Reducing deaths by diet

In Canada, chronic diseases including cardiovascular disease, diabetes, respiratory disease, mental illness, and cancer are the leading causes of disability and premature death. Treatment of chronic disease consumes 67% of all direct health care spending and costs the Canadian economy $190 billion annually—$68 billion is attributed to treatment and the remainder to lost productivity.^1,2 There is little doubt that the most prevalent chronic health conditions today are largely the product of interactions among a small set of well established modifiable risk factors that include physical inactivity, tobacco use, excess alcohol consumption, and unhealthy diet.^3–6 According to the Global Burden of Disease study, unhealthy diet has been the leading risk factor for illness, death, and disability both in Canada and worldwide for more than 2 decades.⁷ Family physicians spend a considerable amount of their time caring for patients with chronic diseases caused or accelerated by unhealthy diet. In addition to treating and counseling individual patients in their practices, family physicians are uniquely positioned to advocate for public health policies designed to improve the diets of Canadians.

Unhealthy diet can be broadly defined as foods and beverages that are high in saturated fat, trans fats, free sugars, and salt. Unfortunately, this is the usual diet consumed by most Canadians today.^8–12 It has been estimated that more than 30 000 deaths could be averted or delayed annually in Canada if our diets complied with dietary recommendations, particularly for greater fruit and vegetable intake.¹³ A recent meta-analysis concluded that, at a population level, the risk of cardiovascular disease was reduced by 4% and that total premature death rate was reduced by 5% for each additional daily serving of fruits and vegetables.¹⁴ This type of evidence underscores both the importance of a healthy diet to our well-being and the importance of public policies to support healthy dietary choices.

Governments, policy makers, and national and provincial health associations can make better use of a range of policies and strategies to improve diet and hence reduce the burden of chronic disease.^5,6,15 The World Health Organization has identified healthy dietary policies as key interventions to reduce the burden of noncommunicable diseases.⁵ While other countries are implementing public policies to reduce dietary risk factors,⁶ Canada continues to promote individual-based approaches and educational strategies targeting behaviour change. While individual approaches are clearly important, without comprehensive public policies and interventions, the challenge of curbing the chronic disease epidemic will not be met.¹⁶

Canada has developed, federally and provincially, a series of chronic disease strategies and frameworks that recommend population-based interventions and dietary policies. These strategies include reducing sodium in the food supply, restricting unhealthy food marketing to children, and implementing healthy food and beverage procurement policies.^17–20 Unfortunately, these strategies and frameworks have yet to result in substantive policy changes.

National health organizations’ response

In response to the absence of comprehensive policy changes, Eat Healthy Stay Healthy. A Call for Action to Implement a Healthy Food Policy Agenda²¹ has been developed and supported by 15 Canadian primary care and health organizations, including the College of Family Physicians of Canada (CFPC).

Echoing the policy recommendations of global and national health organizations and associations,^3,5,6,8,15 the call to action identifies key interventions that, if implemented as part of a comprehensive food strategy, could meaningfully reduce the rising tide of diet-related chronic disease. These include the following:

• restricting the marketing of unhealthy foods and beverages to children;

• regulating the addition of sodium, free sugars, saturated fats, and trans fats in processed food products;

• establishing simple easy-to-understand nutrition labeling on processed food products and in eating establishments;

• introducing targeted subsidies for healthy food products combined with taxation of unhealthy food products;

• implementing healthy food and beverage procurement policies in publicly funded and private sector settings; and

• developing standards to reduce conflicts of interest in nutrition policy development.

Advocacy opportunities

Just as tobacco control required strong leadership, advocacy, research, and policy implementation and evaluation, a comparable approach is needed to address diet as the leading risk of chronic disease–related disability and death in Canada. Canadian governments have the legal authority to reduce the production, marketing, and sale of unhealthy foods and beverages known to contribute to development of chronic disease. To be effective, however, a concerted multistakeholder response is needed from Canada’s health and scientific organizations, the private sector, and individuals, including family physicians. For many Canadians, and especially those living with chronic disease, family physicians are the most frequent point of contact and are familiar with diet-related chronic diseases. In addition to the important clinical role of helping their patients to adopt and maintain healthy diets, there is an opportunity and role for family physicians to advocate through the CFPC and its provincial Chapters. Indeed, the CFPC’s From Red to Green report recommends, among other actions, that the federal government ban junk food advertising to children, improve clarity of food labeling and nutrition information, and explore tax and subsidy strategies to increase the consumption of healthy foods and decrease the consumption of unhealthy foods.²²

To the extent that cardiovascular disease represents the greatest burden of diet-related disease, the family medicine community has an important responsibility at the individual patient and policy levels to improve the diets of Canadians. At the organizational level, the CFPC and its provincial Chapters can continue to support national calls to action. The effects of poor diet on premature morbidity and mortality should be a substantive part of our academic and education-related endeavours. Likewise, individuals and organizations can advocate for more research funding to assess and monitor dietary trends and the effects of nutrition policy on health outcomes to inform future research and policy priorities.

Conclusion

Canada’s policy responses to improving diet are not keeping pace with the successful action being implemented in many other countries. We support the conclusions of a recent Lancet series focused on obesity prevention and control that highlighted 5 messages that need to form the basis of a unified response.¹⁶ First, the epidemic of diet-related chronic disease will not be reversed without strong government leadership. Second, the status quo will be costly in terms of population health, health care expenses, and loss of productivity. Third, assumptions about the long-term effects and sustainability of individual-based efforts are overly optimistic. Fourth, there is a need to accurately monitor and evaluate both basic population nutrition data and intervention outcomes. Fifth, a multisectoral systems approach is critical to success. Family physicians collectively and individually can play substantive roles in advocating for healthy food policies to improve health and reduce the burden of noncommunicable diseases in Canada. Together, we can make changes to improve our patients’ health.