Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 22 - Evidence - October 29, 2014
OTTAWA, Wednesday, October 29, 2014
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:13 p.m. to study the increasing incidence of obesity in Canada: causes, consequences and the way forward.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I'm Kelvin Ogilvie from Nova Scotia, and I will ask my colleagues to introduce themselves.
Senator Eggleton: Art Eggleton, a senator from Toronto, which has a new mayor; I thought I'd slip that in. I'm deputy chair of the committee. I was dragging this out so Senator Merchant could get to her seat.
Senator Merchant: I'm Pana Merchant from Saskatchewan.
Senator Chaput: Maria Chaput from Manitoba.
Senator Nancy Ruth: Nancy Ruth from Toronto.
Senator Enverga: Tobias Enverga from Ontario.
Senator Seth: Asha Seth from Toronto.
Senator Seidman: Judith Seidman, Montreal, Quebec.
The Chair: Honourable senators, we are starting a new order of reference. This is a study to deal with the increasing incidence of obesity in Canada: causes, consequences and the way forward. We hope for a lot of emphasis on the latter and the way forward.
To put it on the record, on February 26, 2014, the Senate adopted an order of reference authorizing the Standing Senate Committee on Social Affairs, Science and Technology to examine and report on the increasing incidence of obesity in Canada, its causes, consequences and the way forward, including but not the limited to food consumption trends, specific elements of diet, the processed food industry, lifestyle, provincial and federal initiatives, and international best practices.
Today the committee is undertaking the first meeting in the study. We will hear from the Canadian Obesity Network and the Childhood Obesity Foundation. I gather we will receive an overview of this complex subject to identify some of the key issues involved and all other advice that they see fit to provide us with today.
By initial agreement we will proceed in the order the witnesses are listed on the agenda. I welcome Ian Janssen, Chair, Science Committee, to present first.
Ian Janssen, Chair, Science Committee, Canadian Obesity Network: This meeting is timely today. I don't know if anyone heard the news from Statistics Canada, the new report on obesity, which says 26 per cent of adults in Canada are obese and roughly 13 per cent of children. The only good news is that figure has plateaued in recent years so it is no longer going up, but it has yet to decrease. Hopefully this committee can get us going on a downward trend.
In my day job I am a professor at Queen's University, and part of the work I do is to serve the Canadian Obesity Network as their science chair.
Before I get into the content, the Canadian Obesity Network is essentially the largest network of obesity professionals. There are over 10,000 members, most are Canadians, and the network is growing. Membership is free. It is the only organization globally where membership is free. Most professional organizations would cost $500 a year to join.
The network includes all relevant stakeholders for obesity, such as researchers like me, health professionals like medical doctors, nurses, dietitians, kinesiologists, policy-makers. Lots of people from the Public Health Agency and Health Canada are members of the network, as well as lots of industry partners, including the food and beverage industry, pharmaceutical industry, the industry related to bariatric care. It encompasses all of the relevant disciplines for obesity.
CON's vision is to reduce the mental, physical and economic burden of obesity in Canada and its mission is to act as catalyst for addressing obesity in Canada by bringing together people to develop effective solutions to prevent and treat obesity. Again, it is tackling both the prevention and treatment aspects.
CON has three main strategic goals and those change every few years. Our current goals address the stigma associated with excess weight. These are things like bullying in children, discriminatory hiring practices, discriminatory enrollments into colleges and universities. It covers the full gamut of any interactions a person suffering from obesity would have.
We want to change the way policy-makers and health professionals approach obesity. In essence, we're trying to increase the attention given to obesity, increase the resources given to obesity and recognize that obesity is a complex issue that will require a complex solution. Quite often the solutions we come up with are simple and therefore ineffective at solving the problem.
Another goal is to improve access to prevention and treatment resources, which can be challenging, particularly in primary care.
I will give examples of some of the things CON is doing to address these goals. An example of an initiative to address the stigma problem is what we call ''Perfect at Any Size.'' By way of background, when the media portrays a person suffering from obesity, it is done in a negative way, someone who is lazy, not motivated and unattractive. This initiative is brought about to give a portrayal of a person suffering from obesity in a positive way. It's creating positive messages and images that people suffering from obesity can be eating well, physically active and attractive individuals doing normal things in the world.
An example of an initiative we have for strategic goal number two, which is to change the way professionals approach obesity, is our obesity boot camp. It's not a boot camp, as many people think, where we're there with children with obesity. It's a boot camp for new professionals and graduate students who are working in obesity.
Traditionally, we are taught in a silo. If you are a cell biologist, you are taught cell biology. If you're an epidemiologist, you're taught epidemiology. In obesity, you have to learn about the different aspects of obesity, and that's what the boot camp is about. It's a nine-day intensive course where we bring together students from different areas, and they learn about all the different complex areas of obesity.
Our boot camp has been held in Kananaskis — the same place the G8 summit was held in 2002 — for the past few years, and I have been participating in the boot camp for seven years. It's a really wonderful initiative.
Another activity we are doing to improve access to prevention and treatment resources is what is called the 5As of Obesity Management for primary care. The experience that many people have when they go to see their primary care doctor is they get on the scale and are weighed and it is determined how tall they are and the doctor calculates a BMI and maybe says, ''You know, you need to lose a few pounds, so eat better and exercise more.'' That's about the extent of the help they are given. The 5As initiative is meant to provide resources and training for primary care doctors to do a better job of assessing and dealing with obesity in their clinics.
That's a little bit again about the Canadian Obesity Network and some of the things we are trying to do.
We were asked today to comment about the causes and things we can do to help solve the problem.
If you look at image 8 of my deck, it's the busiest image that you're ever going to see. That's the image that talks about the causes of obesity. I am given 5 to 7 minutes to talk, and I could spend 5,000 minutes going over this picture. It's really meant to show you how complex this issue is. This is called the Foresight map. It was developed in the United Kingdom. It shows that there are all kinds of things going on and all kinds of things relating to each other.
Slide 9 tries to group those little boxes into different areas. If you look at the central boxes, there is food consumption — what you're eating, how much you're eating and those sorts of things. There is your physical activity — how much you're exercising, how much you're walking, how much you sit during the day when you're at work and those types of things. Then there are outside factors that drive those behaviours. There is food production, food environment, physical activity environment, social influences, and then individual biology or genetics that will influence all of those things.
It's not a simple, silver-bullet problem. There are many things going on. To solve obesity, because it is such a complex problem, it requires complex solutions. You need to tackle many of those causes of obesity and upstream determinants of obesity if you're going to see any benefit on a person's body weight, particularly at the population level. With that being said, most things that we've done to try and solve obesity have been completely ineffective. We would consider them to be not effective whatsoever. There are very, very few examples of population level or community level interventions that have worked over the long term and that have been replicated in more than one setting.
One of the only two or three examples in the world of something that has been successful is something called EPODE. That comes from research that was originally done in France. I don't remember what EPODE means in French, but essentially in English it means ''together let's prevent childhood obesity.'' It's a community-based intervention where there are lots of things going on in the community. There is a project manager, a steering committee, government involvement, usually the mayor or someone high up at the municipal level and private partnerships working together to tackle all of the different areas of obesity in the community. They are doing things in the schools and recreation centres. They are doing things in the libraries, in some situations. They are doing things with the farmers. They are doing all kinds of things simultaneously over a prolonged period of time. This doesn't work in the first year or first two years. It's not until three, four or five years of running this type of intervention that you see any success.
Ideally, you will have many different communities running this type of intervention. There is also a central coordinating committee that provides oversight to individual communities. This would have scientific oversight and then additional resources provided, because there is a lot of replication of what is going on in the individual communities. They can help make sure there is a lot of cross talk and that things working in one community can be given to another community.
For examples of some of the things that we are doing in Canada right now, the example I will give first is a federal initiative. I hate to say it, but the evidence is quite clear that this particular initiative does not work. This is the Children's Fitness Tax Credit. If you are not familiar with it, as a parent, I have two kids under age 18, so for each child I can claim $500 worth of receipts for physical activity programming and things they do that meet certain criteria. Depending on my income level, I might get back up to $75 if I claim the entire $500. It's $75 at the most. I think last year it was about $5 for me, and I spent about $800 on my two kids combined. It doesn't actually make that much of a difference. It's about $100 million a year, I believe, that the federal government spends on this initiative each year. There has been more than the two research studies I've shown here, but essentially they show that the people using this and the people aware of it are the people who don't need it. They are middle-income and high-income families, and they respond that this in no way, shape or form influences whether they enroll their child in the sport in the first place. It did not affect the physical activity behaviour, which is the main thing. It's meant to influence the behaviour, and it simply does not. Again, it only tackles one very small aspect of the behavioural component of obesity: organized sport and physical activity in children. It doesn't tackle anything with nutrition. It doesn't tackle active transportation or active play. It doesn't do a lot of things. This one thing is very small, and it's not going to influence obesity.
With that being said, most initiatives in Canada at the federal, provincial and municipal level would not work because they are too simplistic in their approach. In Canada, some provinces are moving to things that we think are going to work. In Ontario, the Ministry of Health and Long-term Care has recently funded what is called the Healthy Kids Community Challenge. This is just starting to roll out now. They are working on all of the contracts with the communities. Forty-five communities have received up to $1.5 million in funding. This is following the EPODE model. There will be a central coordinating centre, Public Health Ontario, that will provide oversight to the individual communities. They will be given their $1.5 million and be expected to follow the EPODE model that I talked about a few moments ago and do lots of things in their community over a prolonged period of time and hopefully we will see a difference. Quebec has done a similar initiative that is actually winding down because they have lost the private funding for that. We're hoping that, in Ontario, we will see a difference.
I will end with my last slide. I can't say enough in five to seven minutes, but the Canadian Obesity Network does host a five-day conference every two years. Our next conference is in May, coming up, so if you're really interested in knowing more about obesity, I could probably get you in there without paying the registration fee because I have connections. We try and get the decision-makers; we want them to have access. And we certainly would encourage involvement for any or all people on the committee.
The Chair: You mentioned twice during your comments that you had five to seven minutes, and that ballooned up to twelve and a half. Your credibility with regard to impact on obesity may come under challenge if we look at all aspects of this issue. But seriously, thank you very much for your presentation. Now I'll turn to Dr. Tom Warshawski.
Dr. Tom Warshawski, Chair, Childhood Obesity Foundation: Thank you. I wasn't too sure how close we were going to be held to that five to seven minutes, so I cut to the bare bones. I sent the clerk three or four different versions of my talk because I kept paring it down.
The Chair: Because of the subject, I did allow him to go on.
Dr. Warshawski: Excellent. I'm the chair of the Childhood Obesity Foundation. I'm a consultant pediatrician from Kelowna, British Columbia, but I've been involved in medical politics and medical administration at a broad level for a number of years. I became interested in childhood obesity from a policy level and from the broader perspective out of frustration at the lack of the ability to do much in the office. When you see a child or family in the office and they are suffering from overweight and obesity, it is very challenging and very difficult to reverse. Like Ian, we feel that there needs to be a whole-of-society approach. A number of things can be done. Some things, such as the tax credit, simply don't work.
The mission of the Childhood Obesity Foundation is to identify, evaluate and promote the best practices, healthy eating and active living to prevent obesity and the ensuing chronic diseases. Thank you for inviting me to speak on the topic of obesity in Canada: causes, consequences and the way forward. My brief presentation will touch on the causes and focus on one specific action, of which there are many, that can be taken by the federal government. However, I'm more than happy to discuss all aspects of this topic afterwards.
We know Canada faces an epidemic of unhealthy weights among citizens of all ages. Over 30 per cent of our children and youth are overweight; and obesity in adults currently costs Canadian taxpayers billions of dollars each year. This sum is destined to increase dramatically as it reflects the burden of obesity-related diseases when only 15 per cent of youth entered adulthood overweight. We know that obesity-related chronic disease cuts three to seven years off the expected lifespan of an overweight adult. Unhealthy weights exact a significant toll in terms of the dollars cost and the lives lost.
The two strongest risk factors for the development of unhealthy weights in children and youth are excessive exposure to screen time and the overconsumption of sugary drinks. Screen time is problematic because it displaces physical activity as sedentary time increases; and it's the medium used to market unhealthy foods and beverages. Sugary drinks are uniquely obesogenic. We know that sales are driven by effective marketing campaigns directed at the young. Current evidence suggests that excessive weight gain is usually the result of small, consistent caloric imbalances of about 100 to 150 calories per day. That's the number of calories in a regular sized can of pop or one-ounce bag of chips. Junk food and beverages are not harmless treats when purchased at the rates desired by the food industry. Regular consumption of these products is a major driver of the obesity epidemic. The goal of pervasive marketing of junk food is to drive overconsumption. It is clear that the marketing of unhealthy foods and beverages is a major contributor to the obesity epidemic.
We know that obesity is rarely due to gluttony or sloth and that a lean-bodied person may owe as much to genetic good luck as to strength of personality. We need to resist moralistic judgment of the obese and recognize the power of food marketing in creating a lifelong preference for unhealthy foods. We also need to recognize the vital role of government in enhancing our health.
Libertarians dismiss government involvement in shaping the public's behaviour as a manifestation of the nanny state. They contend that the state should not interfere with the individual's right to decide unless the choice harms others. The classic libertarian theory holds that if provided with full and relevant information, individuals will act rationally to maximize outcomes. However, Nobel Prize-winning work in behavioural economics tells us a different story. Most adults often think irrationally and are prone to making hasty choices. Most importantly, the neurobiological design of children and youth renders them particularly vulnerable to poor decision-making. Children need our assistance in making good choices and should not be duped into choosing unhealthy foods and beverages.
Over 90 per cent of Canadians believe that it is primarily the responsibility of parents to ensure that children and youth achieve a healthy weight. Canadian parents are also asking for a more active role from government. Over 85 per cent want government to restrict the marketing of unhealthy foods and beverages to their children. Parents are asking for help in limiting the ability of advertisers to undermine parental efforts to instill healthy habits in their loved ones. The call for restricting the marketing of unhealthy foods and beverages has a strong ethical and pragmatic foundation.
Children lack judgment and are blessed with credulity — a readiness to believe with little evidence. This is a neurobiological developmental stage and not amenable to media training. Children under the age of five years cannot consistently distinguish commercials from programming. At least one third of 11-year-olds do not grasp the persuasive nature of ads. That part of the brain responsible for executive thinking and decision-making is not fully developed until early adulthood.
Children are hardwired to believe what they are told, yet most of the foods and beverages marketed to them are unhealthy and unfortunately marketing works. There is strong evidence that children and youth eat what they watch and while they watch. It is ethically irresponsible to market unhealthy foods and beverages to children who are hardwired to trust us. We are betraying them and ignoring our obligation to protect and nurture.
In November 2010, an FPT task force published a framework for action called ''Curbing Childhood Obesity.'' In it and in a subsequent analysis, a key strategy was to look at ways to decrease the marketing of unhealthy foods and beverages to children and youth. It was suggested that corporations and the advertisers they employ follow voluntary restraints in decreasing the marketing of unhealthy foods and beverages and that they work toward common guidelines. Some corporations devised limits on marketing to kids under the umbrella of the Canadian Children's Food and Beverage Advertising Initiative, or what we refer to as the CAI. In this initiative, each company sets its own standards and then judges itself. Although the CAI found corporations were successful in meeting the standards they set for themselves, the program was not effective when gauged by objective criteria, such as those employed in the United Kingdom. This once more proves the old adage that the fox does a poor job of guarding the chicken coop.
Given the inherent conflict of interest facing the food and beverage industry as they strive to self-regulate, it is imperative that the government accepts the role that parents request of it. The federal government should follow the lead of the U.K. and establish objective criteria for what constitutes healthy foods and beverages and set limits on the marketing of foods and beverages to children and youth. Government must monitor compliance, and if significant breaches of the legislation occur, government must enact consequences.
As stewards of the health care system, we have a pragmatic interest in limiting the costs triggered by obesity-related chronic disease. More importantly, we have a moral obligation to protect our children and youth from the harm caused by the overconsumption of junk food. It is time for Canada to devise a policy framework to shield our children and youth from the marketing of unhealthy foods and beverages. We request the help of the Senate in helping us to move toward this goal. Thank you.
The Chair: Thank you. We will move to questions.
Senator Eggleton: Thank you both for being here and getting us off to a good start on the subject matter. Mr. Janssen, you said at the beginning, ''26'' and ''13.'' Can you explain again what they are?
Mr. Janssen: First, 26 per cent of adults, age 18 and older, have obesity; and 62 per cent of adults are overweight or obese. The norm is not normal weight but overweight or obese in Canadian adults. Second, 13 per cent of children between 3 and 17 years are overweight or obese. For boys, it is 15 per cent and for girls, it is 11 per cent. One in three children is overweight or obese in the pediatric age range.
Senator Eggleton: How is it measured?
Mr. Janssen: It's BMI in this situation. In adults, we use a cut point of 30 BMI to define obesity and a cut point of 25 BMI to define overweight. BMI is simply your weight in kilograms divided by your height in metres squared. In adolescents, it is more complicated because they are growing and maturing, so we use a different cut point to define overweight and obesity depending on the age. It's called a ''growth chart.'' For example, for a 17-year-old, the BMI cut point to define obesity is very close to what it is for an adult. For a five-year-old, it is very different. It takes into consideration that children grow and mature and in growing and maturing their BMI increases naturally. You have to disentangle the natural growth and development from the unnatural growth and development. In a clinic to measure head circumference, height, weight and everything else they use these growth charts; and they use BMI charts as well.
Senator Eggleton: Is BMI the gold standard? Is it the best standard? Some people might dispute that. I certainly agree that weight isn't a measurement.
Mr. Janssen: For population level surveillance, it is what we use. Definitely in a clinical situation dealing with an individual patient, I use the analogy of Arnold Schwarzenegger. I don't mean the current Schwarzenegger, but in his heyday of steroids and bodybuilding, where he would have had an obese BMI yet be muscular. At the population level, we haven't seen an explosion of bodybuilding and people having excess of muscle. In the clinical situation, you don't just rely on BMI; you rely on all the other measures of health as well. There are other measures we use for surveillance, including waist circumference, which is not impacted by your musculature. The waist circumference data is worse than the BMI data.
Senator Eggleton: Do you think it's more indicative of a person being obese?
Mr. Janssen: It's a slightly stronger indicator of many of the health risks of obesity, for example, your risk for type 2 diabetes and cardiovascular disease. The waist circumference is a better predictor of that risk, a little better than the BMI. Regarding the waist circumference data, we've seen people's waist circumference increasing at a faster rate than their BMI.
When Statistics Canada reported that the prevalence of obesity has doubled in Canadian adults since 1980, the prevalence of abdominal obesity has tripled in the same time frame. The prevalence of childhood obesity based on BMI has gone up threefold; based on waist circumference, it has gone up sevenfold in the same time. The waist circumference data presents an even scarier picture of the problem of obesity.
Senator Eggleton: Do you have some description of these different measurements, something you can file with us?
Mr. Janssen: Yes, and I have all the statistics I can give you from all the recent surveys. I'm an epidemiologist, so I have a paper that summarizes all of these things.
Senator Eggleton: Please send it to the clerk.
You said that these latest numbers show that in the last few years the figure hasn't climbed. It climbed, I understand, from the 1980s — I don't know to what point — and then it has levelled off, but it hasn't decreased. What's the reason for this levelling off?
Mr. Janssen: Two things or a combination of both. One of them could be that we have a certain percentage of the population that's susceptible. They have the genes that put them at high risk for obesity. We've saturated the susceptible people, or we're starting to make a difference. We've done more things in the past 10 years to try to solve obesity than we were doing in the previous 10 years. These things, we hope, are starting to make a difference.
Senator Eggleton: What do you think is prime amongst those things? What has worked the most to keep this at a level?
Mr. Janssen: I don't think it's any one thing. It's many things simultaneously. I don't like to say we do this or that, or this policy or this initiative. There are so many things. As I said, it's lots of things.
Senator Eggleton: On the other hand, it's not reducing?
Mr. Janssen: It's not reducing. You have seen in some regions of the world, some states in the U.S., where the prevalence was very high, they've actually started to see it going down. Those are the states where they are doing more, like Alabama.
Senator Eggleton: Like doing what?
Mr. Janssen: They're doing more of everything — more policies, more programs, more to the environment.
Senator Eggleton: Schools and things like that?
Mr. Janssen: Yes. Generally, the places that are investing or doing more tend to be doing better, being more ambitious with what they're doing.
Senator Eggleton: Dr. Warshawski, is it similar for children? Has it levelled off?
Dr. Warshawski: I would say that it has, and for the same reason or a variation of what Ian said. Those who are most susceptible to the current environment are fully saturated; they've reached a peak.
There are two things I want to add to Ian's comments. We know that the diseases that come from obesity are a reflection not just of your BMI or your fat stores but also the duration that you've been exposed to this. It's not so much fat at 40, which is dangerous — that three- to seven-year lifespan reduction — it's 40 years of fat.
In the cohort of teens that graduate into adulthood, 30 per cent are overweight and obese; in 1978, that was 15 per cent. The longer you're exposed to high BMI, the greater your chance of developing type 2 diabetes, coronary artery disease and stroke. We're going to see those resulting illnesses earlier rather than later.
The other fact I want to mention from Statistics Canada is that this young adult cohort, because of the habits they learned in childhood, are gaining weight at a much faster rate than older adults do because they eat too much junk food, drink too many sugary drinks and are sedentary. Statistics Canada data showed that of the group that is between 18 and 24, if you follow them from eight years, of the overweight group, one third became obese. Of the normal weight group, one third became overweight. We have this one-way ramping up of this problem, and the sooner you cross that threshold into that unhealthy weight, you accumulate 30 or 40 years of exposure to the various cytokines. Fat tissue isn't just unsightly or heavy tissue. These are active endocrine organs and do things to the body. The more exposure you have, the greater the risk of developing these diseases. It's very problematic.
Senator Eggleton: What percentage of obese children become obese adults? Do most of them carry it into adulthood, or is there a drop-off?
Mr. Janssen: It depends a bit on the age. When you talk about adolescents, 16, 17, it's 90, 95 per cent. When you're talking about a 2-year-old, it might only be 20 or 30 per cent. It depends on the age.
Dr. Warshawski: It's a growth curve. We know in adulthood there's strong data. If you're 30 years old and your BMI is 30, these are the risk factors. For kids, we're trying to extrapolate a point on a curve, and say, ''If you keep growing like this at this rate, chances are when you're 18, you'll be 25.'' There's a lot more guesswork.
Senator Eggleton: We talk about what people eat, nutritious or non-nutritious foods, junk foods, et cetera. We also talk about exercise. This person said to me it's 90 per cent what you put in your mouth and 10 per cent is lifestyle or exercise. Would you agree with that?
Mr. Janssen: I'm a physical activity person, so I probably would disagree.
Senator Eggleton: I'm asking the wrong person.
Mr. Janssen: I think that's an academic argument. I could find evidence that would support either role. I could have somebody who does not exercise, as we would define exercise, and could eat a balanced diet and maintain a healthy weight. Alternatively, I could find people who exercise heavily, don't eat very well and maintain a healthy weight. For some people, one strategy works, and for some, it's a combination of the two. It's finding the right balance that's important, and that balance will be different for each person.
Dr. Warshawski: He's more of the activity guy. I'm more of a food guy. The fact is, it is both. You can't separate the two. As little as 20 minutes a day of physical activity prolongs lifespan. All exercise is good; more is better. For nutrition, you have to eat your fruits and vegetables. You have to eat well. It's not either/or. You have to do both.
Mr. Janssen: With physical activity, it has to be a lot. With twenty minutes a day, you don't burn a lot of calories. I run a marathon. I did a couple of weeks ago and it was very painful. I could eat the amount of calories that I ran in a marathon in about half an hour, especially if it's a beverage, just suck it back.
The Chair: I think there was an important point here on the issue of the difference between longevity and weight with regard to the exercise issue.
Dr. Warshawski: Exercise has so many benefits. It's the wonder drug, if you can package it and sell it.
The Chair: The point to interject was important. We don't want to take these flat as we observe all these things.
Senator Seidman: Thank you very much. As you can see, we're just beginning this study and are trying to understand some of the issues.
I'd like to pursue the issue of the increasing incidence rates that you were discussing with Senator Eggleton. We do know that globally the incidence of obesity began to climb in the 1980s. Dr. Janssen, you're an epidemiologist, and I would like to ask you what your evidence or hypotheses are about why the rates began to climb in the 1980s, as they now taper off. In discussing that, perhaps the issue is — and you touched on this a bit — what measures we use of obesity. But was reliable weight data collected pre-1980s?
Mr. Janssen: We do have some data pre-1980s, dating back I think as early as the 1950s, and from 1950 to 1980 in Canada, not much change. And it's the same thing globally in the developed world. In the developing world, the trajectories are delayed by about 20 years behind where we are in the high-income country, so it's a bit tricky there.
Why the 1980s? I think it deals with massive changes in food production. For example, in the United States we talk about sugary drinks and the impact they have, particularly soft drinks. There was a big change in the sugar sweetener used. It went from being sugar to corn-based sugar, high-fructose corn syrup. That dealt with policies around corn production and the money farmers are receiving to produce this corn. We've seen increases in the price of fruit and vegetables going up higher than the rate of inflation, whereas the increase in the price of soft drinks, junk food and fast food has increased at a slower rate than inflation.
We've seen the number of McDonald's and Burger Kings, and you can buy food everywhere. I think I counted the number of vending machines within a five-minute walk of my office and I lost track after 50. I counted the number of fast-food restaurants within a 15-minute walk of my office and I stopped at 15. So you can buy it everywhere. It's cheap. It's easily accessible. It's convenient. We have more women in the workforce, so it's hard to make a meal. It's more expensive to buy the foods, to make the homemade, nutritious meal. The portion sizes are bigger. You look at a standard soft drink now, it's not the can; it's the 750 millilitre bottle. So you drink more, eat more, it has more calories in it. It has been happening, and a lot of it took off around the 1980s.
From a physical activity standpoint, for adults, we saw it's not the exercise. It's not what people do in their leisure time. If anything, that's improved. It's what they've done in their occupational time. So what are we doing here? Sitting. You have computers, white-collar jobs, taking over from the blue-collar jobs where you're doing light intensity stuff, but continuously burning calories throughout the day. People are using their cars to get everywhere, walking less.
With kids, it's the same issue around that. Kids are actually engaged in more organized sport now than in the 1980s, but you don't burn a lot of calories in organized sport. Where do you burn calories? In active play. What do you not see outside on the streets? Kids playing. There are a lot of things from the energy intake, energy out. There are other behaviors. We call those the big two. There are other things. There are changes in the prevalence of smoking. Smoking actually increases your metabolism. The way we regulate the temperature in our room has changed. If it's really cold in a room, you shiver more. If it's hot, you burn more calories getting rid of the heat. We sleep less. That's another behaviour implicated with obesity that doesn't get a lot of attention, but is important particularly in the teenage years. There are lots of things behaviourally going on from the physical activity, diet and these other things that might be implicated in obesity as well.
Senator Seidman: I appreciate that. You've offered a couple of ideas as to why rates seem to be levelling off now, so either we're starting to make a difference or we've saturated the genetic predisposition. But it leads me to ask: If you look at other countries in the world less likely to have higher obesity rates, like Japan, Norway and Italy, for example — this is my understanding — do you have any hypothesis about that?
Mr. Janssen: Finland would be a good example. They are doing a lot of things. They have very aggressive policies in Finland. They have environments around nutrition and diet and saturated fat, in particular, which have had tremendous benefits on cardiovascular disease in Finland. They're doing things that are aggressive and at the government policy level that then trickle down.
I think of the Netherlands, where my father was born. The normal means of getting around in Amsterdam is by bicycle. You're not an outlier if you're on a bicycle. Ottawa is a little bit better than Kingston. In Kingston if you're on a bicycle, in a lot of places you're taking your life in your own hands. The environments are more conducive to physical activity. It's the normal. We talked about some economists and the default is to be active in some situations, where our default is to get in a car and drive everywhere.
Senator Seidman: If I could then move directly to something that both of you mentioned, and that has to do with changing the way policy-makers approach the issue of obesity.
Dr. Warshawski, you mentioned this. In fact, you put out something that's very clearly a policy issue that has to do with advertising directed at children.
Dr. Janssen, you talked specifically about how we have to change the way we approach obesity when we make policy.
I will ask the two of you to tell us briefly: If you had to put it in a short, succinct summary, what advice would you give in terms of changing the way we make policy or what would you see as an approach that policy-makers could take in trying to do something effective in this area?
Dr. Warshawski: I would say to enact a health lens on all aspects of policy making. You mentioned the built environment, the walkable cities in Europe, the relative food deserts, the easy availability of junk food and junk drinks positioned right next door to schools. There are all sorts of things that can be done.
When someone is looking at a zoning bylaw, Senator Eggleton, this makes sense because it's not making too much noise, traffic, but just apply the health lens. How does this fit onto the broader societal objective? At each level of governance there are things that need to be taken into account at the municipal level. In Kelowna they built two hockey rinks beside an indoor jogging track and two soccer fields. They didn't put a water fountain in the facility, but they did have a central kiosk selling Slurpees, pop and other things. I had to complain to the mayor and get a water fountain put in there. It was a simple intervention and decreases the consumption of sugary drinks. No one applied that lens at the municipality.
What foods and beverages are allowed for sale in the municipality, and at a provincial level what's allowed to be sold in schools, for school lunches. It's mandatory physical activity, not just physical education, so kids can be active.
At the federal level, which is why I addressed those particular comments here, what are the things at the federal jurisdiction? On the airwaves, it's not just TV marketing that is pervasive; it's Internet. It's everywhere. We know that marketing to kids affects their choices, their preferences. Parents give in, you're pestered, your 5-year-old is pulling on your sleeve, you're tired and you buy this stuff. How can it hurt? The cumulative impact is problematic.
Each level of government has to say what can we do, what's within our sphere of influence and how significant can our actions be and move towards those. That's our perspective.
Mr. Janssen: I agree, especially looking through a health lens when you're developing policies. I think there are also lots of ideas, recommendations and best practices out there, so it's not like you have to draw something up from scratch. We talked about the advertising. There is a lot of work globally on that, and very good recommendations done by obesity researchers and task forces on what those policies should look like. It's the same thing with sugar-sweetened beverages, soda taxes and things of that nature. There are lots of things to call upon and without needing to draw something up from scratch.
Senator Seth: I think it is a very interesting topic, as you have been saying, because there is an increasing rate of obesity developing into chronic diseases in children and in adults. Last week, I held a reception where we discussed how maternity and childhood play a key role in the prevention and delay of adult chronic disease through good nutrition, active lifestyle and regular medical checkups.
In spite of that, 20 per cent of children under 12 are already suffering from a chronic disease. So my question is this: How can you speak about obesity, which plays a role in the development of chronic disease in children? This is the one question I have.
Dr. Warshawski: One of the things we do — we're called the Childhood Obesity Foundation — is to try to shift toward getting the habits right. It's healthy eating and active living. We don't want parents to be overly focused on putting their Jimmy or Jane on a scale if they're overweight or obese. If you get the habits right and are eating well — fruits and vegetables, whole grains, low saturated fat — and being physically active, with 60 minutes per day of moderate to vigorous physical activity, you'll get the life that's right for you.
We also know that the manifestations of chronic disease begin very early, as early as pre-school. There is a recent study out of Italy, as a matter of fact, that looked at obese four- and five-year olds, and they had a 5 to 10 per cent incidence of hyperlipidemia, of hypertension and of changes that suggested that their arteries were becoming thickened.
We know that adolescents, if they have metabolic syndrome, which is a compilation of a big waist circumference, glucose intolerance, hypertension and abnormal blood lipids, actually show structural changes in their brains in MRI studies and cognitive changes. They don't think as well; their brains don't work as well. That ''healthy mind, healthy body'' adage is very true.
We're seeing diseases caused by obesity in childhood, as you say, and we have to work as a whole society to improve these habits, that healthy eating and active living.
Senator Seth: How early can these children develop chronic diseases?
Dr. Warshawski: The chronic diseases that we normally talk about associated with obesity are type 2 diabetes, cardiovascular disease, hypertension and that sort of thing. We don't see type 2 diabetes, usually, until adolescence — 13, 14, 15. Before, it was an extremely rare disease in children. It used to be called ''adult diabetes,'' versus ''childhood onset diabetes.'' It's still relatively uncommon, but the incidence has increased probably a hundredfold because it really doesn't happen until you're 20 or 30. As for other chronic diseases, hypertension begins to happen, but, in kids, there are not the outward manifestations, although it does affect cognition. Your brain doesn't work as well when it's perfused at high pressure as it does when it's perfused at a normal pressure. So it is there. It's significant, and there are things we can do. But, generally, it's about healthy lifestyles — eating better and being more active.
Senator Seth: Is there any role from the start of pregnancy to avoid obesity?
Dr. Warshawski: Absolutely. There is huge data about being overweight and obese during pregnancy and the effects that has on the newborn, including increased risk for obesity later on and other diseases, even such as autism.
Mr. Janssen: It's a field that's called epigenetics, and it actually carries forward more than one generation. For example, if my grandmother was not doing things very well in her pregnancy with my father, that would influence his genetics to a certain extent. That would then carry over not only to him but also to me. There is definitely an importance to having a healthy pregnancy, eating well, being physically active and not gaining too much weight. As I said, there are the five As of obesity management. There is a specific one about pregnancy and appropriate weight gain for pregnant women. Women suffering from obesity actually should gain less weight during a pregnancy than a woman with a healthy BMI.
Senator Enverga: Thank you for the presentations; they were great.
My first question will be: You mentioned that 26 per cent of people are obese in Canada. How did you measure that, through BMI or height-to-weight ratio? I don't know how it was measured.
Mr. Janssen: BMI, body mass index, is a ratio of your weight for your height. Taller people will weigh more. If Tom stood up, he's very tall, so he will have a different weight allowance than someone who is five-foot-two. It takes into consideration that taller people weigh more. It is normalizing your weight for your height.
Senator Enverga: I notice a lot of people have a bigger frame. They will be heavy, right, if they have a bigger frame? They are short but with a bigger frame. Is that factored into the statistics?
Mr. Janssen: At the population level, when we are doing this to determine the surveillance of obesity, we figure that there are people who are big boned, if we want to call it that. There are people who were big boned in 1980 and 1950 and now. So they kind of cancel each other out when looking at the prevalence of obesity and how that has changed over time.
As a doctor, if a patient comes in, you are not just measuring their height and weight and saying that the BMI is the be all and end all of health. You will measure their blood pressure, their lipids, their behaviours and the other things that are important for a patient's health. The BMI is one of many measures of health that you would use on an individual patient.
Senator Enverga: From what I read in some papers, obesity is more like a natural physical trait of a person; is that correct?
Mr. Janssen: There is certainly a tremendous genetic component to obesity. Data would suggest that up to 50 per cent of the variability in body weight is a manifestation of your genes, your genetic predisposition. Certainly, there are people who are predisposed to obesity. Their genes load the gun; the environment pulls the trigger. That's the environment of the food and the unhealthy, inactive living. That's what pulls the trigger and then their susceptible genes make them into a person who has a weight issue.
Dr. Warshawski: I will just to Mr. Janssen's statements because I think your questions are good ones. There are a lot of myths out there about BMI. Mr. Janssen talked about it earlier. It's the weight in kilos divided by the height squared. It is a way to take into account height relative to weight. BMI, as a measure of importance, was actually brought about by the insurance industry as an actuarial measure. In 1920 or so, guys were looking around trying to figure out who was at high risk and who was not. They said, ''These guys who are heavier, divided by their height, die earlier, so we have to up their insurance.'' The doctors got involved, and the epidemiologists said, ''What does this mean?'' It's a proxy measure for fat. It's not the same as measuring body fat through impedance or dumping someone in a vat of water, as we sometimes do, or through skin calipers. It's a proxy measure, and, overall, it's pretty good.
As Mr. Janssen said, there is no epidemic of muscularity out there. When you go there and put someone on a scale and they're heavy, you know right away whether this is Arnold Schwarzenegger and Rosie O'Donnell. You can tell right then that this is going to be a problem.
You mentioned obesity as sort of a natural thing. It's normal now. As Mr. Janssen said, 60 per cent of adults are overly fleshy. It's the new normal. I just lost 25 pounds, actually, because I had a heart attack two months ago. I had a good BMI. I ran. I ate well. Stuff happens, right. I went on a low fat diet and lost 20 pounds. I'm 6'1 and 195. That's actually a good size. My secretary thinks I'm skin and bones because I was 220. That's what she compares me to. My BMI is probably 25. I'm a good size, but the new normal is big. It's not healthy. It's just big.
Mr. Janssen: The new normal is a BMI of about 27. The BMI of 25 is overweight, so the average Canadian adult is at about a BMI of 27. That's overweight.
Senator Enverga: That's a general rule for everyone? You're obese if you have a BMI of 27.
Mr. Janssen: That's the average Canadian adult. We looked at the fiftieth percentile. That's a BMI of 27. A BMI of 25 defines overweight.
Senator Enverga: You stated here that parents need the government to limit advertisements to children. Should we just educate our parents instead of limiting advertisements? We should educate the parents and say, ''You don't listen to this.'' They have control of their kids. They could say, ''You can't buy that. We're not supposed to buy those things.''
Dr. Warshawski: Education just doesn't do it. I'll say that much. I alluded to behavioural economics and what we know about the way people make decisions and choices. People are not rational machines like Spock that go through making rational decisions all the time. We can make rational decisions and use a lot of mental energies to really think things through every so often during the day, but we are inundated with hundreds of decisions each day, and we give in. If we're distracted and tired, we give in more often.
As Ian mentioned, there is food everywhere, and it's cheap and tasty and easy to get. Our kids are subjected to marketing not just on television, but on their phones and on the Internet. It's embedded in television and movies. They are being taught to consume food that is unhealthy. As a parent, if you're a strong parent with an iron will, you can say, ''No, we're not buying that, and no, you can't have it,'' but it doesn't work. That's why we're seeing what's happening in this epidemic.
As Ian said, there are best practices and things that have been adopted by the United Kingdom, South Korea, Finland and Norway. Quebec has a total ban on marketing to kids under the age of 12. There is ample precedent for this. It is doable and it is workable.
Mr. Janssen: To add to that, it's easy for me as a parent of a three-year-old and a five-year-old to restrict. They're not getting a pop if I don't give them a pop. They're not watching TV unless I turn it on for them. It's easy. When they are 13 or 14, I want them to be developing independence. I want them to be making their own decisions because they're becoming adults and that's an important part of their development. That is the age when I'm concerned, when they are at the age of making their own decisions and developing independence.
Senator Enverga: You mentioned Perfect at Any Size. Would that be contradicting the fact that you want a BMI of 27 or whatever? If you're perfect at any size, that would eliminate a lot of concerns, right?
Mr. Janssen: It's really meant to be a tool for the media, that Perfect at Any Size initiative, where particularly for women and young girls, where you have a BMI of 21, which is very low and very healthy, and it's portrayed as being heavy. It's meant to say that there are people who have weight issues and have obese BMI that are physically active and eat well and are quite healthy. Weight is not the be all and end all. It's meant to be something to decrease the stigma and recognize that people who are heavier can be healthy and can do things that improve their health even if it doesn't impact their weight an ounce. If someone is physically active, that's going to have tremendous benefits on their health. If they're eating good foods, in other words, fruits and vegetables, even if they're overweight and obese, eating well will have tremendous benefits on their health even if it doesn't impact their weight.
Again, it's meant primarily to say we have all of this stigma and prejudice against persons suffering from obesity. It is not just a matter of them not making appropriate decisions and not having the willpower. There are other factors that contribute to a person's weight — their job, how much money they make, where they live, what the government is doing. Those are factors that drive and impact their body weight as well, independent of the decisions they make.
Senator Merchant: Thank you for being with us. There is such a plethora of low-calorie foods, zero-calorie colas and sugar substitutes. From your studies, have these helped at all? Does it help your body weight to drink something that has a different sweetener? You read things that say that this isn't helpful because your body can't distinguish the sweetness, whether it's from sugar or from something else. Has that helped at all?
Dr. Warshawski: One of the policy platforms of Childhood Obesity Foundation is to recommend a tax on sugary drinks. There is a lot of noise around diet drinks. On big population studies, you can see an association between diet drinks and an increased risk of type 2 diabetes. That is probably what we call reverse causation. People who are overweight tend to drink diet drinks, and then you see that linkage. It's secondary to the overweight, not causing the overweight. There is robust data on this. If you take people and for eight weeks have them drink a sugary drink, the weight goes up. Switch them to a diet drink, and the weight goes down. For the most part, these sugar-free drinks on a population level are associated with less weight gain and are less prone to the development of weight and obesity, which is not to say they are totally safe. There are other questions about the safety of aspartame and other things. There was recent data about altering gut flora. I didn't read the study. It was in Nature. I'm not sure what that said. For the most part, when I talk to my kids, if they need to drink a pop, I say, ''Have a diet pop. Don't drink that 700 millilitres of Coke every day, because we know that's bad.''
Mr. Janssen: I'm biased because I'm a diet pop drinker. Certainly, to drink a diet pop instead of a sugar pop is clear. The evidence is still out on whether diet pop or diet soda and all those artificial sweeteners are influencing metabolism. For example, I start drinking my diet pop, and it's sugary. It should make me feel full, but it's not hitting the signals in my brain and I'm actually causing a resistance to that signal, according to some of the research out there, so that when I do have a regular sugary drink, that signal is not hitting me and I'm drinking more. It's a very controversial area of research right now. Lots of things are going on about the diet pops and artificial sweeteners and what benefits if any they actually have. Definitely, sugar drinks, not good. You can't go wrong with water.
Senator Merchant: Well, that, too. There are so many waters now that are promoted, bottled waters, that it's very confusing. People are not drinking tap water for health reasons. This has nothing to do with weight.
Can you for the record also tell us what words denote sugar? When you look at something on a container or a recipe, there are other sugars that do not go under the word ''sugar.'' What other things are actual sugars that we should be watching out? Fructose and what other things? Are there words that we should be familiar with?
Dr. Warshawski: I'm not an expert on labelling, but Canada has come out with new food labels that will tell you the grams of sugar in a product. Unfortunately, it doesn't differentiate added sugar from natural sugar. If something has apples, they may count the sugar from apples the same way that they would count the sugar from corn syrup, and they are two very different things, so that's problematic. However, it does help out with what you're saying, which is the chemical alphabet soup, which is dextrose, maltose, high fructose corn syrup. Which one is actually sugar? They are all sugars. That's a problem in labelling.
Senator Enverga talked about people making decisions. Well, when you look at a label, it's hard to know what it means, so it has to be simplified. Labels have to be simple. Canada has taken a step towards that, but they need to differentiate added sugars from natural sugars. If it says ''added sugars,'' try to avoid it. Make it simple. Just try to avoid it.
Mr. Janssen: The other complexity is that a lot of things people don't think of as sugary drinks are sugary drinks. For example, if I go to Tim Hortons or Starbucks and get coffee with shots of this and that, those things have hundreds and hundreds of calories and can be as calorically dense as a soft drink.
A lot of people don't even understand that the things they are drinking, and some of the fruit juices and drinking boxes that kids have, are packed with calories and added sugars. There is a lot of confusion by the general public. I am in the area, and I am confused when I go to buy things. I am not a dietitian. I am more on the physical activity side, but I do follow it, and it is confusing even for me, having a level of expertise in the area about what is sugared and added and not and what is good and bad. I can just imagine the average Canadian really struggling with beverages in particular. That's why I say water, and not even bottled water. I think for most Canadians, tap water will be very safe.
Dr. Warshawski: About water, as an advocate of taxing sugar-sweetened beverages, we're up against a behemoth with the sugar-sweetened industry. In the States right now, there are cities such as San Francisco and Berkeley that are trying to get a tax passed on sugar-sweetened beverages. The beverage industry has put more than $10 million into fighting the organizers of this who have put up $200,000. It's a David and Goliath battle. I promote tap water, but we almost have to let the industry have an out. We can't take away everything they sell, such as bottled water and juice, or they will kick up a storm. They recognize that sugar-sweetened beverage sales are dropping and its product differentiation proliferation; and people want something tasty. My kids, who are 16 and 18, like the odd vitamin water. It only has 10 calories per bottle, not 200 calories per can. They have to have some outlet.
Mr. Janssen: To further address the sugar-sweetened beverage tax, if there is a tax, it has to be significant. A lot of people talk about 1 cent or 5 cents. It has to be meaningful. It's similar with cigarettes. If you add a tax of 10 cents on a pack of cigarettes, will it affect behaviour? Probably not. People pay $9 for a pack of cigarettes. I'm sure the majority of that amount is tax. The taxes have to be significant and meaningful and have to reflect the volume. For example, for a two-litre bottle, you should pay 50 times as much tax as you would pay for one can. It has to be based on the volume, and the evidence is pretty clear on that.
Senator Merchant: I'm wondering about the move to have restaurants post the number of calories in the food we order. What is your opinion on that and has it worked? Can you give us information about that?
Mr. Janssen: I don't think the evidence is very strong as to the extent to which labels and calorie information influence behaviours. It's very challenging to influence a person's behaviour. For the consumer who is interested and wants to know, I would encourage that information to be available. It is challenging when you go into a place that is supposed to have that information to find it and have it available. I sometimes want to know more about the sodium content or whether as a vegetarian I can eat it. It's hard to get that information in many places. The evidence is not very strong that it has meaningful impact on behaviours; but there are things we need to look into.
Dr. Warshawski: It is necessary but not sufficient. There have been studies looking at teens outside McDonald's and whether the caloric content is actually a decision-making matrix. They say no, their decision-making matrix is not based on calories and they don't think about the long-term consequences. We also know that decision-making is not always made on a rational basis but often on an emotional basis if a product is somewhat connected in your brain as ''feel good.'' That's why Coca-Cola likes to have its logo at places where people feel good. They know that will influence choice much more. McDonald's likes to have its logo in playgrounds because it is associated with good emotions. Often that will have more power than that factual information will have. Some people will look at the caloric count, so it is necessary, but we have to do more than that.
Senator Nancy Ruth: I want to go back to BMI. You indicated there was some sort of desegregated data in terms of men and women and measurement. Have you desegregated the data in terms of racial groups?
Mr. Janssen: It's about the perceptions of what a healthy weight is. For women, in particular, if they don't like the girl on the Chatelaine cover, there is a perception that she is overweight, even if she has a very healthy body weight. If a man has a BMI of 25-27, he is perceived as having a healthy weight. There is an expectation of the ideal BMI for a woman that is different from what is perceived as being a healthy BMI for a man. I'm sure many ladies in here are familiar with that. That's just the way the public perceives things.
The actual BMI that defines health risk as being elevated is the same in men and women: A BMI of 25 is the point used to define overweight in men and women; and a BMI of 30 is used to define obesity.
Senator Nancy Ruth: My question is more. An Asian woman of 20 will look different from an Aboriginal woman in Canada. How do you deal with those differences?
Mr. Janssen: With the exception of people of Southeast Asian and Asian descent, we can use the same BMI cut points globally. I can go to an African-American woman and use the BMI of 25 and a Caucasian woman in England and use the BMI of 25. In Southeast Asia, the body fat for a given weight is higher on average; so we tend to use lower thresholds to define the overweight and obese in Southeast Asia. We use a BMI of 27 in adults to define obesity and often a BMI of 23 to define overweight, recognizing that for the same weight, on average, Asians have more body fat and higher health risk than do other racial groups.
Senator Nancy Ruth: Dr. Warshawski, you talked about the criteria in the United Kingdom being objective and about the drinking fountains, a few other things and higher taxes. Can you tell us more about the U.K. criteria and any other ideas you have?
Dr. Warshawski: The Childhood Obesity Foundation conducts actual programs to help kids gain a healthy weight trajectory. We teach kids about beverage choices and policy things that we advocate based on best practices. The U.K. is one of many countries that have been concerned. The WHO has also published some recommendations on restricting the marketing of unhealthy foods and beverages to children. It's a complex issue.
In Canada, a number of NGOs have taken positions including the Heart and Stroke Foundation, Dieticians of Canada and the Canadian Medical Association. There are probably 15 or 20 in all. Not surprisingly, very few of them are congruent. We are working with the Heart and Stroke Foundation to bring people together in an evidence base to try to develop a best practice recommendation for the restricting of marketing foods and beverages to kids and how best to achieve that.
The U.K. developed what they thought would be an appropriate nutrient profile based on the amount of sugar, fat and salt in all food. Eventually you have to draw a threshold and say that if something's more than 50 per cent of the daily salt intake then it's dangerous. We are getting data on where the danger level is for added sugars at around 200 calories per day for an adult and also for fats, in particular trans fats and saturated fats. It's doable. You can get the 80 per cent solution on what is healthy and unhealthy.
They said they would define ''healthy'' and ''unhealthy.'' Now, they have to define ''child.'' I mentioned that the brain is not fully developed until you are in your 20s in terms of decision-making, but it's pretty good by the time you're 18 and terrible at 12. Where along that spectrum do you want to draw the line? They drew it at 16. They took a narrow approach to marketing and said it's television; but we know marketing is more pervasive than that. In Canada television accounts for probably 80 per cent of marketing and most of it is still domestic. You can capture a lot if you focus on television.
Then you have to ask what constitutes children's programming. If it is Barney, that's children's programming. If it's The Voice at 7 p.m., the great majority of children watching are going to be reached by an ad at that time. There are nuances and shades here that we are trying to work together. If we get our internal act together based on best practices, then we can come to government with a cohesive policy recommendation. Taxing sugar in beverages is one that has been enacted in a number of countries. Most recently, Mexico introduced a 10 per cent tax on sugar-sweetened beverages.
For whatever reason, it's been effective. They're seeing a reduction of about 10 per cent in the consumption of sugary drinks and a switch to water. Mexico isn't Canada so their disposable income is less, which may have a bigger hit.
For whatever reason, they are making the switch. A tax would do a couple of things. It would capture the externality of drinking that product. If you're drinking a lot of sugary drinks, you're unhealthy, drive up health care costs, pay as much as the person down the street who just drinks water. It's user pay. If you drink more, you pay for it.
Another reason is that it becomes a point-of-purchase reminder. This is bad. Society says you drink this, it's more dangerous. That's why, when France introduced a tax on sugary drinks, the beverage company said, ''Don't say it has anything to do with obesity. Do it, but don't say why.'' They said, ''No, we're going to say why.'' They also showed a reduction.
Then the third reason is that as you raise the price of something, the price elasticity concept, things get more expensive, you buy less. Tobacco is a perfect example. As price went up, consumption went down, although other things were done in conjunction. There are different policy things that can be done, which can be effective. We're up against huge industry blowback on sugary drink taxation. When you talk about restricting marketing on foods and beverages, there's a group called the Concerned Children's Advertisers and once they get wind of what you're up to, they will probably want to come and make a presentation. They're concerned, but they're concerned about the profits. They're a front group for the candy groups; it's Cadbury, Neilson, Pepsi, Coke. They are concerned and will have things to say about media literacy and all the rest, but it's not evidence-based. When you do your due diligence, you'll get these people coming to speak.
Senator Nancy Ruth: What happened to milk? Do you think there's any hope that the soft drink industries might diversify in dairy?
Dr. Warshawski: They're invested in soft drinks, and water is cheaper to colour and add flavour to than it is to milk a cow. The dairy industry is active enough, I would say. I'll leave it at that.
Mr. Janssen: I wanted to comment a little bit more. We talk about the taxing of the sugar sweetened beverages, and there will be resistance to that. I think the beverage industry would rather have regulation that is uniform across the sector. For example, you say a can of soft drink could only include X number of calories. If it's now 200 calories, it could only be 180 calories, so there has to be a 10 per cent reduction across the board for everyone. They would be much more amenable to that type of regulation than they would be to any tax that's specifically identifying their product.
The Chair: I'm not going to take a stand on this, but it would depend on what the substitute was. As we already heard, that could be worse than the thing. I take your idea, but we must put that in the context of how it would be framed in terms of the substitute.
Senator Cordy: It's an interesting start to our study. It has been great.
I'd like to go back to Professor Janssen. You spoke about stigma among children. I taught elementary school for 30 years and I would say hands down the biggest form of discrimination and stigma among elementary school students would be against students who are overweight. Your idea of having a program to deal with this is an excellent idea, but how do you do that with your terminology about everybody is perfect?
Mr. Janssen: Perfect at Any Size.
Senator Cordy: How do you do that? I agree with that, because it became almost a Catch-22 situation. The students who were discriminated against were then the kids left out of games of tag and whatever on the school ground. How do you do messaging, in terms of Perfect at Any Size, in addition to looking at lifestyle changes perhaps?
Mr. Janssen: It wouldn't be done within the context of the Perfect at Any Size campaign. The Canadian Obesity Network is working with another group called PREVNet, which stands for Promoting Relationships and Eliminating Violence Network. It's preventing violence in relationships and largely dealing with bullying. It's about incorporating weight-related issues into existing bullying interventions in the school. Quite often it's not addressed in those initiatives, interventions. We talk about all these other things and they leave out the weight-related issues. It wouldn't be part of Perfect at Any Size; it would be done within the context of a bullying intervention.
Part of what we're trying to do is raise awareness that with obesity and a lot of it has historically been that it's the person's fault. If you could only eat better, exercise more and you weren't so lazy and had the willpower to stay away from the candy. We're trying to educate people that it's much more complicated than that. That is getting through in the schools. I published a paper on obesity and bullying about 10 years ago and it was one of the very first papers on that topic. Now there's an explosion of papers on that topic. It's really on the radar now. Wendy Craig, who is also a professor at Queen's University and a colleague of mine that leads PREVNet, is doing wonderful things in incorporating weight-related issues into the bullying prevention initiatives in the schools.
Senator Cordy: That's really good to hear because, as you said earlier, it was something you noticed a lot.
I'm also wondering about whether or not you've noticed particular demographic groups. I'm speaking particularly about economic groups because, as others have said earlier, it's expensive to eat a healthy diet. If you look at two litres of pop, soda, it is $1.29, sometimes 99 cents. Two litres of milk is more than double that. Have you done any studies in that area?
Mr. Janssen: There is a subtle correlation with poverty measures, and it's probably the extreme level of poverty. When you have 25 per cent of the population being obese, 62 per cent being overweight, it hits everybody. Certain groups are more disadvantaged. The biggest issue would be in the Aboriginal population where you would see obesity, not overweight, exceeding 60 per cent, even more so in isolated communities in the Far North. So that would be the one group in Canada that is certainly at the highest — I say one group, recognizing that there are many distinct groups within the Aboriginal population. But with Aboriginals, particularly on reserve, where we have very little information, the prevalence of obesity is very high and very strongly linked to the increased risk of diabetes that you see in that population.
Dr. Warshawski: I'm not an epidemiologist, but I pay close attention to the statistics because I'm quite interested in this side as well. My understanding, and correct me if I'm wrong, is that the socio-economic linkage is lower SES women tend to have a higher risk of being obese and lower SES men have a lower risk of being obese. They're physically active in their jobs.
Senator Cordy: What is SES?
Dr. Warshawski: Socio-economic status. I try not to lapse into jargon. I've done quite well most of the day. If you're poorer as a woman, you tend to be more overweight. In kids, there seems to be a flat line. In the data we have, the 2004 Canadian Community Health Survey didn't really show a link between incomes. Where the link is fairly strong is in education. So the more educated the adult is, the lower the risk of overweight and obesity. That seems to be a bit independent of income, but I also perhaps wonder if they're better educated, they're better able to fend off marketing, fend off these things. I'm not too sure. You might want to comment on education.
Mr. Janssen: I think there are associations, but they are subtle. They're very subtle. They're also inconsistent with men, women and children. It's not a strong determinant. There's a better linkage with the behaviours, particularly diet behaviours and the type of physical activity they might do. There's a link more with the behaviours, which I think is more important than the obesity itself.
Senator Cordy: I also thought about your comment — I forget who made it — that it's not necessarily organized sports that's the be-all and end-all. If you're playing a hockey game, you're sitting on the bench for much of the time, but it is the physical activity. You don't see the kids outside running.
Mr. Janssen: My area of research is physical activity and obesity in children. When you play an organized sport, I use the analogy that you have mom, dad, the child playing in the sport and the other kid in the family who get in the van, drive 30 minutes to the arena to watch one kid play a game for an hour, but only get 20 minutes of activity because the Zamboni takes 10 minutes. They're on the bench for a big part of the game, and then you drive home and stop at Tim Hortons to reward everybody with the Timbits and all that kind of stuff. We call that compensation.
Organized sport is great. Don't get me wrong. I grew up playing lots of organized sports. It's great for a lot of reasons. In terms of a strategy to fight obesity, it is not going to work because you just don't do it enough. You're going to play hockey a couple of times a week.
When you talk about active play, this is something every kid can do and for several hours every day, and they have the time. The average Grade 6 student in Canada is spending five or six hours a day in front of a screen. That's more time in a year they spend in front of a screen in their free time than in a classroom. They have the time to be engaging in play. It's there. We talked earlier on about the shifts since the 1980s. When I was growing up in the 1980s, we were outside playing, and now I think kids are inside being bombarded with screens.
Senator Cordy: What about the percentage of people who lose weight? We hear about all these magic diets. Again, the emphasis is on diets, not on lifestyle changes. What percentage of people, and it doesn't have to be a percentage specifically, but in general terms, who lose significant amounts of weight who actually keep it off and make a lifestyle change, not just a diet change?
Mr. Janssen: The percentage is very low. Less than 5 per cent of people who lose a significant amount of weight — it might even be less than 1 per cent — are able to maintain that weight loss for the long term. When I say ''long term,'' this is two years plus. There's a registry in the United States of people who have lost, I believe 50 or more pounds and who have been able to maintain that. The evidence is very clear that these people are very meticulous with their calorie counting. You get stories of people carrying their own salad dressing in their purse when they go out to a restaurant, and they are very active. Again, it's not that they're doing a bit of the food. They're doing both. Physical activity, particularly for the maintenance of lost weight, is very important. It's very hard to expend enough calories to lose weight. You have to exercise about an hour a day every day to lose one pound a week. Walk briskly for an hour a day, every day. It's doable. I've been in studies where we've been able to get people to do it. It's tough. It's much easier to reduce your calories by eating less than it is to exercise more. When it comes to maintaining the weight loss, particularly for the long term, the evidence is very clear that adding the physical activity component is very important, if not required in many cases.
Dr. Warshawski: That's why prevention is so critical, because once it's established, excess weight is hard to take off. The body will do everything it can not to allow you to lose weight. We're evolutionarily pre-equipped to eat as much as we can, whenever we can, not be active and save the additional calories as fat to prepare us for those lean times. When the body all of a sudden perceives lean times — there are no more calories coming in — you slow down your basal metabolic rate. The body makes all sorts of adjustments to slow down the weight loss. Then when you begin to eat again, it saves it all back because it wants to get back that fat. It's very hard to take it off and keep it off once you have done it. Ideally, you have to prevent. But you can't forget about those who have gained excess weight because there are health implications. We have to put more of a focus on meaningful prevention.
Mr. Janssen: It's better not to have lost the weight at all than to have lost the weight and put it back on and be going on a yo-yo, up and down. It's better to not lose the weight in the first place.
Senator Cordy: You both touched on it. I know in Canada we have asked industry to voluntarily reduce the sodium and transfats in their products. Some industries and some areas have done it. Many have not. Do volunteer requirements for industry work?
Dr. Warshawski: Certainly not when it comes to marketing of unhealthy foods and beverages. I talked about the Canadian Children's Food and Beverage Advertising Initiative. This gives the illusion of meaningful restrictions. They set their own guidelines. Each corporation says, ''This is what we're going to do. This is how we define 'unhealthy,"' and then they say, ''We made it; we did it,'' and then publish their results and say they did it all.
If you compare companies that belong to the Canadian Children's Food and Beverage Advertising Initiative (CAI) to those that don't and look at what they actually market, the people who belong to CAI market way worse stuff than those that don't belong. So it was an opportunity for those to greenwash or whitewash to make it look like they were doing things.
Voluntary regulation simply doesn't work when it comes to advertising, and I don't think it works in any meaningful way when you have a conflict of interest. Your job as a corporation is to make money for your shareholders. It's not health promotion. All of us with RRSPs want our guys to be following the bottom line and make money on our investments — ''your job is not health promotion; let someone else do that.'' We can't expect them to self-regulate.
Mr. Janssen: The recommendation a few years ago was lower the sodium. I believe it was Campbell's that lowered the sodium content in their soups. They were one of the few that did, and you saw all the nice commercials about it. Sales went down. What did they do? They jacked the sodium content back up to where it was before because everybody else in the industry was not regulating to the same standard they were, because it was self-regulation.
Senator Chaput: Senator Cordy touched on a few of the questions that I had, but regarding sodium, you've talked a lot about sugar and how it contributes to obesity. We know that too much sodium is unhealthy, but does it also contribute to obesity?
Mr. Janssen: It's not a calorie. It's not energy. It's more the types of foods that might contain a lot of sodium, processed foods, things like that. It might be more of an indication or a reflection of types and patterns of foods and the way people are eating and their behaviours. It's not about the salt itself, unless the salt makes you get thirsty and chug back a sugar-sweetened beverage. It just goes with the types of things you're eating, chips and pretzels and so forth.
Dr. Warshawski: There's a book called Salt Sugar Fat written by a reporter. It is a very good book and he talks about how foods are engineered. Where salt would contribute is in the crafting of the bliss point. When you look at potato chips, for example, which I love, barbecued potato chips have a mixture of salt, sugar and fat. Chemists adjust the amount of each of these proportions so you cannot stop eating these. They say that's the point. That's where salt comes in, I would say.
Senator Chaput: Do you think behaviours are starting to change in Canada? I think more and more we see in supermarkets, as an example, people shopping and checking the amount of sugar on the labels, whether they're seniors or families or even teenagers.
In schools, we see a change in physical activities. I'll give you an example. My granddaughter is in Grade 12, and for physical activities, she has so many hours of physical activity in the gym, but then also, out of school it can be a question of whether she walked the dog or used her bicycle to go to school, that kind of thing. Do you think that behaviours are beginning to change or not that much?
Mr. Janssen: I'm talking about children here, and their overall physical activity is not pointing to a positive change. When we look at different areas of physical activity, for example, participation in organized activities, in particular, and things that are organized at school and outside in the community, we are seeing an increase.
When we're looking at the unorganized things such as active play, walking to get places, which actually should contribute to a majority of a child's physical activity, those are probably going in the opposite direction. We don't have good measures of those things. We do with active transportation to school. We've seen in one generation the prevalence of kids that normally walk and bike to school be halved. It was over 40 per cent. Now it's at about 25 or 30 per cent. We do know that active transportation to school has gone down, and I imagine it's even worse if we talk about walking to the corner store — just utilitarian travel.
Senator Chaput: What can we do? What should we do? What's the first step?
Dr. Warshawski: I would say again that it's a whole-of-society approach. When you say what could ''we'' do, if it means as a legislative body, I think there are things that can be done.
One of the drivers for food choices and preferences is marketing and marketing to kids. You asked if things are changing. Sugar sweetened beverage consumption is dropping off worldwide and that's part of a growing awareness of the ill effects of sugar. Next is labelling — effective labelling, not just labelling in a way that you need a degree in biochemistry to figure out what's going on. Effective labelling, say with a green light, red light, yellow light system. You look at this package and it is a green light. It is all kale chips and canola oil, so it's a green light; kids, have as much as you want. However, with a red light, let's think about this. That's very effective.
My kids used to go to swim class and the vending machines would have a happy face or a frowning face. I would tell them to choose the happy face. It takes it away from parents having to say these things. When you go down a shopping aisle and you have a bunch of shopping to do, it's exhausting to look at every label and think ''How much fibre is in that? Is that for a 30- or a 50-gram serving? How much am I going to eat? How much fat is in that?'' You must have things simplified. We can do lots of things with labelling, taxation and restrictive marketing to kids at the federal level.
Mr. Janssen: At the federal level it's easier to tackle the food, diet and nutrition issues. I believe with the physical activity issues, particularly in children, it's more things that will be regulated at the municipality level. For children, again, it's about doing more active play and transportation. The underlying things that will determine that are parents and kids feeling safe and letting the kids go outside feeling safe in the neighbourhoods.
A lot of it involves misconceptions about the safety issues. You have one child hit by a car and everybody hears about it for weeks on end. However, you have one child in a car that gets in an accident and you don't hear about that. You have one kidnapping, which is usually by a parent, and you'll hear about that in the news for an extended period of time. There's this perception that it's very unsafe for children to be outside, on the streets, walking to places and playing. In actuality, environments today are much safer than they were one generation ago. It's about the sense for physical activity in children. It's not about organizing more but about doing the traditional things and more the sense of community, neighbourhood and safety. I think that's more a municipality thing. There could be some help from the federal level, but it's more things that have to happen in the municipalities than initiatives done at the federal level.
Senator Stewart Olsen: My apologies for missing your presentations. I have read through them, though.
I do want to ask your opinion. I think it's really difficult today to lose weight. One reason, I think, is because of the plethora of stuff out there that says you can lose weight by this or by that. If you adopt a certain style, wait five years and, sure enough, you're going to get a new study that says it wasn't good. What you did was dumb because fats are good for you.
I don't know. I think we're complicating some things. It's going to be really hard to come up with a good answer in this report because everything is so complicated and overwhelming. For instance, you talk a lot about BMI. Most people are now saying BMI actually means nothing. I know you say it, but that's what people hear. There is a plethora of stuff out there that people hear. What are they supposed to listen to? That's my big question for you.
Dr. Warshawski: There are two things, I guess. One is with the Childhood Obesity Foundation, we promote a 5, 2, 1, 0 rule because I'm a believer in keeping things simple. The American Academy of Pediatrics says the same thing. We have a program in B.C. that also promotes this: eat five or more servings of fruits and vegetables per day; limit your screen time to no more than two hours per day; get one hour or more of physical activity; and no sugary drinks. If you can do that, you'll get the weight that's right for you. That's a little rule of thumb. It can't be too complicated. Michael Pollan, is an excellent food writer — you may have read The Omnivore's Dilemma or some of his other work. His mantra is: eat food that your great-grandmother would recognize as a food. If you have to look at this and say what do I do with this, don't eat it. Eat mainly plants and not too much. You must have a few simple rules to go by. If you do that, then you're going to do okay.
I agree with what you said. The medical nutrition professions say don't eat eggs. Then, eggs are okay. What about margarine? Oh, margarine has trans fat. That was a problem. You are going back and forth. Go back to basics and exercise.
Mr. Janssen: My advice is this: Do not focus at all on the weight and BMI. As you said, people will get their backs up to that. They won't respond to that.
You weren't here for the presentation, but in our program that the ministry is rolling out at the community level there's no mention of weight. It's Healthy Kids Community Challenge. I hope there's nothing at all in the materials sent to the communities that mentions BMI, weight or anything like that. It will be about behaviours; focus on the behaviours.
My other comment is that whatever the diet flavour of the week is, I don't really care. The evidence is clear that it's the compliance that's important. If you go on this diet or that diet, or eat this fat or that fat, or choose this program or that one, it's about the compliance. People who comply with the programs, irrespective of what they are, are more successful than people who don't. It's about long compliance and sustainability. If you go on a diet and you're not going to be able to sustain it — for example, I can never eat carbohydrates or whatever it is — and you can't maintain it, then it won't work. It's about doing things that are sustainable and people's ability to comply with whatever that diet or physical or exercise program is.
Senator Stewart Olsen: I certainly understand that. Thank you. I think the simplicity will be very good if we can stick to that in our report as well.
When you say go back to traditions, I can because I grew up in a poor family and I'm older. That was when the traditions were such that you had meat; you probably didn't have dessert and stuff like that. Kids today can't go back to anything traditional because they've been eating McDonald's. Our terminology on things like that is an expectation that we can't do. You say they should walk to school. That's fine. But if you live in a rural area, kids can't because they're bused two hours a day to school. It's facing what we have today and trying to come up with more realistic solutions. I'm not in any way criticizing you; everything is good. However, I am saying that parents face a huge amount of difficulty keeping kids on any kind of schedule. Most parents work. They can't say you can only be on your computer for two or three hours, because, let's face it; it's not going to be workable. The dilemma is huge, I think.
Mr. Janssen: Certainly. I'm a parent. I don't know if you were here, but I have a 5-year-old and a 3-year-old who go to school. We're 10 kilometres to school so they take the bus. I walk them to the bus stop which is three or four blocks away; I don't drive them in my car. When we go downtown, we don't drive from store to store. We park somewhere. We live on the outskirts of the city. There are ways that we can get active transportation into our lives. When we go to the big box stores, we don't drive. There are creative solutions. I often say why do they have to drop my kids off at the school? There's a Tim Hortons that connects through a path at the school that is half a kilometre away. Drop them off at the Tim Hortons. Of course, there are the liability issues and other things there that they would get tied up in, but there are creative solutions to these types of problems.
Dr. Warshawski: I'll echo Ian's sentiment, too, about it's the habits and not focusing on weight. You talked about mealtimes. We know that mealtimes are important for family cohesion and mental health. We know that physical activity is important for cognition. Kids who are physically active learn better in school. We have to market this. This is social marketing as well. There are forces, but these forces, McDonald's and Coke, spend billions of dollars persuading people to do healthy things. The federal government as well can take a role in assertive marketing about things that really do matter. Family meals decrease the risk of depression and anxiety and improve school performance. You have to package it as a lot of reasons to do this, as opposed to not to do it. Think a bit outside our silos as a doctor and obesity. Again, although we're called the Childhood Obesity Foundation, everything we promote now is about healthy habits. You get the habits right and you'll have a healthy life.
Mr. Janssen: There are examples of successful interventions around setting rules for screen times, not putting screens in children's bedrooms. Putting a television in a child's bedroom is like giving them a pack of cigarettes. That's absolutely ridiculous. The same applies to computers and letting kids have cellphones in their rooms when they're trying to sleep and they have text messages coming in at three o'clock in the morning that they need to respond to. There are rules and regulations and things parents can do to help control those types of behaviours.
Senator Stewart Olsen: If I may, what you're really saying is get them while they're young because when they get to 13, 14 and 15 they're not going to listen to you telling them they can't be on the cellphones or on the screens or whatever.
Mr. Janssen: It's certainly easier to start younger than to go back. As with anything, you start young on a healthy track and it's easier to maintain that then it is to go down the unhealthy track and improve, yes.
Dr. Warshawski: I say get them while you can. Parents in prenatal classes are very receptive to ideas about how to teach their kids about reducing screen time and limiting junk food. Five- and six-year-olds believe everything so you can tell them things — you have to be true of course — so you get a chance to indoctrinate them.
Teens, unfortunately, what they're most concerned about is their complexion and their weight so it's sex appeal. How do we package this and what will work for them? Let's think outside the still boring doctor talk and think about what will work at every age.
Senator Eggleton: It may be that you might better be able to submit some stuff in writing to this question, but I welcome any quick answers.
Coming back to the federal level and what we would legislate here, Dr. Warshawski mentioned three. First, you mentioned marketing the television stuff, the broadcasting stuff; second, a more simplified kind of labelling system — red light, green light, that kind of thing; and third, you mentioned taxation. Are there good examples of these in an international context?
Dr. Warshawski: Yes, plenty actually. For restriction of the marketing of food and beverages to kids, we had a webinar a few weeks ago — I can send you the link and you can look at it on our website — on international best practices. It involved the United Kingdom, Finland, Mexico, South Korea and Quebec as a distinct society. They all had variations on how they restrict the marketing of foods and beverages to children. There are plenty of examples out there.
On taxation of sugar sweetened beverages, Mexico just enacted, France has got it, Hungary has it, so it's out there in different jurisdictions and hopefully Berkeley and San Francisco will have it soon as well.
On labelling, I believe England has an example of effective food labelling and there are some private groups in the States including one supermarket chain that I don't know but I can compile that and send it to you.
Senator Eggleton: Yes, could you compile that and send it to the clerk?
Dr. Warshawski: Yes.
Mr. Janssen: I've seen something even in Australia where they are equating the calories to the amount of exercise you would have to do. They would say that this is equivalent to doing a 30-minute walk or a 1-hour walk.
Senator Eggleton: Please send us any of those links or data. That would be great. Thank you.
The Chair: We've had a pretty good overview for the first meeting on this topic. I wanted to ask a couple of specific questions, one for clarification. Dr. Janssen, I wasn't quite sure I got it correctly but this is what I thought I heard you say but I may have had it backwards: It's better to lose weight and regain it than not to lose the weight at all. I'm sure it has to be backwards.
Mr. Janssen: I think I said it backwards. I apologize for that. It is a terrible thing to be on a yo-yo, as we say, up and down, up and down.
The Chair: That's what I thought. If I heard you correctly I was going to ask you to explain that because everything I have read suggested that's exactly the worst thing to do.
Indeed, with regard to Dr. Warshawski's comments with regard to this, the data that I have read indicates that the body has a memory in regard to weight in terms of this issue, when it goes below and wants to come back and feel healthy again but there is a swing and the way it brings it back tends to force the body beyond the original weight in terms of the actual experiential issues.
Dr. Warshawski: That aspect of physiology isn't my expertise but I'm informed an obesity series in the Lancet a few years back where they looked at how the body adjusts in terms of the basal metabolic rate. If you're 30-kilos overweight, the first 10 kilos is really easy to lose, the next 10 kilos is harder to lose and the next 10 take twice as long as the first because of the body is changing its metabolic rate. It's trying so hard to save those calories and that then predisposes you at the same caloric intake to save more as fat.
I would just say a caveat in terms of the yo-yo effect. You probably know the literature, but in the New England Journal of Medicine last year they had ''Obesity Myths'' as one of their articles and one actually questioned that data on the yo-yo. I'm only going to say I don't know the answer to this but I would say that if they don't know and I don't know then I don't know if anybody knows the whole answer on that.
I would say that it's better to try to lose some weight. It's better to adopt healthy habits, be physically active and eat the right foods. If you are physically active for 20 minutes a day it's not the best but it will move you in the right direction. Eat more fruits and vegetables and it will displace the junk food from you diet. Take water; if you do that you'll probably lose a bit of weight.
For someone with type 2 diabetes, losing as little as 15 per cent of your body weight makes huge changes in your life expectancy so some is better than nothing. It's lifestyle.
The Chair: On that note I will come back to the issue of activity, which I'm convinced from being very old now and having observed a great deal of things that general activity by individuals, particularly children, is an enormously important issue. My own bias is that the school system has driven that out of the general behaviour with regard to the idea that the school has to be an incredibly safe environment. Many schools won't even allow a soccer ball in the playground, or any kind of activity that involves bursts of activity, largely initially aimed at young males who were very active and very aggressive in the area, which of course allowed them, when I was kid, to burn up those calories to become very active and it created a general attitude in terms of life activity. They are doing this at an age when children are exceedingly susceptible to instruction from authority.
If the idea of being very active and very busy and bumping and so on, if those kinds of things are considered to be both unhealthy or wrong — largely they are considered to be wrong because they are considered to be adverse activities in the environment — it could have a very significant long-term impact on the way in which children will look at the idea of random activity, which, as you both indicated, tends to be one that burns up more calories in a period of time then the organized sports.
Do you have a quick comment?
Mr. Janssen: I am in 100 per cent agreement with what you said. In Ontario we do things in the curriculum time. We have something called ''daily physical activity'' and I believe they have that now in B.C. and Alberta as well, where it's 20 minutes a day of required moderate to vigorous physical activity. We're not sure about the compliance. It's probably quite poor, but that's the best evidence we have.
Where we're seeing the real problem is the decrease in recess time. In Ontario we have something called ''the balanced day'' so they get a 40-minute break in the morning and a 40-minute break in the afternoon and 20 minutes of each of those is for nutrition and 20 minutes outside time. They get 40 minutes of outside time, which is highly regulated and supervised and I'm sure much more so than when we grew up.
I think it's not allowing the boys in particular to learn how to take risks, manage their risks, and there's a whole line of research on this that suggests if you're not learning how to take these manageable risks at a young age then when you get to be a teenager and adult and you're put into very dangerous situations you won't know how to manage those risks.
There are examples of kids at age 14 not being able to walk across fairly busy intersections. Two years later they are going to be in a car driving through those intersections. Kids need to be put at manageable risk that they're capable of for their age and that will help with their long-term development.
Dr. Warshawski: One point is that everyone looks to schools for the answer. In school you've got to do this, you've got to do that. We've worked a lot with schools and they get really ticked off now because they have the basic reading, writing and arithmetic, along with morality, nutrition and everything else they have to teach. Schools are doing the best they can. They are underfunded and it has to be a priority of the provincial governments, which are responsible for education, to fund schools appropriately to have daily quality physical activity taught by qualified physical educators, so that when they spend 30 minutes on physical activities they are actually exercising and doing things. That's number one.
Another thing with regard to schools is the fact there is a two-tiered education system around physical activity. Private schools almost all have mandatory physical activity every single day. They recognize the link between learning and physical activity. In Canada, we, and rightly so, are justifiably proud and defensive of our health care system, the fact that it is universal, but we're working into this two-tiered education system where the private schools do everything they can to help their kids succeed, including daily physical activity, and at the public school level we are sacrificing physical activity, because we think it doesn't help academics.
In B.C. a few years ago the now-premier, Christy Clark, tried to introduce mandatory physical activity in high school. Parents rebelled, thinking that their kids would suffer academically. There is a lack of integration and recognition that this isn't about weight loss or preservation. You're going to think better and learn better. That has to be taught.
The Chair: When I was a kid it didn't cost anything to play outside in the yard. Organized physical activity costs a great deal. There is an inverse relationship between the benefit and the level.
In addition to the generalizations that are important to us that Senator Eggleton summarized, one of the observations that was important is that we have to understand there isn't a one-size-fits-all body type and gene type and so on, but we can look at society as a whole and consider these things in large areas.
With my bias as a chemist and my background I wouldn't touch a sugar alternative under any circumstance. I would far rather learn to avoid sweetening my coffee and tea if the alternative is taking any kind of substitute. I know the structures of those things, and I will not mention any one because they are watching upstairs. I don't want to spend the rest of my career in court.
Perhaps to me the best and clearest sign of the complexity of the issue that we had before us, Dr. Janssen, was your slide. I think this summarized for me the tremendous forest that we have to get through and try and identify some trees and then put back together some of the packages that you reduced some of these down into and try to find a way to deal with that.
With that, I thank you both on behalf of the committee for being here.
(The committee adjourned.)