Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 36 - Evidence - June 4, 2015
OTTAWA, Thursday, June 4, 2015
The Standing Senate Committee on Social Affairs, Science and Technology met this day, at 10:30 a.m., to continue its study on the increasing incidence of obesity in Canada: causes, consequences and the way forward.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I'm Kelvin Ogilvie, chair of the committee, from Nova Scotia. I'm going to invite my colleagues to introduce themselves, starting on my right.
Senator Seidman: Judith Seidman from Montreal, Quebec.
Senator Raine: Nancy Greene Raine from B.C.
Senator Frum: Linda Frum, Ontario.
Senator Wallace: John Wallace from New Brunswick.
Senator Nancy Ruth: Nancy Ruth from Ontario.
Senator Merchant: Pana Merchant, Saskatchewan.
Senator Stewart Olsen: Carolyn Stewart Olsen, New Brunswick.
[Translation]
Senator Chaput: Maria Chaput from the province of Manitoba.
[English]
Senator Eggleton: Art Eggleton, senator from Toronto.
The Chair: And deputy chair of the committee.
For the benefit of those watching, this meeting is a continuation of our committee's study, which is to examine and report on the increasing incidence of obesity in Canada, causes, consequences and the way forward.
I am very pleased today to be able to welcome, as our witness for this session, from the Organization for Economic Co-operation and Development, the OECD, Franco Sassi, Senior Health Economist, Health Division. He's joining us by video conference, and I now would like to welcome him to the committee and invite him to make his presentation. Mr. Sassi, please.
Franco Sassi, Senior Health Economist, Health Division, Organisation for Economic Co-operation and Development: Thank you. I'm very pleased to be here today. Good morning.
The presentation I've prepared is very short. I'm not able to show you PowerPoint slides, unfortunately, by video link, but I can point to the figures that are in the document that I circulated. I assume every member of the committee has a copy of the document. Is that correct?
The Chair: That's correct.
Mr. Sassi: Thank you.
I will briefly introduce the subject by illustrating a few findings of OECD work on the growth of obesity in Canada and across the OECD countries, some of which I'm sure you're aware of because they might have been brought up in previous discussions in front of this committee.
Essentially, Canada is consistently at the top of the league table of OECD countries in terms of obesity and overweight rates — not at the very top. It's not the leading country, but it's among a small group of countries that have the highest rates of obesity. It has been consistently so since we measured these indicators across OECD countries.
The graph you see in figure 1, in particular, shows how Canada compares with all other OECD countries, plus a number of countries that are not formally members of the OECD but are what we call "Key Partners." These are emerging economies like India, China, Brazil and so on. You can see that Canada ranks in fifth place in this league table, with about one in four people who are obese in the adult population.
The rates that are reported in this figure are measured rates, based on measured height and weight, which is not, unfortunately, as consistently measured as self-reported obesity, based on self-reports of height and weight, which inform some of the other analyses that I presented in my notes.
Child obesity is also a great concern in Canada. Canada has very high rates of child obesity. One in ten boys is obese, which is really at the top of the OECD league table.
Rates of obesity have continued to increase in Canada. In our latest Obesity Update, published in June of last year, we showed that a number of OECD countries have somehow managed to slow down the increase in obesity in the adult population, but Canada is not one of them. Obesity maybe has been growing at a slower pace than in some other countries, but it has continued to grow even in the last few years.
In 2010 we made projections, and the rates of obesity that we have observed after 2010 have really followed the progression that we predicted back then.
What you can see in figure 2 is actually the increasing rates of obesity over time, since the early 1990s up to 2011, and the projections for further growth from now to 2020.
In this graph, we have self-reported rates of obesity, which are lower than the rates of obesity based on measured data. But, unfortunately, measured obesity, as I mentioned before, is not consistently available over time, so these long-term time series can only be calculated based on self-reported rates, which nevertheless provide a good picture of how obesity has been growing over time.
The reasons why we should be concerned about obesity include not just the health consequences of obesity, which are major. Obesity has very close links with diseases like diabetes, cardiovascular disease, certain types of cancer and musculoskeletal diseases, but there are also social and economic impacts, which are of major concern in OECD countries. In particular, we know that labour market outcomes are affected by obesity. People who are obese have a lower probability of being employed. They earn less when they're employed, up to 18 or 20 per cent less in some countries, and they have a lower productivity at work and a higher probability of retiring from their job early on illness grounds.
These are all factors that contribute to a social burden of obesity that has been of major concern to our member countries, and Canada is clearly in a critical position relative to other OECD countries.
A large part of the work that the OECD has done has been focused on what countries can do to address the obesity epidemic. We have spent a considerable amount of time looking into policy options, and Canada is one of the countries that we focused on in particular, with analyses that were published in 2010 in the run-up to the 2010 OECD meeting of health ministers and just before the UN high-level meeting on non-communicable diseases in New York in 2011.
The results that we have produced for Canada show that if Canada were in a position to adopt a comprehensive prevention strategy, this would have the potential to add 60,000 years of life in good health every year to the health expectancy of the Canadian population.
We also calculate the number of years free of major diseases like cardiovascular disease and cancer, and we have calculated that over the 10 years following the implementation of such a comprehensive prevention strategy, Canada could have a gain of 150,000 years of life free of cardiovascular disease and 250,000 — a quarter of a million — years of life free of cancer over the next, as I say, 10 years.
The cost of implementing such a prevention package would be relatively limited compared to what a country like Canada is spending today on prevention. We calculated that it would be about $30 per person in Canada, which is about one tenth of what Canada is currently spending on prevention.
The solutions that have been adopted in Canada to some extent reflect what other countries have also been doing. There is a consistent trend towards a tightening of policies to tackle obesity in OECD countries, as countries have been realizing that the consequences of obesity are major for the health of their population and for their economies.
Many countries have been trying to use measures like fiscal policies, including taxes, and subsidies sometimes. Canada has led the way in the use of a tax credit, which has been an example for other countries. But in terms of taxation, other countries have been more proactive and have adopted taxes, for instance, on sugar-sweetened beverages or on products high in saturated fat. Not all of these taxes have been successful. Clearly, these taxes are complex measures to implement, and they require very careful design to prevent unintended consequences.
Generally speaking, a prevention strategy that is effective must include multiple approaches. There should be a combination of population-wide approaches that address the problem on a large scale for a large number of people and population groups. As well, there should be individual approaches based on the targeting of those who are most at risk for the consequences of obesity, like, for instance, through primary care physicians who can counsel patients who have the first signs of obesity and diabetes and prevent further disease consequences in these patients.
I think I should stop here probably. Our work at the OECD has covered a lot more in terms of the development of the obesity epidemic and ways of addressing it, but I'm happy to take specific questions on aspects that are of more interest to the committee.
The Chair: Thank you very much, Mr. Sassi. It's a sobering summary that you have presented. I'm now going to open the floor up to my colleagues.
Senator Eggleton: Thank you very much for your presentation and for your work, over years, in this area.
I can understand that the last point you made about physician counselling would be very beneficial. We've heard this before. We're trying to get our heads around just how that might happen. Physicians don't come under federal regulation to start with, but we can work our way around that.
What about other prevention interventions? What about food labelling? What about food advertising regulations? Do you have any suggestions in that area?
On the one that I first raised, the physician counselling, are there any countries that have done particularly that well, who have implemented plans that are showing signs of reducing the obesity rate?
Mr. Sassi: If you look at figure 4 in the note I circulated, it shows a ranking of the policy interventions that we have looked at in Canada, and policy options for Canada. Basically we see — and it's a consistent finding across all countries that we have been looking at — that physician/dietitian counselling in primary care is by far the most effective way of addressing the problem, because it focuses on people who are at high risk. It has been proven in a number of studies to be very successful in changing behaviour at the individual level.
The challenge with this type of intervention is precisely in the ability of countries to scale up these interventions at the national level and overcome the capacity constraints that typically affect primary care in all countries. There may be legal constraints as well in some countries, as you mentioned, but there are capacity constraints virtually everywhere in primary care.
There's also a lack of awareness on the part of primary care physicians of the potential value of some of these interventions. That applies to diet and physical activity, as well as to other behavioural aspects, like harmful alcohol use. Primary care physicians do not always realize that spending more time with patients, counselling them on lifestyles, is at least as important as addressing the disease concerns that they may be reporting to their physicians.
For these problems, I'm afraid that no country has been successful in scaling up these types of programs. Some countries have tried to provide incentives, even monetary incentives, to physicians to do this, but I must say that the evidence of the success of these programs has been very limited.
Food labelling and advertising regulation, as you can see in this ranking, rank much lower than other interventions in terms of the effects that they can produce. What we know is that people react to these interventions only to a limited extent.
I should probably address them separately, because the problem with advertising regulation is that clearly it's mainly aimed at children. The forms of regulation of advertising that have been implemented so far in countries have been focusing on the advertising of potentially unhealthy foods to children. The time it takes for these interventions to produce visible effects at the population level in terms of reduction of chronic disease rates and improvement in population health is extremely long. There is a lot of uncertainty as to whether the benefits of reducing exposures in childhood are carried forward in adult life.
Food labelling is a different question. I think we are still experimenting with different approaches to food labelling. There is some evidence that certain types of food labelling have been effective, but not all of them. I think the jury is still out on what can be achieved by using food labelling.
In Canada, a lot of emphasis has been placed, perhaps more so than in other countries, on voluntary programs like healthy checkmarks on certain food products, which have shown to be effective in some small-scale studies, but they have yet to be proven effective in terms of improving population health on a large scale.
Senator Raine: Thank you very much. In your opening message, you said that Canada is among the countries that have led the way. I wish you would rephrase that to say that Canada is among the worst countries, because we like to lead the way, but not in this.
Could you give us some examples? You said the issue of taxes on sugar-sweetened beverages is complex and the regime needs to be carefully designed. Could you give us examples or name countries that have done this successfully, and what we should look at?
Mr. Sassi: Yes. Taxes on sugar-sweetened beverages are probably the single intervention that is most widely debated at the moment — and has been so for the last few years — on obesity. There has been a polarization of views. The expectations have probably been too high on the part of the supporters of sugar-sweetened beverage taxes, and on the other hand there has been criticism that they are not always justified.
Basically, the main concern is what can be achieved. There is enough evidence to show that taxes on sugar-sweetened beverages can certainly contribute to reducing the consumption of free sugars, which have been shown to have contributed to the obesity epidemic, not least by the recent work of the WHO and the guidelines that have sanctioned this into a formal framework, but also preventing some of the disease consequences of obesity in the long term.
There's no question that taxes can be effective in improving population health. The criticism centres around the regressive effects of taxation, which are clearly a concern for many countries, particularly at a time of crisis, with rising unemployment and knowing that many people who engage in heavy consumption of sugar-sweetened beverages are often from the most disadvantaged social classes.
The regressive effects of taxes need to be looked at in perspective. The proportion in which people in different social classes are affected financially by taxes on sugar-sweetened beverages has been shown to be about 1 to 10 for people in high social class versus people in low social class. Essentially, people in low social class bear 10 times as large a burden of taxation as people in high social class.
However, this may not be so much of a concern if you look at the actual numbers involved. At least one study from the United States has shown that this 1 to 10 proportion is actually translated into monetary amounts of $19 to $23 per year. So there is a $4 per year difference between low-income households and high-income households in terms of what they spend on sugar-sweetened beverage taxes in a simulation model. So we are talking about a regressive measure, but a measure that has effects that are relatively limited on the finances of individual households.
The other question is what people would be substituting into. If they stop drinking sugar-sweetened beverages, what will they drink instead? That is a big question that no country has been able to address in a comprehensive way, because the taxes on sugar-sweetened beverages that have been designed and implemented in different countries are actually applied to different groups of products, with different types of substitutions resulting from the tax as a consequence of the relative changes in prices.
For instance, France has decided to tax all soft drinks, sugar-sweetened beverages, as well as artificially sweetened beverages, which means that the substitutions from sugar-sweetened beverages into artificially sweetened beverages have not been possible or have not been encouraged very much.
Other countries have decided to tax only sugar-sweetened beverages, such as Mexico. That is the country that has most recently applied this tax. More substitution into artificially sweetened beverages is expected, although the data have not yet been produced of the effects of the tax in Mexico.
The problem of designing the tax base in this case is extremely important. The rate at which the tax is applied is also extremely important, because if we want to achieve meaningful effects at the population level, the tax rate needs to be sufficiently high.
We know that the demand for many commodities like soft drinks is often inelastic — that's what the economists say — which means that people change their consumption to a relatively modest extent compared to the size of the change in price. We know that if we want to get a meaningful change in the consumption of a particular product, we need to impose high rates of tax, which not all countries are in a position to do or politically willing to do.
Senator Raine: What, in your opinion, is the country that's doing the best job on this in terms of that balance between a tax that is high enough to make a difference and I suppose taxing just the sugary drinks?
Mr. Sassi: Hungary is doing a good job in a number of ways. There are early evaluations of the taxes imposed in Hungary, which are broader than sugar-sweetened beverages. They cover a number of products that are deemed less healthy and seem to have been successful in early evaluations. Hungary has also earmarked part of the tax revenues to fund health care activities. So there is an added value of the tax from a health care point of view, which is not common to other countries.
Mexico is an example that many countries are looking at. As I say, we are eagerly waiting for the results of the early evaluations of the Mexican experience. They have combined a tax on sugar-sweetened beverages with a tax on snack food, so food high in calories and low in nutrients, which is a potentially promising combination in the use of fiscal measures to prevent obesity. But, as I say, we are still waiting for the results of these evaluations.
Senator Raine: Do you know if the United States is looking seriously at this intervention?
Mr. Sassi: There are local areas. The City of Berkeley has approved the use of a soda tax. In other cities, particularly in California, there have been a number of referendums to vote on tax measures on sugar-sweetened beverages. As far as I know, Berkeley is the first one that has passed this tax.
At the national level, the time when the debate seemed to be leading seriously to the implementation of a tax was when the Affordable Care Act was being debated, so when President Obama had just been elected to office. But the proposal at that point was abandoned and was not revived after that, so I don't think there is a serious prospect of a federal tax being implemented in the United States in the short term.
Senator Nancy Ruth: Picking up on the same issue of tax, you said in your paper that Denmark introduced a tax on foods high in saturated fat and it didn't work. Could you tell us why it didn't work in Denmark and provide other examples where it's not working? Could you tell us what the rates of tax sugared drinks are in Berkeley and California and other places?
Mr. Sassi: I don't have comprehensive information about the tax rates, but I can tell you a bit about that in a moment. Let me start with Denmark.
The example of Denmark is not actually an example of failure. I think in a way it can be described as a political failure because the government first implemented the measure and then withdrew it only after one year.
From the point of view of the health effects of this tax, it has been widely regarded as a successful tax. It's a unique example. Denmark was very brave in trying to tax saturated fat, which for a long time has been considered one of the major causes of obesity and poor health, particularly cardiovascular health. It is a challenging tax to implement because saturated fat is in many different types of food and it occurs in different quantities. Devising a system that targets the foods that are highest in saturated fat was not an easy task for the Danish finance minister.
They managed to implement a system that was reasonably well designed, and the tax, as I say, was very successful. All evaluations have shown that the consumption of saturated fat had decreased, that health had improved. A number of recent evaluations have taken into account health outcomes that have shown an improvement.
On the other hand, there has been a change of government, which is a major consideration of course. There has been strong opposition by the food industry. Media opposition turned the tide of public opinion against this tax at some point. There have been claims that were, to some extent, misleading about cross-border trade, people travelling across the German border to purchase foods high in saturated fat, and all of this contributed to the government deciding that the tax was no longer politically sustainable and deciding to withdraw it.
As I say, all the information we have, all the evidence that exists on the health effects of this tax, is favourable to the tax. The revenues that were raised through the tax were quite important. They were actually higher than some of the alcohol taxes that Denmark has. They were predicted very precisely by the finance minister. So the tax was very well planned.
The problem with sugar-sweetened beverage taxes that exist today is that the rates are not particularly high. That is one of the aspects of these taxes that has been criticized by economists who have been looking at the implications of these taxes.
The tax that we have here in France, for instance, is ridiculously low. It is at the level where it probably makes a tiny, if any, difference in the amount of sugar-sweetened beverages that people consume. The tax in Mexico has also been criticized by advocacy groups as being too low. I think the tax that has been approved in Berkeley is "penny-per-ounce" tax, which had also been advocated at the federal level within the debate I mentioned before, in the process of approving the Affordable Care Act. When it was actually getting into the nitty-gritty of designing the tax, the discussion was about a "penny-per-ounce" tax, which has more effect on the price at the point of consumption, and is large enough to make a difference in terms of people's health.
Senator Nancy Ruth: Were the food industries involved in the Danish experiment when they decided to tax this? You talked about a media campaign and change in political thinking, but if I were a food manufacturer and I saw my sales going to Germany, I would be out doing something about it. Do you know what relationship they had to the food industry before they initiated this policy?
Mr. Sassi: I don't think the food industry was consulted on this policy. If they had been, certainly they would have opposed it. The food industry is clearly campaigning against the use of taxes on any foods, mainly on the grounds that they distort competition, that they unfairly target some foods and not others. In the case of Denmark, they claimed that people were going across the border to purchase foods. It was largely unsubstantiated, but it is one of those claims that once they make the headlines, they can make a difference in terms of public opinion.
In a climate in which Europe was concerned about loss of jobs and the slow recovery of the economy, clearly that claim was important in the public debate.
Senator Nancy Ruth: Have you seen any indication in the OECD from beverage manufacturers or food manufacturers to lower their rate of sugar or fat?
Mr. Sassi: There are many examples. Without mentioning specific companies, I think all producers of sugar-sweetened beverages have recently increased their investments in alternative sweeteners and many products have been launched to replace the traditional sugar-sweetened beverages.
One of the problems with substitutions that I mentioned before is that, in principle, we would want people to switch from sugar-sweetened beverages to other types of beverages that do not contain sugar. But the World Health Organization does not recommend replacing sugar-sweetened beverages with artificially sweetened beverages because safety and the long-term health effects of those beverages are still quite uncertain.
I am not an expert on this; I am not a nutritionist. However, it is my understanding that there is quite a bit of evidence that artificial sweeteners increase the craving for sugar in consumers. So they may end up having the opposite effect in terms of overall sugar consumption. There are still big question marks as to whether it is useful to incentivize people to shift from sugar-sweetened beverages to artificially sweetened beverages.
Senator Seidman: Thank you very much, Mr. Sassi.
I would like to ask you about the basis for some of the evidence and the measures you have presented to us. Specifically, could we look at figures 4 and 5 of your document?
I would like to know what kind of studies you used for your prevention interventions. You list school-based interventions, mass media campaigns, food advertising and a series of things as interventions, but did you classify particular kinds of studies? If so, how many studies are across these interventions altogether?
Mr. Sassi: The approach we used here at the OECD, in the particular case of obesity, was designed in collaboration with the World Health Organization. We had a close partnership in this work. It is work based on computer simulation models.
Essentially, we developed jointly with the World Health Organization a simulation model that enables us to reproduce the epidemiology of diet, physical activity, obesity and the diseases associated with them in a population. Then we test what the impact of specific policies would be on the risk factors and diseases that are linked with obesity.
The policies are selected on the basis of the strength of the evidence base on the effects of these policies. We have selected interventions for which there is a stronger evidence base, for which there are a larger number of studies that are methodically stronger. We have comprehensively reviewed the available evidence of the effects on behaviour of each of the interventions in figure 4. We estimated the impact at the population level of the implementation of these interventions and the changes that they would produce at the individual level in the consumption of foods, for instance, in the levels of physical activity that people do and in the diseases that will be affected by those behaviours.
Senator Seidman: Basically you have done a computer simulation? I am trying to understand.
Mr. Sassi: That is right.
Senator Seidman: It is based on reviews of the literature across all these countries; is that correct? Is it peer-reviewed literature, clinical studies of one sort or another that have been classified? In other words, it's a meta-analysis, or something like that, so you are clearly using consistent methods across studies, categorized outcomes and things of that nature; is that correct?
Mr. Sassi: Absolutely, yes. That is correct.
Senator Seidman: How do you measure life years in good health?
Mr. Sassi: Life years in good health is a simplification to avoid using the acronym that is used by the WHO, which is called DALY, the disability adjusted life year. I didn't assume that people would know what a DALY is, so I didn't use that acronym. This is what we are measuring. It is an established measure that was designed in the early 1990s by the WHO and the World Bank for estimating the global burden of disease.
We are using it in the framework of our effectiveness and cost effectiveness analysis of the policy options to tackle obesity as a measurable outcome. It combines life expectancy with levels of disability associated with the diseases that may be linked with obesity. It is a way of combining mobility and mortality in the same measure, basically.
Senator Seidman: I presume that under fiscal measures in this same figure you mean tax, the kinds of things we talked about. Would those be tax measures?
Mr. Sassi: Absolutely. It's a combination. In this particular analysis, we tested a combination of taxes and subsidies. The tax would be on foods high in fat, and the subsidy would be on fruits and vegetables.
In both cases, we assumed there would be a change in price of 10 per cent following the tax and the subsidy, so the price of foods high in fat would go up by 10 per cent and the price of fruits and vegetables would go down by 10 per cent. Based on the existing evidence, that would have the effect of changing consumption by 2 per cent in either direction of fat and fruits and vegetables.
Senator Seidman: Thank you.
Regarding figure 5, you have the economic impacts of prevention programs in Canada, and you evaluate ways based on intervention costs, health expenditure and then a net cost. How do you measure the intervention cost and the health expenditure?
Mr. Sassi: Figure 5 is important because it shows that prevention doesn't always save money, which is counterintuitive for many because people often have high expectations of prevention. They expect that by preventing diseases from occurring in the first place, they would reduce health expenditures dramatically.
In fact, health expenditures are only reduced to some extent. What you see in the red bars below the horizontal axis is the size of the reductions in health care expenditures that can be achieved by implementing the interventions listed in the graph. These savings in health care expenditures, to answer your question, are measured in terms of the reduction in treatment costs for the diseases linked with obesity.
For instance, by reducing levels of obesity, if we prevent a case of myocardial infarction or cancer, those would be counted as reduced expenditure. The value of the simulation model we are using is that we don't stop there; the life of the individual continues after the disease event is prevented. These persons will end up developing either the same disease a bit later in time or a different disease.
In terms of impact on the health care budget, it would be much more limited than just the disappearance of the cost of treating the initial event that had been prevented.
This is why the size of those red bars — the size of the savings in health care expenditures — is relatively modest, especially when compared with the cost of implementing these interventions, which is what you see in the blue bars. These are essentially the costs involved in delivering the programs listed there.
Of course, physician/dietitian counselling based in primary care is, by far, the most expensive program because we need to take into account the time the physician spends with a patient as well as the time required to select the patients that can potentially benefit from counselling. Other interventions like fiscal measures, for instance, or mass media campaigns have a relatively small cost of implementation because they are reasonably less resource-intensive.
Senator Seidman: So in fact the most effective intervention as you have described, physician/dietitian counselling, produces the most life years in good health and has the highest cost.
Mr. Sassi: Absolutely, yes.
It's important not to mix up two different concepts that we need to keep separate. One is whether interventions save money, and that is the case for only a small number of interventions in the case of obesity prevention. Here we only have fiscal measures and possibly food advertising self-regulation, which save money, but all others have costs of implementation that exceed the savings in health care expenditures, so they cost money. There is a net cost from the implementation of those policies.
A different concept is whether these interventions are cost effective, whether they are good use for the money spent. All of these interventions are very good value for the money spent. All of these are cost-effective. Even physician/ dietitian counselling, despite the relatively high cost compared to other interventions, has a very low cost-effectiveness ratio when we compare it to things we do in our health care services that we consider to be totally acceptable and reasonably priced.
Senator Seidman: You are now answering my next question, which is very nice. I would like to ask you about the cost-effectiveness. In fact, you make a statement here that the price of a comprehensive package of measures to counter obesity in Canada was estimated by the OECD in 2010 as $33 Canadian. That sounds like a pretty amazing cost-effectiveness package to me. Could you tell me what you mean by that? What is the comprehensive package of measures and how do you calculate $33?
Mr. Sassi: Essentially, the $33 is the sum of the costs that you see in the blue bars in figure 5. Of course, it is $33 is per person, whereas the costs in figure 5 are the total costs at the population level for Canada.
The package of interventions includes a mix of the individual interventions that you see listed in figures 4 and 5. If I remember correctly, we have a mass media campaign, a school-based intervention, fiscal policies and physician/ dietitian counselling. It is a combination of these measures designed in a way that covers the broadest possible range of population groups. Clearly, these policies affect people of different ages and different social conditions as well, so we tried to devise a package that covers the broadest possible range of population groups and the largest number of people in the population.
Senator Seidman: Basically, all of the information you have provided to us is based on analyzed studies and then computer model simulation; is that correct?
Mr. Sassi: That is correct. There is no way to empirically estimate the effects of policies like the ones listed here. There is no way we can observe effects that occur 20 or 30 years down the line that can be confounded by many factors, including individual behaviours as well as environmental factors. So using computer models is a necessity.
Of course, we need to start from empirical studies that tell us the effectiveness of these policies in changing individual behaviour. That can be measured empirically in the short term. Then, if we want to project those effects at the population level, we need computer simulation models.
Senator Seidman: Yes, thank you. I understand your explication for us. It has been very helpful.
Senator Merchant: Thank you, Mr. Sassi. I am looking at figure 1 of your materials, which is the prevalence of obesity in adults in OECD countries.
On the chart that you have given us, most of the data is self-reported rather than measured. I want to be sure exactly what you mean by "self-reported." How reliable is that? You have given Canada a very bad grade, but when I look at this chart, I see the people that have a bad grade at the bottom of this chart are "measured data." The ones getting away with it are "self-reported." What do you mean by "self-reported" and how reliable is it?
Mr. Sassi: That is a very fair point.
Self-reports of BMI are based on interviews, typically interview surveys in which people are asked about their height and weight. People are known to misreport their height and weight. In particular, there is evidence that women under-report their weight and men over-report their height. So there are patterns that have been shown clearly in several reports.
The United States is one of the countries that has done multiple surveys that measure as well as ask individuals for their height and weight. The direct comparison in the same survey between the measured data and the self-reported data clearly show there is a gap.
The gap is reasonably consistent over time in most countries, and that is the reason why, in figure 2, we are using self-reported data for Canada to show the progression of obesity rates, because we don't expect the bias in self-reports to be changing over time. At least we can get a good picture of how obesity rates are growing over time if not the absolute level of obesity rates.
In fact, you see here that in 2011 the level of obesity according to self-reported data in Canada was below 20 per cent — it was around 18 per cent — whereas we know that obesity rates were actually around 24 per cent in Canada at that time. There is an under-estimation of about 6 percentage points at the national level. That certainly applies to other countries as well. Hypothetically, if we had measured data for all the countries that you see listed in figure 1, I think there would still be relatively few that would overtake Canada in the ranking.
When we look at child obesity rates, for which we have measured obesity rates for virtually all OECD countries — for different age groups, sometimes — Canada is still ranking at the top of the league table. I think it is fairly accurate to say that Canada is one of the countries with the highest obesity rates, despite the good point that you made, which is certainly valid, that countries with lower rates tend to have self-reported BMI only and not measured BMI.
Senator Merchant: It is also interesting to see that three out of the five countries with the highest obesity rates are in North America. You had Mexico, Canada and the U.S., as well as Australia and New Zealand. That was interesting.
Also, at the top of the chart with the least prevalence — much lower — were countries in Asia and in the Far East. Is it dietary patterns? What do you deduce from all the work that you do? What can you tell us that would be informative or instructive? We are looking at reasons for obesity, as well. Does that tell us something here? The European countries all seem to be in the middle.
Is it the government programs that are encouraging this? Is it people's dietary habits? Are you able to make any deductions from that?
Mr. Sassi: What we know is that policy has a relatively limited influence on the differences we observe across countries. I don't think there is anything in the policy environment in countries along this ranking that would justify the position or the ranking of individual countries in this picture.
We know that what we call the "obesogenic environment," a common phrase that has become mainstream, is the main cause of obesity. The way the technological, social and food-choice environments have changed over time is really the driving force behind the development of the obesity epidemic. There is certainly something about North American and Anglo-Saxon countries in terms of these types of environmental changes that have made obesity especially likely, that have made it grow faster in the past 20 to 30 years.
Various things need to be considered. Yes, Asian countries have lower levels of obesity. Japan and Korea, as you can see in figure 1, have measured rates. Nevertheless, these rates are extremely low — around 4 per cent. However, in these countries, the thresholds of BMI that link higher levels of BMI with disease have been shown to be much lower than in Western countries.
People, including in the WHO, have argued that we should apply lower BMI thresholds to define obesity in Asian countries, which would probably bring up these rates to a level that would be similar to the OECD average, if not to the highest obesity countries.
For Europe, there is indeed a problem of self-report bias. Many European countries are in the middle of this ranking just because they don't have good data. Some countries like France, for instance, where I am speaking from, or Italy still keep reporting low obesity rates, but small-scale studies that have been done in parts of these countries have shown that measured obesity rates are far higher than the ones that are still being considered valid at the national level.
There are different national situations that have to be considered, but I think the difference between the environment in which people make their choices both in connection with physical activity and food consumption in North America and in Anglo-Saxon countries is the main reason we are seeing higher obesity rates in those countries.
Senator Merchant: Can you tell us whether obese children become obese adults? Do you have any indication that obese children can overcome that? Can you tell us anything about that?
We have been concentrating a lot on children and how we can help at the very start of life to encourage people to have lifestyles that will not result in health issues, obesity and all the things related with it.
Mr. Sassi: A clear link between child obesity and adult obesity was established a long time ago, and it remains a valid link. There is also evidence that adult obesity can be avoided through appropriate interventions that reduce the levels of obesity in children.
Of course, measures need to be in place to ensure that lifestyle changes that are induced by interventions in children are then maintained over time when children grow up and become adults, because that is the weak point of the interventions that have been tried so far, especially school-based interventions. They are effective when delivered at the school level, in the years when children are attending school and are exposed to these programs, but after the end of these programs, children often take up their old habits again.
There have to be measures in place to make these changes sustainable over time. That is a crucial requirement for childhood obesity not to translate into adult obesity.
Senator Frum: Thank you very much, Mr. Sassi.
In your presentation, you said that Canada has a higher rate of obese boys than girls. It's not surprising, therefore, that we see the continuation of that statistic with more obese men than women. If it starts at childhood, why more boys than girls? Can you give me any theories?
Mr. Sassi: That is a very difficult question to answer. I pointed out that finding because it is unusual. It varies between countries, of course, but it tends to be women who have higher obesity rates in OECD countries, whereas men have higher rates of being overweight.
In Canada, we have the opposite trend. It is really difficult to say why that may be the case. I don't think I have an explanation. One of the things we say is that there is a link between socio-economic status and obesity, which is different in men and women. If you look at our statistics on social disparities in obesity, they show very clearly a strong social gradient in women. Women with less education and lower socio-economic status are much more likely to be obese than women who are more educated and better off. This gradient is not always observed in men. Even when it is observed, it is very small.
In Canada, that is also different. We see men and women having pretty much the same gradient. It's illustrated in figure 3 in my note. As you can see, the gradient is pretty clear, and it's about men and women with low levels of education and socio-economic status being about 1.5 times as likely as men and women with higher levels of education and socio-economic status to be obese. That, again, is unusual.
It may be that there are more men in Canada in manual professions that are linked with higher levels of obesity, which affect the overall proportion of men with obesity compared to other countries. The difference seems to be concentrated in this lower socio-economic status group of men. But the reasons why this may be the case, I don't think we know that.
Senator Frum: It's an interesting puzzle.
Also, to go back to the policy proposal of taxing sugary drinks, I have a chart in front of me from a nutrition journal, and they have a graph of the amount of sugar in various drinks. The amount of sugar, grams per litre, in Minute Maid 100 Per Cent Apple Juice is higher than what's in Pepsi, Coke, Dr. Pepper and Arizona Iced Tea. As you alluded to earlier when we were discussing this, is the policy recommendation maybe not for a type of drink, like pop, but the amount of sugar in a drink, whether it is juice or soda? Is that the way we should be approaching the issue?
Mr. Sassi: That is a very good point. I think the WHO made it very clear in their recent guidelines that it's the amount of free sugars that we are eating or drinking that makes a difference. Fruit juices have a large amount of sugar, even if they come from fruit and even if they have no added sugar in them. The issue of substitutions is crucial. If we use taxes, we must be very careful with the way we define the range of products that are taxed because that would drive what people would substitute to. We could end up having lots of people drinking fruit juices, which, again, WHO doesn't recommend. Fruit is clearly a very important part of our diets, and we should eat more. But fruit juices are not the same as fruit. The risk that we are preventing damage from a particular type of drink and are accepting damage from a different type of drink is very plausible if we don't design these taxes correctly.
Senator Frum: Right, because the point this journal makes is that for all the schools that have banned soda pop in schools, they then fill the dispenser with fruit juice options and have not solved the problem whatsoever. So there's an illusion going on there, even if it's not taxation, just a "healthy choice option." The next big topic becomes: What do we do about fruit juice? You've addressed that. Thank you very much.
Senator Raine: I think I'll follow along on that because when I went to school — it was a long time ago — we didn't have vending machines in our schools. We had drinking fountains. When you were thirsty, you went and drank water. We spend a lot of money in Canada to provide clean drinking water out of our taps and drinking fountains. Now, all of a sudden, everything you drink is part of a business, and the business model is to get you to drink more of their products.
Have any studies been done on the impact of the marketing, that we need to drink things that come in plastic or glass bottles versus drinking water? I'm concerned because I think our country is probably one of the best in the world in terms of being able to turn on the tap and drink safe, clean drinking water, and yet we're marketing "Drink bottled water." Something is wrong here, and I'm just wondering if this is only in Canada or around the world.
Mr. Sassi: I'm afraid this is much broader than Canada. The City of Paris and the City of London are really trying to incentivize people to drink tap water. The power that a city council might have in advertising their water is nowhere near the marketing power of big multinational companies that can promote their products with much more sophisticated campaigns.
In a way, the fact that water has become a business can be helpful, especially because the companies that have the business of bottled water are in some cases the same as the ones who have the soft drinks and the sugar-sweetened beverages business. For instance, in the United States, when the First Lady launched the Drink Up campaign, which was especially aimed at promoting the drinking of water instead of other types of drinks, the alliance — I think it's called Partnership for a Healthier America, which includes business stakeholders — has managed to have the support of the beverage industry precisely because of the bottled water business. So, in a way, it has been a way to get support from business on this campaign, which clearly can make a difference. Having big business against in a promotional campaign is like a lost battle from the start because, as I say, there's no way that a public organization, a government, a city council, can outgun private business in a promotional or media campaign.
Having said that, clearly there is a lot of scope for people to switch to drinking water. If not through promotional campaigns, the only other incentive is price. The only other way that governments and public agencies have to incentivize people to drink more tap water is to make it even more affordable than it is now. If that can be shown to be an effective way, possibly more governments would try that, but it's very difficult.
Senator Raine: I've always thought that the beverage companies have to be part of the solution, but we should probably get them to at least admit that they're part of the problem so that they can be part of the solution in a more directed way. They do have the ability to deliver clean drinking liquids to everybody on the planet, and there are a lot of countries in which obtaining clean drinking water is not that easy. But they can always get a pop. So we need them to be part of the solution.
I guess the frustrating thing is that when you recognize the danger in terms of too many calories, then I agree that drinking water is better than drinking calories. I was interested to see that one of the major companies is — I used to avoid their drinking water because I knew that it was demineralized — now marketing it as re-mineralized. I was kind of interested.
Thank you very much for that.
Senator Merchant: We have had criticism from some of our witnesses about Canada's Food Guide, that this is maybe part of the eating problems in Canada. Are you familiar at all with Canada's Food Guide, and how does it compare to other OECD countries?
Mr. Sassi: I remember looking at Canada's Food Guide a while ago when we were doing the analysis specifically on Canada. There are many food guides or guidelines about diet that can be criticized in different countries. One thing that is really striking is if you look at these guides and guidelines across countries, they tend to conform to the national economy. Essentially, the dominant food businesses in those countries are the ones that influence those guidelines, and the guidelines end up reflecting a balance of diet that puts more weight on foods that are nationally produced. That is clearly an indication of the value these guidelines may have.
I don't think it's so important what the guidelines contain. I think very few people would know them in detail anyway. I think the question is really to get very simple messages across to a large number of people in a way that is effective in changing their behaviour.
There are only very few types of incentives that we can use to get people to change their behaviour. One is making them understand, providing information. But the risk, as we just discussed, is that in some cases the information provided by governments clashes with the information provided by business and other stakeholders, and consumers are confused; they don't know what to think about whether foods are healthy or not, and they don't get any clear messages and eventually don't change their diet. Price incentives are much less exposed to that kind of risk, but clearly they have limitations, some which we have discussed, particularly in terms of substitutions, that need to be taken into account.
I think it's far more important that we get the message across and give clear incentives to people than the content of complex instruments like nutrition guidelines that people would not know in detail anyway.
The Chair: Mr. Sassi, our discussion has been very interesting. I have a couple of questions for clarification.
Going back to the Denmark example that you gave, if I heard you correctly, you indicated that their tax on saturated fat-containing foods lasted for one year; and yet, if I also heard you correctly, you said there was a clear indication that it had an impact.
I'm wondering, first, did I hear you correctly? Second, how is it possible to know that simply one year of implementation had a clear impact on society?
Mr. Sassi: Yes, you heard it correctly. That's exactly what I said. The evaluations have been based on changes in consumption of foods high in saturated fat. They are based on the tax revenues that were collected and they are based on sales data that have shown a reduced consumption of foods high in saturated fat. All the evidence that has been produced on the health effects has been based on evidence of changes in consumption.
The fact that it's been successful from a health point of view clearly doesn't mean that a government should necessarily consider that tax as a desirable thing. Unfortunately, the perspective of health ministers is often a minority perspective within governments. Clearly, there are other parts of government that may not be equally interested in the types of positive outcomes that I've outlined, and they may be more concerned about other outcomes of the tax on the economy and on markets and competition between economic agents. Clearly, whether or not the claims that the tax had been damaging from an economic point of view are founded, the Government of Denmark must have viewed them as more important than the health consequences of the tax.
The Chair: I thought that was probably the case, but I wanted to get clearly on the record what you were using as an indicator of success, and that was the measure of the changes in sales patterns and the taxation issue. Thank you very much.
The second thing that I want to comment on is an observation, when you referred to the issue of sugar substitutes versus sugar itself and the WHO observations in this particular area. There was a report, a summary of which I read this week, in which this particular series of studies seems to indicate that the potential damage of long-term use of chemical sugar substitutes is greater, and in the same areas that we're dealing with. Other than obesity, the health issues are greater than the actual health issues related directly to excess sugar consumption. I was very interested in your summary of that with regard to the WHO observations.
Mr. Sassi, I want to thank you on behalf of our committee. You have brought a great breadth and depth of understanding of the underlying issues to us. I think you have been able to articulate on complex issues clearly and effectively to the committee, and you've been very helpful to us. I wouldn't be surprised if some of your contributions to us today wind up directly in our report.
With that, sir, I thank you on behalf of the committee.
(The committee adjourned.)