INTRODUCTION

Non-communicable diseases (NCDs) cause 41 million deaths each year, representing 74% of global mortality [1]. In Canada, 88% of deaths are attributable to NCDs, with cancer and cardiovascular disease (CVD) being the leading causes of mortality [2,3]. Many of these deaths could be prevented by addressing behavioral risk factors such as unhealthy diet, physical inactivity, smoking, and excessive alcohol consumption [4]. Eight out of 10 Canadians over age 20 have at least 1 of these modifiable risk factors [5], indicating that upstream population-level interventions have considerable potential to improve health and reduce mortality.

Combining healthy lifestyle behaviors significantly reduces cancer, CVD, and all-cause mortality regardless of body mass index (BMI) [6], region of the world, economic conditions, race, ethnicity, gender, or education level [7]. Compared to others, individuals who do not smoke and who follow recommendations for alcohol consumption, physical activity (PA), and healthy eating have a 66% lower risk of all-cause mortality [8], a 58% lower risk of CVD mortality [7], and a 41% lower risk of cancer [9]. Although studies consistently show that smoking is the behavior most strongly associated with all-cause mortality [7,10–13], findings differ regarding the relative importance of other behaviors [10,11]. Moreover, while some studies report no gender differences in how behaviors influence mortality prevention [8], others observe important gender-based differences [10]. These inconsistencies contribute to uncertainty about how to prioritize limited health-promotion resources.

Uncertainty about the true effects of lifestyle changes on mortality also persists because many previous estimates assume an unrealistic scenario in which the entire population adheres fully to all behavioral recommendations [6–13]. To assess the potential impact of more realistic population-level changes and to determine which behaviors would offer the greatest health benefits if improved, this study estimated the number of deaths attributable to NCDs that could be delayed or avoided if the average lifestyle behaviors of Canadians matched those of residents in the provinces with the healthiest behaviors for each recommendation. To allow comparison with previous studies, we also estimated the number of deaths that could be prevented if Canadians’ average behaviors aligned with recommendations for healthy behaviors.

METHODS

Advances in simulation modeling represent powerful policy support and prioritization tools that can provide estimates of the impacts of hypothetical scenarios even before new policies or interventions are adopted and implemented [14,15]. This study used the Preventable Risk Integrated Model (PRIME) macrosimulation model to estimate the number of NCD-related deaths that could have been averted or delayed through changes in Canadians’ behaviors. PRIME is an open-access modeling tool [16] that estimates the differences in health outcomes expected if a population shifts from a baseline scenario to a counterfactual scenario. To generate estimates, PRIME requires as inputs age-specific and gender-specific data for: (1) the population size of interest; (2) anthropometric measures (height and BMI); (3) the number of deaths attributable to each of 24 health outcomes in the year of interest; (4) the population distribution of behavioral risk factors (baseline scenario); and (5) the counterfactual distribution of behavioral risk factors. PRIME integrates these data with meta-analytic estimates of the associations between behavioral risk factors and each health outcome (including 13 cancers, 7 CVDs, diabetes, chronic obstructive pulmonary disease, kidney disease, and liver disease) to estimate how annual NCD mortality would have differed if the average behaviors of the population reflected the counterfactual rather than the baseline scenario [17]. In this analysis, the baseline scenario used health behaviors and mortality data for Canadians in 2015, the most recent year for which Statistics Canada provides estimates for all behaviors included in the model. Two counterfactual scenarios were tested: an optimal scenario in which Canadians’ average lifestyle matched all national behavioral recommendations, and a realistic scenario in which Canadians’ average behaviors matched those of the province most closely adhering to these recommendations.

Data Sources

We used Statistics Canada CANSIM tables [18] to extract the number of Canadians in each age category (5-year age bands) and gender category in 2015, as well as mortality data associated with cancers (International Classification of Diseases, 10th revision [ICD-10] codes: C00–C14, C15, C16, C18–20, C23, C25, C34, C50, C54, C64), CVDs (ICD-10 codes: I05–I09, I10, I12, I15, I20–I25, I50, I60–I69, I71), diabetes (ICD-10 codes: E11, E14), chronic obstructive pulmonary disease (ICD-10 codes: J40–J47), kidney disease (ICD-10 code: N18), and liver disease (ICD-10 codes: K70, K73–K74). Objectively measured anthropometric data (height and BMI) were obtained from the 2015 Canadian Health Measures Survey (CHMS).

Dietary intake

Dietary data were obtained from the Canadian Community Health Survey (CCHS), Nutrition 2015 component, which surveyed 20 487 Canadians across all ten provinces (response rate 61.6%). Dietary intake information was collected using a 24-hour recall of all foods and beverages consumed in the preceding 24 hours. The estimates extracted for PRIME included mean daily intakes of energy (kcal/day), fruits (g/day), vegetables (g/day), fiber (g/day), dietary cholesterol (mg/day), sodium (mg/day), total fat (% energy intake [EI]), saturated fat (% EI), monounsaturated fat (% EI), and polyunsaturated fat (% EI). We also calculated the proportion of individuals who consumed fewer than 1 serving of fruit and 1 serving of vegetables per day and validated our intake estimates by comparing them with those reported in recent studies [19–24].

Alcohol intake

Alcohol data were obtained from the 2015–2016 CCHS, Annual Component. This cross-sectional survey included 110 095 participants (response rate 59.5%). Among participants reporting any alcohol consumption, mean daily ethanol intake (g/day) was calculated using the average number of weekly alcoholic drinks, converted into grams of pure alcohol. In Canada, 1 standard drink contains 17.05 mL or 13.45 g of pure alcohol [25]. Thus, the weekly number of drinks was multiplied by 13.45 g and divided by 7 to obtain average daily consumption. The proportion of non-drinkers (those consuming <1 g of ethanol per day) included participants who reported no alcohol consumption in the previous 12 months and those who reported not drinking in the previous week.

PA

PA level was derived from the 2015–2016 CCHS, Annual Component, in which participants reported all PAs performed in the preceding 7 days. PA level was calculated by summing the metabolic equivalent (MET) values of all activities, determined by multiplying the minutes spent in each activity by its assigned MET value. Because 1 MET reflects the energy expenditure of resting, METs quantify energy expenditure as multiples of the resting metabolic rate. The proportion of the population classified as “sedentary” was defined as the proportion of participants reporting zero minutes of PA in the preceding 7 days.

Tobacco smoking

Data on tobacco use were obtained from the 2015–2016 CCHS, Annual Component. Participants who reported daily or occasional smoking were classified as “current smokers.” Those who reported past use of tobacco products but were not currently smoking were classified as “former smokers.” Participants who reported not currently smoking and who had not smoked more than 100 cigarettes in their lifetime were classified as “never smokers.”

Counterfactual Scenarios

To reflect the timing of data collection, counterfactual values for the first scenario (optimal scenario) were based on the 2015 behavioral recommendations in Canadian national guidelines (or international guidelines when no national guidance existed) (Table 1). For recommendations expressed as ranges, the observed Canadian population mean served as the counterfactual value when it fell within the recommended range; otherwise, the boundary closest to the observed intake was used. Standard deviations (SDs) for the baseline scenario were also used for this counterfactual scenario, based on the assumption that although population averages may shift, within-population variability would remain similar. Because Canadian recommendations for fruit and vegetable intake combine both food groups and PRIME requires separate values, the recommendation was divided according to the observed fruit-to-vegetable intake ratio. Canada’s Low-Risk Alcohol Drinking Guidelines recommend that youth (under age 18 or 19, depending on the province) delay alcohol consumption until late adolescence; we interpreted this recommendation as implying no alcohol consumption among youth. PA recommendations are typically expressed in minutes per week, whereas PRIME requires activity in MET-min/wk. Therefore, the guideline of 150 min/wk of moderate-intensity aerobic PA was multiplied by 3 METs, corresponding to that activity intensity. For the second scenario (realistic scenario), we used the behavioral patterns of the provinces with the most favorable behaviors as the counterfactual values.

Statistical Analysis

All analyses applied Statistics Canada’s sampling weights for the CCHS to ensure representativeness. Means, SDs, and proportions were calculated to characterize the baseline scenario, generate PRIME input values, and identify provinces with the most favorable population-level behaviors. PRIME incorporates a Monte Carlo simulation to quantify uncertainty around estimated deaths averted. In this analysis, 95% uncertainty intervals (UI) correspond to the 2.5th and 97.5th percentiles across 5000 model iterations. In each iteration, the relative risks used in the model varied stochastically based on distributions reported in the literature. The resulting UI indicates the range within which 95% of plausible outcome values lie.

Ethics Statement

This study was based on publicly available data sources and did not involve direct interaction with human participants. Therefore, this research was exempted from full institutional research ethics review.

RESULTS

In 2015, the average diet of Canadian men included only about 49% of the recommended intake of fruits and vegetables and 52% of the recommended fiber intake. Similarly, Canadian women consumed, on average, only 46% of the recommended intake of fruits and vegetables and 67% of the recommended fiber intake. Men’s sodium intake exceeded recommendations by 34%, although Canadians were generally close to recommended intake levels for the other dietary components. Average alcohol consumption was about 4% higher than recommended for both men and women. Approximately 1 in 4 men and women reported no PA in 2015, while 20% of men and 17% of women reported smoking (Table 1).

Total Deaths Averted or Delayed Based on an Optimal Scenario

An estimated 30 756 deaths could have been averted or delayed in Canada in 2015 if Canadians had followed lifestyle recommendations (Table 2). This optimal scenario was estimated to avert or delay 22% of all NCD-related deaths in that year (Supplemental Material 1). Among all behaviors examined, diet—and especially fruit and vegetable consumption—showed the greatest potential for reducing mortality if recommendations were met (Table 3). Alone, meeting fruit and vegetable intake recommendations could prevent up to 59% of all deaths averted (calculated by dividing the deaths attributable to that behavioral change in Table 3 by the total number of deaths averted in Table 2). This is followed by smoking (25%), fiber intake (17%), and physical activity (10%). The number of deaths that could potentially be prevented by modifying fat- and alcohol-related behaviors was not significant. Most of the lives saved through behavioral changes were associated with reductions in CVDs, which accounted for 69% of all preventable or delayed deaths in 2015. Other notable causes of death that could have been avoided if Canadians met recommended behaviors included lung, colorectal, and esophageal cancers.

Total Deaths Averted or Delayed Based on a Realistic Scenario

Mean behaviors varied across provinces, and most provinces emerged as the healthiest for at least 1 behavioral component (Supplemental Material 2). We estimated that 6758 deaths could have been averted or delayed in 2015 if Canadians’ average behaviors matched those of the province with the healthiest lifestyle profile (Table 4). Of all behaviors assessed, diet accounted for 72% of the preventable or delayed deaths (Table 5). Specifically, increasing fruit and vegetable intake would prevent the greatest number of deaths, while reducing smoking among men and increasing PA among both men and women would also represent highly beneficial behavioral changes with respect to reducing population mortality. In this realistic scenario, most preventable deaths were attributable to reductions in CVDs. However, significant numbers of deaths due to lung, colorectal, and esophageal cancers could also be averted through behavioral changes consistent with this scenario. Overall, this realistic scenario could have reduced the number of NCD-related deaths in Canada in 2015 by 5%.

DISCUSSION

This study estimates that 30 756 deaths could have been averted or delayed in 2015 if Canadians had followed recommendations for diet, PA, smoking, and alcohol consumption. However, this idealized scenario may be unrealistic given the difficulty of modifying behaviors at the population level. Nonetheless, our results also demonstrate that nearly 7000 deaths could have been prevented in 2015 under a realistic scenario in which Canadians’ behaviors improved to the levels observed in provinces with the most favorable lifestyle habits. Under both scenarios, increasing fruit and vegetable consumption emerged as the most important behavioral change for reducing preventable deaths. Gender-based differences were also identified, indicating that after increasing fruit and vegetable intake, reducing smoking would be the most beneficial behavioral change among men, whereas increasing PA would be the next most important behavior to target among women.

The difference in mortality prevention between the optimal and realistic models can be explained by the large gap between Canadians’ lifestyle behaviors and current recommendations. This gap was particularly pronounced for fruit and vegetable consumption, smoking, and the proportion of individuals living a sedentary lifestyle. However, recent national estimates of tobacco use show that meaningful population-level improvements are possible, as smoking prevalence declined from 18% in 2015 to 12% in 2022 [26]. Moreover, the behavioral changes required for substantial mortality reduction are modest. For example, compared with their 2015 diet, Canadians would only have needed to consume an additional 79 g of fruit and 24 g of vegetables per day to match intake levels in the provinces with the highest consumption, potentially preventing 4509 deaths that year. This corresponds to roughly half an apple and 2 baby carrots per day. These amounts would need to be higher today, given the 30% relative decline since 2015 in the proportion of Canadians consuming fruits and vegetables 5 or more times per day [27]. Considering this shortfall, and evidence that fruit and vegetable intake can be effectively increased [28], best practices should be shared across provinces to support healthier behaviors. In particular, a comparison of lifestyle promotion strategies in British Columbia with those in other provinces may be informative, as British Columbia demonstrated the greatest adherence to health recommendations.

In contrast to many studies identifying smoking as the leading behavior associated with premature mortality [29,30], our estimates point to fruit and vegetable consumption as the most important behavior to improve for preventing deaths in Canada. This is because increasing fruit and vegetable intake benefits the entire population, whereas in our models only smokers benefit from the mortality risk reduction associated with quitting smoking. For individuals who smoke, however, smoking remains the strongest risk factor for mortality compared with other lifestyle behaviors [31]. Efforts to promote smoking cessation must therefore continue to address this major public health threat [32].

While cancer remains the leading cause of death in Canada, our results align with previous studies indicating that CVD presents the greatest opportunity for mortality prevention through healthier lifestyles [7,33,34]. This may be due to the strong associations between CVD and behavioral risk factors, including tobacco use, unhealthy diet, and physical inactivity [35]. Although lifestyle behaviors also contribute significantly to cancer risk, various non-behavioral determinants—such as genetics and environmental exposures—play major roles in the development of many cancers [36,37]. Regardless of cause-specific patterns, public health interventions are needed to reduce the burden of NCDs. Given that our analyses identified gender-specific differences in which behaviors offer the greatest benefits, gender-targeted interventions should be considered. This is consistent with evidence that gender-targeted approaches are more effective than universal interventions for improving nutrition and PA outcomes [38].

Strengths of this study include its ability to quantify the potential impact of realistic lifestyle changes among Canadians. Additionally, the macrosimulation model used relies on rigorous meta-analyses that establish strong associations between lifestyle factors and NCD outcomes [17]. Limitations include the use of self-reported data, which may underestimate the prevalence of behavioral risk factors and thus underestimate the number of preventable deaths. Moreover, because participants often reported only the number of servings consumed, assumptions were required regarding serving sizes; these were based on standard serving sizes from Government of Canada resources but may overestimate or underestimate true intake. Including individuals who had not consumed alcohol in the past week as non-drinkers may have overestimated the proportion of non-drinkers, and classifying individuals as sedentary based on reporting zero minutes of PA in the previous week may have underestimated the prevalence of sedentary behavior. Both issues could result in underestimating the potential impact of reducing alcohol intake and increasing PA. The cross-sectional nature of the PRIME model also prevents estimation of time-lag effects, in which behavioral changes may take years to influence mortality. Finally, because the most recent available data were from 2015, the estimated effects reflect adherence to the guidelines in place at that time.

These results highlight the substantial and positive impact that even small population-level behavioral changes could have on preventing NCD-related mortality in Canada. Our findings also show that among the various behaviors examined, diet—particularly improvements in fruit and vegetable consumption—appears to offer the greatest potential for reducing preventable deaths nationwide.

Data Availability

Supplemental Materials

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

This study was supported through a Canadian Institutes of Health Research Canada Graduate Scholarship and a Scholarship from the Université de Sherbrooke Medical Research Centre.

Acknowledgements

None.

Author Contributions

Conceptualization: Tanguay L, Mekari S, Belanger M. Data curation: Tanguay L, Belanger M, Registe PPW. Formal analysis: Tanguay L, Belanger M, Faivre P. Funding acquisition: Tanguay L. Methodology: Tanguay L, Belanger M. Project administration: Tanguay L, Belanger M. Visualization: Tanguay L, Belanger M, Richard E, Russell J. Writing – original draft: Tanguay L, Mekari S, Belanger M. Writing – review & editing: Tanguay L, Faivre P, Mekari S, Registe PPW, Richard E, Russell J, Belanger M.

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References

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