Food's impact on health care

The relationship between food and health is much clearer (though still murky at times) than the relationship between food and health care spending.  Many studies show that poor diet contributes to ill health (see reviews by Global Panel on Agriculture and Food Systems for NutritionTFPC, 1997Global Burden of Disease Studies; Jeffery, 2019a,b)  Proponents of food system change then argue that improved diets will dramatically reduce health care costs. But demonstrating that good diets  lead to lower health care costs is a bit trickier.  That's because the food story is interwoven with many other factors that create health, and also with the intricacies of health care delivery in Canada.

We have an acute care system in Canada, not a health promotion system.  This is because only part of the Tommy Douglas vision for health care was implemented. In Douglas' plan,  phase I was about the removal of financial barriers, accomplished by created publicly funded health insurance, which we largely have. Phase II was about the shift  to disease prevention and health promotion, the creation of more group practice, improved coordination, and democratic governance.  Only bits and pieces of phase II have been realized.

So, essentially, we have a curative system driven by the availability of curative professionals and equipment, the vast majority of resources devoted to health care.  There are numerous incentives in the system to find more sick people and devote more resources to curing illness, the traditional billing system for doctors being a prime example.  Introducing health promotion to such a system is an uphill battle because if the demand for services goes down because people are healthier, the system faces a financial crisis.    Having invested so much in the hard and soft infrastructure of hospitals, diagnostic equipment and procedures, and specialists, the financial pressures are to keep those resources fully occupied.  In this kind of supply driven  environment, if demand goes down, the system has to create new demand.

Improvements in diet will not cure all diseases and conditions, so some precision is required regarding where the improvements can happen and how that affects health care spending.  Diet clearly is linked to many chronic diseases - heart, type II diabetes, hypertension, many cancers, Low Birthweight births, obesity - but much less to many trauma injuries, respiratory problems, muscular-skeletal system problems, and nervous system disorders.  It can play, however, a significant role in senior's health and associated trauma events, such as falls and fractures and medications required because of suppressed immune system function.

Approximately five per cent of patients account for two-thirds of health care costs, usually people with multiple, complex conditions  (Ontario Ministry of Health). And we also know that most of us use the vast majority of our lifetime demand for health care resources at the end of our lives, often the last 6 months.  However, healthy seniors use fewer health care resources.  Those with 3 or more reported chronic conditions have 3 times the visits of those with no reported chronic conditions.  They comprise 24% of seniors but account for 40% of health care use among seniors  (CIHI , 2011).

All this suggests that using a compression of morbidity framework might be the best way to understand how food can reduce health care costs.  There is now significant evidence that those with fewer lifetime modifiable risk factors cost the system less than those with more risk factors.  Fundamental to this line of thinking is the evidence that increases in average population lifespan are largely associated with major reductions in infant mortality and that we have yet to significantly invest in "through the lifetime" strategies that extend the disability free years at the end of life. The argument that if we prevent diseases, people will just die of something else that costs money is the product of a system that doesn't invest in reducing disability.  We need strategies that not only prevent disease, but also reduce total years of disability and dependence (Mirolla, 2004).  If we are able to delay the onset of diseases and compress the period of illness (compression of morbitity), then we can save the system money (Fries, 1983).

Diet is a significant factor in compressing morbidity. "...... behaviours like non-smoking, exercise, good diet, and healthy weight, as well as social conditions, greatly delay the onset of many chronic diseases, modify the aging process, and support vitality and independence in old age" (Mirolla, 2004:95). In US analyses, three  factors accounted for  nearly three-quarters of all preventable causes of death, and more than half of preventable hospital days: tobacco (27% of preventable deaths; 20% of preventable hospital days); high blood pressure (24% of preventable deaths; 12% of preventable hospital days); and over-consumption of high-calorie, fatty foods, ( 23% of preventable deaths; 20% of preventable hospital days) (Aldana, 2001).  Diet is, of course, also a significant risk factor for high blood pressure.

There are certainly circumstances where diet has a more immediate impact on diseases and conditions.  LBW has a high correlation with nutritional status of an at risk mother at the time of conception.  LBW births have immediate financial consequences in hospitals and health problems can result for the individual right through adulthood (TFPC, 1997).  Those food insecure report higher health care utilization than those not food insecure (Tarasuk et al., 2015), and for those severely food insecure, with lives shortened by 9 years (Men et al., 2020).  Both LBW and food insecurity are associated with poverty and adverse social conditions and both income and related interventions are required to properly address them (see Goal 1 Income Security).  But many other circumstances require a "through the lifespan" approach to creating more positive food environments. This entire web site is about changing food environments.  The rest of this section addresses interventions that are more specific to the health care system.