Marie-Claude Paquette

Health Canada's new guidelines for body weight classification in adults: challenges and concerns

In 2003 Health Canada released its new Canadian Guidelines for Body Weight Classification in Adults ,[1][1]an update of the weight classification system that had been in use in this country since 1988.[2][2]The guidelines were updated in response to advances in the understanding of the relation

Is Sugar the new Tobacco? Insights from Laboratory Studies, Consumer Surveys and Public Health

In the Americas, mean energy intake from added sugar exceeds recent World Health Organization recommendations for free sugars in the diet. As a leading contributor to this excess, sugar-sweetened beverage (SSB) overconsumption represents a risk for the population’s health. This article provides an overview of clinical and epidemiological evidence, marketing practices, corporate influence and prevention strategies related to added sugar and SSB. For each aspect of this multidimensional profile, we briefly compare SSB to the case of tobacco pointing to similarities but also major differences. Tobacco control has demonstrated the effectiveness of long term multifaceted prevention strategies in multiple settings supported by strong public policies which may be applied to the consumption of SSB. However, translating these policies to the specific case of SSB is urgently needed, to inform preventive actions, decide which intervention mix will be used, and evaluate the process and impact of the chosen strategy.

PotentialSSB TaxationSignal Effects “Signal” EffectsSignal Effects, SSB Taxation from Sugar-Sweetened Beverage Taxation

Many characteristics of the market, school and family environments contribute to making or maintaining frequent soda consumption a social norm, particularly among youth. In such circumstances, soda/sugar-sweetened beverage (SSB) taxation could be used as “alarm signal” facilitating the emergence of a “moderate consumption” norm, provided the price hike is sufficiently salient, the population aware of the tax, and these two conditions sustained by a communication campaign. Unfortunately, such effects remain weakly documented and counterproductive effects cannot be ruled out. SSB taxation could also be used as a coercive signal pushing manufacturers to move beyond voluntary commitments, be this in terms of product reformulation and/or in terms of marketing to children. On this particular point, the evidence remains mixed and anecdotal. A tax linearly indexed on the sugar content of the beverages or based on a threshold of sugar content above which beverages are taxed may provide additional benefits. Here again, it remains to be demonstrated.

Feasibility of Sugar-Sweetened Beverage TaxationFeasibility, of SSB Taxation in Canada in CanadaSSB Taxationin CanadaFeasibility of

Exploring the feasibility of soda/sugar-sweetened beverage (SSB) taxation in Canada requires considering federal and provincial powers and prerogatives in terms of public health and taxation. In this chapter, the applicability of various types of soda taxes is considered for both jurisdictions. Overall, excise duties generally are the more documented and recommended option to tax soda. Introducing such a tax in Canada is likely feasible, but at the federal level only. At provincial level, the introduction of a special tax on SSBs sold at retail according to the tobacco and alcohol special tax models is an avenue deserving particular attention. Defining the tax scope would likely raise some issues since generally, in the Canadian fiscal nomenclature, all carbonated beverages are considered regardless of their calorie content and composition. As regards taxation rate, Chaps. 6 and 7 of this book suggest that it is reasonable to expect SSB consumption to decrease as a result of a significant tax (i.e. provided it generates a 10–20 % price hike). Finally, a robust mechanism facilitating the administration and the earmarking of tax revenues for health promotion initiatives and social programmes would likely be desirable and feasible in Canada.

Body weight classification

James Douketis notes that waist circumference cut-offs have been validated, citing an excellent paper by Janssen and collaborators.1 Those authors demonstrated that the use of waist circumference cut-off points helps to identify subjects at increased health risk within normal-weight, overweight and class I obese BMI categories, but their study was not a validation of waist cut-offs. Accordingly, they acknowledged that their results do not imply that the specific cut-off values of 102 cm for men and 88 cm for women are the ideal threshold values denoting increased risk.1 They also pointed out that the waist circumference values that best predict health risk within different BMI categories are still unknown.1 We acknowledge that more research is needed on waist circumference cut-offs and on other indicators to better assess the health risks of people in the overweight category, especially given that decreasing the BMI cut-off for this category (from 27 to 25 kg/m2) has resulted in increased heterogeneity in terms of health risk.2 In addition, we wish to stress our concern about reducing the lower limit for the normal weight category (from 20 to 18.5 kg/m2). In our current sociocultural context, where thinness is highly valued, such changes to BMI categories could intensify peoples (notably womens) excessive concern about body weight,3which unfortunately may lead them to seek rapid weight loss and to use unhealthy and even dangerous weight loss methods.4The impact of these changes in BMI classification is not trivial and must be recognized. Reducing the lower BMI cut-off for normal weight (to 18.5 kg/m2) may lead to risks associated with delayed identification of eating disorders, but such a change can also prevent early recognition of disordered attitudes and behaviours concerning eating and physical activity, a situation that precedes the onset of eating disorders and affects more adult women than do eating disorders.5 Although Douketis is correct in stating that the guidelines are not designed for intervention purposes in individuals, the BMI remains well known to the public. BMI calculators can be found easily on the Internet and in magazines, and it is impossible to control how people will interpret their BMI in the absence of advice from a health care provider. Finally, we agree that more discussion is needed concerning the guidelines. It is essential for health care providers to be better informed on how to interpret and use the new weight classification system. Simone Lemieux Departement des sciences des aliments et de nutrition Universite Laval Sainte-Foy, Que. Marie-Claude Paquette Lyne Mongeau Institut national de sante publique du Quebec Sainte-Foy, Que. For the members of the GTPPP (Quebec Provincial Working Group on Weight Related Issues)

Eating-Related and Psychological Outcomes of Health at Every Size Intervention in Health and Social Services Centers Across the Province of Québec

Purpose: To report the outcomes of a Health at Every Size (HAES) intervention in a real-world setting. Design: Quasi-experimental design evaluating eating behaviors and psychological factors. Setting: The HAES intervention is offered in Health and Social Services Centers in Québec (Canada). Participants: For this study, 216 women (body mass index [BMI]: 35.76 [6.80] kg/m2) who participated to the HAES intervention were compared to 110 women (BMI: 34.56 [7.30] kg/m2) from a comparison group. Intervention: The HAES intervention is composed of 14 weekly meetings provided by health professionals. It focuses on healthy lifestyle, self-acceptance, and intuitive eating. Measures: Eating behaviors (ie, flexible restraint, rigid restraint, disinhibition, susceptibility to hunger, intuitive eating, and obsessive-compulsive eating) and psychological correlates (ie, body esteem, self-esteem, and depression) were assessed using validated questionnaires at baseline, postintervention, and 1-year follow-up. Analysis: Group, time, and interaction effects analyzed with mixed models. Results: Significant group by time interactions were found for flexible restraint (P = .0400), disinhibition (P < .0001), susceptibility to hunger (P < .0001), intuitive eating (P < .0001), obsessive–compulsive eating (P < .0001), body-esteem (P < .0001), depression (P = .0057), and self-esteem (P < .0001), where women in the HAES group showed greater improvements than women in the comparison group at short and/or long term. Conclusion: The evaluation of this HAES intervention in a real-life context showed its effectiveness in improving eating-, weight-, and psychological-related variables among women struggling with weight and body image.

Effects of Taxation on Sugar-Sweetened Beverage Prices

When the primary objective of a tax on sugar-sweetened beverages (SSBs) is to discourage consumption on the short term, a key issue is to know whether the tax is actually passed onto retail prices. On the one hand, when the tax is levied on manufacturers, they may decide to under- or overshift the tax. On the other hand, larger contextual factors (e.g. seasonal effects, other policies) may counteract or attenuate tax effects on prices. In this chapter, we present key pieces of evidence from various places where soda taxes have been implemented across the world. Overall, the evidence suggests that such taxes are generally followed by price increases in the short term, sometimes beyond or below the increase theoretically generated by the tax.

Sugar-Sweetened Beverage Taxation Logics and Ethical Concerns

Three sugar-sweetened beverage (SSB) taxation logics generally emerge in the literature: (1) increasing SSB prices in order to decrease consumption and impact the health of the population; (2) raising fiscal revenues that may be earmarked for health-related causes; and (3) sending a salient signal to consumers as a way to change social norms, and to manufacturers as a way to encourage product reformulation. Making clear which short-term and long-term logics are pursued is an essential prerequisite to assess the relevancy of an SSB tax proposal in Canada. Furthermore, the economic and ethical justification of SSB taxation remains controversial (e.g. as regards freedom of choice and autonomy) and should be carefully considered before implementation. A democratic dialogue involving all stakeholders (including consumers) may help disentangle this debate.

Sugar-Sweetened Beverage Taxation as a Public Health Policy Instrument

The manufacturing cost of sugar-sweetened beverages (SSBs) is particularly low. It contributes to making these drinks particularly affordable and to encourage consumption. Taxation has been increasingly suggested as a way to increase SSB price and discourage demand, as part of a comprehensive prevention strategy. Lessons from tobacco control confirm that taxation can be a valuable instrument, although the comparison with SSB should be made cautiously. Economic simulations tend to position SSB taxes among the most cost-effective interventions because of their low cost of implementation, the critical mass of the population they may reach, the revenues they generate and their sustainability. Evidence from soda taxes implemented in the “real world” has to be considered to confirm these predictions.

Distribution of Sugar-Sweetened Beverage Taxation Effects in the Population

The evidence reviewed in Chaps. 5 and 6 suggests that a tax on soda/sugar-sweetened beverages (SSBs) causing a 10–20 % price increase could result in a lower-average SSB consumption in the population. But beyond average values, would the poorest consumers be disproportionally burdened by the tax? Would they benefit from larger health gains? Overall, the evidence suggests that the financial contribution to tax revenues would be relatively modest for most consumers and not much different across income groups. Low-income households consuming large SSB amounts and not prone to reduce their consumption may be more negatively impacted than other consumers. As regards SSB taxation health benefits, these are hardly predictable (see Chap. 7) and it remains unclear whether these could be greater in lower-income households and in the heaviest SSB consumers. Inequity concerns surrounding SSB taxation could be somewhat mitigated through the earmarking of tax proceeds for health promotion causes.