ABSTRACT
Objective: The aim of this paper is to highlight the potential impact of costs associated with overweight and obesity for provincial policy and prevention initiatives.
Method: Prevalence-based cost-of-illness methodology was used to estimate the direct costs (hospital care, drugs, physician care, institutional care, additional costs) and indirect costs (short- and long-term disability, premature mortality) associated with excess weight for 22 health conditions. Total costs for each health condition were estimated using the Public Health Agency of Canada's Economic Burden of Illness database. Population attributable fractions (PAF) were also estimated using 2004 and 2005 CCHS data and current literature reviews.
Results: In 2005, the cost of excess weight in Alberta totaled $1.27 billion. The direct cost of excess weight was $630.1M (49.5%), the indirect cost $643.8M (50.5%). Excluding costs associated with premature mortality and caregiving, obesity accounted for 69.5% ($500.8M) of costs and overweight the remaining 30.5% ($220.2M). Among the 22 health conditions, coronary heart disease had the highest costs attributable to excess weight ($307.1M), followed by osteoarthritis ($167.7M) and type 2 diabetes ($161.5M). The total cost of excess weight equated to 5.6% of the province's annual health care expenditures for 2005.
Conclusion: While obesity costing research often focuses on the direct health care costs, this study reveals that the indirect costs of excess weight are also significant and can account for over half of the total costs. Interventions to reduce excess weight among Canadians have the potential to improve the health of the population while reducing provincial and national health care costs.
Key words: Obesity; overweight; Canada; cost; cost of illness
La traduction du r�sum� se trouve � la fin de l'article. Can J Public Health 2011;102(2):144-48.
Obesity is a well-established risk factor for many chronic health conditions, including cardiovascular disease, several types of cancer and type 2 diabetes.1 The treatment and consequences of obesity-related health conditions impose an increased economic burden on health care systems, employers, families and individuals. Obesity has been estimated to account for 2% to 7% of health care costs in developed countries:1 in Canada, the cost of obesity has been estimated to account for 2.2-4.1% of health care costs.2-4 However, the true costs are likely to be higher because often only a limited number of obesity-related conditions are considered,1 while conditions like osteoarthritis, respiratory diseases and certain types of cancer are excluded.
The purpose of this study was to estimate the direct and indirect costs associated with overweight and obesity and to inform, using economic rationale, the provincial planning of obesity control initiatives. Overweight- and obesity-attributable direct and indirect costs of 22 health conditions were estimated among men and women aged 15 to 99 years for Alberta in 2005. While most earlier costing studies relied on self-reported height and weight to assess excess weight,3,4 this study uses directly-measured height and weight data or adjusted self-reported data, resulting in an improvement in the accuracy of obesity prevalence and attributable cost estimates.
METHOD
This study used cost-of-illness methodology to estimate the direct and indirect costs of obesity. Direct costs and indirect short- and long-term disability costs were estimated using a prevalence-based approach, which is commonly used in cost-of-illness studies.2,3 Mortality costs were estimated using an incidence-based, human capital approach, which is used by Health Canada to estimate the costs of premature mortality.5
Data sources
The prevalence of excess weight was estimated using directlymeasured BMI data from the 2004 Canadian Community Health Survey (CCHS)6 and adjusted self-reported BMI data from the 2005 CCHS.7 The Body Mass Index (BMI) reference cut-off values for overweight and obesity are from the Canadian Guidelines for Body Weight Classification in Adults.8 Relative Risks (RRs) were calculated using self-reported disease prevalence and directly-measured or adjusted self-reported national BMI data from the 2004 and 2005 national CCHS datasets. National rather than provincial CCHS datasets provided more stable estimates due to small numbers at the provincial level. RRs (or, as necessary, population attributable fractions) from the literature were also used for conditions that were not included in the 2004 or 2005 CCHS (Table 1). For cancer (14 types combined), prevalence estimates for obesity class 1, 2 and 3 by age group and obesity category were not available due to small numbers, and therefore they could not be calculated for all health conditions.
The direct and indirect costs of the 22 health conditions were obtained from the Public Health Agency of Canada's (PHAC) Economic Burden of Illness in Canada, 2000 (EBIC) unpublished report.16 Direct costs included expenditures for hospital care, drugs, physician care, institutional care, and additional direct costs such as capital investments, public health, and research. The direct cost of informal caregiving among adults aged 65 and older was estimated using the average weekly hours of work for an Albertan caregiver, 17 and the out-of pocket and hourly costs of caregiving in Alberta.18,19 Caregiving costs could not be allocated to diagnostic categories because they were not reported to this detail20 but aggregate costs attributable to obesity were estimated using data from other studies.21 Indirect costs included the value time lost due to both short- and long-term disability, and years of life lost due to premature mortality.5 Premature mortality estimates in this study included only deaths occurring between the ages of 15 and 74 years because this range corresponded to the age-specific costs provided by EBIC.
Analysis
Population Attributable Fractions (PAFs)
The population attributable fractions (PAF) determined in this analysis represent the proportion of each health condition that was attributable to excess weight. PAFs were estimated for all BMI categories in each age group (18-24, 25-34, 35-44, 45-54, 55-64, 65-74, 75 and over) and sex group. The obesity-attributable proportion of caregiving costs among seniors (aged 65 years and older) was estimated from the literature to be 15.5%.21 The proportion of premature mortality caused by overweight and obesity for each health condition was taken from the WHO Global Burden of Disease (GBD) report,22 due to a lack of recent Canadian longitudinal data needed to determine RRs for premature mortality by BMI category and cause of death.
Costs of Excess Weight and Economic Adjustment
The costs of obesity and overweight were derived by multiplying the PAFs for disease prevalence and premature mortality by the Alberta-specific cost of each health condition in 2000. Economic inflation was accounted for by applying the Alberta government's current expenditure implicit price index (IPI); between 2000 and 2005, the IPI increased 28.7%.23 Indirect costs were adjusted using the more general consumer price index (CPI) for Alberta, which rose by 14.4% between 2000 and 2005.24
RESULTS
In 2005, the cost of excess weight in Alberta totaled $1.27 billion, representing 5.6% of the total cost of all health conditions in Alberta. Among the 22 health conditions attributable to excess weight, coronary heart disease (CHD) accounted for the greatest proportion of the $1.27 billion cost, contributing 28.3% ($307.1 million) of the total costs. Each exceeding $100 million, osteoarthritis, type 2 diabetes, hypertension and cancer had the next highest costs. Taken together, these five conditions accounted for 80.5% of the overall costs of excess weight associated with the 22 health conditions evaluated (Table 2). Direct costs contributed the highest pro- portional costs for hypertension, type 2 diabetes, gallbladder disease and depression (Table 2).
The cost of excess weight was split between direct costs (49.5% or $630.1 million) and indirect costs (50.5% or $643.8 million). Men contributed a greater proportion of the cost of excess weight than women (55.4% or $607.2 million versus 44.6% or $488.7 million), a difference that was largely explained by the higher obesityattributable cost of CHD among men (Table 2). With the exception of CHD and type 2 diabetes, women had higher costs attributable to excess weight for most of the other health conditions. However, the obesity-attributable costs of all cancer sites combined and hypertension were similar among men and women.
When examined by BMI classes, including all cost components except premature mortality and caregiving, 30.5% of the total cost of all health conditions in Alberta was attributed to overweight ($220.2 million) and 69.5% was attributed to obesity ($500.8 million) (Figure 1). Overweight also accounted for the greatest proportion of costs attributed to excess weight for all cancers combined (44.0%) and CHD (41.0%), while obesity class 1 contributed the greatest proportion of costs for type 2 diabetes (44.6%), hypertension (37.6%), osteoarthritis (40.3%) and asthma (44.3%). Although the prevalence of class 2 and 3 obesity (combined) was only 16.2% in Alberta, these BMI categories accounted for the greatest proportion of the weight-related costs for cerebrovascular disease (42.6%), gallbladder disease (44.9%) and depression (43.9%) (Figure 1).
DISCUSSION
In 2004, the prevalence of overweight and obesity in Alberta was 60.9%,7 which, in 2005, translated into costs for the provincial health care system of $1.27 billion. The cost of obesity (all classes) represented approximately 70% of the total cost of excess weight, despite the prevalence of overweight among Albertans being 10% higher than the prevalence of obesity (35.7% versus 25.2%).7 Therefore a shift from obese to overweight status within the provincial population could have substantial economic effects.
The estimated costs of excess weight accounted for 5.6% of the province's total health care costs, with direct and indirect costs contributing nearly equally to this total. Earlier estimates of the cost of obesity in Canada indicated that 2.2-4.1% of health care expenditures in Canada can be attributed to excess weight.3,4 These estimates are lower than the 5.6% of total health care expenditures that was attributed to excess weight in this study, and the 4.1% of total health care costs that was attributed to the direct costs of excess weight in another recent Canadian study.2 These differences may be explained by several factors, such as the inclusion of more obesity-related co-morbidities, cost estimates for both overweight and obesity, inclusion of caregiving costs, inclusion of indirect costs, and the use of objectively-measured BMI status instead of more readily available self-reported BMI status.
Obesity costing research often focuses on direct rather than indirect costs of obesity.3,25 The failure of these studies to include indi- rect costs due to limitations in data availability, likely results in significant underestimates of the true costs of obesity. We found the indirect costs of obesity were significant and account for approximately half of the costs; a finding that is consistent with studies that have assessed the indirect costs of excess weight.2,26,27
There are necessary limitations in this study due to its use of previously- collected data and a prevalence-based methodology. The cross-sectional costs of excess weight over a one-year period did not account for the time lag between the onset of overweight/obesity and the subsequent development of negative health outcomes.28 This time-based process is an important consideration for assessing both the lifetime costs of excess weight and the cost-effectiveness of obesity reduction interventions over the long term. Few incidence-based cost-of-illness studies have been completed due to insufficient time-based data on the development of weight-related health conditions and costs incurred. Conflicting results from modeling studies suggest that further research is required in this area.29,30
Thompson et al. developed a dynamic model to estimate the lifetime risks of five obesity-related diseases and their associated medical costs, and life expectancy for adults aged 35-54 years.29 Lifetime medical costs of the five diseases increased incrementally with increases in BMI, and were similar to the medical costs attributable to cigarette smoking. Compared to normal weight status (BMI of 22.5), a BMI of 27.5 kg/m2 increased lifetime medical expenditures for the five diseases by 20%, a BMI of 32.5 kg/m2 increased expenditures by 50%, and a BMI of 37.5 kg/m2 nearly doubled expenditures. 29 Van Baal et al. also modeled the lifetime health care costs of obese and normal weight people and found that annual health expenditures were higher among obese individuals than normal weight individuals, but the lifetime medical expenditures for these two weight classes were not significantly different because of differences in life expectancy.30 Lifetime health expenditure was highest among normal weight people who developed diseases unrelated to obesity in their years of life gained. Van Baal et al. concluded that while obesity prevention is important for improving public health, it may not decrease health care expenditures, as is suggested by most prevalence-based studies.30 An important consideration is that their study did not include the indirect costs of obesity, which, as our study reveals, can bear a substantial economic burden on society.
In determining PAFs and calculating costs attributable to overweight and obesity, several assumptions were necessary due to limitations in data availability. Areas for improvement in data availability and quality include: improved allocation of costs by diagnostic category (including caregiving), more recent costing data, PAF estimates for premature mortality for a broader range of health conditions and information on the variability of costs that are specific to Canada and the provinces. Controlling for the coexistence of multiple weight-related co-morbidities in the same individuals may have decreased PAFs and direct cost estimates; however, these could not be accounted for in this analysis because of data limitations both for co-morbidity and costing information. For example, a proportion of CHD can be attributed to both type 2 diabetes and hypertension. Controlling for the inclusion of type 2 diabetes and hypertension in the necessary calculations could result in lower PAFs for the relationship between excess weight and CHD, and lower costs attributable to excess weight.
PAFs were mostly calculated using cross-sectional data from the Canadian Community Health Survey (CCHS), creating the potential for confounding and the assumption of the temporality of body weight and subsequent disease risk. Several dietary factors and physical inactivity, independent of body weight, have been associated with an increased risk of numerous co-morbidities, including coronary heart disease, type 2 diabetes, several types of cancer, musculoskeletal disorders and numerous others.31 Conversely, an illness may lead to sedentary lifestyle and obesity. Popkin et al. found that the combined effects of diet and physical activity, both through their direct effects on health and via their effects on obesity, have a much larger total effect than any separate pathway, such as obesity on its own.31 As a result, if the independent costs of certain dietary factors and low levels of physical activity were available and included here, the total cost would likely be higher.
Information on other obesity-related costs could not be included in this study, such as private out-of-pocket costs not reimbursed by governmental agencies, cost of reduced productivity during work hours (presenteeism), and some of the intangible costs of pain and suffering experienced by individuals and families. Improving the quality of available data would increase the accuracy of cost estimates, however it would also require substantial resources; therefore, it must be clear that the accuracy gained is worth the expense. While assumptions were necessary to overcome some of these limitations and these choices represent a source of uncertainty, the final analysis erred on the side of conservatism.
Cost-of-illness studies reconfirm that obesity is a serious societal problem with substantial costs but they have been criticized for failing to quantify potential solutions and being insufficient to inform government priority setting. While this limitation is acknowledged, this study provides some evidence of where interventions are most needed and have the greatest potential for cost savings. The breakdown of costs by sex and BMI status are more detailed than prior obesity costing studies in Canada,2-4 and may be particularly useful for targeting interventions where the disease burden and costs attributable to excess weight are highest. A necessary and critical next step will be evaluating the efficacy and costeffectiveness of potential solutions, with careful consideration of the needs and characteristics of target populations.
CONCLUSION
Currently, the majority of Albertan adults are overweight or obese. The direct and indirect costs of this excess weight were equivalent to 5.6% of Alberta's annual health care expenditures in 2005 ($1.27 billion). Among the 22 health conditions attributable to excess weight, coronary heart disease (CHD) followed by osteoarthritis, type 2 diabetes, hypertension and cancer had the next highest costs. Taken together, these five conditions accounted for 80.5% of the costs of excess weight in this study. The cost of excess weight represents a considerable economic and social burden to the health care system and provides further rationale for the development and implementation of comprehensive programs and policies to prevent and reduce obesity.
[Sidebar]
Table 1. Overweight and Obesity-attributable Health Conditions
Type 2 Diabetes
Hypertension*
Coronary Heart Disease*
Cerebrovascular Disease[dagger]
Osteoarthritis[dagger]
Gallbladder Disease[double dagger]
Asthma[dagger]
Depression[dagger]
Cancer
Colorectal cancer�
Postmenopausal breast cancer (diagnosed after age 50)�
Endometrial cancer�
Kidney cancer�
Esophageal cancer[double dagger]
Ovarian cancer�
Prostate cancer�
Pancreatic cancer�
Non-Hodgkin's lymphoma�
Multiple myeloma�
Leukemia�
Liver cancer[double dagger]
Bladder cancer[double dagger]
Stomach cancer||
* RRs estimated using self-reported disease prevalence and directly measured BMI data from the 2004 CCHS.
[dagger] RRs estimated using self-reported disease prevalence and adjusted selfreported BMI data from the 2005 CCHS.
[double dagger] RRs taken from the literature.9-12
� RRs not determined and Canadian PAFs estimated from the literature.13,14
|| Neither an RR nor a PAF could be found, and consequently an odds ratio (OR) from the literature was used.14 An OR may approximate an RR if the incidence of the disease is relatively rare (e.g., less than 10%) and if the OR is between 0.9 and 2.5,15 which was true for stomach cancer.14
[Sidebar]
R�SUM�
Objectif : Souligner l'impact possible des co�ts associ�s au surpoids et � l'ob�sit� sur les politiques et les initiatives de pr�vention de la province de l'Alberta.
M�thode : Par une m�thode de calcul du co�t de la maladie bas� sur la pr�valence, nous avons estim� les co�ts directs (soins hospitaliers, m�dicaments, soins m�dicaux, soins en �tablissement, co�ts suppl�mentaires) et indirects (incapacit� de courte et de longue dur�e, mortalit� pr�matur�e) associ�s � l'exc�s de poids pour 22 affections m�dicales. Les co�ts totaux de chaque affection ont �t� estim�s � l'aide de la base de donn�es de l'Agence de la sant� publique du Canada sur le fardeau �conomique de la maladie au Canada. Nous avons aussi estim� les fractions attribuables dans la population (FAP) � l'aide des donn�es de 2004 et de 2005 de l'Enqu�te sur la sant� dans les collectivit�s canadiennes et d'analyses documentaires r�centes.
R�sultats : En 2005, le co�t de l'exc�s de poids en Alberta s'est �lev� � 1,27 milliard de dollars. Son co�t direct �tait de 630,1 M$ (49,5 %) et son co�t indirect, de 643,8 M$ (50,5 %). Exception faite des co�ts associ�s � la mortalit� pr�matur�e et � la prestation des soins, l'ob�sit� repr�sentait 69,5 % des co�ts (500,8 M$), et le surpoids, les 30,5 % restants (220,2 M$). Sur les 22 affections m�dicales, la maladie coronarienne pr�sentait les co�ts imputables � l'exc�s de poids les plus �lev�s (307,1 M$), suivie de l'arthrose (167,7 M$) et du diab�te de type II (161,5 M$). Le co�t total de l'exc�s de poids correspondait � 5,6 % des d�penses annuelles en soins de sant� de la province pour 2005.
Conclusion : Les recherches sur le calcul des co�ts de l'ob�sit� s'attachent souvent aux co�ts directs des soins de sant�, mais notre �tude montre que les co�ts indirects de l'exc�s de poids sont tout aussi consid�rables et peuvent repr�senter plus de la moiti� des co�ts totaux. Les interventions visant � r�duire l'exc�s de poids chez les Canadiens pourraient donc am�liorer la sant� de la population tout en r�duisant les co�ts provinciaux et nationaux des soins de sant�.
Mots cl�s : ob�sit�; surpoids; le Canada; co�ts; co�t de la maladie
[Reference]
REFERENCES
1. World Health Organization. Obesity and Overweight. Global Strategy on Diet, Physical Activity and Health. Geneva, Switzerland: WHO, 2006.
2. Anis AH, Zhang W, Bansback N, Guh DP, Amarsi Z, Birmingham CL. Obesity and overweight in Canada: An updated cost-of-illness study. Obes Rev 2009;11(1):31-40.
3. Birmingham CL, Muller JL, Palepu A, Spinelli JJ, Anis AH. The cost of obesity in Canada. CMAJ 1999;160(4):483-88.
4. Katzmarzyk PT, Janssen I. The economic costs associated with physical inactivity and obesity in Canada: An update. Can J Appl Physiol 2004;29(1):90- 115.
5. Health Canada. Economic Burden of Illness in Canada, 1998. 2002.
6. Tjepkema M. Adult obesity in Canada: Measured height and weight [Internet]. 2005. Available at: http://www.statcan.ca/english/research/82-620-MIE/ 2005001/pdf/aobesity.pdf (Accessed October 30, 2009).
7. Connor Gorber 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.
8. Health Canada. Canadian guidelines for body weight classification in adults: Application in clinical practice to screen for overweight and obesity and to assess health risk. 2003.
9. Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA 1999;282(16):1523-29.
10. Engeland A, Tretli S, Bjorge T. Height and body mass index in relation to esophageal cancer; 23-year follow-up of two million Norwegian men and women. Cancer Causes Control 2004;15(8):837-43.
11. Larsson SC, Wolk A. Overweight, obesity and risk of liver cancer: A metaanalysis of cohort studies. Br J Cancer 2007;97(7):1005-8.
12. Koebnick C, Michaud D, Moore SC, Park Y, Hollenbeck A, Ballard-Barbash R, et al. Body mass index, physical activity, and bladder cancer in a large prospective study. Cancer Epidemiol Biomarkers Prev 2008;17(5):1214-21.
13. Luo W, Morrison H, de Groh M, Waters C, DesMeules M, Jones-McLean E, et al. The burden of adult obesity in Canada. Chron Dis Can 2007;27(4):135-44.
14. Pan SY, Johnson KC, Ugnat AM, Wen SW, Mao Y, Canadian Cancer Registries Epidemiology Research Group. Association of obesity and cancer risk in Canada. Am J Epidemiol 2004;159(3):259-68.
15. Zhang J, Yu KF. What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA 1998;280(19):1690-91.
16. Public Health Agency of Canada. The Economic Burden of Illness in Canada. Ottawa, ON: PHAC, 2000. ISBN 0-662-33144-3.
17. Statistics Canada. 2007 General Social Survey: Care Tables. Ottawa, 2009. Catalogue no. 89-633-X.
18. Taking Care Incorporated. Long term care in Alberta [Internet]. 2009. Available at: https://hermes.manulife.com/canada/repsrcfm-dir.nsf/Public/ThecostoflongtermcareinAlberta/ $File/ALBERTA_LTC_CostReport.pdf (Accessed August 26, 2009.
19. Health Canada. National Profile of Family Caregivers in Canada - 2002: Final Report. Ottawa, 2002.
20. Cranswick K, Dosman D. Eldercare: What we know today. Can Soc Trends 2008;86:49.
21. Jenkins KR, Kabeto MU, Fultz NH, Langa KM. Informal caregiving and Body Mass Index among older adults. J Gerontol Nurs 2007;33(4):42-51.
22. World Health Organization. Global burden of disease summary tables. Geneva, 2008.
23. Statistics Canada. The Daily. Selected Economic Indicators, Provincial Economic Accounts: Alberta. Catalogue no. 11-001-XIE. ISSN: 1205-9137. Ottawa, 2007.
24. Statistics Canada. Consumer Price Index (CPI), Annual (2002=100), CANSIM Table 326-0021 for Alberta, 2007. Available at: http://www.statcan.gc.ca/ pub/81-582-x/2007001/tbl/20090501/tbl-f3-eng.htm (Accessed August 26, 2009).
25. House of Commons. Comptroller and Auditor General. Tackling obesity in England. House of Commons 220 Session 2000-2001. London, United Kingdom: National Audit Office, 2001.
26. Wolf AM, Manson JE, Colditz GA. The Economic Impact of Overweight, Obesity and Weight Loss. Obesity: Mechanisms and Clinical Management. Philadelphia, PA: Lippincott, Williams and Wilkins, 2002.
27. Leal J, Luengo-Fernandez R, Gray A, Petersen S, Rayner M. Economic burden of cardiovascular diseases in the enlarged European Union. Eur Heart J 2006;27(13):1610.
28. Finkelstein EA, Fiebelkorn IC, Wang G. National medical spending attributable to overweight and obesity: How much, and who's paying? Health Aff 2003;22(3S):219-26.
29. Thompson D, Edelsberg J, Colditz GA, Bird AP, Oster G. Lifetime health and economic consequences of obesity. Arch Intern Med 1999;159(18):2177-83.
30. van Baal PH, Polder JJ, de Wit GA, Hoogenveen RT, Feenstra TL, Boshuizen HC, et al. Lifetime medical costs of obesity: Prevention no cure for increasing health expenditure. PLoS Med 2008;5(2):e29.
31. Popkin BM, Kim S, Rusev ER, Du S, Zizza C. Measuring the full economic costs of diet, physical activity and obesity-related chronic diseases. Obes Rev 2006;7(3):271-93.
Received: February 18, 2010
Accepted: October 2, 2010
[Author Affiliation]
Ellen Moffatt, MPH, RD,1 Lorraine G. Shack, MSc, PhD,2 Graham J. Petz, MA,3 Janis K. Sauv�, MSc,4 Karen Hayward, BSc,5 Ron Colman, PhD5
Author Affiliations
1. Health Promotion, Disease and Injury Prevention, Population and Public Health, Alberta Health Services, Calgary, AB
2. Public Health Innovation and Decision Support, Population and Public Health, Alberta Health Services, Calgary, AB; Preventive Oncology and Community Health Sciences, University of Calgary, Calgary, AB
3. Leading Practices - Knowledge Management, Quality Practice and Partnerships, Alberta Health Services, Calgary, AB
4. Public Health Innovation and Decision Support, Population and Public Health, Alberta Health Services, Calgary, AB
5. Genuine Progress Index (GPI) Atlantic Incorporated
Correspondence: Ellen Moffatt, Health Promotion, Disease and Injury Prevention, Population and Public Health, Southport Location, 10101 Southport Road SW, Calgary, AB T2W 3N2, Tel: 403-943-6778, E-mail: ellen.moffatt@albertahealthservices.ca
Acknowledgements: The Cost of Obesity in Alberta Report was produced by Ronald Colman and Karen Hayward, Genuine Progress Index (GPI) Atlantic Canada Incorporated. The report was made possible through Alberta Health Services, Health Promotion, Disease and Injury Prevention. The authors acknowledge Monica Schwann, Corinne Parker, Lisa Petermann, Jennifer Dotchin, Tony Mottershead, Kerry Coupland and Geraldine Lo Siou for their assistance with the project. Funding for this project was supported by Alberta Health Services, as well as the Canadian Partnership Against Cancer.
Conflict of Interest: None to declare.
