From Salamon Chapter 1, Section 4 “The Tools of Government” – available on Facebook and Moodle in the ‘important links’ document
See Important Links in Moodle, there are many resources there.
Re: briefing note assignment
As a group, people with a BMI over 30 have a higher risk of morbidity and mortality.However, telling a physically active individual with a BMI of 30.1, that he or she is ‘obese’ and therefore ‘high risk’ is poor health literacy.
We have the miracle cure, why not use it?
(Family of 4 on ODSP has $25/month of discretionary income after rent and groceries)
Week 5 - Obesity and Chronic Disease
Policy Issues:Obesity and Chronic Diseases HLTH 405 / Canadian Health Policy Winter 2012 School of Kinesiology and Health Studies Course Instructor: Alex Mayer, MPA
Topics for today’s lecture:Doing Policy• What is ‘policy’?• Looking at ‘policy tools’• Your briefing notePolicy 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
The Policy Paradigm3 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)
Doing PolicyA 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
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.
Policy ToolsThe full menu of actions available to governmentare 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”
5 Dimensions forEvaluating a Tool of ActionWhen choosing a tool, keep these in mind:• Effectiveness• Efficiency• Equality• Manageability• Legitimacy/Political Feasibility
5 Dimensions forEvaluating 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.
5 Dimensions forEvaluating 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.
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?
Determining EfficiencyAnswer: Tool Ao It costs $50/LY added, whereas Tool B costs $333/LY added. Tool A is more cost-effective.Therefore, investing a predetermined sum ofmoney in Tool A would yield the greatest benefit(most LYs added) to the population’s health.
Math Challenge!What if, after doing some solid research, youdetermined that province-wide implementation ofTool A would impose a $4M compliance cost onbusinesses, whereas Tool B would not?$4M / Ontario population (13.5M) = additional costof $396/person.
Math Challenge!CostA = $396+$50x per person BenefitA = (x)LY per personCostB = $333x per person BenefitB = (x)LY per personIntercept (CostA = B) is x = 1.4LY per personTherefore, Tool A is now only more cost-effective than Tool Babove a threshold of 1.4LY per person (i.e. if Ontario invests atleast $466 per person, or $6.29B, in the program).If the government intends to spend any less than this, Tool B isthe most cost-effective! (How fun! And interesting!)
5 Dimensions forEvaluating 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?
5 Dimensions forEvaluating 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.
5 Dimensions forEvaluating 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?
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?
DefinitionsAccording to the World Health Organization…• Overweight is defined as a BMI (kg/m2) > 25• Obesity is defined as a BMI > 30Though far from perfect, the WHO states thatbody mass index (BMI) provides the most usefulpopulation-health measure of mortality riskattributable to excess body fat and associatedmetabolic illnesses.
Definitions“Metabolic Syndrome”:Cluster of risk factors (central obesity, insulinresistance, hypertension, low cardiovascularfitness) that, when presenting together, areclinically associated with significantly higher risksof coronary artery disease, stroke, and type 2diabetes.
Let’s be clearWhether one speaks of ‘obesity’ or ‘metabolicsyndrome’, these are indicators of risk to beinterpreted only as a statement of provencorrelations with health outcomes at thepopulation level.• In absence of qualifying variables, it is not by itself the most reliable measure of health risk at the individual level.
Population LevelAs a group, people with a BMI over 30 have ademonstrably higher risk of morbidity and mortality.
Individual LevelHowever, telling Ronnie Coleman that his BMI of 41.4makes him ‘morbidly obese’, and therefore ‘extremely highrisk’, is just poor health literacy.
Some ContextGlobally…• 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).
Some ContextIn 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
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.
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
Cost of Obesity & Physical InactivityIn 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 $46Bhealth budget being consumed to treat preventable chronicillnesses, not to speak of the human cost (i.e. suffering).
Cost of Physical Inactivity Source: Katzmarzyk, 2012.
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.
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.
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).
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
The obvious:Healthy eating, weight control andregular physical activity togetherprevent the majority of chronicillness.
The not-so-obvious:How to ensure that everyone hasaccess to the knowledge, materialresources and opportunities to leadhealthy lifestyles – and thenactually takes advantage of them!
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 InterventionsThese are the most well-studied, but there are many morepossibilities!
OECD Report (2010):‚The Economics of Obesity Prevention‛
Good Places to StartMost cost-effective approaches…• Physician-Dietitian Counseling• Fiscal Measures• Worksite InterventionsAlthough school-based interventions take a longtime to generate cost savings, we may also want toinvest there.If you were to design them, what would thesepolicies look like?
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
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?
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?