Diet quality in Canada: policy solutions for equity
===================================================

* Dana Lee Olstad
* Norman R.C. Campbell
* Kim D. Raine

KEY POINTS
*   Problems related to poor diet quality are prevalent in Canada, particularly among Canadians with a lower social position, and these differences are referred to as dietary inequities.

*   Health Canada’s new Healthy Eating Strategy is intended to improve diet quality at a population level, but some aspects have potential to widen dietary inequities.

*   The Healthy Eating Strategy is still primarily directed at supporting informed choice (e.g., revisions to *Canada’s Food Guide*), which does not address the root causes of poor diet quality in the conditions of daily life.

*   Nutrition policies will have a suboptimal impact if they are not also accompanied by meaningful change in policies that address the root causes of poor diet quality in the social determinants of health.

*   Further efforts to improve diet quality and reduce dietary inequities in Canada should leverage the synergistic potential of equity-oriented nutrition and social policies.

Most Canadians consume diets that are inconsistent with Health Canada’s recommendations.1 Problems related to poor diet quality are particularly evident among Canadians with a lower social position (i.e., as shown by lower levels of education and household income), as both overall diet quality and fruit and vegetable intake decline with each step down the social ladder.1,2 These differences are referred to as “dietary inequities,” because unlike biological differences, they are avoidable and are therefore considered unjust. Poor diet quality is a concern because it is a leading risk factor for morbidity and mortality,3 and inequities in its distribution contribute to the higher burden of ill health among individuals with a lower social position.4,5 However, the most effective means of improving diet quality at a population level, while also reducing dietary inequities, remains unclear.

## What factors shape diet quality?

Poor diet quality results from a range of influences, some of which are particular to individuals (e.g., food preferences), but most of which are contextual and therefore outside of individual control.6–8 Canadian policy-makers are recognized as being among the first worldwide to acknowledge formally that individuals do not simply choose to eat healthfully or not.9,10 Rather, it is factors such as their childhood environments, gender, Indigenous status, income, education and occupation that shape their opportunities to do so.1,2,11–14 Collectively referred to as the social determinants of health, these factors largely explain why the diets of Canadians with a higher social position are healthier than the diets of those with a lower social position, and are ultimately responsible for much of the diet-related disability and death in Canada.

## What policies exist in Canada to improve diet quality?

Despite early Canadian leadership in acknowledging the contextual drivers of poor diet quality, nutrition policies in Canada have generally not reflected this perspective. Indeed, most nutrition policies in Canada focus on supporting informed choice (e.g., nutrition facts tables on packaged foods, *Canada’s Food Guide*) and very few policies aim to reduce dietary inequities. This preponderance of information-based nutrition policies intimates that Canadians consume unhealthy foods either because they do not know that they are unhealthy or because they lack the motivation to stop consuming them. However, evidence from 2 systematic reviews indicates that provision of nutrition information is insufficient to change dietary behaviours, particularly among disadvantaged groups with fewer resources at their disposal.15,16

Recently, Health Canada announced a Healthy Eating Strategy, which will unfold over the next several years.17 Information-based nutrition policies continue to occupy a central role in the strategy via a revised *Food Guide*; warning labels on foods high in saturated fat, sodium and sugar; and updates to nutrition facts tables and ingredient lists. Notably, several other policies extend beyond mere provision of information to ban industrially produced trans fats in food, promote voluntary sodium reductions, restrict marketing of unhealthy food to children and expand Nutrition North Canada (an existing program that provides nutrition education and food subsidies in remote Northern communities); these policies will position Canada as an international leader in several respects. Nevertheless, despite this important progress, more could be done to ensure effective and equitable policies to improve diet quality in Canada.

## What can be done to craft more effective and equitable policies to improve diet quality in Canada?

Improving diet quality at a population level and improving dietary equity are not necessarily synonymous. Health Canada’s Healthy Eating Strategy is intended to improve diet quality at a population level; improving dietary equity is not its core aim. This is a concern because policies that improve diet quality at a population level may maintain or even increase dietary inequities if attention is not paid to reducing them.18,19 There is cause for hope that some elements of the new Healthy Eating Strategy will not exacerbate and may even help to narrow these dietary inequities. For instance, all consumers will benefit from the ban on industrially produced trans fats in food. To the extent that Canadians with lower incomes may be more reliant on processed foods high in trans fats, by virtue of the lower prices of these foods,20,21 they may even derive greater benefits from this policy than Canadians with higher incomes. Similarly, expanding Nutrition North Canada to additional communities may help to reduce geographic inequities in food access (although recent evidence suggests that many Northern families are still not able to afford healthy food22,23). However, other elements of the Healthy Eating Strategy that are primarily directed at supporting informed choice, such as updates to nutrition facts tables, have potential to widen dietary inequities. This may occur because individuals with higher incomes and levels of education may be better able to use nutrition facts tables to identify healthier items, and once such items have been identified, can more readily afford to purchase them.24 Thus, ongoing research will be critical to identify potential unintended negative consequences of the Healthy Eating Strategy, a prospect that will be challenging given the infrequent nature of dietary surveillance in Canada (i.e., the 2 most recent nationally representative nutrition surveys were carried out in 2004 and 2015).

Despite some key innovations, the Healthy Eating Strategy is still primarily directed at supporting informed choice (e.g., revisions to *Canada’s Food Guide*). Such policies are unlikely to substantially improve diet quality in Canada, particularly among individuals with a lower social position, because they do not address the root causes of poor diet quality in the conditions of daily life. By way of illustration, even if warning labels are placed on unhealthy processed foods, lower-income Canadians may nevertheless purchase them if healthier options remain unaffordable to them. Adding examples of culturally appropriate foods to *Canada’s Food Guide* may improve its cultural relevance, but it will not alter the colonialist legacy that has disrupted the traditional food systems of Indigenous Canadians, with profound adverse social, dietary and health consequences. And although home-cooked meals enjoyed in familial settings benefit physical and social health, families cannot follow these recommendations if they live in substandard, pest-infested housing lacking a safe water supply or food storage and preparation facilities.

To be clear, information-based nutrition policies are not entirely without effect, as some consumers have sufficient resources (e.g., disposable income, social support) to put nutrition information to use. Moreover, nutrition information can underpin other policy measures to improve food environments; e.g., if standards in *Canada’s Food Guide* are used to determine which foods may be offered in schools.

Finally, nutrition policies alone cannot ameliorate the very real dietary constraints imposed by the challenging life conditions that many Canadians experience. Nutrition policies will have a suboptimal impact if they are not also accompanied by meaningful change in policies that address the root causes of poor diet quality in the social determinants of health, most of which lie outside Health Canada’s jurisdiction. Strong social policies are essential to ensure individuals have sufficient resources to realize the positive potential of nutrition policies.

## What is needed to promote dietary equity in Canada?

Perhaps most urgently needed now are not further enhancements to nutrition labels on foods, nor additional health care spending on nutrition counselling and treating nutrition-related chronic disease,25 although these may yield small incremental dietary and health gains. Instead, more radical improvements in population-level diet quality might be achieved by leveraging the collective capacities of government ministries with responsibility for health, Indigenous affairs, housing, the status of women, education, taxation and others, and to gain the support of political and community leaders, for meaningful change to policies that address the social determinants of health. Social policy and nutrition policy can work together to prevent Canadians from developing poor-quality diets in the first place.

Thus, we propose that the next phase of action to improve the quality of Canadians’ diets should concentrate on partnerships with nonhealth actors on bold policy measures to address the social determinants of health, along with equity-oriented nutrition policies. Some of the most powerful policies will be those that improve economic security, reduce precarious employment and ensure access to postsecondary education regardless of ability to pay. Moreover, it will be critical to raise public and media awareness of the importance of taking action on the social determinants of health, as the belief that a high-quality diet can be achieved through individual choice is pervasive. We are not aware of any countries that have deployed a comprehensive suite of equity-oriented social and nutrition policies. In our estimation, Canada should reprise its role as a world leader in health promotion by being the first to do so.

### Conclusion

Nutrition policies alone, particularly those that are predominantly information based, cannot ameliorate the very real dietary constraints imposed by the challenging life circumstances of many Canadians. Despite the presence of nutrition policy, progress in improving the quality of Canadians’ diets will ultimately be limited unless we also address the root causes of poor diets in the conditions of daily life. Therefore, at this critical juncture, further efforts to improve diet quality and reduce dietary inequities in Canada might be maximized through leveraging the synergistic potential of equity-oriented nutrition and social policies.

## Footnotes

*   **Competing interests:** Norman Campbell reports receiving personal fees from the Novartis Foundation (2016–2017) to support the Better Hearts Better Cities program, which included travel support for site visits and a contract to develop a survey. He also reports receiving personal fees for providing consultative advice on accurate blood pressure assessment to Midway Corporation (2017). He is an unpaid member of World Action on Salt and Health. No other competing interests were declared.

*   This article has been peer reviewed.

*   **Contributors:** Dana Lee Olstad conceived of and drafted the initial manuscript. Kim Raine and Norman Campbell critically reviewed the manuscript for important intellectual content. All authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work.

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