1. Policy Issues:
Obesity and Chronic Diseases
HLTH 405 / Canadian Health Policy
Winter 2012
School of Kinesiology and Health Studies
Course Instructor:
Alex Mayer, MPA

2. Topics for today’s lecture:
Doing Policy
• What is ‘policy’?
• Looking at ‘policy tools’
• Your briefing note
Policy Issue #1: Obesity & Chronic Disease
• Childhood obesity trends & associated outcomes
• Social & physical determinants of chronic disease
• What is the appropriate role for government?
• Policy actions to support healthy living

3. Doing Policy

4. The Policy Paradigm
3 Necessary Assumptions
o The private sector is the fundamental source of
economic wealth
o But, government has a key role to play – maintaining the
rule of law and ensuring the safety of its citizens
o Additionally, the government can deliver policies that
more broadly promotes the social wellbeing of its
citizens (e.g. good health, equality, economic wellbeing)

5. Doing Policy
A Balancing Act
o Putting personal biases aside and objectively
balancing the many diverse interests of society
o Using the best available evidence to implement ideas
that we have strong reason to believe can generate a
net gain in social wellbeing

6. So, What is a ‘Policy’?
Policy:
• (General sense) A party line or perspective on an
issue of importance, which guides a strategy.
• (Specific sense) A set of specific actions oriented
towards mitigating an immediate social problem
or a long-term objective.

7. Policy Tools
The full menu of actions available to government
are collectively known as ‘policy tools’.
Policy Tools:
• ‚An identifiable method through which
collective action is structured to address a public
problem.‛
- Salamon, 2002. “The Tools of Government”

9. How do we choose?

10. 5 Dimensions for
Evaluating a Tool of Action
When choosing a tool, keep these in mind:
• Effectiveness
• Efficiency
• Equality
• Manageability
• Legitimacy/Political Feasibility

11. 5 Dimensions for
Evaluating a Tool of Action
• Effectiveness
o Is there sound evidence that it would generate the desired
outcome, given the situation’s circumstances?
Find supporting evidence & extrapolate appropriately
o Primary sources of info:
• CIHI, Statistics Canada, WHO, HQO, peer-reviewed
journals
o Expert reports
• Thinktanks, Professional Associations, public servants,
etc.

12. 5 Dimensions for
Evaluating a Tool of Action
• Efficiency
o Balance the benefits against the implementation costs of
the tool. What tool provides the most ‘bang for your buck’?
o Costs can be direct costs borne by government (e.g.
program costs) but also indirect, as when they are borne
by some other segment of society (e.g. businesses,
consumers, demographic group) in the form of
compliance costs, lost revenue or time costs.

13. Determining Efficiency
• Tool A has been shown in a pilot project to
generate 1 added life-year (LY) per person (on
average) for a total program cost of $50/person.
• Tool B has been shown to generate 3 added life-
years (LY) per person (on average) for a total
program cost of $1,000/person.
Where should the government invest its money?

14. Determining Efficiency
Answer: Tool A
o It costs $50/LY added, whereas Tool B costs
$333/LY added. Tool A is more cost-effective.
Therefore, investing a predetermined sum of
money in Tool A would yield the greatest benefit
(most LYs added) to the population’s health.

15. Math Challenge!
What if, after doing some solid research, you
determined that province-wide implementation of
Tool A would impose a $4M compliance cost on
businesses, whereas Tool B would not?
$4M / Ontario population (13.5M) = additional cost
of $396/person.

16. Math Challenge!
CostA = $396+$50x per person BenefitA = (x)LY per person
CostB = $333x per person BenefitB = (x)LY per person
Intercept (CostA = B) is x = 1.4LY per person
Therefore, Tool A is now only more cost-effective than Tool B
above a threshold of 1.4LY per person (i.e. if Ontario invests at
least $466 per person, or $6.29B, in the program).
If the government intends to spend any less than this, Tool B is
the most cost-effective! (How fun! And interesting!)

17. 5 Dimensions for
Evaluating a Tool of Action
• Equity
o If the tool is distributive, is it fair in its distribution of
benefits among citizens? Does it unintentionally
discriminate against some group?
o When redistribution of wealth is the aim of the policy, as is
often the case, does it properly channel benefits
disproportionately to those who lack them?

18. 5 Dimensions for
Evaluating a Tool of Action
• Manageability
o Would the program be able to distribute benefits according
to simple criteria and be easy to operate?
o Would it require constant judgment calls, be prone to
error, be prone to exceed its budget, or be excessively
exposed to external factors and pressures?
o All other things being equal, choose the simplest, most
direct and most elegant solution.

19. 5 Dimensions for
Evaluating a Tool of Action
• Legitimacy/Political Feasibility
o A program that does not win public support cannot make
headway, so would the tool’s implementation be widely
viewed as an ‘appropriate’ government action?
o What are the societal interests that would oppose the
policy?
• Can they be brought into the fold without unduly
compromising the tool’s effectiveness, efficiency, equity
and manageability?

20. You’ve found the perfect tool. Now what?

21. Write a briefing note!

22. Any questions?

23. Policy Issue #1:
Obesity and Chronic Diseases

24. Policy Issue #1:
Obesity and Chronic Diseases
• Obesity trends & associated outcomes
• Social & physical determinants of chronic
disease
• Policy actions to prevent obesity and support
healthy living
• What is the proper role of government?

25. Definitions
According to the World Health Organization…
• Overweight is defined as a BMI (kg/m2) > 25
• Obesity is defined as a BMI > 30
Though far from perfect, the WHO states that
body mass index (BMI) provides the most useful
population-health measure of mortality risk
attributable to excess body fat and associated
metabolic illnesses.

26. Definitions
“Metabolic Syndrome”:
Cluster of risk factors (central obesity, insulin
resistance, hypertension, low cardiovascular
fitness) that, when presenting together, are
clinically associated with significantly higher risks
of coronary artery disease, stroke, and type 2
diabetes.

27. Let’s be clear
Whether one speaks of ‘obesity’ or ‘metabolic
syndrome’, these are indicators of risk to be
interpreted only as a statement of proven
correlations with health outcomes at the
population level.
• In absence of qualifying variables, it is not by
itself the most reliable measure of health risk at
the individual level.

28. Population Level
As a group, people with a BMI over 30 have a
demonstrably higher risk of morbidity and mortality.

29. Individual Level
However, telling Ronnie Coleman that his BMI of 41.4
makes him ‘morbidly obese’, and therefore ‘extremely high
risk’, is just poor health literacy.

30. Some Context
Globally…
• Obesity is attributable for
o 2.8 million deaths per year
o 44% of the global diabetes burden
o 23% of the ischemic heart disease burden
o 7-41% of cancer burdens (endometrial, breast, colon)
• 5th leading risk of mortality in the world
• Represents one of the largest sources of preventable
illness and mortality (environmental/lifestyle
changes can mitigate a majority of the associated
health risks).

31. Some Context
In Ontario…
• 13% of children and 25% of adults are now obese
(BMI>30)
• Between 1994 and 2005 alone, rates of high blood
pressure have skyrocketed by 77%, diabetes by
45% and obesity by 18%
• It is estimated that 45% of males and 40% of
females will now develop cancer in their
lifetimes

32. Childhood Obesity
• Canada has 5th highest rate of childhood obesity
(13%) out of 34 countries in the developed world
(OECD).
• Higher risk of obesity, premature death and
disability in adulthood.
• Associated with breathing difficulties, increased
risk of fractures, hypertension, early onset of
cardiovascular disease, insulin resistance and
psychological effects.

33. Obesity as a Risk Factor
• Excess body fat is associated with:
o 4.5X higher risk of developing hypertension
o 3.7X higher risk of developing type II diabetes
o 3.3X higher risk of contracting gall bladder disease
o 2.2X higher risk of developing coronary artery disease
o 2.0X higher risk of developing osteoarthritis
o 1.5X higher risk of stroke, colon cancer, post-menopausal
breast cancer
• The correlations are far from trivial

34. Cost of Obesity &
Physical Inactivity
In Ontario…
• Obesity accounts for $4.5B in health care costs per year
• Physical inactivity accounts for another $3.4B per year
(Katzmarzyk, 2012)
Lumped together, that’s equal to ~17% of Ontario’s $46B
health budget being consumed to treat preventable chronic
illnesses, not to speak of the human cost (i.e. suffering).

35. Cost of Obesity
Source: Katzmarzyk, 2012.

36. Cost of Physical Inactivity
Source: Katzmarzyk, 2012.

37. Obesity and Chronic Disease
Strange Logic?
• We spend hundreds of millions of dollars annually
on cancer drug research and development.
• Yet we spend only a small fraction of this on healthy
living programs, despite knowing that 30-40% of all
cases of cancer could be prevented through healthy
eating, weight control and regular physical activity.

38. Healthy Diets Make a
Difference!
According to a study by Dr. Henri Joyeux (one of
France’s most eminent oncology and nutrition
experts), the average lifetime medical cost of a
vegetarian is 19,818€, compared to 92,994€ for non-
vegetarians.
• Mortality attributable to cancer is reduced by 40%
among vegetarians.
• Mortality attributable to cardiovascular disease is
reduced by 50% among vegetarians.

39. Perhaps Bill is on to
something…

40. Determinants of Health
• However, reducing obesity to an outcome
associated merely with dietary or lifestyle
choices, as in the traditional health care
paradigm, can lead to a culture of ‘victim-
blaming’ and stigmatization.
• This reductionist view is not only presumptuous
and unhelpful, it is grossly unfair (especially to
children and low-income people).

41. Determinants of Health

42. Determinants of Health
• Tangible barriers for many low-income families:
o Inadequate income
o Food deserts
o Low education – poor nutritional and health literacy
o High cost and perishability of fresh fruits and
vegetables
o Neighborhoods are not safe for recreational activity
o Lack of mobility/transportation for regular grocery
trips
o Relatively cheap calories offered by restaurant meals

43. The obvious:
Healthy eating, weight control and
regular physical activity together
prevent the majority of chronic
illness.

44. The not-so-obvious:
How to ensure that everyone has
access to the knowledge, material
resources and opportunities to lead
healthy lifestyles – and then
actually takes advantage of them!

46. Some Policy Approaches
to Obesity Prevention
• Fiscal Measures (i.e. junk food taxes)
• Food advertising Regulation
• Industry Self-regulation
• Food Labeling
• Mass Media Campaigns
• Physician-Dietitian Counseling
• Physician Counseling
• School-based Interventions
• Workplace Interventions
These are the most well-studied, but there are many more
possibilities!

47. OECD Report (2010):
‚The Economics of Obesity Prevention‛

48. What does the evidence show?

49. What does the evidence show?

50. What does the evidence show?

51. Good Places to Start
Most cost-effective approaches…
• Physician-Dietitian Counseling
• Fiscal Measures
• Worksite Interventions
Although school-based interventions take a long
time to generate cost savings, we may also want to
invest there.
If you were to design them, what would these
policies look like?

52. Many Opportunities for
Improvement
• McGuinty Government has implemented new policies
focusing on the provision of healthy foods in schools.
• However, less than 50% of physicians in Ontario
routinely collaborate with dietitians (2007).
• The Canadian Food Guide is confusing and not reflective
of the best available evidence; Restaurant menus don’t
display even basic calorie counts – how are people to
make informed decisions?
• Health impact assessments in urban planning
• Incentivizing workplace wellness programs

53. Discussion:
Government’s Role
• Libertarianism versus Collectivism
• Views can differ sharply – this has implications
for legitimacy/political feasibility!
o E.g. Japan’s approach to population weight control
reflects tolerance for collectivist/interventionist
government actions.
• Where do you stand?

54. Recap
• Obesity trends & associated outcomes
• Social & physical determinants of chronic
disease
• Policy actions to prevent obesity and
support healthy living
• What is the proper role of government?

55. Have a great week!