Thursday, March 24, 2011

Funding the full ounce of prevention

News that our Health Ministers are ready to ‘dialogue’ on the threat of rising obesity drew groans from experts who’ve been demanding action for many years.

Canadians have been porking up for decades – nearly two-thirds of us are now either overweight or obese (O/O). Coupled with a sedentary lifestyle, this energy imbalance is causing disease and sending healthcare costs skyward.

In the twenty-five years from 1980 - 2005, O/O rose to 65% of males and 53.4% of females (up ten percent each). This growth of girth parallels a rise in our daily salt intake (fast foods) and sugar consumption (syrupy pop).

Even more alarming, in the same timeframe O/O among children aged six to seventeen has more than doubled, with girls (25%) and boys (27%) bulking up at similar rates.

One result is the meteoric rise of late-onset (type two) diabetes and its appearance among children, a development with huge implications for public health. Type-two diabetes (TTD) is a lifestyle disease resulting from the body’s inability to handle the high glycemic load dumped into it daily by processed foods.

Glycemic overload results from putting too much fatty, salted, sugary, energy-dense and nutrient-empty food into a body that’s sedentary. The result is a condition that over time ruins a person’s health, prompting outcomes like heart disease, cancer, blindness, amputations, and finally kidney failure.

In 2006, while serving as provincial health critic, I learned from a report done by our provincial health officer that there were some 220,000 British Columbians living with type-two diabetes (TTD). A mere five years later, we are already up to 338,000 living with TTD, and we are forecast to reach 548,000 by 2020!

That would be over ten percent of our population in 2020 living with a life-threatening lifestyle disease. The good news is, it’s largely preventable. The bad news is, we’re still not doing anything to prevent it.

Experts and advocates are calling for change in two general directions.

First, we need to recognize that diabetes develops from obesity and physical inactivity in combination. Our physiological decline is caused by environmental factors that are susceptible of change: too much energy in, not enough energy out.

The physical environment we inhabit needs strategic modification – we are simply too dependent on cars for transport. So much so that the way we’ve arranged our work and home lives, and our ways of getting between, makes weight gain difficult to avoid.

Modifying our built environment to enable more exercise, especially of the kind incidental to transport, is a key way to reduce population weight gain. Societies that provide more safe and appealing walking and cycling infrastructures achieve significantly higher levels of daily physical activity.

Modifying our physical environment needs to be done at a regional and local scale, led by local governments working with new funds from senior governments. Coupled with more greenspace closer to home and work, and linear greenways linking both, more people will be attracted to walk and cycle.

Think for example of the impact the Galloping Goose has had on travel choices in the Capital Region. It serves as an incubator for walking and cycling trips, both for commuting and as travel to non-work destinations.

Overall we need to build more compact, complete communities as we densify around urban nodes, and link those nodes with sustainable transport. The evidence is robust that where such infrastructures are provided, people are much more likely to walk and cycle daily. Moderate regular exercise is the single best preventive against all causes of disease and mortality.

Currently, nearly all costs for making cities more walkable and bikeable fall to the local property tax base. Transit upgrades similarly fall on local sources in the CRD (currently about 70% of all costs).

As property tax is over-stressed already, progress in retrofitting our cities for sustainable mobility is very slow. Senior governments, who collect 92 cents of every dollar of taxation, need to invest earmarked funding in retrofitting cities for walking, cycling and rapid transit use.

A second policy direction to prioritize is gradual modification of our food environment, putting new emphasis on fresh and local, and de-emphasizing salty carbohydrates and sugary drinks. There’s a compelling need to mandate reductions in salt use in industrial and restaurant foods (80% of our salt intake is from prepared foods). There should also be front-of-package labeling of calorie, sugar and salt loads in all food products.

These are both non-cost policy changes that will beneficially modify diet and enable consumers to make more discerning food choices. Recently the federal government dissolved its expert salt taskforce, which was to have developed a national salt-reduction strategy. Wrong direction Ottawa! The mandate is fitness, not fatness.

Taxation on sugar-sweetened beverages is a tool available to policy makers. It could both curb consumption and provide a revenue stream for investing in modifications of our physical environment.

But why pick on pop? Because pop is one of the bigger culprits in societal weight gain – while our consumption has ‘leveled off’ at about 72 litres a year per person, many people ingest a can or more a day (!!). A single can of pop contains 39 grams of sugar, or about ten teaspoons worth! It would take over an hour of vigorous physical activity to neutralize the calories in a single can.

Kids are prone to pop addiction. According to StatsCan research, 50 percent of 15-year-old males recalled having a soft drink in the previous 24 hours, with the average serving size being 700 ml. As Victoria’s Dr. Tom Warshawski points out, doing that just twice a week gets you to 72 litres a year.

Recent polling showed that 70% of British Columbians supported a tax on sugar if the proceeds were invested in health promotion. I’d amend ‘promotion’ to read, if the proceeds are invested in modifications to our food and urban environments so that we can make healthier, more active choices more easily.

What we don’t need is Participaction 3.0. No offense, but if you don’t create new opportunities for people to use their legs as part of daily life, you’ll never get the numbers to dance. And that goes double for cycling – without safe, convenient bikelanes and trails, people won’t feel attracted to the activity. But if you build it, they will come.

There’s a lot to learn from Europe:
  • Finland moderated its salt consumption and reduced its incidence of heart attacks and strokes dramatically.
  • Over half of Dutch and German elders get around by walking or cycling, while in the USA it’s a mere six percent.
  • In Copenhagen, nearly fifty percent of commuter travel is by bicycle, a phenomenon that has happened solely by choice with the provision of safer cycling environments.
Then there’s the great policy crossover, between what we need to do to reduce greenhouse gas emissions and what we have to do to get ourselves moving – turns out they’re identical!

Targetted investments in walking, cycling and zero-emission rapid transit will both reduce daily carbon emissions and raise daily exercise levels. Remember, every transit trip involves two short walk trips.

Our greatest challenge lies in blowing past the ingrained pessimism of professional politicians. The B.C. legislature has unanimously endorsed a strategy to address childhood obesity and physical inactivity. That was back in 2007, and the strategy has been collecting dust on a shelf ever since.

But Type Two Diabetes hasn’t stood still, adding 110,000 new victims since the politicians pledged to act. B.C.’s direct healthcare costs from TTD are rising rapidly, at $1.3-billion last year, rising to over $1.9-billion by 2015.

A public health strategy to address obesity by modifying our physical environment in ways that predispose more walking and cycling is feasible and long overdue. It would also not cost that much to implement: two capital funds earmarked for walking and cycling, each with $25-million annually to invest in cost-sharing of mobility retrofits in cities and towns.

Transit could be scaled up rapidly by dedicating existing and future carbon tax revenues, as well has having senior governments devolve some of the motor fuel taxes collected currently at the pump.

In 2006, the BC Standing Committee on Health estimated that ending the tax exemptions on candy, confections and soda pop would generate $40 - $45-million a year in new tax revenues.

This step alone could finance the investment stream for retrofitting infrastructure in our cities.

Is it time to Act Now and fund the full ounce of prevention? Or will we continue whistling Dixie instead?

John Pucher's Making Walking and Cycling Safer, Lessons from Europe is at:

A Strategy for Combatting Childhood Obesity and Physical Inactivity in British Columbia: