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Modifiable Risk Factors Methodology

Modifiable Risk Factors
Short description of Indicator

Percentage of Ontario adults (ages 19 years and older) who report consuming alcohol at levels that exceed the cancer prevention recommendation for alcohol consumption

Percentage of Ontario adults (ages 18 years and older) who are overweight or obese according to self-reported height and weight

Percentage of Ontario adults (ages 18 years and older) who report levels of physical activity that do not meet the cancer prevention recommendation to be moderately to vigorously physically active for 30 minutes or more each day

Percentage of Ontario adults (ages 18 years and older) who report that they consume vegetables (excluding potatoes) or fruit less than 5 times a day

Percentage of Ontario adults (ages 20 years and older) who report that they are current tobacco smokers

Rationale for measurement Modifiable risk factors are behaviours and exposures that can lower or raise a person’s risk of cancer and that can be changed. Evidence confirms strong associations between five major risk modifiers (tobacco, alcohol consumption, body fatness, physical activity and healthy eating) and the risk of certain cancers. Reporting on risk factor prevalence in Ontario is important for effectively monitoring trends over time, supporting the development of health promotion strategies and evaluating outcomes of provincial and local interventions.
Evidence/references for rationale

Evidence supporting association between modifiable risk factors and cancer risk: 

  • World Cancer Research Fund/American Institute for Cancer Research. Diet, Nutrition, Physical Activity and Cancer: a Global Perspective. Continuous Update Project Expert Report 2018. Available from: https://www.wcrf.org/dietandcancer (accessed May 17, 2019)
  • World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR, 2007
  • Parkin DM, Boyd L, Walker LC. 2011. 16. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. Br J Cancer. 105:S77-S81.
  • International Agency for Research on Cancer. IARC monographs on the evaluation of carcinogenic risks to humans. Volume 100E. A review of human carcinogens. Part E: Personal habits and indoor combustions. Lyon: International Agency for Research on Cancer; 2012
Calculations for the indicator

Alcohol consumption 

((weighted number of adults ages 19 years and older who on average exceed the maximum recommended alcohol consumption for cancer prevention) ÷ (weighted total population ages 19 years and older)) x 100 

  • The maximum recommended alcohol consumption for men is two drinks per day and for women is one drink per day, as specified by the World Cancer Research Fund and the American Institute for Cancer Research.
  • Respondents who answered yes, refusal, don't know, or not stated to the pregnancy question were excluded.

Overweight/obese

((weighted number of adults ages 18 years and older with BMI (corrected) ≥ 25.0) ÷ (Weighted total population ages 18 years and older)) x 100

Where BMI (corrected)1 is calculated as follows:

  • Males: BMI (corrected) = - 1.07575 + [1.07592 x BMI (self- reported)]
  • Females: BMI (corrected) = -0.12374 + [1.05129 x BMI (self-reported)]
  • Respondents who were pregnant at the time of the survey were excluded.
  • The calculation of BMI excluded respondents less than 3 feet (0.914 m) tall or those greater than 6 feet 11 inches (2.108 m).
  • BMI is categorized using standard international weight cutoffs.2

Physical inactivity

((weighted number of adults ages 18 years and older who were on average moderately or vigorously physically active for less than 30 minutes each day) ÷ (weighted total population ages 18 years and older)) x 100 

  • Physical activity includes active transportation, sports and recreation and/or other physical activity, such as household chores.

Inadequate vegetable and fruit consumption

((weighted number of adults ages 18 years and older eating vegetables (excluding potatoes) and fruit less than 5 times per day) ÷ (weighted total population ages 18 years and older)) x 100 

  • Respondents who reported consuming fruit juice more than once daily were considered as having consumed it only once.

Current smoking

((weighted number of adults ages 20 years and older who smoke daily or occasionally) ÷ (weighted total population ages 20 years and older)) x 100 

General exclusions:

  • All calculations excluded respondents in the non-response categories (refusal, don't know, and not stated) for required questions.

General analytic notes:

  • Bootstrapping techniques were used to obtain variance estimates and 95% confidence intervals of all estimates.3 Statistics Canada requires estimates with coefficients of variation of >15.0% to 35.0% to be noted with a warning to users to interpret with caution, and estimates with coefficients of variation >35.0% to be suppressed.4 

References:

  1. Connor Gorbor S, Shields M, Tremblay MS, McDowell I. The feasibility of establishing correction factors to adjust self-reported estimates of obesity. Health Rep 2008;19(3):71–82.
  2. Health Canada. Canadian Guidelines for Body Weight Classification in Adults [Internet]. Ottawa: Health Canada; 2003 [cited 14 Dec 2017}. Available from: https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/healthy-weights/canadian-guidelines-body-weight-classification-adults/questions-answers-professionals.html.
  3. Statistics Canada. 2005. Bootvar: User Guide (Bootvar 3.2 – SAS version). Ottawa: Statistics Canada; 2010.
  4. Statistics Canada. Canadian Community Health Survey (CCHS) Annual component. User guide: 2015 Microdata file. Ottawa: Statistics Canada; 2017
Standardized Rate Calculation Adult modifiable risk factor estimates were age-standardized to the 2011 Canadian population using the age groups from the CCHS person-level sampling strategy: 18–34, 35–49, 50–64, 65 and over (exceptions for the lowest age range were made for alcohol consumption where 19–34, and current smoking where 20–34, were used).
Unit Percentage (%)
Data sources Canadian Community Health Survey 2015–2017. Statistics Canada, Ontario Share File, Ontario Ministry of Health and Long-Term Care.
Time Frame 2015 - 2017
Geographic Scale Provincial
Denominator description ​See method of calculation above
Numerator description See method of calculation above
Considerations 
  • Beginning in 2015, the Canadian Community Health Survey (CCHS) underwent major changes in the design of the survey and collection of data. As a result, no comparisons should be made to previous years of the CCHS for any variables.
  • The CCHS excludes individuals living on Indian Reserves and on Crown Lands, institutional residents, full-time members of the Canadian Forces, and residents of certain remote regions.
  • CCHS data on modifiable risk factors are self-reported. Respondents of self-reported surveys tend to under-report behaviours that are socially undesirable or unhealthy (alcohol use, tobacco use, etc.) and over-report behaviours that are socially desirable (physical activity, vegetable and fruit consumption, etc.).
  • For body composition, BMI is calculated using sex-specific correction equations for adjusting self-reported measures of BMI developed by Statistics Canada to provide more accurate estimates of overweight and obesity prevalence in the population;1 BMI classifications used here may be limited in determining health risks for muscular adults, naturally lean adults, young adults who have not reached full growth, seniors, and certain racial/ethnic groups.1
  • The definition of “adult" applies to individuals ages 18 and over, with the exceptions of alcohol at ages 19 and over to match Ontario's legal drinking age, and 20 and over for smoking-related indicators. 
  • Socio-demographic characteristics were defined as follows:
    • ​​​​Urban/rural residencerespondents living within any Census Metropolitan Area (CMA) or Census Agglomeration (CA) were considered “urban residents"– and those living outside of any CMA or CA were classified as “rural residents".
    • Household income quintile: sorts respondents' derived household income into quintiles based on the ratio of household income to the low income cut-off (LICO) for the household size and community. Starting in 2011, Statistics Canada imputed all missing household incomes to account for the one-third of missing responses to the income question. In 2017, the derived variable only calculated income deciles. Deciles were combined to create quintiles. 
    • Education: highest level of education attained by the respondent, according to three categories: less than secondary school graduation; secondary school graduation or some post-secondary education; and post-secondary graduation.
    • Immigration status: distinguishes immigrants at different times since immigration from the Canadian-born population, according to three categories: Canadian–born; immigrant > 10 years in Canada; and immigrant ≤ 10 years in Canada. The years since immigration refers to the first time the respondent arrived into Canada (excluding holidays) to live as a landed immigrant, by claiming refugee status, with a work permit or with a study permit.
  • Socio-demographic characteristics were analyzed for adults aged 25 and older to restrict the sample to those who have likely completed their education and reached their adult socio-demographic status.
  • Socio-demographic characteristics were compared against the following reference variables: urban areas for analyses by urban/rural residence, income quintile 5 (Q5) for analyses by household income quintile, post-secondary graduate for analyses by education status and Canadian-born for analyses by immigration status.

Survey Questions – Canadian Community Health Survey

Smoking (Smoking module):

  • At the present time, do you smoke cigarettes every day, occasionally or not at all?

Overweight/obesity (Height and weight module; Main activity module):

  • How tall are you without shoes on?
  • How much do you weigh?
  • Are you pregnant?

Alcohol consumption (Alcohol use module; Alcohol use during the past week module; Main activity module):

  • A 'drink' refers to:
    • a bottle or small can of beer, cider or cooler with 5% alcohol content, or a small draft;
    • a glass of wine with 12% alcohol content;
    • a glass or cocktail containing 1½ oz. of a spirit with 40% alcohol content.
  • Thinking back over the past week, did you have a drink of beer, wine, liquor or any other alcoholic beverage?
  • Starting with yesterday, how many drinks did you have?
  • Are you pregnant?

Physical activity (Physical activities – adults 18 years and older module)

  • In the last 7 days, did you use active ways like walking or cycling to get to places such as work, school, the bus stop, the shopping centre or to visit friends?
  • In the last 7 days, did you do sports, fitness or recreational physical activities, organized or non-organized, that lasted a minimum of 10 continuous minutes? Examples are walking, home or gym exercise, swimming, cycling, running, skiing, dancing and all team sports.
  • In the last 7 days, did you do any other physical activities while at work, in or around your home or while volunteering? Examples are carrying heavy loads, shoveling, and household chores such as vacuuming or washing windows. Please remember to only include activities that lasted a minimum of 10 continuous minutes.
  • Did any of these recreational/other physical activities make you sweat at least a little and breathe harder?
  • How much time in total, in the last 7 days, did you spend doing these activities? Please only include activities that lasted a minimum of 10 continuous minutes.

Vegetable and fruit consumption (Fruit and vegetable consumption module):

  • In the last month, how many times per day, per week or per month did you drink 100% PURE fruit juices, such as pure orange juice, apple juice or pure juice blends? Do not include fruit-flavored drinks with added sugar or fruit punch.
  • In the last month, not counting juice, how many times did you eat fruit? Please remember to include frozen, dried or canned fruit.
  • In the last month, how many times did you eat dark green vegetables such as broccoli, green beans, peas and green peppers or dark leafy greens including romaine or spinach? Please remember to include (frozen or canned vegetables and) vegetables that were cooked in soups or mixed in salad.
  • In the last month, how many times did you eat orange-coloured vegetables such as carrots, orange bell pepper, sweet potatoes, pumpkin or squash? (Please remember to include frozen or canned vegetables and vegetables that were cooked in soups or mixed in salad).
  • Excluding the green and orange vegetables as well as the potatoes you have already reported, in the last month, how many times did you eat OTHER vegetables? Examples include cucumber, celery, corn, cabbage and vegetable juice.

References:

  1. Health Canada. Canadian Guidelines for Body Weight Classification in Adults [Internet]. Ottawa: Health Canada; 2003 [cited 14 Dec 2017}. Available from: https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/healthy-weights/canadian-guidelines-body-weight-classification-adults/questions-answers-professionals.html
  2. Statistics Canada. 2005. Bootvar: User Guide (Bootvar 3.2 – SAS version). Ottawa: Statistics Canada; 2010.
Data availability & limitations N/A