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International Modifiable Risk Factors

How does Ontario compare?

“Working together to create the best health systems in the world” is Cancer Care Ontario’s vision. Is Ontario succeeding with respect to cancer? To find out, we sought out national and international data against which to compare Ontario’s results. The selected findings below identify where Ontario is doing well and where improvement is needed in relation to other jurisdictions.

To find out more about modifiable risk factors in Ontario, see the Modifiable Risk Factors section of this year’s Cancer System Quality Index (CSQI)

A note on jurisdictional comparisons

  • This is the ninth year that the CSQI has showcased international benchmarks for Ontario’s performance.
  • We compare Ontario with select jurisdictions, primarily because they have healthcare and data systems similar to those in Ontario.
  • Ensuring that we have comparable data and measures from multiple jurisdictions is a challenge. It is wise to be mindful of the different data definitions, methodologies and years used in indicators measured outside Canada. Data also may be missing or not publicly available for some countries. Cross-jurisdictional comparison is still useful, however, for providing a rough indication of how well Ontario is doing compared to other jurisdictions.

Table 1. Jurisdictional comparisons in modifiable risk factors: Obesity

Jurisdiction

Year

Age range

Type

Data

Source

Canada

2015–2016

Adults (age ≥18 years) with a BMI of 30 or more (BMI is a ratio of weight to height: kg/m2)

Self-reported

Both sexes: 26.3%
All men: 28.0%
All women: 24.7%

 

Canadian Community Health Survey 2015–2016

Best in Ontario

2015–2016

Individuals age ≥18 years with a BMI of 30 or more (BMI is a ratio of weight to height: kg/m2)

Self-reported

City of Toronto Health Unit

Both sexes: 19.1%
All men: 19.0%
All women: 19.3%

Canadian Community Health Survey 2015–2016

Ontario

2015–2016

Individuals age ≥18 years with a BMI of 30 or more (BMI is a ratio of weight to height: kg/m2)

Self-reported

Both sexes: 26.2%
Males: 27.7%
Females: 24.7%

Canadian Community Health Survey 2015–2016

Best Province

2015–2016

Individuals age ≥18 years with a BMI of 30 or more (BMI is a ratio of weight to height: kg/m2)

Self-reported

British Columbia

Both sexes: 21.3%
All men: 23.1%
All women: 19.5%

Canadian Community Health Survey 2015–2016

Australia, New South Wales

2016

Percentage of individuals age ≥16 years who are obese (BMI ≥30)

 

Self-reported

Both sexes: 21.4%

All men: 21.5%

All women: 21.2%             

Health Statistics NSW

New Zealand

2016–2017

Percentage of individuals age ≥15 years who are obese (BMI ≥30)

 

Measured

Both sexes: 32.2%

All men: 30.5%

All women: 33.8%

Annual Update of Key Results 2016/17: New Zealand Health Survey

Netherlands

2015

Percentage of individuals age ≥15 years who are obese (BMI ≥30)

 

Self-reported

Both sexes: 12.8%

All men: 11.3%

All women: 14.2%

Organization for Economic Co-operation and Development (OECD)

Sweden

2016

Percentage of individuals age ≥16 years who are obese (BMI ≥30)

 

Self-reported

Both sexes: 13.0%

All men: 14.2%

All women: 11.6%

 

Swedish Living Conditions Survey, 2016-2016
 

United Kingdom

2016

Percentage of adults age ≥16 years who are classified as obese (BMI ≥30)

Measured

Both sexes:
26.1%
All men:
25.7%
All women:
26.6%

 

Health Survey for England, 2016 trend tables

United States, New York State

2016

 

Percentage of individuals age ≥18 years who are classified as obese (BMI ≥30)

Self-reported

Both sexes: 25.5%

All men: 25.9%

All women: 25.2%

 

 

Behavioral Risk Factor Surveillance System (BRFSS)

United States, Best (excluding Virgin Islands and territories)

 

2016

Percentage of individuals age ≥18 years who are classified as obese (BMI ≥30)

Self-reported

Colorado

 

Both sexes: 22.3%

All men: 22.4%

All women: 22.1%

 

Behavioral Risk Factor Surveillance System (BRFSS)

United States (States and D.C.)

2016

Percentage of individuals age ≥18 years who are classified as obese (BMI ≥30)

Self-reported

Both sexes: 29.9%

All men: 30.3%

All women: 29.5%

 

Behavioral Risk Factor Surveillance System (BRFSS)

Ireland

2014–2015

Percentage of individuals age ≥15 years who are classified as obese (BMI ≥30)

Self-reported

Both sexes: 23%

All men: 25%

All women: 22%

Healthy Ireland Survey, 2015

Table 2. Jurisdictional comparisons in modifiable risk factors: Vegetable and Fruit consumption

Jurisdiction

Year

Age range

Type

Data

Source

Canada

2015–2016

Percentage of individuals age ≥12 years who report consumption of fruits and vegetables 5 times or more per day

Self-reported

Both sexes: 30.8%
All men: 23.8%
All women: 37.4%

Canadian Community Health Survey 2015–2016

Best in Ontario

2015–2016

Percentage of individuals age ≥12 years who report consumption of fruits and vegetables 5 times or more per day

 

Self-reported

Waterloo Health Unit

Both sexes: 33.9%
All men: 28.2%
All women: 39.2%

 

Canadian Community Health Survey 2015–2016

Ontario

2015–

2016

Percentage of individuals age ≥12 years who report consumption of fruits and vegetables 5 times or more per day

Self-reported

Both sexes: 27.8%
Males: 21.7%
Females: 33.5%

Canadian Community Health Survey, 2015–2016

Best Province

2015–2016

Percentage of individuals age ≥12 years who report consumption of fruits and vegetables 5 times or more per day

Self-reported

Quebec

Both sexes: 38.6%
All men: 30.2%
All women: 46.8%

Canadian Community Health Survey 2015–2016

New Zealand

 

 

2016–2017

Adults age ≥15 years who meet the vegetable and fruit intake guidelines (3+ servings of vegetables and 2+ servings of fruit per day)

Self-reported

Both sexes: 38.8%

Males: 32.8%

Females: 44.5%

 

 

 

Annual Update of Key Results 2016/17: New Zealand Health Survey

United Kingdom

2016

Percentage of adults age ≥16 years who are consuming 5 or more portions of fruits and vegetables per day

 

 

Self-reported

Both sexes: 26.3%

All men: 24.3%

All women: 28.2%

 

 

Health Survey for England, 2016 trend tables

Ireland

2014–2015

Percentage of adults age ≥15 years who are consuming 5 or more portions of fruits and vegetables per day

Self-reported

Both sexes: 26%

All men: 21%

All women: 31%

Healthy Ireland Survey, 2015

Table 3. Jurisdictional comparisons in modifiable risk factors: Smoking

Jurisdiction

Year

Age range

Type

Data

Source

Canada

2015–2016

Individuals age ≥12 years who currently smoke cigarettes daily or occasionally

Self-reported

Both sexes: 17.4%
All men: 20.0%
All women: 14.8%

Canadian Community Health Survey, 2015–2016

Best in Ontario

2015–2016

Individuals age ≥12 years who currently smoke cigarettes daily or occasionally

Self-reported

Peel Regional Health Unit

Both sexes: 11.6%
All men: 16.1%
All women: 7.3%

Canadian Community Health Survey, 2015–2016

Ontario

2015–2016

Individuals age ≥12 years who currently smoke cigarettes daily or occasionally

Self-reported

Both sexes: 16.7%
All men: 19.8%
All women: 13.8%

Canadian Community Health Survey, 2015–2016

Best Province

2015–2016

Individuals age ≥12 years who currently smoke cigarettes daily or occasionally

Self-reported

British Columbia

Both sexes: 14.1%
All men: 17.1%
All women: 11.2%

Canadian Community Health Survey, 2015–2016

Australia, New South Wales

2016

Individuals age ≥16 years who smoke daily or occasionally

Self-reported

Both sexes: 15.0%

All men: 18.6%

All women: 11.6%

Health Statistics NSW

Netherlands

2015

Percentage of the population age ≥15 years who report being daily smokers

Self-reported

Both sexes: 19.0%

All men: 21.2%

All women: 16.9%

Organization for Economic Co-operation and Development (OECD)

New Zealand

2016–2017

Percentage of individuals age ≥15 years who report being current daily or occasional smokers (have smoked more than 100 cigarettes in lifetime and currently smoke at least once a month)

Self-reported

Current smokers—daily or occasional

Both sexes: 15.7%

All men: 17.4%

All women: 14.1%

Daily smokers

Both sexes: 13.8%

All men: 15.1%

All women: 12.6%

Annual Update of Key Results 2016/17: New Zealand Health Survey

Sweden

2016

Percentage of individuals age ≥16 years who report being current smokers (daily)

Self-reported

Both sexes: 10.9%

All men: 10.6%

All women: 11.2%

Swedish Living Conditions Surveys, 2016-2016

United Kingdom

2016

Percentage of adults age ≥16 years who report being current smokers (data have been weighted for non-response)

Self-reported

Both sexes:

Current smokers: 17.7%

All men:

Current smokers: 20.0%

All women:

Current smokers: 15.5%

Health Survey for England, 2016 trend tables

United States, New York

2016

Respondents age ≥18 years who report having smoked ≥100 cigarettes in their lifetime and currently smoke every day or some days

Self-reported

Both sexes: 14.2%

All men: 16.7%

All women: 11.9%

Behavioral Risk Factor Surveillance System (BRFSS)

United States, Best

(excluding Virgin Islands and territories)

2016

Respondents age ≥18 years who report having smoked ≥100 cigarettes in their lifetime and currently smoke every day or some days

Self-reported

Utah

Both sexes: 8.8%

All men: 10.4%

All women: 7.1%

Behavioral Risk Factor Surveillance System (BRFSS)

United States (States and D.C.)

2016

Respondents age ≥18 years who report having smoked ≥100 cigarettes in their lifetime and currently smoke every day or some days

Self-reported

Both sexes: 17.1%

All men: 18.8%

All women: 15.3%

Behavioral Risk Factor Surveillance System (BRFSS)

Ireland

2017

Percentage of adults age ≥15 years who currently smoke cigarettes who are daily and occasional smokers

Self-reported

Both sexes: 22%

All men: 25%

All women: 20%

Daily: 18% Occasionally: 4%

Healthy Ireland Survey, 2017

Table 4. Jurisdictional comparisons in modifiable risk factors: Alcohol consumption

Jurisdiction

Year

Age range

Type

Data

Source

Canada

2014 reporting year

Percentage of adults age ≥18 years who report exceeding low-risk drinking guidelines (an average of 2 drinks per day for males and 1 drink per day for females) in the last 12 months

Self-reported

Manitoba
Both sexes: 7.5%

Saskatchewan
Both sexes: 8.2%

Newfoundland
Both sexes:7.6%

Ontario
Both sexes: 7.9%

Quebec
Both sexes: 9.3%

Nunavut
Both sexes: 3.6%

British Columbia
Both sexes: 8.6%

PEI
Both sexes: 6.6%

The 2016 Cancer System Performance Report, Canadian Partnership Against Cancer Statistics Canada, Canadian Community Health Survey

Figure 1. Percentage of Ontarians with select modifiable risk factors, compared to best reported jurisdiction

Notes

  • Data compared are not all from the same year. Ontario data are from 2015–2016 Canadian Community Health Survey. “Obesity, best jurisdiction” is taken from the Organization for Economic Co-operation and Development (OECD) in 2015. “Smoking, best jurisdiction” is taken from the Behavioral Risk Factor Surveillance System (BRFSS) for 2016. “Alcohol, best jurisdiction” is taken from the 2016 Cancer System Performance Report. “Fruit and vegetable consumption, best jurisdiction” is taken from the Annual Update of Key Results 2016/17: New Zealand Health Survey.”
  • Ontario rates are from 2015-2016 except for alcohol consumption.

Data Table 1. Percentage of Ontarians with select modifiable risk factors, compared to best reported jurisdiction

Modifiable risk factor Obesity (%) in 2015 Smoking (%) in 2016 Alcohol (%) in 2014 Fruit and vegetable consumption (%) in 2016-2017
Ontario 26.2 16.7 7.9 27.8
Best reported jurisdiction 12.8 8.8 3.6 38.8

Note:

  1. Ontario rates are from 2015–2016 except for alcohol consumption.
  2. Data compared are not all from the same year. Ontario data are from 2015–2016 Canadian Community Health Survey.
  3. "Obesity, best jurisdiction" is taken from the Organization for Economic Co-operation and Development (OECD) in 2015.
  4. "Smoking, best jurisdiction" is taken from the Behavioral Risk Factor Surveillance System (BRFSS) for 2016.
  5. "Alcohol, best jurisdiction" is taken from the 2016 Cancer System Performance Report.
  6. "Fruit and vegetable consumption, best jurisdiction" is taken from the Annual Update of Key Results 2016/17: New Zealand Health Survey."

Obesity in Ontario: better than New Zealand and the United States, but higher than Australia, Ireland, the Netherlands and Sweden (Table 1).

  • Obesity is a risk factor for a number of cancers, including cancer of the esophagus (adenocarcinoma), colon and rectum, pancreas, breast (post-menopausal), endometrium, kidney and liver. It also has been associated with an increased risk of cancer of the stomach, gallbladder, ovary and prostate (advanced) [1, 2].
  • The rates reported here are primarily self-reported, so a degree of self-reporting bias should be expected. Self-reported height and weight in the Canadian Community Health Survey, for instance, have been shown to yield obesity estimates that are about 8% lower than estimates based on measured height and weight [3]. The use of measured height and weight instead of self-report also is a likely contributor to the higher estimates of obesity for New Zealand reported in Table 1.
  • As a rough estimate, the prevalence of obesity based on self-reports in Ontario is lower than rates in New Zealand and the United States, but it is higher than rates reported in Australia, Ireland, the Netherlands and Sweden.
  • Of the countries considered in this section that have obesity measures based on self-report, the country with the highest self-reported obesity rate is New Zealand. The country with the lowest self-reported obesity rate is the Netherlands.

Vegetable and fruit consumption in Ontario: better than Ireland and the United Kingdom, but lower than other provinces and New Zealand (Table 2).

  • Recommendations for reducing the prevalence of chronic diseases—including cancer, cardiovascular diseases and diabetes—routinely include healthy eating. Consumption of non-starchy vegetables and fruit probably protects against cancers of the mouth, larynx and pharynx, and fruits may protect against lung cancer [1]. Vegetable and fruit consumption also serves as a marker of a healthy diet that contains other constituents (such as carotene and lycopene) that probably protect against some cancers [1, 4].
  • As a rough estimate, vegetable and fruit consumption in Ontario appears to be higher than in Ireland and the United Kingdom but lower in comparison to other provinces and to New Zealand.
  • The United States was excluded from this analysis because as of 2010, the Behavioral Risk Factor Surveillance System changed how it reported on vegetable and fruit consumption.

Ontario smoking rate: higher than Australia, New York, New Zealand, Sweden and Utah (Table 3).

  • Smoking has a significant effect on cancer, particularly lung cancer incidence and mortality. Tobacco use is estimated to cause 29% of all cancer deaths in high-income countries like Canada [5].
  • The prevalence of current (daily or occasional) smoking in Ontario is slightly lower than the Canadian estimate.
  • Smoking rates in Ontario, however, are higher than they are in Australia, British Columbia, New York, New Zealand, Sweden and Utah. They are lower than the prevalence of current smoking in Ireland, the Netherlands, the United Kingdom and the United States.

Alcohol consumption in Ontario: comparable to most reported provinces (Table 4).

  • The World Cancer Research Fund states that there is no “safe” level of alcohol consumption that does not increase the risk of cancer. There may be benefits in avoiding even small amounts of alcohol [5].
  • There is convincing evidence that alcohol increases the risk of cancer of the oral cavity, pharynx, larynx, esophagus (primarily squamous cell carcinoma), colon and rectum, breast (post-menopausal) and liver [1]. Stomach and pre-menopausal breast cancers also may be caused by alcohol consumption, although more research is needed to confirm this association [1].
  • Comparable measures of alcohol consumption in other jurisdictions were found across 8 of the 13 Canadian provinces and territories for adults (males reporting they had more than 2 drinks per day and females reporting they had more than 1 drink per day). Nunavut had the lowest alcohol consumption rate (3.6%), followed by PEI (6.6%) and then Manitoba (7.5%). Ontario is ranked fifth, with an alcohol consumption rate of 7.9%.

Moving forward

  • In the future, we hope to expand the number of jurisdictions compared with Ontario and increase the number of measures reported. This will allow us to provide a more meaningful analysis of Ontario’s relative progress compared to the international environment.
  • We hope this will be possible through the following steps:
    • Cancer Care Ontario’s continued participation in international benchmarking studies.
    • Investigations into more research that offers meaningful comparisons.
    • Consideration of opportunities in data analysis (e.g., modifiable risk factors) where definitions may align more closely across jurisdictions.

Notes

  1. Our Cancer Prevention Recommendations [Internet]. London (UK): World Cancer Research Fund International; c2018 [cited 2018 Feb 14]. Available from: here.
  2. World Cancer Research Fund; American Institute for Cancer Research. Food, nutrition, physical activity, and the prevention of cancer: a global perspective. Washington, D.C.: American Institute for Cancer Research; 2007.
  3. Shields M, Connor Gorber S, Tremblay MS. Estimates of obesity based on self-report versus direct measures. Health Rep. 2008;19(2):61–76.
  4. Garriguet D. Diet quality in Canada. Health Rep. 2009;20(3):41–52.
  5. Danaei G, Vander Hoorn S, Lopez AD, Murray CJL, Ezzati M. Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors. Lancet. 2005;366:1784–93.