approach to the causes of diabetes, starting (predictably and non-controversially) with a description of overweight and obesity, and the contributions of limited physical activity and unhealthy eating. A list of self-reported barriers to physical activity is reproduced, as is a list of factors influencing food choices that includes nutritional knowledge, perceptions of healthy eating, media advertising and "lower socio-economic status and social inequity," which is not further explored.

The report's treatment of socioeconomic gradients is similarly descriptive, confined to gradients among adult Canadians across Canada, stated by income quintile and education level, in self-reported obesity, physical inactivity, inadequate fruit and vegetable consumption, and daily tobacco smoking. Curiously, data on socioeconomic gradients in actual prevalence of diabetes are not presented, although according to Canadian Community Health Survey data prevalence of Type 2 diabetes in the lowest household income group (income less than $15,000) is more than four times as high as in the highest income group (over $80,000). According to the authors of this last study, "individual risk behaviours do not explain a substantial part of the income association," suggesting "that the diabetes burden associated with poor health behaviours should be looked at through the lens of socioeconomic conditions."

Diabetes-map-1Age- and sex-adjusted diabetes prevalence per 100 persons of all ages, Toronto, 2001-02. Source: Booth GL, Creatore MI, Gozdyra P, Glazier RH. Diabetes in Toronto, Chapter 2: Patterns of Diabetes Prevalence, Complications and Risk Factors. Toronto: Institute for Clinical and Evaluative Sciences; 2007. Reproduced by permission.


Diabetes-map-2Average annual household income, Toronto, 2000. Source: Creatore MI, Gozdyra P, Booth GL, Ross K, Glazier RH. Diabetes in Toronto, Chapter 3: Socioeconomic Status and Diabetes. Toronto: Institute for Clinical and Evaluative Sciences; 2007. Reproduced by permission.

Finer-grained examinations of how socioeconomic conditions affect the origin, management and prognosis of diabetes can be found in several places. The Toronto diabetes atlas project of the Institute for Clinical Evaluative Sciences produced a multi-volume mapping of diabetes prevalence and a range of neighbourhood characteristics; just two of the 140 maps generated by the project are shown here. To oversimplify a complex set of findings, the project found that higher-income neighbourhoods generally had lower prevalence of diabetes. Prevalence was especially high in low-income neighbourhoods outside the downtown core, with high proportions of recent immigrants and members of recent minority groups. These neighbourhoods tended to have lower population densities, poor walkability, limited access to public transit and long distances to stores selling fresh fruits and vegetables (the 'food desert' problem) and other so-called healthy resources like parks. Conversely, high incomes seemed to have a protective effect against diabetes, even in neighbourhoods where adverse outcomes would be expected based on place-related characteristics. "We noted a striking mismatch," the authors concluded, "between areas of Toronto where healthy resources were most needed and where they were located."

Diabetes-posting-pic-2Activity-friendly urban environments like this may be inaccessible to people in low-income neighourhoodsThere is also, as I have pointed out in previous postings, the simple arithmetic impossibility of eating a healthy diet for many people living on low incomes if they are also paying market prices for housing. Indeed, a series of interviews by York University's Dennis Raphael and colleagues (1) with people trying to manage diabetes in Toronto on incomes below Statistics Canada's Low-Income Cutoff (LICO) found food insecurity and inability to afford an adequate diet widespread "even with almost two-thirds [of participants] living in some form of government-assisted housing or shelter." Two recent articles (2,3) by Claudia Chaufan and colleagues similarly explore the interaction of low incomes, limited availability (and high local prices) of healthy food, high transportation costs and other variables like insecure employment in a Latino and immigrant neighbourhood in Northern California, concluding that structural factors limit the relevance of health and lifestyle education interventions – a point that should by now be familiar, but nevertheless merits continued repetition. One interview respondent summed up the range of problems: "You know, it's a full time job to be poor."

Variables like those identified in the Toronto and Northern California studies are not prominent in the PHAC report, beyond brief generic discussion of healthy food choices and of the built environment. New York-based researchers Rodrick and Deborah Wallace have eloquently compared individualized explanations of obesity that focus on imbalance between caloric intake and exercise to "the remark by US President Calvin Coolidge on the eve of the Great Depression that 'unemployment occurs when large numbers of people are out of work' ... and as Raphael pointed out in a holiday posting on his Social Determinants of Health listserv, the word "poverty" appears nowhere in the PHAC report. (I checked; it doesn't.) That report remains useful, yet at the same time shows how very much still needs to be done to integrate social justice and social determinants into the everyday worldview of public health professionals.


(1) Raphael D, Daiski I, Pilkington B, Bryant T, Dinca-Panaitescu D, Dinca-Panaitescu S. A toxic combination of poor social policies and programmes, unfair economic arrangements and bad politics: the experiences of poor Canadians with Type 2 diabetes. Critical Public Health 2011 [online publication] (full text unfortunately not available for open access).

(2) The Twin Epidemics of Poverty and Diabetes: Understanding Diabetes Disparities in a Low-Income Latino and Immigrant Neighborhood. Journal of Community Health 2011;36:1032-43, (full text unfortunately not available for open access).

(3) Chaufan C, Constantino S, Davis M. 'It's a full time job being poor': understanding barriers to diabetes prevention in immigrant communities in the USA. Critical Public Health 2011 [online publication] (full text unfortunately not available for open access).

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