The economic burden of inadequate consumption of vegetables and fruit in Canada

Abstract

Objective
Public health decision makers not only consider health benefits but also economic implications when articulating and issuing lifestyle recommendations. Whereas various estimates exist for the economic burden of physical inactivity, excess body weight and smoking, estimates of the economic burden associated with our diet are rare. In the present study, we estimated the economic burden attributable to the inadequate consumption of vegetables and fruit in Canada.

Design
We accessed the Canadian Community Health Survey to assess the inadequacy in the consumption of vegetables and fruit and published meta-analyses to assemble risk estimates for chronic diseases. Based on these inadequacy and risk estimates, we calculated the population-attributable fraction and avoidable direct and indirect costs to society. Direct costs include those for hospital care, physician services and drugs in 2015.

Results
About 80 % of women and 89 % of men consume inadequate amounts of vegetables and fruit. We estimated this to result in an economic burden of $CAN 3·3 billion per year, of which 30·5 % is direct health-care costs and 69·5 % is indirect costs due to productivity losses. A modest 1 percentage point annual reduction in the prevalence of inadequate vegetables and fruit consumption over the next 20 years would avoid approximately $CAN 10·8 billion, and an increase of one serving of vegetables and fruit per day would avoid approximately $CAN 9·2 billion.

Conclusions
Further investments in the promotion of vegetables and fruit will prevent chronic disease and substantially reduce direct and indirect health-care costs.

Full text

The economic burden of inadequate consumption of vegetables
and fruit in Canada
John Paul Ekwaru
1
, Arto Ohinmaa
1,
*, Sarah Loehr
1
, Solmaz Setayeshgar
1
,
Nguyen Xuan Thanh
2
and Paul J Veugelers
1
1
School of Public Health, University of Alberta, 3–50 University Terrace, 8303 –112 Street, Edmonton, Alberta,
Canada, T6G 2T4:
2
Institute of Health Economics, Edmonton, Alberta, Canada
Submitted 13 May 2016: Final revision received 7 September 2016: Accepted 21 September 2016: First published online 7 November 2016
Abstract
Objective: Public health decision makers not only consider health benefits but also
economic implications when articulating and issuing lifestyle recommendations.
Whereas various estimates exist for the economic burden of physical inactivity,
excess body weight and smoking, estimates of the economic burden associated
with our diet are rare. In the present study, we estimated the economic burden
attributable to the inadequate consumption of vegetables and fruit in Canada.
Design: We accessed the Canadian Community Health Survey to assess the
inadequacy in the consumption of vegetables and fruit and published meta-analyses
to assemble risk estimates for chronic diseases. Based on these inadequacy and risk
estimates, we calculated the population-attributable fraction and avoidable direct and
indirect costs to society. Direct costs include those for hospital care, physician
services and drugs in 2015.
Results: About 80 % of women and 89 % of men consume inadequate amounts of
vegetables and fruit. We estimated this to result in an economic burden of $CAN
3·3 billion per year, of which 30·5 % is direct health-care costs and 69·5 % is indirect
costs due to productivity losses. A modest 1 percentage point annual reduction in the
prevalence of inadequate vegetables and fruit consumption over the next 20 years
would avoid approximately $CAN 10·8 billion, and an increase of one serving of
vegetables and fruit per day would avoid approximately $CAN 9·2billion.
Conclusions: Further investments in the promotion of vegetables and fruit will
prevent chronic disease and substantially reduce direct and indirect health-care costs.
Keywords
Economic burden of disease
Nutrition
Public health
Health-care costs
Vegetables and fruit
Chronic diseases are the leading cause of morbidity and
mortality worldwide
(1)
. In Canada, chronic diseases
account for 89 % of all deaths
(2)
and for more than
$CAN 93 billion in direct and indirect health-care costs
per year
(3)
. Dietary intake, sedentary lifestyle, body weight
and cigarette smoking have long been established as
modifiable risk factors for chronic disease
(4)
. Despite the
issuing of public health recommendations to reduce the
burden of chronic diseases, recent studies revealed that
74 % of Canadians consume less than the recommended
daily number of servings of vegetables and fruit
(5)
,85%of
adults are not meeting recommendations for physical
activity
(6)
, 62 % have excess body weight
(7)
and 18·1 % use
tobacco
(7)
.
Public health decision makers not only consider
potential health benefits but also financial implications
when articulating and issuing their recommendations.
Various studies have estimated the economic burden in
terms of costs for treatment and management of chronic
diseases and for productively losses resulting from
physical inactivity, excess body weight and smoking
(8–16)
.
For Canada, Krueger et al. estimated the economic burden
attributable to physical inactivity, excess body weight and
tobacco smoking to be $CAN 10·8 billion, $CAN
23·3 billion and $CAN 18·7 billion per year, respec-
tively
(17)
. Estimates of the economic burden associated
with dietary intake, however, are uncommon. For
Australia, the economic burden attributable to low vege-
tables and fruit consumption was estimated to be $AU 269
million in 2008
(15)
, and for the UK the costs for treatment
and management of chronic diseases attributable to a poor
diet to be £4·9 billion in 2006/2007
(15)
. No such estimates
exist for the Canadian setting, whereas country-specific
estimates are essential to reflect differences in lifestyle,
culture, food choices, dietary recommendations and
health-care costs. Since the majority of Canadians are not
Public Health Nutrition: 20(3), 515–523 doi:10.1017/S1368980016002846
*Corresponding author: Email arto.ohinmaa@ualberta.ca
© The Authors 2016. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original
work is properly cited.

meeting the recommendations for vegetables and fruit
(5)
,
the associated economic burden is expectedly substantial.
An estimate of this burden may help prioritizing public
health intervention strategies. The objective of the present
study was to estimate the economic burden attributable to
the inadequate consumption of vegetables and fruit in
Canada.
Methods
We estimated the economic burden associated with
inadequate consumption of vegetables and fruit with a
population-attributable fraction (PAF) approach and a
societal perspective
(18)
. In doing so, we considered the
consumption of vegetables and fruit by Canadians, the risk
that inadequate consumption poses for chronic diseases
and the costs for the treatment and management of these
diseases, as detailed below.
Consumption of vegetables and fruit in Canada
The Canadian Community Health Survey (CCHS) is a large
cross-sectional survey that collects information related to
health status, health care and health determinants for the
Canadian population
(19)
. The CCHS collects data from
participants 12 years of age or older living in the ten
provinces and the three territories of Canada and incorpo-
rates population weighting to provide estimates that are
representative for the Canadian population. Since 2007, data
for the CCHS are collected annually instead of every two
years with a target sample size of 65 000 respondents each
year. We accessed the 2014 responses of 63 964 Canadians
to validated questions on the consumption frequency of
vegetables and fruit. These responses had been summarized
by means of a single variable representing the total number
of servings of vegetables and fruit consumed daily. Since
risk estimates are available for increases per 80 g (1 serving)
per day in vegetables and fruit intake (see next section),
we retrieved age- and gender-specific distributions of
vegetables and fruit consumption in the intervals of 0–<1,
1–<2, 2–<3, 3–<4, 4–<5, 5–<6, 6–<7, 7–<8and8+
servings/d. Since the CCHS covers only participants aged 12
years or older, we applied the distribution of vegetables and
fruitconsumptionobservedinthe12–14 years age group
to those under 12 years old. In Canada, males are
recommended a minimum of 4–6, 8, 8–10 and 7 servings
vegetables and fruit/d for the age groups 2–<14, 14–<19,
19–<51 and 51+ years, respectively. For females, this is a
minimum of 4–6, 7, 7–8 and 7 servings vegetables and fruit/
d for the age groups 2–<14, 14–<19, 19–<51 and 51+ years,
respectively. To align these age-specific recommendations
with the available age categories for health-care costs (see
below), we adapted this for males to a minimum of 5, 8
and 7 servings vegetables and fruit/d for age groups <15,
15–<55 and 55+ years, respectively. For females, we
considered a minimum of 5 and 7 servings vegetables and
fruit/d for age groups <15 and 15+ years, respectively.
Risk of inadequate vegetables and fruit
consumption for chronic disease
We accessed reports by the WHO and the World Cancer
Research Fund/American Institute for Cancer Research,
complemented with published meta-analyses, to assemble
established estimates of the risk of inadequate vegetables
and fruit consumption for chronic diseases
(4,20–24)
. Based
on these sources, we considered risk estimates for type 2
diabetes
(21)
, CVD (IHD, ischaemic stroke)
(4)
and cancers
(lung
(22)
, colorectal
(25)
, oesophagus
(20)
, stomach/gastric
(4)
,
bladder
(24)
, oral
(20)
, larynx
(20)
and breast
(23)
). Because
we were interested in the effect of the combination of
vegetables and fruit, in cases where a meta-analysis
reported separate effects of vegetables only and of fruit
only, we considered the lower risk estimate.
Estimation of population-attributable fraction
The PAF represents the proportional reduction in chronic
disease that would occur if all Canadians would consume
the recommended number of servings of vegetables and
fruit. The PAF applies the risk of inadequate vegetables and
fruit consumption for chronic disease to the distribution of
vegetables and fruit consumption in the Canadian popula-
tion in the formula
(26)
PAF =
P
n
i=1
PiðRRi1Þ
1+P
n
i=1
PiðRRi1Þ
;
where:
P
i
is the proportion of individuals in interval i;
i(interval) refers to the consumption of 0–<1, 1–<2,
2–<3, 3–<4, 4–<5, 5–<6, 6–<7, 7–<8 and 8+ servings/d;
RR is the relative risk for each serving increase in
vegetables and fruit consumption;
RRi=RRðXiLÞis the relative risk for interval irelative to
the recommended number of servings;
X
i
is the mid value of interval i;
Lis the recommended number of servings; and
nis the number of intervals below the recommended
number of servings.
We calculated the PAF using the distribution of vegetables
and fruit consumption (described above under ‘Consump-
tion of vegetables and fruit in Canada’) and the relative risk
for disease (described above under ‘Risk of inadequate
vegetables and fruit consumption for chronic disease’)for
each of type 2 diabetes, IHD, ischaemic stroke, and lung,
colorectal, oesophagus, stomach/gastric, bladder, oral,
larynx and breast cancer.
Costs
We obtained the proportions of costs for hospital care,
physician services and drugs for each of the diseases of
interest from the Economic Burden of Illness
516 JP Ekwaru et al.

in Canada (EBIC 2008) online tool
(27)
. For costs for type 2
diabetes, we further applied the proportion of 0·96 to the
costs of all diabetes (type 1 and type 2 combined)
(28)
.
We multiplied these proportions by the total costs (all
diseases combined) in 2015 for hospital care, for physician
services and for drugs, available through the Canadian
National Health Expenditure Trends report
(29)
,tocompute
the direct health-care costs. These costs were then multiplied
by the PAR to estimate the avoidable direct health-care costs.
We estimated indirect costs following the human capital
approach applied in the Economic Burden of Illness in
Canada (EBIC 1998)
(30)
:wecalculatedtheratio of indirect
costs to direct costs for each disease of interest, assumed
these ratios to be stable over time, and used the product of
the ratio and the estimated avoidable direct health-care costs
for each of the diseases of interest to represent the avoidable
indirect health-care costs. The economic burden represents
the sum of avoidable direct health-care costs and avoidable
indirect costs for all diseases of interest.
Confidence intervals
We carried out 50 000 Monte Carlo simulations to obtain
95 % confidence intervals for the economic burden
estimates. In these simulations, we assumed the reported
relative risks to follow lognormal distributions and
estimated variance parameters from the reported 95 %
confidence intervals.
Scenario analysis
The economic burden is an estimate of the potential cost
savings if all 35·8 million Canadians were to eat adequately in
terms of vegetables and fruit. As an alternative scenario, we
calculated the potential cost savings for a scenario whereby
all Canadians with an inadequate consumption of vegetables
and fruit would increase this consumption by one extra
serving daily. As a third scenario we estimated the potential
cost saving of a modest 1 percentage point annual decrease
in the proportion of individuals with inadequate consumption
of vegetables and fruit. For this scenario, we assumed that all
Canadians with inadequate vegetables and fruit consumption
had an equal probability to become adequate in their
consumption of vegetables and fruit. Krueger et al.
(17)
had
previously applied a similar scenario for decreases in physical
inactivity, body weight and tobacco use, assuming the
projected Canadian population from 2015 to 2035
(31)
.
Results
Table 1 shows the distribution of vegetables and fruit
consumption of Canadians. For girls below the age of
15 years, 51·3 % did not meet the recommendations of five
or more daily servings of vegetables and fruit. Of these girls,
3·0, 6·0, 9·6, 15·7and17·0 % reportedly consumed 0–<1,
1–<2, 2–<3, 3–<4and4–<5 servings vegetables and fruit/d,
respectively (Table 1). The prevalence of inadequate
vegetables and fruit consumption ranged from 51·3to81·5%
by age group among girls and women and from 58·2
to 92·0 % among boys and men. For all Canadians
combined, the prevalence of inadequate consumption of
vegetables and fruit was 84·2 %. If all Canadians would
eat the minimum recommendation, 249 million servings
would be consumed daily. However, Canadians reportedly
consume a total of 171 million servings daily. A total of
92 million extra daily servings of vegetables and fruit are
needed to have all Canadians increase their vegetables and
fruit consumption to the recommended number of servings
(Table 1).
Table 2 lists the retrieved relative risks and estimated PAF
values associated with inadequate vegetables and fruit
consumption for various chronic diseases by gender and age.
The estimated PAF ranged from 0·9 % for colorectal cancer
among girls below 15 years of age to 67·9% for larynx and
oral cancers among men aged 35–54 years. Table 2 also lists
the estimated direct and indirect costs for the chronic diseases
of interest by gender and age. The highest direct costs, $CAN
636 million per year, were reported for type 2 diabetes
among men in the age range of 35–54 years. Table 3
reveals direct and indirect costs attributable to the inadequate
consumption of vegetables and fruit by chronic disease, by
age and by gender. The type 2 diabetes-associated total costs
attributable to the inadequate consumption of vegetables and
fruit was $CAN 789 million per year, from which 45·7%came
from direct health-care costs (Table 3). The total costs
attributable to the inadequate consumption of vegetables and
fruit were higher among men and higher in older age groups.
Overall, the economic burden of inadequate consumption of
vegetables and fruits in Canada was estimated to be $CAN
3·3(95%CI0·9, 5·2) billion in 2015. About $CAN 1 (95% CI
−0·05, 1·9) billion of these were direct costs (costs for
hospitals, physicians and drugs) and $CAN 2·3(95%CI1·0,
3·4) billion were indirect costs due to losses in productivity
(Table 3). The estimate for the economic burden was $CAN
2·3(95%CI1·6, 2·9) billion, $CAN 0·6(95%CI0·4, 0·8)
billion in direct costs and $CAN 1·7(95%CI1·2, 2·1) billion
in indirect costs, when costs related to type 2 diabetes,
oesophageal cancer and stomach/gastric cancer were
excluded (Table 3).
The above estimates of the economic burden represent
the sum of direct and indirect costs that would be avoided if
all Canadians would have diets adequate in vegetables and
fruit. In a scenario where all Canadians with inadequate
diets would increase their vegetables and fruit consumption
by 1 serving/d, the avoided cost would total $CAN 362
million in the first year and would reach $CAN 551 million in
2035 for a total of $CAN 9·2 billion in cumulative avoided
costs over 20 years (Fig. 1). In the scenario with a
1 percentage point annual reduction in the prevalence of
vegetables and fruit inadequacy, avoided cost would total
$CAN 39 million in the first year and would reach $CAN 1·1
billionin2035foratotalof$CAN10·8 billion in cumulative
avoided costs over 20 years (Fig. 2).
Economic burden of poor diet in Canada 517

Discussion
The present study estimated that the cost to Canada
attributable to the inadequate consumption of vegetables
and fruit totals $CAN 3·3 billion per year, with 30·5% in
direct health-care costs and 69·5 % in indirect costs due to
productivity losses. Canada spent an estimated $CAN
219·1 billion on direct health-care costs in 2015
(29)
,of
which an estimated $CAN 19·8 billion was for the treat-
ment and management of diabetes, CVD and cancer.
About 5 % of these costs for diabetes, CVD and cancer
could have been avoided if Canadians had complied with
existing recommendations for vegetables and fruit
(32)
.
With a Canadian population of approximately 35·8 million,
the avoidable costs for health care and productivity loss
approximate $CAN 92 per capita per year.
Cadilhac et al. estimated the economic burden attribu-
table to a low consumption of vegetables and fruit to be
$AU 269 million in 2008
(15)
, which approximates to per
capita avoidable costs of $CAN 11 per Australian per year.
Differences with our per capita estimate of $CAN 92 per
year may originate from differences in lifestyle, culture,
food choices, dietary recommendations and health-care
costs between the two nations, as well as from methodo-
logical differences between the studies. With respect to the
later, for example, Cadilhac et al. estimated avoided
costs associated with a 172 g/d increase in the consum-
ption of vegetables and fruit, whereas we estimated costs
associated with inadequate consumption of vegetables
and fruit using national dietary recommendations as a
reference. Scarborough et al. estimated the costs asso-
ciated with the treatment and management of diabetes,
CVD and cancer attributable to poor diet to be £4·9 billion
in 2006/2007
(15)
, which approximates to per capita
avoidable costs of $CAN 133 per UK citizen per year.
It is important to note that Scarborough et al. took a
broader perspective by considering everyone consuming
600 g vegetables and fruit/d, having total cholesterol levels
of 3·8 mmol/l and a BMI of 21 kg/m
2
as the counterfactual
of poor diet
(15)
, thus capturing more costs than those
attributable to low vegetables and fruit consumption only.
Because Scarborough et al. estimated the costs attributable
to poor diet, and Cadilhac et al. costs associated with low
vegetables and fruit consumption, the present study
represents the first study to estimate costs associated with
the inadequate consumption of vegetables and fruit using
national dietary recommendations as the criterion for
adequate consumption.
The effects of diet on chronic diseases are multifactorial
and include both risk reducers and risk factors. In addition
to vegetables and fruit, the WHO lists fish and fish oils,
potassium and moderate alcohol intake as risk reducers
for which research has provided convincing evidence,
and dietary fibre, wholegrain cereals, nuts, folate and
unsaturated fatty acids as risk reducers with less
convincing evidence. Diets high in sodium, high in alcohol
Table 1 Vegetables and fruit consumption in Canada by gender and age group
Gender/age
Canadian
population in
Approximated
recommendation
% consuming given number of servings of
vegetables and fruit/d
% Mean
Total
recommended
servings/d
Total
consumed
servings/d
Consumption
deficit* servings/d
group 2015 (’000) (servings/d) 0–<11–<22–<33-<44–<55–<66–<77–<8 8+ inadequate servings/d (’000) (’000) (’000)
Male
<15 years 2948 5 2·28·814·817·215·311·39·25·515·758·25·0 14 740 14 756 3273
15–34 years 4830 8 4·211·415·617·416·810·28·05·710·789·34·6 38 640 21 992 17 820
35–54 years 4977 8 3·410·418·220·018·39·87·74·38·092·04·3 39 818 21 310 19 168
55–64 years 2402 7 2·910·020·222·316·99·96·74·86·388·94·1 16 814 9922 7278
65–74 years 1584 7 2·27·318·020·518·015·08·64·06·489·64·3 11 087 6860 4421
75+ years 1035 7 1·94·915·421·419·514·89·35·67·387·14·5 7242 4696 2679
Total 17 776 3·410·017·419·617·510·87·84·98·689·04·4 128 342 79 536 54 638
Female
<15 years 2801 5 3·06·09·615·717·016·612·46·912·751·35·2 14 007 14 463 2538
15–34 years 4705 7 2·17·613·116·915·315·210·87·012·280·95·0 32 932 23 455 11 266
35–54 years 4973 7 1·55·511·416·218·216·111·28·211·780·25·1 34 811 25 336 11 125
55–64 years 2435 7 1·46·312·117
·517·514·811·87·311·181·55·0 17 042 12 188 5638
65–74 years 1697 7 1·34·911·415·916·616·313·18·811·679·65·2 11 880 8744 3653
75+ years 1457 7 1·03·610·716·519·616·012·28·911·579·65·2 10 200 7530 3074
Total 18 068 1·76·111·916·617·115·611·57·711·879·55·1 120 873 91 716 37 294
Overall 35 844 2·58·014·618·117·313·29·76·310·284·24·7 249 214 171 252 91 933
*Consumption deficit represents the number of daily servings needed to have all Canadians with inadequate consumption of vegetables and fruit increase their consumption to the recommended number of servings.
518 JP Ekwaru et al.

Table 2 Relative risk (RR), population-attributable fraction (PAF) and estimated direct and indirect health-care costs associated with chronic
diseases in Canada by gender and age group
2015 costs (’000 $CAN)
PAF (%) Direct†Indirect
Age group/chronic disease (ICD-10 code) RR* 95 % CI Male Female Male Female Male Female
<15 years
IHD (I20–I25) 0·90 0·82, 0·99 11·88 9·91 717·4 595·7 1226·3 1018·3
Ischaemic stroke (I63) 0·94 0·89, 0·99 6·94 5·74 159·385·2 272·3 145·7
Lung cancer (C34) 0·97 0·95, 0·98 3·40 2·79 55·4 171·2 264·4 817·6
Colorectal cancer (C20) 0·99 0·98, 1·00 1·12 0·91 30·934·3 147·8 163·7
Oesophagus cancer (C15) 0·94 0·88, 1·01 6·94 5·74 9·45·744·727·3
Stomach/gastric cancer (C16) 0·94 0·86, 1·03 6·94 5·74 8·619·240·991·7
Bladder cancer (C67) 0·97 0·95, 0·99 3·40 2·79 30·835·5 147·0 169·7
Oral cancers (C00–C14) 0·77 0·66, 0·89 29·62 25·64 1208·9 302·5 5772·3 1444·2
Larynx cancer (C32) 0·77 0·66, 0·89 29·62 25·64 34·036·2 162·2 172·8
Breast cancer (C50) 0·98 0·97, 1·00 2·25 1·84 10·518·450
·087·9
Diabetes mellitus (E10–E14) 0·96 0·86, 1·07 4·56 3·76 26 914·1 13 720·2 31 926·4 16 275·3
15–34 years
IHD (I20–I25) 0·90 0·82, 0·99 33·92 23·80 1991·7 2290·6 3404·5 3915·6
Ischaemic stroke (I63) 0·94 0·89, 0·99 21·12 14·35 5401·2 1746·6 9232·7 2985·7
Lung cancer (C34) 0·97 0·95, 0·98 10·82 7·18 640·6 962·6 3058·9 4596·4
Colorectal cancer (C20) 0·99 0·98, 1·00 3·66 2·40 2331·1 3035·6 11 131·0 14 495·3
Oesophagus cancer (C15) 0·94 0·88, 1·01 21·12 14·35 307·4 162·2 1467·7 774·4
Stomach/gastric cancer (C16) 0·94 0·86, 1·03 21·12 14·35 776·1 1277·1 3706·0 6098·2
Bladder cancer (C67) 0·97 0·95, 0·99 10·82 7·18 681·9 364·7 3255·9 1741·3
Oral cancers (C00–C14) 0·77 0·66, 0·89 67·20 52·61 1486·7 1419·3 7099·1 6777·1
Larynx cancer (C32) 0·77 0·66, 0·89 67·20 52·61 69·3 172·5 331·1 823·6
Breast cancer (C50) 0·98 0·97, 1·00 7·27 4·79 83·6 18 354·3 399·3 87 642·2
Diabetes mellitus (E10–E14) 0·96 0·86, 1·07 14·32 9·58 69 359·9 78 738·4 82 276·8 93 401·9
35–54 years
IHD (I20–I25) 0·90 0·82, 0·99 34·80 22·39 25 681·0 16 608·2 43 898·9 28 389·8
Ischaemic stroke (I63) 0·94 0·89, 0·99 21·80 13·45 189 441·0 50 547·9 323828·8 86 406·2
Lung cancer (C34) 0·97 0·95, 0·98 11·23 6·72 22 454·6 38 061·0 107221·1 181 741·8
Colorectal cancer (C20) 0·99 0·98, 1·00 3·82 2·24 59 743·6 42 034·6 285 276·5 200 716·0
Oesophagus cancer (C15) 0·94 0·88, 1·01 21·80 13·45 8500·3 2267·0 40 589·0 10 824·9
Stomach/gastric cancer (C16) 0·94 0·86, 1·03 21·80 13·45 11 578·0 8056·5 55 285·1 38 469·7
Bladder cancer (C67) 0·97 0·95, 0·99 11·23 6·72 13 231·0 5777·3 63 178·3 27 586·5
Oral cancers (C00–C14) 0·77 0·66, 0·89 67·85 50·12 17 179·9 7172·7 82 034·3 34 249·9
Larynx cancer (C32) 0·77 0·66, 0·89 67·85 50·12 5277·1 1292·2 25 198·1 6170·2
Breast cancer (C50) 0·98 0·97, 1·00 7·56 4·48 849·9 218453·9 4058·4 1 043 120·9
Diabetes mellitus (E10–E14) 0·96 0·86, 1·07 14·83 8·97 636 180·4 340905·0 754 656·2 404 391·7
55–64 years
IHD (I20–I25) 0·90 0·82, 0·99 28·58 23·05 49 845·1 23 924·5 85 204·8 40 896·3
Ischaemic stroke (I63) 0·94 0·89, 0·99 17·59 13·88 238 919·2 84 192·0 408406·4 143 917·1
Lung cancer (C34) 0·97 0·95, 0·98 8·95 6·95 63 167·0 59 677·1 301623·7 284 959·0
Colorectal cancer (C20) 0·99 0·98, 1·00 3·01 2·32 101 788·5 64 200·7 486 041·7 306 559·5
Oesophagus cancer (C15) 0·94 0·88, 1·01 17·59 13·88 19 641·4 4921·9 93 788·1 23 502·3
Stomach/gastric cancer (C16) 0·94 0·86, 1·03 17·59 13·88 16 322·4 6804·9 77 939·6 32 493·5
Bladder cancer (C67) 0·97 0·95, 0·99 8·95 6·95 31 721·7 11 669·6 151 471·4 55 722·3
Oral cancers (C00–C14) 0·77 0·66, 0·89 59·15 51·17 24 972·5 8962·2 119 243·9 42 794·8
Larynx cancer (C32) 0·77 0·66, 0·89 59·15 51·17 12 312·9 3243·8 58 794·1 15 489·4
Breast cancer (C50) 0·98 0·97, 1·00 6·00 4·63 922·0 251 645·8 4402·4 1 201 612·7
Diabetes mellitus (E10–E14) 0·96 0·86, 1·07 11·87 9·26 457 808·4 348 787·7 543 066·1 413 742·4
65–74 years
IHD (I20–I25) 0·90 0·82, 0·99 26·70 21·69 84 631·6 59 642·5 144 668·5 101 952·3
Ischaemic stroke (I63) 0·94 0·89, 0·99 16·34 13·00 244 077·3 122 163·8 417 223·6 208 825·8
Lung cancer (C34) 0·97 0·95, 0·98 8·28 6·48 104 089·1 89 181·4 497 027·2 425 842·8
Colorectal cancer (C20) 0·99 0·98, 1·00 2·78 2·16 142 985·6 93 821·2 682 758·4 447 997·9
Oesophagus cancer (C15) 0·94 0·88, 1·01 16·34 13·00 18 510·3 5453·9 88 387·1 26 042·2
Stomach/gastric cancer (C16) 0·94 0·86, 1·03 16·34 13·00 25 162·9 13 421·4 120 153·2 64 087·6
Bladder cancer (C67) 0·97 0·95, 0·99 8·28 6·48 58 672·9 16 787·5 280 164·2 80 160·5
Oral cancers (C00–C14) 0·77 0·66, 0·89 56·40 49·01 18 600·8 9259·9 88 819·0 44 216·3
Larynx cancer (C32) 0·77 0·66, 0·89 56·40 49·01 15 704·0 3648·7 74 986·7 17 422·4
Breast cancer (C50) 0·98 0·97, 1·00 5·54 4·32 946·4 118 011·8 4519·1 563 508·5
Diabetes mellitus (E10–E14) 0·96 0·86, 1·07 10·99 8·65 405 867·9 350 053·0 481 452·7 415 243·4
75+ years
IHD (I20–I25) 0·90 0·82, 0·99 25·09 21·21 151 947·0 220 169·9 259 736·9 376 356·5
Ischaemic stroke (I63) 0·94 0·89, 0·99 15·28 12·72 287 136·5 285 716·5 490 828·6 488 401 ·2
Lung cancer (C34) 0·97 0·95, 0·98 7·71 6·35 93 793·3 77 547·3 447 864·5 370 289·4
Colorectal cancer (C20) 0·99 0·98, 1·00 2·58 2·11 178 159·7 165 099·0 850 715·7 788 350·4
Economic burden of poor diet in Canada 519

and containing trans and saturated fats are listed as the
risk factors with convincing evidence
(33)
. Calculations that
consider each of these dietary risk reducers and risk
factors will produce higher estimates for the economic
burden of poor diets relative to the estimates that consider
solely the inadequate consumption of vegetables and fruit,
the approach of the present study. Where some nations
have distinct recommendations for vegetables and for
fruits, Canadian recommendations specify the combined
number of servings of vegetables and fruit. This poses
challenges for the estimation of the economic burden. For
example, in their meta-analysis, Li et al.
(21)
revealed a
statistically significant protective effect of fruit and of green
leafy vegetables on the development of type 2 diabetes,
but no statistically significant effect of the combined
number of servings of vegetables and fruit on type 2
diabetes. A calculation that considers fruit and green leafy
vegetables, rather than the grouping of vegetables and
fruit, will provide more accurate estimates of the economic
burden. However, the reality is that Canadian public
health decision makers settled on a recommendation for
the combination of vegetables and fruit, and thus it is
desirable to provide an economic burden associated with
this recommendation. Excluding type 2 diabetes, as well as
oesophageal cancer and stomach/gastric cancer for which
the evidence is also mixed
(34)
, revealed a substantially
lower estimate, although more precise, for the economic
burden ($CAN 2·3 billion per year). Some may,
Table 2 Continued
2015 costs (’000 $CAN)
PAF (%) Direct†Indirect
Age group/chronic disease (ICD-10 code) RR* 95 % CI Male Female Male Female Male Female
Oesophagus cancer (C15) 0·94 0·88, 1·01 15·28 12·72 16 483·9 6955·2 78 710·9 33 211·1
Stomach/gastric cancer (C16) 0·94 0·86, 1·03 15·28 12·72 31 140·6 24 021·6 148 696·6 114 703·6
Bladder cancer (C67) 0·97 0·95, 0·99 7·71 6·35 87 545·7 28 430·8 418 032·2 135 757·7
Oral cancers (C00–C14) 0·77 0·66, 0·89 53·94 47·92 17 833·7 11 211·9 85 156·1 53 537·0
Larynx cancer (C32) 0·77 0·66, 0·89 53·94 47·92 10 672·2 2203·7 50 960·0 10 522·5
Breast cancer (C50) 0·98 0·97, 1·00 5·15 4·23 989·2 94 321·9 4723·7 450 388·5
Diabetes mellitus (E10–E14) 0·96 0·86, 1·07 10·25 8·47 294 213·3 295 700·6 349 004·6 350 768·9
ICD-10, International Statistical Classification of Diseases and Related Health Problems, 10th Revision.
*RR per 1 serving/d increase.
†Direct costs include costs for hospital care, physician services and drugs.
Table 3 The economic burden of inadequate vegetables and fruit consumption by chronic disease, gender and age group in 2015 in Canada
Attributable direct costs in 2015 (’000 $CAN)
All Excluding mixed/weak evidence*
Direct Indirect Total Direct Indirect Total
Chronic disease (ICD-10 code)
IHD (I20–I25) 154137 263 481 417 618 154 137 263 481 41 718
Ischaemic stroke (I63) 239 201 408 888 648 089 239 201 408 888 648 089
Lung cancer (C34) 41 576 198 528 240 105 41 576 198 528 240 105
Colorectal cancer(C20) 22 023 105 161 127 185 22 023 105 161 127 185
Oesophagus cancer (C15) 13 522 64 570 78 092
Stomach/gastric cancer (C16) 21 442 102 387 123 829
Bladder cancer (C67) 20125 96 095 116 220 20 125 96 095 116 220
Oral cancers (C00–C14) 66 811 319 022 385 833 66 811 319 022 385 833
Larynx cancer (C32) 30 785 146 999 177 784 30 785 146 999 177 784
Breast cancer (C50) 31 638 151 073 182 711 31 638 151 073 182 711
Diabetes mellitus (E10–E14) 360 875 428 081 788 956
Age group
<15 years 2371 4574 6945 625 2493 3118
15–34 years 23 682 42 379 66 061 5777 19 578 25 354
35–54 years 230 971 468 259 699 230 100 268 292 520 392 788
55–64 years 226 083 543 391 769 474 131 495 402 640 534 135
65–74 years 232 931 563 617 796 548 148 452 428 989 577 440
75+ years 286 098 662 066 948 163 219 680 543 028 762 708
Gender
Male 640 613 1441 712 2 082 325 380 664 1 042 391 1 423 056
Female 361 523 842 574 1 204 096 225632 646 856 872 488
Total 1 002136 2 284 285 3286 421 606 296 1 689 248 2295 544
ICD-10, International Statistical Classification of Diseases and Related Health Problems, 10th Revision.
*Excluding Type 2 diabetes, stomach and oesophagus cancers.
520 JP Ekwaru et al.

however, consider the latter estimate too low as it does not
capture the risk-reducing effects of fruit and green leafy
vegetables
(21)
.
Krueger et al. estimated the economic burden of
smoking tobacco, excess body weight and physical
inactivity to be $CAN 23·3 billion, $CAN 19 billion and
$CAN 11 billion, respectively
(17)
. In their approach,
Krueger et al. were more inclusive in their consideration of
health-care costs. Specifically, where we considered costs
for hospital, physician services and drugs, Krueger et al.
also included costs for health research and for other
health-care professionals (except dental) and expendi-
tures. In 2015, the costs for items we considered con-
stituted about 86 % of the costs for the items considered by
Krueger et al.
(17)
. If we had been as inclusive as Krueger
et al., our estimate for the economic burden of inadequate
consumption of vegetables and fruit would have been
$CAN 3·8 billion per year. The estimate of the economic
0
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1500
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2500
3000
3500
4000
4500
5000
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2016
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2018
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2030
2031
2032
2033
2034
2035
Economic burden (million $CAN)
(attributable to inadequate consumption of vegetables and fruit)
Calendar year
Fig. 1 (colour online) Effect of increasing the consumption of vegetables and fruit by 1 serving/d on health care-costs in Canada: ,
costs attributable to the inadequate consumption of vegetables and fruit; , costs avoided (cumulative =$CAN 9·2 billion)
0
500
1000
1500
2000
2500
3000
3500
4000
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2030
2031
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Economic burden (million $CAN)
(attributable to inadequate consumption of vegetables and fruit)
Calendar year
Fig. 2 (colour online) Effect of reducing the prevalence of inadequate vegetables and fruit consumption by 1 percentage point per
year on health-care costs in Canada: , costs attributable to the inadequate consumption of vegetables and fruit; , costs avoided
(cumulative =$CAN 10·82 billion)
Economic burden of poor diet in Canada 521

burden of inadequate vegetables and fruit consumption
should be considered an economic burden in addition to
the estimates for smoking tobacco, excess body weight
and physical activity by Krueger et al., because the relative
risks used in our estimation originated from meta-analyses
of mostly clinical trials and observational studies that
were adjusted for tobacco use, excess body weight, and
physical activity among other confounders
(4,20–24,28)
.
By expanding the estimates by Krueger et al. with an
estimate for the economic burden of inadequate intake of
vegetables and fruit, we provide policy makers with
further evidence-based options for interventions aimed at
preventing chronic diseases and reducing associated
health-care expenditures.
We estimated that Canadians collectively consume
171 million servings of vegetables and fruit daily and
that an additional 92 million servings are needed for
consumption to increase to adequate levels for all
Canadians. As many vegetables and fruit in Canada can be
purchased for a price of approximately $CAN 0·30
(35)
, this
would translate into approximately $CAN 10 billion per
year in costs to consumers. Our estimate of $CAN 3·3 billion
in avoidable costs to society provides an appealing
incentive for further investments in the promotion of
vegetables and fruit. These investments should not only
target education and behavioural change of consumers, but
also strategize vegetables and fruit production. Investments
and changes in the consumption of vegetables and fruit are
not expected to come quick. Our scenario analyses showed
that a gradual target of a modest 1 percentage point annual
reduction in the proportion of individuals consuming less
than the recommended servings of vegetables and fruit
daily would avoid approximately $CAN 10·8 billion in
20 years and an increase of one serving of vegetables and
fruit daily would avoid approximately $CAN 9·2 billion
in 20 years.
Our estimates of the economic burden of inadequate
vegetables and fruit consumption are based on those chronic
diseases for which there are published meta-analysis show-
ing a significant relationship with vegetables and fruit. Our
estimates did not consider chronic diseases for which the
relationship with vegetables and fruit has not been studied or
for which there is insufficient evidence. The evidence on
importance of vegetables and fruit in the causation of cancers
is evolving, with recent publications suggesting a more
modest risk than earlier publications. For the above reasons it
is essential that our estimates be updated when new and
better evidence on the health benefits of vegetables and fruit
becomes available. Established limitations of dietary research
apply to the present study: the assessment of dietary intake
depends on self-report, which is prone to error, and
reporting of food frequency does not translate accurately into
absolute consumption. In addition, the CCHS summary
variable on consumption of vegetables and fruit includes
potatoes, which has been shown not to provide the same
benefit in terms of preventing chronic disease as other
non-starchy vegetables
(36,37)
. Other limitations of the present
study relate to the PAF approach that did not consider a
latency period, which may lead to an overestimation of the
cost savings of the two intervention scenarios. As a further
limitation we note that although we used direct cost
estimates provided in the Canadian National Health
Expenditure report
(29)
, the allocation of these costs to specific
disease categories was based on the assumption that the
distribution of costs by disease category and the ratio of
direct to indirect costs do not change over time. However, it
is likely that disease-specific costs may change due to
changes in treatments over time. Third, we adapted some of
the age-specific recommendations for vegetables and fruit to
align them with the available age categories for health-care
costs. For some age/gender groups we used the lower
bound of the recommended range. Had we used a
mid-range value or otherwise a higher value for the recom-
mendation, our estimates of the economic burden would
have been higher. Lastly, since the CCHS included only
participants aged 12 years or older, we assumed that the
distribution of vegetables and fruit consumption observed in
the 12–14 years age group applied to those under 12 years of
age. The overall error this may have introduced is assumed
to be very small as the contribution of the ‘under 15 years
age group’is less than 0·2 % of the estimated burden
(Table 3).
Conclusion
In conclusion, we estimated that $CAN 3·3 billion of
annual health-care costs in Canada are attributable to
inadequate consumption of vegetables and fruit. Further
investments in the promotion of vegetables and fruit will
prevent chronic diseases and substantially reduce direct
and indirect health-care costs.
Acknowledgements
Acknowledgements: The authors thank Statistics Canada
and Irene Wong for facilitating access to the CCHS.
Financial support: The authors wish to thank the Research
Data Centre at the University of Alberta for providing
assistance and access to the CCHS data. The present study
was funded through the Collaborative Research and
Innovation Opportunities (CRIO) Team programme from
Alberta Innovates Health Solutions awarded to P.J.V. and
A.O. P.J.V. holds a Canada Research Chair in Population
Health, an Alberta Research Chair in Nutrition and Disease
Prevention, and an Alberta Innovates Health Scholarship.
The funders had no role in the design, analysis or writing
of this article. All interpretations and opinions in the
present study are those of the authors. Conflict of interest:
None. Authorship: J.P.E., A.O. and P.J.V. conceptualized
the manuscript. J.P.E. conducted statistical analyses. J.P.E.,
A.O., P.J.V., S.L., S.S. and N.X.T. participated in drafting,
522 JP Ekwaru et al.

review and editing of the manuscript. Ethics of human
subject participation: Not applicable.
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