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Modifiable Risk Factors

Key findings

Roughly one-fifth of Ontario adults currently smoke cigarettes, and almost two-thirds are overweight or obese. The majority of Ontario adults do not adhere to the cancer prevention recommendations for vegetable and fruit consumption or physical activity.

Women have lower rates of smoking and inadequate vegetable and fruit consumption, and they are less likely to be overweight or obese. However, women are more physically inactive. Physical inactivity increases with age, and younger adults (age 18 to 34) have the lowest rates of overweight and obesity. The rates of smoking are highest in young adults and are lowest in adults age 65 and older.

What are modifiable risk factors?

Modifiable risk factors are behaviours and exposures that can lower or raise a person’s risk of cancer. They are modifiable because they can, in theory, be changed.

The following specific modifiable risk factors are discussed in this section:

  • tobacco use (current smoking);
  • alcohol consumption (in excess of the maximum amount recommended for cancer prevention);
  • excess body weight (overweight and obesity);
  • inadequate vegetable and fruit consumption; and
  • physical inactivity.

 

In contrast to past years, these risk factors are only examined at a high level (by sex and age group) in this year’s Cancer System Quality Index (CSQI). Due to changes made to the Canadian Community Health Survey (CCHS) study design in 2015, estimates cannot be compared to data collected in prior years, and because combining CCHS data collected before and after those changes is not possible, only limited analyses were able to be conducted. However, additional variables like socio-demographic factors will be examined in future years.

Modifiable risk factors among Ontario’s First Nations, Inuit and Métis populations are examined in more detail in the Modifiable Risk Factors in Cancer in First Nations in Ontario, Modifiable Risk Factors for Cancer in Inuit in Ontario and Modifiable Risk Factors for Cancer in Métis in Ontario sections of the CSQI.

If my parents had taken better care of themselves, their disease probably would have been caught sooner. I would like to see more education for the prevention, detection and treatment of cancer.

Chris W., Patient/Family Advisor

Figure 1. Percentage of adults reporting selected modifiable risk factors (current smoking, excess alcohol consumption, overweight and obese, inadequate vegetable and fruit consumption, physical inactivity), by sex, Ontario, 2015

More information regarding the methodology is available.

Report date: January, 2018

Data source: Canadian Community Health Survey, 2015 (Statistics Canada)

Prepared by: Cancer Care Ontario, Prevention and Cancer Control (Population Health and Prevention)

Note:

  1. Estimates are adjusted to the age distribution of the 2011 Canadian population.
  2. Current smoking (adults age 20 years and older): Individuals who are daily or occasional smokers.
  3. Excess alcohol consumption (adults age 19 years and older): Exceeding the cancer prevention recommendations defined as: > 2 drinks/day for men and > 1 drink/day for women
  4. Overweight and obese is defined by Body Mass Index (BMI) values, corrected to account for misreporting of height and weight by CCHS survey respondents.
  5. Overweight and obese (adults age 18 years and older): BMI 25 or greater.
  6. Inadequate vegetable and fruit consumption (adults age 18 years and older): Respondents who reported eating vegetables (excluding potatoes) and fruit less than 5 times per day.
  7. Physical inactivity (adults age 18 years and older): Respondents whose levels of physical activity do not meet the cancer prevention recommendation, defined as being moderately to vigorously physically active for 30 minutes or more each day.
  8. I represent 95% confidence intervals.

 

Figure 2. Percentage of adults reporting selected modifiable risk factors (current smoking, excess alcohol consumption, overweight and obese, inadequate vegetable and fruit consumption, physical inactivity), by age group, Ontario, 2015

More information regarding the methodology is available.

Report date: January, 2018

Data source: Canadian Community Health Survey, 2015 (Statistics Canada)

Prepared by: Cancer Care Ontario, Prevention and Cancer Control (Population Health and Prevention)

Note:

  1. Estimates are adjusted to the age distribution of the 2011 Canadian population.
  2. Current smoking (adults age 20 years and older): Individuals who are daily or occasional smokers.
  3. Excess alcohol consumption (adults age 19 years and older): Exceeding the cancer prevention recommendations defined as: > 2 drinks/day for men and > 1 drink/day for women.
  4. Overweight and obese is defined by Body Mass Index (BMI) values, corrected to account for misreporting of height and weight by CCHS survey respondents.
  5. Overweight and obese (adults age 18 years and older): BMI 25 or greater.
  6. Inadequate vegetable and fruit consumption (adults age 18 years and older): Respondents who reported eating vegetables (excluding potatoes) and fruit less than 5 times per day.
  7. Physical inactivity (adults age 18 years and older): Respondents whose levels of physical activity do not meet the cancer prevention recommendation, defined as being moderately to vigorously physically active for 30 minutes or more each day.
  8. *Youngest age group differs between indicators; it is 20–34 for current smoking, 19–34 for alcohol consumption, and 18–34 for overweight and obese, inadequate vegetable and fruit consumption, and physical inactivity.
  9. I represent 95% confidence intervals.

 

Data Table 1. Percentage of adults reporting selected modifiable risk factors (current smoking, excess alcohol consumption, overweight and obese, inadequate vegetable and fruit consumption, physical inactivity), by sex, Ontario, 2015

Sex Current smoking estimate (%) Current smoking 95% lower confidence interval Current smoking 95% upper confidence interval Excess alcohol consumption estimate (%) Excess alcohol consumption 95% lower confidence interval Excess alcohol consumption 95% upper confidence interval Overweight and obese estimate (%) Overweight and obese 95% lower confidence interval Overweight and obese 95% upper confidence interval Inadequate vegetable and fruit consumption estimate (%) Inadequate vegetable and fruit consumption 95% lower confidence interval Inadequate vegetable and fruit consumption 95% upper confidence interval Physical inactivity estimate (%) Physical inactivity 95% lower confidence interval Physical inactivity 95% upper confidence interval
Both sexes 18.5 17.4 19.6 8.3 7.5 9.0 60.5 59.0 62.0 75.3 74.0 76.7 51.5 50.1 53.0
Male 21.7 19.9 23.5 8.5 7.3 9.7 66.4 64.2 68.5 81.7 80.0 83.5 47.9 45.8 50.1
Female 15.4 14.0 16.8 8.0 7.0 9.0 54.6 52.6 56.7 69.2 67.3 71.2 55.0 53.1 56.9

Report date: January, 2018

Data source: Canadian Community Health Survey, 2015 (Statistics Canada)

Prepared by: Cancer Care Ontario, Prevention and Cancer Control (Population Health and Prevention)

Note:

  1. Estimates are adjusted to the age distribution of the 2011 Canadian population.
  2. Current smoking (adults age 20 years and older): Individuals who are daily or occasional smokers.
  3. Excess alcohol consumption (adults age 19 years and older): Exceeding the cancer prevention recommendations defined as: > 2 drinks/day for men and > 1 drink/day for women
  4. Overweight and obese is defined by Body Mass Index (BMI) values, corrected to account for misreporting of height and weight by CCHS survey respondents.
  5. Overweight and obese (adults age 18 years and older): BMI 25 or greater.
  6. Inadequate vegetable and fruit consumption (adults age 18 years and older): Respondents who reported eating vegetables (excluding potatoes) and fruit less than 5 times per day.
  7. Physical inactivity (adults age 18 years and older): Respondents whose levels of physical activity do not meet the cancer prevention recommendation, defined as being moderately to vigorously physically active for 30 minutes or more each day.
  8. I represent 95% confidence intervals.

 

Data Table 2. Percentage of adults reporting selected modifiable risk factors (current smoking, excess alcohol consumption, overweight and obese, inadequate vegetable and fruit consumption, physical inactivity), by age group, Ontario, 2015

Age groups (years) Current smoking estimate (%) Current smoking 95% lower confidence interval Current smoking 95% upper confidence interval Excess alcohol consumption estimate (%) Excess alcohol consumption 95% lower confidence interval Excess alcohol consumption 95% upper confidence interval Overweight and obese estimate (%) Overweight and obese 95% lower confidence interval Overweight and obese 95% upper confidence interval Inadequate vegetable and fruit consumption estimate (%) Inadequate vegetable and fruit consumption 95% lower confidence interval Inadequate vegetable and fruit consumption 95% upper confidence interval Physical inactivity estimate (%) Physical inactivity 95% lower confidence interval Physical inactivity 95% upper confidence interval
Ages 18 to 34* 22.5 19.8 25.1 9.7 7.9 11.6 44.3 41.2 47.4 75.4 72.7 78 41.5 38.5 44.5
Ages 35 to 49 17.4 15.4 19.4 7.2 5.8 8.7 64.8 61.8 67.8 73.2 70.4 76.1 50.4 47.3 53.5
Ages 50 to 64 22.1 19.8 24.4 9.0 7.7 10.4 70.3 67.7 73 76.8 74.5 79.2 54.1 51.3 56.9
Ages 65+ 9.3 7.7 10.8 6.6 5.3 7.9 66.1 63.5 68.7 76.3 73.7 78.8 65.7 63.3 68.2

Report date: January, 2018

Data source: Canadian Community Health Survey, 2015 (Statistics Canada)

Prepared by: Cancer Care Ontario, Prevention and Cancer Control (Population Health and Prevention)

Note:

  1. Estimates are adjusted to the age distribution of the 2011 Canadian population.
  2. Current smoking (adults age 20 years and older): Individuals who are daily or occasional smokers.
  3. Excess alcohol consumption (adults age 19 years and older): Exceeding the cancer prevention recommendations defined as: > 2 drinks/day for men and > 1 drink/day for women.
  4. Overweight and obese is defined by Body Mass Index (BMI) values, corrected to account for misreporting of height and weight by CCHS survey respondents.
  5. Overweight and obese (adults age 18 years and older): BMI 25 or greater.
  6. Inadequate vegetable and fruit consumption (adults age 18 years and older): Respondents who reported eating vegetables (excluding potatoes) and fruit less than 5 times per day.
  7. Physical inactivity (adults age 18 years and older): Respondents whose levels of physical activity do not meet the cancer prevention recommendation, defined as being moderately to vigorously physically active for 30 minutes or more each day.
  8. *Youngest age group differs between indicators; it is 20–34 for current smoking, 19–34 for alcohol consumption, and 18–34 for overweight and obese, inadequate vegetable and fruit consumption, and physical inactivity.
  9. I represent 95% confidence intervals.

 

What do the results show?

Current smoking

  • Smoking rates in Ontario have been declining for at least 2 decades [1]. In 2015, however, nearly one-fifth (19%) of Ontarians age 20 years and older reported that they were daily or occasional smokers (Figure 1). Smoking rates were higher in males (21.7%) than females (15.4%). Adults age 35 to 49 and those over the age of 65 had significantly lower rates of smoking than adults age 18 to 34. The lower prevalence in the older age group likely reflects a combination of higher rates of successful cessation among people who have ever smoked and greater tobacco-related mortality as smokers age.

Alcohol consumption

  • Approximately 8% of Ontario adults age 19 years and older in 2015 (equivalent to nearly 1 million people) drank more alcohol than the maximum amount recommended for cancer prevention (more than 2 drinks per day for men and more than 1 drink per day for women). Rates were highest in adults age 19 to 34 and were significantly lower in adults age 65 and older (Figure 2). Rates did not differ between males and females (Figure 1).

Overweight and obesity

  • The proportion of adults who are overweight or obese has been increasing for at least 2 decades [2]. In 2015, approximately 60% of Ontarians age 18 and older were overweight or obese. Rates were higher in men than women, and they were significantly lower in those age 18 to 34 years compared to every other age group (Figure 2).

Inadequate vegetable and fruit consumption

  • Eating at least 5 servings of vegetables (excluding potatoes) and fruit a day is a good marker of overall diet quality [3], but three-quarters (75%) of Ontario adults currently report eating less than 5 servings per day. Males had higher rates of inadequate consumption than females (Figure 1), and there were no differences in consumption by age group (Figure 2).

Physical inactivity

  • The proportion of Ontario adults who do not meet the cancer prevention recommendations for physical activity (to be moderately to vigorously physically active for 30 minutes or more each day) is high (52% in 2015). Rates of physical inactivity are lower for men than women (Figure 1), and they are significantly lower in those age 18 to 34 than among all other age groups (Figure 2).

Why is this important to Ontarians?

Healthier behaviour reduces cancer risk

  • Tobacco use (active cigarette, cigar and cigarillo smoking, and exposure to second-hand smoke and smokeless tobacco) is a major preventable cause of morbidity and mortality. Active tobacco smoking causes cancers of the lung, upper aerodigestive tract, esophagus, stomach, colon and rectum, liver, pancreas, cervix, ovary, kidney, bone marrow (myeloid leukemia), and bladder and other urinary organs [4].
  • All types of alcoholic beverages increase the risk of cancers of the oral cavity and pharynx, esophagus (primarily squamous cell carcinoma), larynx, liver, colon and rectum, and breast (post-menopausal). Stomach and pre-menopausal breast cancers may also be caused by alcohol consumption, although more research is needed to confirm this association [5, 6].
  • Obesity is a complex issue with multiple causes and contributors. While eating a diet rich in vegetables and fruit and participating in moderate-to-vigorous physical activity contributes to maintaining a healthy weight, those actions also provide independent health benefits for the prevention of chronic disease, specifically cancer.
  • Excess body weight (i.e., overweight or obesity) increases the risk of cancers of the esophagus (adenocarcinoma), colon and rectum, pancreas, breast (post-menopausal), endometrium, kidney and liver, and it probably increases the risk of cancers of the stomach, gallbladder, ovaries and prostate [5, 6]. Cancer risk is influenced by degrees of body fatness consistent with obesity and overweight, and even within a range that is generally considered to be healthy.
  • Consumption of non-starchy vegetables and fruit probably protects against cancers of the mouth, pharynx and larynx, and consuming fruit also may protect against lung cancer [6]. Consumption of vegetables and fruit is also a good marker of overall diet quality [3]. Vegetables and fruit contain a number of nutrients, including vitamins and antioxidants, that may lower the risk of several cancers [7].
  • Regular moderate-to-vigorous physical activity has been shown to reduce the risk of colon cancer, and it probably protects against cancers of the breast and endometrium [5, 6].

What’s happening in Ontario?

Policies and programs to reduce cancer risk factor prevalence

  • From 2004 to 2013, an estimated 22% of total healthcare costs in Ontario resulted from smoking, excessive alcohol consumption, unhealthy eating and physical inactivity. However, healthcare costs associated with these risk factors decreased by 1.9% (or $4.9 billion) during the same period. The majority of these savings may be linked to the reduction in smoking prevalence related to Ontario’s comprehensive tobacco control strategy [8].
  • Improving the health of Ontarians so that fewer people develop cancer is central to ensuring a sustainable cancer system for future generations. That is a strategic goal of the Ontario Cancer Plan IV, 2015–2019 [9]. CCO’s Chronic Disease Prevention Strategy, 2015–2020 supports this goal by providing a plan for the way CCO works with its partners to reduce the prevalence of cancer and other chronic diseases [10]. The strategy’s goals focus on informing and promoting evidence-based policies and programs that support the health of the population as a whole, and improving the health of disadvantaged groups by promoting healthy environments and lifestyles and cancer screening. It also aims to improve the long-term outcomes of cancer survivors and people living with cancer or other chronic diseases.
  • In 2015, Cancer Care Ontario began publishing the Prevention System Quality Index (PSQI), a regular report that monitors system-level policies and programs that can reduce the prevalence of cancer risk factors and exposures in Ontario. Aimed at governments, non-governmental organizations and public health units, the PSQI identifies cross-sectoral opportunities to strengthen the prevention system [11]. The PSQI was developed to improve measurement and monitoring of the prevention system in Ontario, addressing a recommendation that Cancer Care Ontario and Public Health Ontario made in their 2012 report, entitled Taking Action to Prevent Chronic Disease: Recommendations for a Healthier Ontario [12].
  • Ontario currently has several system-level policies and programs that can help reduce cancer and chronic disease risk factors in the population. However, a comprehensive chronic disease prevention strategy is not currently in place [13].
  • The Ontario government has made significant progress in reducing tobacco use through Smoke-Free Ontario, which includes preventing youth from starting to smoke, protecting people from second-hand smoke and helping smokers quit. In 2017, the Ministry of Health and Long-Term Care established the Executive Steering Committee for the Modernization of Smoke-Free Ontario to inform the development of an updated Smoke-Free Ontario strategy. Among the committee’s recommendations was a strategy to work towards reducing tobacco use in the province to less than 5% by 2035. To date, the report’s recommendations have not been implemented [14].
  • Based on evidence that quitting smoking at the time of cancer diagnosis can lower the risk of dying by 30% to 40%, Cancer Care Ontario began implementing smoking cessation programs in all 14 Regional Cancer Centres in 2013. New cancer patients are screened for tobacco use, advised on the benefits of quitting smoking and referred to cessation services for support. For more information on Cancer Care Ontario’s smoking cessation program, see Smoking Cessation section .
  • Menu calorie labelling may reduce the number of calories bought and consumed by some people, and it can also result in nutritionally beneficial product reformulations by restaurants [15–18]. In January 2017, the Healthy Menu Choices Act, 2015, came into effect in Ontario. It requires restaurants and other food service providers with 20 or more locations in the province to display the calorie content of standard food and beverage items on their menus and a contextual statement about the average caloric needs of adults and children [19].
  • Cancer Care Ontario co-led the development of the Ontario Food and Nutrition Strategy, which is a plan for healthy food and food systems in Ontario using a coordinated cross-government and cross-sectoral approach to developing evidence-based food policy. Published in 2017, it was developed by 26 organizations with roles in food systems and health. Although the strategy has not been endorsed by the provincial government, organizations are working to collectively advance the goals of the strategy.
  • Cancer Care Ontario, in partnership with the Ministry of Health and Long-term Care, launched MyCancerIQ in 2015. An evidence-based online cancer risk assessment tool, MyCancerIQ allows Ontarians to complete confidential risk assessment questionnaires for cervical, colorectal, female breast, lung, kidney and melanoma. Users receive a personalized action plan with information about cancer prevention and behaviour change resources. My CancerIQ is actively promoted to healthcare providers and the public through a wide range of marketing strategies. As of December 2017, there had been more than 1.1 million visits to the website and more than 410,000 cancer risk assessments completed.

Focus on health equity

  • Health equity is achieved when everyone can reach their full health potential, no matter where they live, what they have or who they are. Health inequities are differences in health that are systematic, avoidable and unfair. Health inequities arise from social inequities, including those related to income, education, residence, gender, race, sexual orientation, mental health and disabilities.
  • Many Ontarians facing health inequities have higher rates of some cancer risk factors, are more likely to get certain cancers and are less likely to survive them.
  • Cancer Care Ontario’s Prevention System Quality Index: Health Equity report, published in April 2018, describes the distribution of tobacco use, alcohol consumption, unhealthy eating and physical inactivity across sub-populations. It also demonstrates how system-level policies and programs with the potential to reduce these risk factors can affect groups facing health inequities. A major focus of the report are First Nations, Inuit and Métis populations. The report includes evidence-based policy opportunities, such as protecting vulnerable populations in social housing from second-hand smoke and continuing to develop and implement the Government of Ontario’s Food Security Strategy and poverty reduction policies [20].
  • CCO has also developed Ontario Cancer Profiles, an interactive mapping tool that includes provincial and regional data on cancer burden, screening, selected social determinants of health, and risk factors.
  • The Cancer Risk Factor Atlas of Ontario is another tool that allows users to assess risk factor prevalence. It provides estimates of the distribution of modifiable risk factors for cancer in small geographic areas to help with the identification of priority local areas for prevention activities.

CCO’s prevention work in First Nations, Inuit and Métis communities

  • First Nations, Inuit and Métis peoples face health inequities rooted in colonialism, racism and social exclusion, and they have higher age-standardized cancer mortality rates, rising rates of cancer incidence and poorer cancer survival than non-Aboriginal Ontarians. Guided by the Aboriginal Cancer Strategy III, 2015–2019, CCO’s Aboriginal Cancer Control Unit has built strong relationships with First Nations, Inuit and Métis communities to develop culturally relevant and co-developed strategies, policies and programs to improve cancer and chronic disease prevention. For example, the Aboriginal Tobacco Program works with Aboriginal communities to develop culturally appropriate messaging and strategies to address commercial tobacco prevention, protection and cessation.
  • In 2016, CCO and its partners published Path to Prevention—Recommendations for Reducing Chronic Disease in First Nations, Inuit and Métis, which provided the Ontario government with 22 evidence-based policy recommendations to reduce the prevalence of 4 key chronic disease risk factors in Aboriginal communities: alcohol consumption, commercial tobacco use, physical inactivity and unhealthy eating. CCO is monitoring progress on these recommendations. In 2017, CCO led an inaugural Path to Prevention Partnership Table meeting. The aim of the Partnership Table is to align and support work in chronic disease prevention to work towards implementing the Path to Prevention recommendations.
  • Thirteen Aboriginal Relationship and Cultural Competency courses were developed by Cancer Care Ontario to provide healthcare professionals and people working with First Nations, Inuit and Métis populations with a variety of courses to improve person-centred care for First Nations, Inuit and Métis by applying cultural safety practices. The courses are free of charge and available to anyone. To access the courses, please register here: elearning.cancercare.on.ca

Notes

  1. Ialomiteanu AR, Hamilton, HA, Adlaf EM, Mann RE. CAMH monitor eReport: substance use, mental health and well-being amoung Ontario adults, 1977–2015 (CAMH research document series no. 45) [Internet]. Toronto: The Centre for Addiction and Mental Health; cited 2018 March 6. Available from here.
  2. Chief Medical Officer of Health of Ontario. 2004 Chief Medical Officer of Health report: healthy weights, healthy lives [Internet]. Toronto: Queen’s Printer for Ontario; 2004 [cited 2013 Feb 19]. Available from here.
  3. Garriguet D. Diet quality in Canada. Health Rep. 2009 Sep;20(3):41–52.
  4. 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.
  5. World Cancer Research Fund International. Our cancer prevention recommendations [Internet]. London (UK): WCRF International; c2018 [cited 2018 Feb 14]. Available from here.
  6. World Cancer Research Fund; American Institute for Cancer Research (US). Food, nutrition, physical activity, and the prevention of cancer: a global perspective. Washington, D.C.: American Institute for Cancer Research; 2007.
  7. Norat T, Aune D, Chan D, Romaguera D. Fruits and vegetables: updating the epidemiologic evidence for the WCRF/AICR lifestyle recommendations for cancer prevention. Cancer Treat Res. 2014;159:35–50.
  8. Manuel DG, Perez R, Bennett C, Laporte A, Wilton AS, Gandhi S, et al. A $4.9 billion decrease in health care expenditure: the ten-year impact of improving smoking, alcohol, diet and physical activity in Ontario. Toronto: Institute for Clinical Evaluative Sciences; 2016.
  9. Cancer Care Ontario. Ontario Cancer Plan IV, 2015–2019. Toronto: Queen’s Printer for Ontario; 2015.
  10. CCO. Chronic Disease Prevention Strategy, 2015–2020. Toronto: Queen’s Printer for Ontario; 2017.
  11. Cancer Care Ontario. 2016 Prevention System Quality Index: monitoring Ontario's efforts in cancer prevention. Toronto: Queen's Printer for Ontario; 2016.
  12. Cancer Care Ontario; Ontario Agency for Health Protection and Promotion. Taking action to prevent chronic disease: recommendations for a healthier Ontario. Toronto: Queen's Printer for Ontario; 2012.
  13. Office of the Auditor General of Ontario. Annual report, 2017. Toronto: Queen’s Printer for Ontario; 2017.
  14. Executive Steering Committee for the Modernization of Smoke-Free Ontario. Smoke-Free Ontario Modernization: report of the Executive Steering Committee. Toronto: Queen's Printer for Ontario; 2017.
  15. Kiszko KM, Martinez OD, Abrams C, Elbel B. The influence of calorie labeling on food orders and consumption: a review of the literature. J Community Health. 2014;39(6):1248–69.
  16. Long MW, Tobias DK, Cradock AL, Batchelder H, Gortmaker SL. Systematic review and meta-analysis of the impact of restaurant menu calorie labeling. Am J Public Health. 2015;105(5):e11–24.
  17. Sinclair SE, Cooper M, Mansfield ED. The influence of menu labeling on calories selected or consumed: a systematic review and meta-analysis. J Acad Nutr Diet. 2014;114(9):1375–88.e15.
  18. Bruemmer B, Krieger J, Saelens BE, Chan N. Energy, saturated fat, and sodium were lower in entrées at chain restaurants at 18 months compared with 6 months following the implementation of mandatory menu labeling regulation in King County, Washington. J Acad Nutr Diet. 2012;112(8):1169–76.
  19. Healthy Menu Choices Act, 2015, S.O. 2015, c. 7, Sched. 1, 2016 (2017 Jan 1).
  20. Government of Ontario. Building Ontario’s first Food Security Strategy (Discussion paper) [Internet]. Toronto: Queen’s Printer for Ontario; 2017 [cited 2017 Jun 29]. Available from here.