Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 26 - Evidence - February 4, 2015
OTTAWA, Wednesday, February 4, 2015
The Standing Senate Committee on Social Affairs, Science and Technology met this day, at 4:18 p.m., to examine and report on 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, chair of the committee. I'm going to invite my colleagues to introduce themselves, starting on my left.
Senator Eggleton: Art Eggleton, senator from Toronto and deputy chair of the committee.
Senator Merchant: Hello. Pana Merchant, senator from Saskatchewan.
[Translation]
Senator Chaput: Maria Chaput from Manitoba.
[English]
Senator Raine: Nancy Greene Raine from British Columbia.
Senator Nancy Ruth: Nancy Ruth from Toronto.
Senator Wallace: John Wallace from New Brunswick.
Senator Enverga: Tobias Enverga from Ontario.
Senator Stewart Olsen: Carolyn Stewart Olsen, New Brunswick.
Senator Seidman: Judith Seidman from Montreal, Quebec.
The Chair: Thank you very much, colleagues. I will remind us that we are continuing to examine and report on the increasing incidence of obesity in Canada — remember, we're dealing with the increasing incidence of obesity — its causes, consequences and the way forward.
Today we have two witnesses, one joining us by teleconference and one live with us here in the committee room. By agreement, I will invite Dr. William Flanders to present first. He is a professor in the Department of Epidemiology, Rollins School of Public Health, Emory University.
Dr. Flanders, would you make your presentation, please.
Dr. William Flanders, Professor, Department of Epidemiology, Rollins School of Public Health, Emory University, as an individual: Thank you for inviting me to share some thoughts with you about obesity.
My comments will be about something called "the obesity paradox'' — otherwise stated, or more clearly stated, as the effects of obesity on mortality among people who have a pre-existing disease. So it's that subgroup that I'm talking about, not the overall effects.
I have a handout. If you refer to the second panel of the handout, there is a little number at the bottom right corner. These are excerpts from an article in the New York Times in 2012, and it summarizes the issue quite nicely.
The title is "In 'Obesity Paradox,' Thinner May Mean Sicker,'' by Harriet Brown. The first excerpt says:
Diabetes patients of normal weight are twice as likely to die as those who are overweight or obese. That finding makes diabetes the latest example of a medical phenomenon that mystifies scientists. They call it the obesity paradox.
That's what I'm here to talk about.
To date, scientists have documented these findings in patients with heart failure, heart disease, stroke, kidney disease, high blood pressure and now diabetes.
If you turn to panel 3, it's another example, MedPage Today, of an article in the lay press that emphasizes this reversal idea and the idea that perhaps being overweight is protective.
On panel 4 is the article that these two lay press articles are referring to. This was published in The Journal of the American Medical Association, by Carnethon et al. Their conclusion is that "Adults who were normal weight at the time of incident diabetes had higher mortality than adults who are overweight or obese'' — again that reversal of the expected association.
In the fifth panel, these are two survival curves. Let's just focus on the graph at the top of the page. That graph on the horizontal axis is time since the diagnosis of diabetes, and on the vertical is survival. You see two lines coming down and getting lower and lower. The top line is the survival for overweight patients at the time of diagnosis, and the bottom line is the line for survival of normal-weight patients. You can see that the survival of the overweight patients is higher; that line is higher for overweight than for normal weight patients, again indicating the phenomenon that obesity is associated with better survival and lower mortality in the subgroup of patients with diabetes.
In panel 6 I've listed some of the other examples of the obesity paradox, where again it appears that obese people with some of these diseases tend to live longer than normal-weight people with the same disease.
So the question, and what I have been researching in my research at Emory University, is what underlies this phenomenon where something that we believe is harmful — obesity — tends to be associated with a better prognosis and lower mortality?
In panel 7 are the three key relationships that underlie this phenomenon. It's accepted, I think by most people, that obesity is one of the causes of end-stage renal disease, of kidney failure. It is also accepted by most people that obesity causes premature death. But what is observed — and this is not always observed, but typically it is, and more often than not — is that for people who have end-stage renal disease, ESRD, the obese people tend to have lower mortality than normal-weight people. So there is this reversal of the association.
Trying to get at the causes of that reversal, in panel 8 is what is called a causal graph, or a DAG, directed acyclic graph. If you look at that graph, ESRD stands for "end-stage renal disease.'' Obesity and death are in there, and then there's this U, which is my notation for an unmeasured factor. In the graph, an arrow points from cause to effect. You see that obesity causes ESRD, which most people would agree is true. There is an arrow from obesity to death because obesity is accepted to be a cause of death. Then there is this U, wherein this unmeasured factor — and we're presuming that there are unmeasured factors, because we can't measure everything — is a cause of end-stage renal disease, and it's a cause of death. The bias comes in because when we select people with end-stage renal disease, it tends to distort the relationship between obesity and death in the presence of an unmeasured factor.
In panel 9 is the title of a paper that I've just published, or has just been accepted. It's electronically published, but it's not yet out in paper version. The paper goes into a lot of detail explaining the phenomenon that I just tried to explain in a couple of seconds, and really it's not enough time to get into it in detail. The paper does go into it in a lot more detail, and it explains how collider bias, which is well known, applies in this situation where we are selecting people with a chronic disease like diabetes or end-stage renal disease.
Going to my conclusions — and I'm happy to answer questions about these things, because I know I've gone very fast — the reversal of association that's seen in these examples of the obesity paradox, among people with diseases like end-stage renal disease, is at least partly explained by this collider bias. I did simulations, which I did not show you. The simulations suggest that the bias can be strong enough to make an actual harmful effect of obesity appear to be beneficial.
It's hard to document the exact magnitude of this bias, but my personal conclusion is that the apparent beneficial effect of obesity among those with pre-existing disease like end-stage renal disease, like myocardial infarction, like diabetes, is likely due mostly to bias.
That concludes my prepared comments.
The Chair: Thank you very much. I will now turn to Dr. Adamo and ask her to present.
Kristi Adamo, Scientist, Healthy Active Living and Obesity Research Group, CHEO Research Institute: Thank you very much for this opportunity to present here today. I will speak a little bit about pregnancy, so if you can follow along with the slide set that you have.
We know that obesity is a complex and multi-factorial condition. Everybody knows that. Pregnancy and the in utero period is arguably the most critical period for weight regulation and preventative efforts. This is critical for the baby because that nine months in the womb is the most dramatic period of growth and development that you will see across the lifespan. For the mom, it's a critical period of weight management and often the trigger for lifelong struggles with weight.
If you follow along into panel 4, while this is a very dramatic statement, "Life in the womb will be written on your tomb,'' this really points towards the seminal work of the late Sir David Barker, whose developmental origins of health and disease concepts spawned interest in the field of developmental programming. Essentially what this means is that the conditions that we encounter in utero — so in that growing environment in the womb — have been shown to impact disease risk. The effect of these exposures can be graded and subtle. So it's not necessarily that they disrupt typical development, but they affect susceptibility and the speed at which somebody might develop a disease.
Following along to panel 5, this concept even made its mark in mainstream media. You will see that there's a cover of Time magazine from 2010. Many researchers in this field advocate that the womb may be even more important than the home.
As indicated on the slides you have in front of you, there are two important maternal contributors often referred to when it comes to the future of obesity risk. These are entering pregnancy with a high BMI and gaining too much weight during pregnancy.
I will focus my attention on gaining too much weight during pregnancy. The reason I'm going to do this is that we know that over 50 per cent of women have unplanned pregnancies — so it's a moot point to try to address pre- pregnancy BMI — and that pregnancy weight gain is still modifiable. Once a woman is pregnant, you can't impact her pre-pregnancy weight, but you can certainly impact where she goes from there.
Looking at the slide with the table, you might wonder how much is too much weight to gain during pregnancy. The table indicates the Institute of Medicine guidelines developed in 2009 in light of the obesity epidemic. These evidence- based guidelines consider both the maternal and the fetal outcomes and try to balance the risk of high and low weight gain with risk to mom and to baby. As you can see on the table, there is quite a broad difference in the range of acceptable weight gain, depending on where you start. Women with a lower BMI have a greater range and greater suggested recommendation with regard to gestational weight gain. For a woman who is overweight or obese, that range is significantly smaller because the risk of entering pregnancy overweight and exceeding the guideline leads to greater risk.
You might ask why this is important. As a matter of fact, 60 per cent of Canadian women exceed the gestational weight gain guidelines. These women are at three times' greater risk of pregnancy-related labour and delivery issues, one of which is downstream obesity and obesity in the child. Other things are spontaneous abortion, stillbirth, gestational diabetes, pre-eclampsia and higher C-section rates; so there are many things we have to be concerned about. Fetal macrosomia, which is a very big baby weighing more than 4,000 grams that is very difficult to deliver, leads to long-term consequences when it comes to cardio-metabolic health, like diabetes and hypertension.
Here we come to my favourite set of slides, which is the intergenerational cycle of obesity. Let me orient you to the slide that has all the arrows. Weight gain in excess of the Institute of Medicine guidelines, regardless of where you start, whether you are a lean woman or an overweight or obese woman, is predictive of delivering a large baby. It's thought to be related to an abnormal intrauterine growing environment. Babies who are born large for gestational age are more likely to follow this growth trajectory over time because obesity tracks over time. They become obese children and obese adolescents. If that child happens to be a girl, by the time she's ready to procreate it perpetuates that cycle. If she's overweight going into a pregnancy, she might exceed her gestational weight gain guidelines; and that just increases the risk.
In parallel, a woman who has exceeded the gestational weight guidelines and holds onto weight after that pregnancy is more likely to go into a second pregnancy bigger than the first. This again continues to perpetuate the cycle of obesity. That's something my research team is very interested in.
We know that excessive gestational weight gain increases the risk of childhood obesity by 30 per cent to 40 per cent — a stunning number. We know that weight-related issues exceed smoking as the lifestyle-related risk factor with the greatest number of adverse pregnancy outcomes. We've done a pretty good job of targeting smoking and alcohol consumption during pregnancy, but we have not addressed excessive gestational weight gain.
Why are we interested in gestational weight gain? It is realistic to focus on gestational weight gain because we cannot go back in time once a woman is pregnant and address her pre-pregnancy weight. It's highly prevalent: 60 per cent of these women who exceed these guidelines perpetuate the intergenerational cycle of obesity. Gestational weight gain is relevant to all women and something to be addressed in all women. This is a specific time in a woman's life when we can modify her behaviour because she is willing to change her patterns for the health of her child — a critical period in life. What can we do about it?
There is considerable evidence to suggest that we can reduce the amount of weight a woman gains during pregnancy if she's involved in some sort of prenatal healthy lifestyle intervention. This might address patterns of diet, physical activity, sleep, sedentary behaviour or some of the psychosocial barriers to a healthy lifestyle. In-person delivery of these interventions is costly and can target only a small percentage of the population and thus is not scalable in today's health care landscape in Canada. We need a novel direction.
Follow along to the slide with a smartphone. We've learned from our interactions with women that today's women are not getting what they need from their health care providers. They want real time information given to them on their own schedule on their own time. They don't want to go to appointments and run all over the city. They want it given to them within their own environment. I lead a group called the Smart Moms Canada Research Network. They are health professionals, stakeholders and researchers across Canada. We have amalgamated our collective expertise and decided that we have to capitalize on emerging technologies to tackle this prenatal problem.
This is a direction where many health care interventions are going now because it is a great opportunity for a wide reach for a reasonable cost. We also know that 99 per cent of Canada is covered by wi-fi networks, and about 90 per cent of Canadians own mobile phones, most of which are the smartphone variety. This is one of the few areas that does not see a socio-economic divide. People on the poor end of the spectrum also have smartphones as well as those at the upper end of the spectrum. This is an opportunity to target a great audience of people. Using mobile technology to target the prenatal environment offers many opportunities for intervention.
I have one more quick point to make. You will see that the second last slide gives an idea of how mobile technology can be used to target the prenatal period, allowing for the bi-directional transmission of information to the mom. This will overcome some of the barriers that moms say they find when not getting what they need from their prenatal care provider. We believe that this will offer a cost-effective way to target women. We're waiting for the Public Health Agency of Canada to sign off on a project that they've agreed to in principle. We've been waiting for a year, and it would be nice to evaluate this properly before it can be rolled out in the health system.
I thank you for your time and for the opportunity to talk about the prenatal period, focusing on moms and their health. The World Health Organization has commissioned something similar to end childhood obesity. They have a specific working group that targets only the prenatal period. This has reached all health bodies throughout the world. We should all be putting our efforts into this.
The Chair: I will open the floor to questions, but first, I would like Dr. Flanders to clarify one item on his slides — the obesity ESRD example and the relationships. In your first point, you say that it is accepted that obesity causes end- stage renal disease. Is there a higher percentage of ESRD in obese persons relative to non-obese persons? Is there a higher prevalence in obese persons?
Dr. Flanders: Yes. That statement is based on an amalgamation or a synthesis of the available information. Many studies have shown that obese people have a higher risk of developing ESRD. It is accepted by most people that it's a cause. It's not just any one study, and it's not just the prevalence. It is really the risk — what is their chance of developing it over their life. It's higher in the obese than in the non-obese. That's accepted.
The Chair: Do you have a factor for that? Is it 30 per cent higher, or do you have a quantitative figure on that?
Dr. Flanders: I'm a little hesitant to throw one out. I guess it's in the range of 40 per cent to 50 per cent, but that's a ballpark.
The Chair: The reason I'm asking is to determine the relationship of your third point, which is that those who are obese have a lower mortality once they have developed the disease. I just wanted to put it in that context, so thank you very much.
Senator Eggleton: Professor Flanders, I need to get straight here in view of your comments exactly where obesity is a problem. In the New York Times article, diabetes patients of normal weight are twice as likely to die as those who are overweight or obese, and you go on to explain that further, and you have just clarified some of that with the chair. Where do you see obesity is a problem in our society?
Dr. Flanders: Well, I tried to say when I was giving my prepared remarks that my comments focused specifically on the subgroup of the population who already have a disease. This is the subgroup with end-stage renal disease or a subgroup with congestive heart failure. It's a very special subgroup. They are sick people.
Why do I think obesity is a problem? I think the studies that find the reverse association in the special subgroups are biased. I don't think obesity is actually protecting them. I think it is a marker of a better prognosis, but I don't think it's actually a protective cause. It's not causing lower mortality; it is merely associated with it. The reason I think that's true is because of unmeasured factors. We can't measure every factor for mortality. It's just impossible. There is, I believe in every study, something unmeasured. We don't know why everybody dies and what the causes are. We can classify it as cancer or something, but we can't classify the environmental factor or the dietary factor for every person. There are unmeasured factors, and it's those unmeasured factors that become associated with obesity when we select people with a disease. That's the mechanism that causes the bias.
It's hard to explain, but it's a statistical phenomenon that when you select a subgroup such as end-stage renal disease. If you look at figure 8 in the little handout, ESRD is caused by two factors. There is a little number in the lower right corner of each panel.
Senator Eggleton: I'm not sure it came out on our copy. I don't see it on my copy, for example. What's the title of the page?
Dr. Flanders: The title in the upper left corner is "End-stage Renal Disease,'' and it has arrows, and they point from the cause to the effect. It's a statistical phenomenon that when you select people that have something caused by two other factors, those two other factors will tend to be associated in the selected subgroup. If we select people represented in the figure by ESRD, the obesity will tend to become associated with the unmeasured factors in the group selected, and that bias is the obesity outcome or death association. I know it's complicated, but that's why it was such a mystery for a long time. Now I think it's not a mystery.
Senator Eggleton: Thank you.
Dr. Flanders: Or shouldn't be viewed as one.
Senator Eggleton: Let me go to Ms. Adamo. You were presenting your Smart Moms proposal, using mobile technology. Are you up and operating on this?
Ms. Adamo: We're waiting for money.
Senator Eggleton: From whom?
Ms. Adamo: The Public Health Agency of Canada.
Senator Eggleton: There's a very blunt, concise request.
Ms. Adamo: We received a letter from them in December 2013 basically saying they approved our project in principle, and it's just been waiting. Anyways, we're seeking other funds from elsewhere so we can move forward. You have a window with these technologies, and they close very quickly, so you need to get feet on the ground quickly.
The Chair: Maybe the long gestation period will lead to increased weight of the money you're going to get.
Ms. Adamo: Maybe if we wait, it will just get worse, is what you're saying.
Senator Eggleton: You think this is a key answer. You're pointing out that people by and large of different income levels, which is an area that concerns me, lower-income people, do have this technology. What about languages? Are you going to be able to do this in different languages?
Ms. Adamo: Right now, our plan is to have it in French and English, obviously, in Canada, but futuristically, after the testing is done and if we evaluate it and see that it does do what we hope that it does, it is easily translatable to any language, essentially. We have been working with our American colleagues on this. They haven't yet translated it into Spanish, but here in Canada, where we have two official languages, it will be a necessity.
Senator Eggleton: I may have missed one or two of your things. I was so engrossed trying to figure out what I was going to ask Professor Flanders that I might have missed a point. Are you saying that mothers who give birth to overweight babies, or that if they're overweight, they give that problem on to their babies? Or is it something that comes in later in lifestyle?
Ms. Adamo: There are two prongs to this. One part of it is that if a woman is overweight or obese, the growing environment for the baby then is probably less than ideal because obesity is associated with inflammation, with high fatty acids, a milieu that is not helpful necessarily. Yes, it can certainly be passed on to the child.
Another thing that we have to be concerned about is this is not just an overweight or obesity issue. Even a lean woman who gains too much weight during pregnancy is also prescribing that same environment to the child. This isn't just overweight or obese; it is all women who are able to exceed those guidelines that we need to be concerned about.
Senator Eggleton: I see some fairly recent articles about food for babies and toddlers suggesting that taste preferences begin early and probably last a lifetime, which is reason for concern about heavily salted and sugary foods targeted at children. Research has been done in this country and some in the United States on this whole thing, and it suggests that those early stages after birth are critical. Can you comment on that?
Ms. Adamo: There are multiple ways I can comment. I can talk about it from the intrauterine environment specifically. There is animal model data that suggests that what can happen in utero is that you can reprogram somebody's neurobiology, so the growing fetus's neurobiology can essentially be reprogrammed to have different taste preferences. Based on what they're seeing in that environment, it can change the wiring essentially in their brain to when they're outside out of the womb, so in the postpartum period they can seek or prefer a certain type of food. We don't have the human evidence on that yet, but we certainly have animal evidence on that.
What you're getting at as well is that what a baby is seeing in the postnatal environment is also very important, and that's true. The intrauterine environment isn't the end all and be all. It is a contributor. But absolutely what happens once the child is out of the womb is also important and how they're fed and the sorts of things that they are introduced to.
Senator Eggleton: What do you think government should be doing about this? Maybe it's something you can put on your Smart Moms program too.
Ms. Adamo: In the Smart Moms program, one of the things we would definitely have is we would be giving suggestions, so there are all sorts of nutritional suggestions and label reading to guide women through what they should be choosing to eat. But in the postpartum period, generally women may or may not be struggling to get their child to eat, so often they feed their child what their child wants for a period of time solely to get them to eat, because moms particularly are always worried that their child is not eating enough, so that might lead to some inappropriate eating behaviours, and that's a hard nut to crack. It's very difficult to tackle.
Education is important, but, as you know, with the media and with information coming from multiple different resources, I do feel that parents in general don't know what to believe. One day high-carbohydrate diets are the way to go. The next day high-protein diets are the way to go. Too much salt, not enough salt. I really think that the messaging is very confusing for the person. If they do not have the appropriate background to really be able to discern and go through all of that, it can be quite challenging.
Whether or not this is a Health Canada related thing that they have to make sure the labelling is clear and then that it's obvious what is considered a healthy food, I suppose that would be one way that the government could intervene or assist.
Senator Eggleton: Thank you.
Senator Seidman: Dr. Flanders, there is no question that the methodological and/or design issues that you presented are intriguing, but I don't want to particularly get into the issues of selection bias or confounding. I would like to ask you a question about a study that you were involved in, as you're an author on a paper that was published in JAMA Internal Medicine, in 2013: "Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults.'' In the results of that study, the data collected in chunks of time, between 1998 and 2010, those periods were compared and looked at the adjusted mean percentage of daily calories from added sugar. The interesting thing is that the adjusted mean percentage of daily calories from added sugar was approximately from 15 to 18 per cent over that entire period of time. There was a segment where it was about 15 per cent and then it was up a little bit and then down a little bit. There weren't any huge differences over what is a fairly substantial period of time.
I found that interesting. I wondered if in that study, you found some kind of a dose response relationship between added sugar intake and cardiovascular disease mortality, or if you had some other interesting results from that particular study to help us try to understand the increase in incidence of obesity.
Dr. Flanders: Thank you. I must say I didn't prepare myself to talk about that issue and I haven't looked at the paper since probably a few months before it was published, since there is a time delay. I think I had better not comment because you have it in front of you, and since it has been a while, I don't remember the details at all. I have it on my computer, I think, but I don't happen to have it front of me. I apologize for that.
I was prepared to discuss this other issue. I know there are a lot of things that are probably of broader interest, but this obesity paradox is something that maybe gets overlooked and maybe misinterpreted. I apologize for that.
Senator Seidman: That's fair enough. I appreciate that.
If I might then turn to Ms. Adamo? In your presentation, you said that the average gestational weight gain has increased dramatically over the last four decades, around the world. How do you account for that increase? Is there some research or some evidence that you or studies have found?
Ms. Adamo: Our lifestyles have changed over those 40 years, so everything now is automated and digitized. At one point, pregnant women were still doing a considerable amount of household activities or things that would not be considered traditional exercise programs but that were keeping them active. In the last little while not only has the obesity epidemic come upon us, but because our lifestyles have changed so drastically, pregnancy is thought of as an opportunity to perhaps put your feet up and to eat what you want.
There are wives tales that are continually perpetuated. You're eating for two. Don't do that, it's bad for the baby when it comes to physical activity. There is no evidence to suggest that you cannot be physically active during pregnancy, within reason. There is evidence to suggest the exact opposite — that you should be physically active during pregnancy. When it comes to eating, you are not eating for two. For most of your pregnancy you are feeding something that is the size of a pea. It's not the size of a football until your third trimester. So you do not need an extra 1,000 calories in your first two trimesters. You only need to increase what you eat in your third trimester, and only by a small amount. There is a perception that you can eat for two and this is particularly true in today's environment where we have access to food 24-7. We are not foraging for food any more. There are corner stores on every block. There is availability and access that wasn't there 40 years ago. I'm not saying that's the total reason, but it has contributed. The obesogenic environment that we live in now is certainly.
Senator Seidman: It's interesting. There may have been trends in what women have been advised.
Ms. Adamo: I think there absolutely was.
Senator Seidman: I can certainly remember a period where physicians advised women that they should not gain more than 30 pounds for example. Is there any research? Is there any evidence that looks at physician advising patterns over time? I look at what you say. It has increased dramatically over the last four decades around the world. So now we have a situation where 60 per cent of women exceed the guidelines in terms of gestational weight gain.
Ms. Adamo: You're talking about patterns of interaction with health care providers, and I think that that interaction has changed over time. We know that our health care providers are expected to do a lot. They see patients for a very short period of time, and they have to address things in this short period of time. Oftentimes weight is not one of them.
Weight is a very sensitive issue, and not all women want to talk about it. Many health care providers are not comfortable discussing it, nor do they feel competent in telling a woman what to do. You have a double-whammy situation where they don't feel comfortable discussing it and they don't feel they have the appropriate knowledge to deliver a message that women can take away and use.
I think that has changed. I think we are starting to turn things around. I sit on a group that has just recently devised a tool kit for maternal health care providers; it's called the 5As of Healthy Pregnancy Weight Gain. We've done this in collaboration with the Canadian Obesity Network. It's a tool to guide health care practitioners in having sensitive conversations with their patients to address weight. It is to help them. This is problem that has largely been ignored. We need to do something about it, but it needs to be done in sensitive way.
Senator Seidman: That's helpful. You are involved in this Healthy Active Living and Obesity Research Group. I presume that you're involved in developing strategies for reducing obesity among children. Have you developed some strategies and found means of evaluating whether they are successful or not?
Ms. Adamo: I do a lot of intervention work, which takes a long time. My team has been intervening with a maternal population for the last five years. We moved into mobile technology because we recognized that pregnant women have all sorts of things going on in their lives. It's an overwhelming period, and there are all sorts of situations that you might be dealing with. It is very difficult to get women to be confined and adherent to an in-person delivery of an intervention. You expect them to be somewhere at a certain time, to see somebody at a certain place. This can be very inconvenient for women. We have been trying to intervene with the pregnant population.
I have been heavily involved in intervention in the daycare setting. We chose a daycare setting because we know kids spends upwards of eight or nine hours in a daycare setting. That's a captive audience and a great target, so we have been working with daycare providers to train them how to offer a healthy curriculum when it comes to more physical activity and less sedentary behavior.
Actually, Ottawa Public Health is now working with us to devise a set of policies that will be implemented in the daycare setting. It's not necessarily in hopes that it will stave off the obesity epidemic, but to create an environment where children will be active more often and will learn behaviours that they can take home and basically take on in the rest of their life as well, so at least as a healthy active living strategy, not necessarily as an obesity management strategy. But we do know that health behaviours are adopted and ingrained early, so the earlier you can get those in, the more likely somebody is going to carry those on through time. So we are trying to intervene with specific target populations.
There are other people in our group that are dealing with school-age children and adolescents, but I'm the early- years person, so that's kind of my focus.
Senator Seidman: Specifically, what I had hoped to hear is whether this is being monitored, whether these programs, these interventions, are being monitored to be evaluated for whether they are successful or not.
Ms. Adamo: Of course. Research — that's what we do. I do clinical trials, so of course they are being evaluated; and we have measures and outcomes, absolutely.
Senator Stewart Olsen: Dr. Flanders, if I could ask you a question about your study. Did you find in your study a difference between men and women? Were your results the same?
Dr. Flanders: You're talking about the study that is in the panel, the handout?
Senator Stewart Olsen: Yes.
Dr. Flanders: We didn't evaluate any difference between men and women. That was not part of our goal, anything that we set out to do.
Senator Stewart Olsen: Was part of your study based on the onset of the disease? You studied pre-existing disease patients. Were your patients all around the same time of onset of disease, or was there a continuum that may have produced results that were different?
Dr. Flanders: It's a good question. I didn't really describe the study very much, and I probably should.
Senator Stewart Olsen: Just briefly, though, for us.
Dr. Flanders: Yes, just briefly. The main point to make is that it was really a statistical or a theoretical study to show how these biases can occur. Then we did some simulations with varying ages of onset and so on. We did evaluate different times of onset, but it was not actually real data. It was modelled after real data, but it was not real data. I had no individual patients whatsoever, no individual people, real people, whatsoever in that study.
There are advantages and disadvantages. When you make up the data, you know the truth, and you know what is bias and what isn't; whereas if you use real data, you really don't know whether doing something got you closer to the truth or didn't get you closer to the truth, because you don't know the truth.
Anyway, the point of the paper was how this bias can actually be quite strong and make something that's truly harmful appear to be protective.
Senator Stewart Olsen: Thank you, Dr. Flanders.
Dr. Adamo, if you could just give us a brief explanation of why weight gain in mothers causes a weight gain in children. I know you've said intrauterine conditions, et cetera, but I don't understand. I can understand with smoking, because that interferes with the oxygen, et cetera. I don't know what fat cells would do.
Ms. Adamo: Think about it this way: The placenta is a barrier between mom and baby. It's the link between maternal and fetal circulation. Everything in mom's circulation is being transmitted, like oxygen, but nutrients are being transmitted through the placenta to the fetus.
Let's say, for instance, mom is eating what we would consider a very unhealthy diet, high in sugar, fatty acids, whatever nutrient of the day that we know can lead to adipose cell development. The baby then will see that through maternal circulation, through the placenta, so it can lead to accretion of fat cells.
We know that women who have gestational diabetes, a disease state during pregnancy, generally have very high glucose because they are insulin-resistant. The baby sees mom's glucose but has to create their own insulin, and insulin is a growth-promoting hormone. If they have to basically produce a lot of insulin to counteract the high glucose that they are seeing, they are growing. So it has a lot to do with the nutritional milieu that they might be seeing, or the signals that they might be seeing from the maternal circulation — growth factors, hormones and/or nutrients. There are multiple reasons for that. Mom is producing that environment, and if it's an unhealthy environment, it can lead to overgrowth during the fetal period of time.
There is a newish area of research called epigenetics, which I'm sure Senator Ogilvie could speak to, to a much greater extent than I.
What is thought to happen is that the fetus is exposed to various things in the intrauterine environment that can change the way the DNA code is read. This can modify proteins and basically the behaviour of their cells, which can be fat cells, muscle cells or multiple types of cells. This can lead to growth in one area or another. These are the thoughts out there with regard to why it might be leading and contributing to overgrowth.
Senator Stewart Olsen: Thank you. That's helpful. I can explain that better to people.
How does the ever-changing information about what is a good food and what is a bad food affect your whole premise?
Ms. Adamo: To be completely honest, for those of us in research, particularly in health research, it is an incredible challenge. Today, sugar is the new tobacco, whereas yesterday it was fat, and tomorrow it might be protein. Who knows? It is very difficult for us to keep up. If you are not a specialist in that area, to really understand the underlying or underpinning reasons is hard. We have sort of a global understanding of what constitutes a healthful diet, but I will wholeheartedly accept that it is hard for most people in our area to understand, let alone the general public. I really do think that there is messaging that is very confusing for folks, when it is even confusing for those of us who are "specialists.''
Senator Raine: Thank you both for being here. I have to say, Dr. Flanders, your study is very intriguing. When I look at the New York Times headline and the article you mentioned on the obesity paradox, I can see why you were intrigued to study what is causing this. Am I right in thinking that you have come to the conclusion that it's kind of been caused because it wants to be caused? It's almost like we want a little excuse so we will have this thing happen? It seems very bizarre to me. The take-away to me is there is no indication that obesity is good, that's it's healthy.
Dr. Flanders: Yes, that's sort of the bottom line for me, that these obesity paradox studies that might be interpreted as saying obesity is helpful, I think most of them, and in most situations, it's not helpful; it's harmful. That's my personal conclusion. What I was able to show definitively is that the bias can be so strong as to make something that is harmful appear beneficial, which is what these studies are doing. Whether the bias really is that strong or not remains speculative. I personally believe that the bias is strong and that it explains most of these reversals, but I can't prove that. That remains an open question to some extent. Personally, I think they are. I think the bias explains it.
Ms. Adamo: I'm hoping Dr. Flanders can help me with this. What is your perception, then, on the metabolically healthy obese, so the fragment or subset of the population that is obese by phenotype, essentially, but are actually healthy — they are eating well and exercising; they just happen to be carrying extra weight? But theoretically, when it comes to their markers of disease, they are actually quite healthy.
Do you believe in that phenotype? What is your opinion on that, because we get asked this sort of question all the time?
Dr. Flanders: There are multiple indicators of health. Obesity is one, and there are other endogenous indicators, such as lipid levels, exercise ability, VO2 max, blood pressure and so on. A person's health is a sum of all of those things, so that's where I come down on that.
Senator Raine: I want to ask about your chart. Can you give us an example of other risk factors?
Dr. Flanders: A big one would be genetic factors. Another would be recognized risk factors that are imperfectly measured, such as blood pressure, lipids, combination of lipids, glucose levels, attitude, behaviours and diet. Almost any risk factor, even if we recognize it, is difficult to measure accurately and to control appropriately so that you can represent both known and unknown factors. The known ones are those that we are unable to measure accurately and adequately; and the unknown ones are genetic factors and others that we have not thought of yet or included in studies. For example, inflammatory factors would be a whole other category.
Senator Raine: In a way it's the whole scenario, going back to the article in the New York Times. It is a bit disingenuous to say that obesity is okay. It's like saying your grandfather smoked all his life and he didn't die so you won't die if you smoke all your life. That's not too smart.
Dr. Flanders: I would agree that it's not too smart. It flies in the face of what I think is common sense, but people see the association and think that because there is an association, it's causal. Our point is that it's not causal. It does not have to be causal for sure, and the extent to which it is harmful raises some uncertainty. Taking everything together, I still believe that obesity is harmful, in spite of these studies.
Senator Merchant: Dr. Flanders, I find all your comments today very interesting and some of them a little difficult to understand as I'm not a scientist. You have done this study. Beyond that, how do you impart the important information that you have found to the general public? What do you do once you have collected all this information? How do you engage the population? We all know people who are obese, have a lot of health issues and are very confused by all kinds of factors, such as diets and labels. Not everybody can work as easily as you because it's not a language that we understand. How do you go beyond what you are doing? We are trying to find out here how to help these studies about obesity. How can we help people to understand?
Dr. Flanders: Relevant to what you're saying, an important point to make is that in these paradoxical studies, the obesity predated the disease. For example, conceptually it might have been someone's being overweight or obese when they were a teenager and then at ages 20, 30, 40 or 50 they developed diabetes. Someone says, "Oh look — having been obese as a teenager, you have a better prognosis as your mortality is lower.'' The practical point is that it's too late by the time they're 40 to change their obesity status as a teen. In order to make this practical, we should be doing intervention studies at the time of the diagnosis to see whether a dietary intervention, a physical activity intervention and a weight loss program are beneficial. There is uncertainty about that.
My belief is that it would be beneficial for most people, depending on the disease and severity. Even though I think it would be beneficial typically and for most people, it should be studied in an intervention study because to make a clinical recommendation that flies in the face of all these reverse studies would be too much uncertainty for me. The way to go forward would be to do studies for these people with diabetes. What is beneficial for people with kidney disease? Is weight loss or physical activity beneficial? Remember, these are very select groups that these issues apply to.
Senator Merchant: How do you then impart your knowledge and your results? How does that information reach the ordinary person on the street? Until you came before us, I had never seen these articles. How do people become better educated? You are doing all this work. How does this move to the next level to benefit people? Do doctors pass this on or health practitioners? How do we use your knowledge and information to help the ordinary person?
Dr. Flanders: The steps could be first to publish it in the scientific literature to get it more widely appreciated among scientists before going to the public and saying, "If you have diabetes, you should do this with your weight,'' because there is still uncertainty. My belief is that it is not beneficial to be overweight; it is harmful. To be confident in making a recommendation to the public, I would like clinical trials done. I'm not going to the public to say what they should do. I would not be comfortable. I believe it would be found to be so, but I don't know that. I've proven in this study that the bias can be bad enough to reverse it and be totally biased; but I don't know that's the case. It could be done in clinical trials. Before going to the public, there should be intervention studies to show the impact of changing weight when it's possible to change it.
Senator Merchant: I'm looking at your chart with the map of Canada. I come from Saskatchewan. Some people have a coloured chart, but Saskatchewan has a blank space. Why is that?
Ms. Adamo: It's because everybody in Saskatchewan is perfect.
That's a map I got off the Internet.
Senator Merchant: I see now that it's yellow. I understand.
Last night I went to a debate in Saskatchewan. This relates back to a question that Senator Eggleton posed earlier about your computerized cellphone thing. I heard from a lot of women last night who are at a lower socio-economic level. Their days are frantic. They are single mothers. They have children. They are trying to go to school. One of them was in nursing. They were all in tears because they really can't cope, and they don't have the financial means to get any kind of help. To whom is this program targeted? Will it help those women?
Ms. Adamo: We are hoping to be able to help those women because that is the type of women who have a hard time going to in-person interventions because you have to go to a certain location. You have to drive there. You have to park there. You have to be available at a certain time. If your working hours aren't conducive to that, it's very hard for you to attend those. We are hoping that a program like this would be more acceptable for a population that has different working hours or is overwhelmed at various times of the day so that they can get the data and information on their time, when they need it and when they want it, rather than when we're telling them they need it. We are hoping it would be more personalized that way. Is it going to solve all the problems? We're not 100 percent certain, but we know that these women that you're talking about are the women that we have a hard time engaging with right now in the traditional fashion in which we deliver interventions.
Senator Enverga: Dr. Flanders, I was struck by your report that said obese persons have higher lifespan compared to a normal person with disease, and I'm pretty sure the junk food makers loved your report on this. I'm pretty sure about that.
On another note here, according to some books I read, or maybe just magazines, fats are more like stored energy or a natural protective layer or shock absorber for some people. I don't know if that is true, and maybe you can let me know. Does the study suggest that in case you have a disease, you should eat more because it will help you live longer? Have you come up to that?
Dr. Flanders: No. That's what other people have been suggesting for some diseases like diabetes and congestive heart failure, but my conclusion is that that may be all bias, so it's just the opposite. I think probably for most of these diseases it would be a mistake to recommend gaining weight and eating more in hopes of living longer. I don't think that's the case.
Senator Enverga: Why do you think it is bias? Was it done by a reputable institution?
Dr. Flanders: Well, it's the difference between an observed association, which they are finding, and I believe they found the association that's there, but every association doesn't mean causation. These unmeasured factors, and there are unmeasured factors, likely explain why there is the distortion when they just look at the observed association. It's a theoretical result, and it shows that the bias can be strong enough to reverse it. The next step is to actually go out and study what happens if we do put obese people who have diabetes or end-stage renal disease on a diet, versus no diet, and see if it is beneficial or not.
Senator Enverga: I guess what you're saying is that we need more studies on this and we should make more research on this particular portion of the statistics.
Dr. Adamo, in your report, you said something about abortion.
Ms. Adamo: Spontaneous abortion associated with women who gain an excessive amount of weight during pregnancy. It's miscarriage, just another word for it.
Senator Enverga: Does it also mean that abortion can cause you to gain weight?
Ms. Adamo: No. You're asking about the reverse? I'm not familiar with that. I'm suggesting that there is a greater risk of spontaneous abortion in women who go into pregnancy overweight as well as those who gain excessive weight during pregnancy.
Senator Enverga: I know some people who have reported that they have had multiple abortions. You mentioned here the next pregnancy is larger than the first. Is abortion included in pregnancy?
Ms. Adamo: By that, I mean that if you've gained excessive weight during a pregnancy and then you don't lose all the weight afterwards in the postpartum, so let's say a year after you have had baby number one and you're still holding on to an extra 20 pounds, and then going into the next pregnancy 20 pounds more than when you went into your first pregnancy. Over time, if you have two or three children, you can carry that weight over time. When you were 25 and had your first baby, you might have weighed 140 pounds. When you have your second baby, you weigh 160 pounds. When you have your third baby, you weigh 180 pounds. It is just the cycle that you are holding on to extra weight. I know in our research and the research of others, when you ask women when their weight struggles began, their answer would be, "When I had kids.''
Senator Enverga: It has nothing to do with pregnancy per se.
Ms. Adamo: It does have to do with pregnancy because you are gaining weight during pregnancy and you don't lose all of the weight, but it's not necessarily the state of pregnancy on its own. It is how your body adapts to pregnancy and what happens to you during pregnancy. No two women are alike. Some women gain excessively, and others don't. Some women can lose the weight, and others can't. There are multiple factors there for sure. It's not simple.
Senator Enverga: On your smartphone applications you are referring to, I know that some of our smartphones are getting smarter. Now they have kilometre counters, heart monitors and pulse rate. Will you be integrating that with your application?
Ms. Adamo: It is absolutely integrated. We have a wi-fi enabled scale, and we have a wi-fi enabled Fitbit, and we actually have a remote food photography method all built into it. We'd like to be able to add more, but the more bells and whistles you add, the more complex it becomes. We want to start with the things that we know could have self- monitoring benefits, and then down the line you can add more. This is the direction things are going. There are actually now phones that have sonograms built in so that when you're pregnant you can actually hear the heartbeat of your child and look at various intrauterine pieces. Technology is growing astronomically. If we don't capitalize on it, I think we are falling behind. We need to be able to use this to our advantage because our health care system is strained enough as it is. Whatever we can do to help, we need to do our due diligence.
Senator Enverga: Good luck with your project. Thank you.
Senator Chaput: An article published in 2014 suggests that there could be a link between childhood obesity and maternal use of antibiotics. Have you heard about such an article, and what is your view on that?
Ms. Adamo: That's not my area. I am not an antibiotic-specific person. But that's an interesting thought. The fact that women who were on antibiotics have a greater propensity to give birth to children who go on to develop obesity. Did they say anything about the mechanism?
Senator Chaput: I don't know. Haven't got a clue. Does anybody know?
The Chair: There are a number of issues here, and they're not tied down. One of the things ties into your biota and the idea that if you significantly change the bacteria in your system, it will influence a number of health issues in a number of ways, and one of the possibilities is that it could change it in such a way that for particular people, it could lead to an increase in weight. The whole idea of medicine moving toward the whole person and your microbiome is part of an evolving area, but I think we should stop there with regard to that issue.
Senator Chaput: That's fine.
Senator Raine: I'm curious. You've been involved at HALO for quite some time on issues of childhood obesity, and this study is looking at the increasing incidence of childhood obesity. There are lots of statistics and stuff out there. I guess the big question is, why are people eating too much? Why are they eating the wrong food? Why are they not getting exercise, even if they know it's good for them? Why aren't they booting their kids out to play? These are the things that I want to try to wrestle with.
Will your smartphone help to answer those questions? Will it give feedback to the woman? Hopefully when she's looking at her smartphone to figure out what she should be doing, the kids will be active.
Ms. Adamo: The smartphone app is specifically addressing the prenatal period. It's not for the children.
You're intervening to change somebody's lifestyle, so you hope they will adopt these behaviours that they will pass on to their children. If they institute these healthy behaviours during that period of time, we hope that it will become engrained and that they will continue over time and share it with their kids; but that's not always the case. We live in an environment that is not conducive to being physically active and choosing healthful foods all the time. We're bombarded with ease-of-use things.
We all drive everywhere. We drive our kids to school. We protect them to such an extent that we're afraid to send them out to play on their own in case they get kidnapped or fall into some dangerous situation, even though we know the environment today is much safer than it was 20 or 30 years ago. We live in a society where we have 24-7 media, so there is considerable sensationalism of things, which leads parents to believe that if they let their children go out to play on their own, they're not concerned enough about their children's health and welfare.
Products are available now for purchase when it comes to food that we didn't have 20 or 30 years ago. We didn't have huge sugar-laden slushy drinks and two-litre bottles of pop that anyone can buy for an economical price. The environment in which people are raising their children is much different; and the obesogenic environment is contributing to these issues. It would be nice to be able to tackle that, but it's more than one person can do. Perhaps a societal-level change needs to take place in a graded fashion over multiple years. It's something huge to tackle. It's unfortunate that we find ourselves here, but here we are.
Senator Raine: I look at the mobile health technology devices. They're educating. It's an opportunity to educate the parent. I believe that when a woman is pregnant and when the baby is born, there is no greater time for them to learn because every mother wants the best for their child. You could take that prenatal period and teach them what to do. Babies don't come with any manuals. If this can do that, it would be valuable.
It goes back to the same thing, though. Many people get bombarded with different things all over the place. How will a woman know that this is valid, solid take-this-as-gospel information?
Ms. Adamo: That's an excellent question. That's why it needs to be evaluated. That's why we're trying to find money to evaluate it. If we can't evaluate it, we can never ask a physician in a health care system to be a proponent. We developed it in an evidence-based manner, and we believe it has merits; but we need to be able to test it to see if it resonates with our audience to lead to change. We know that pregnant women are a specific population and eager to do things for the health of their children that they might not have been eager to do for themselves. With a child in the picture, women are generally more receptive to change. We hope it can lead to behaviour change, whether it will do it for all women; but we don't know because it needs to be tested.
Senator Raine: In your smart tips, for instance, you could change the knowledge base so that the parent realizes that having their child play outdoors in the fresh air actively is good and that having them watch the screen is child abuse.
Ms. Adamo: You're right.
Senator Eggleton: Ms. Adamo, what about nutrition and food labelling. Do you have any suggestions in that regard?
Ms. Adamo: It's a very challenging area. Health Canada and the dietitians of Canada are always struggling with how much information to put on a food label, what information is important and how someone will interpret it. I'm sure everyone has looked at a food label before, but you don't know what you should be looking at. Are you looking at the fat, the sugar or the fibre? There needs to be a manual, or everyone needs to be taught the three key things they should take away from a food label. We're going to expect people to do a degree in personal education so they can learn, but it's not simple.
Maybe we could flag certain items. I know that various organizations in Canada, for example the Heart and Stroke Foundation, have heart and stroke symbols, and Loblaws is instituting something where they will mark products. You can't pay or buy to have your symbol on a box of cereal. It needs to meet a degree of healthfulness determined by somebody with the right knowledge, for example a dietitian.
Senator Eggleton: In some jurisdictions, instead of the numbers shown on the labels, they use the green light, red light or orange light system.
Ms. Adamo: The traffic light diet.
Senator Eggleton: Do you think that works?
Ms. Adamo: I think it works. Interventions in the U.S. have done exactly that, but not necessarily with food products but in dietary recommendations. Green means eat this all the time; orange means eat this in moderation; red means eat this only on special occasions. We've fallen away from the only-on-special-occasions piece, and it's now a daily expectation.
Senator Eggleton: There is an article in Springer science magazine that one of your colleagues at the Healthy Active Living and Obesity Research Group, Jean-Philippe Chaput, was part of writing. I don't know if you are familiar with this particular research. It's on the basis that insufficient sleep is a contributor to weight gain and to obesity and heart problems. Do you have any comment on that?
Ms. Adamo: I'm not the sleep expert, but I know well enough as we've published together a few times. We call him "Dr. Sleep'' at work. There are associations with insufficient sleep. If a person is up for a longer period of time, they have more opportunities to eat, for example if you're up for 18 hours during the day rather than 14 hours. If you are getting insufficient sleep, you're likely more tired, and if you're more tired, you're not as motivated to be physically active. It's a double-edged sword. We know that kids who get enough sleep and adults who get enough sleep are more likely to have other behaviour patterns conducive to healthy active living.
Senator Eggleton: I have one final question to both of you: There are a number of suggestions that BMI is not the way do the measurement and that a circumference method is better. Could you both comment on that?
Ms. Adamo: I can certainly comment on that. The research community shares the concern that BMI is probably not the best measure for adiposity. It's a measure of height and weight and the relationship between the two. It's not ideal. In epidemiological research we use that because it's the easiest one to measure. All you need is height and weight. You don't need fancy scales or other equipment, such as a CT scan or an MRI. It's a relatively easy way to make a measurement.
It causes problems in people that are heavily muscular, or it can under-predict for women or men who are thin but obese in that they may have a lot of body fat but they just don't weigh much.
Definitely on both sides of that spectrum there is an issue, and it is an imperfect measure. There are many measures that are better but considerably more expensive, and not everybody has the technology to measure them. Unfortunately, we often go back to BMI because it's simple. But I agree; it has a degree of flawed logic.
The Chair: Dr. Flanders, do you have a comment?
Dr. Flanders: I agree. I don't have anything to add.
The Chair: Thank you very much. Dr. Flanders, I think your presentation — and you've illustrated it well, and you've covered this issue, and that is that one can measure things and come to nice charts that seem to indicate a very clear conclusion, but in actual fact they may not lead to the conclusion that appears obvious from the charts.
One of the difficulties in this sort of thing is that the press grabs any headline that they think is really fascinating. Probably a lot of people would love to think that additional weight will help you if you have a serious disease and lead to a better outcome. I think you've gone to great lengths to try to help us understand your interpretation of the data in that area, and I want to thank you for that.
Ms. Adamo, in terms of smartphone technology, I thought the key in what you were saying is that this is a technology that is available across all economic spectrums. In fact, there may even be an extra density in the lower socioeconomic areas of smartphone use. The ability therefore to have access to something that's commonly available, and then to be able to develop programs, where I think the key out of the discussions you have had with several of the senators is that the message has got to be simple and clear. The reason the green light, red light kind of concept catches on in some areas is that it's exceedingly simple, and it's very easy for everyone to relate to what those colours mean in a given situation. I am hoping that as you go forward and are able to determine that certain detection, certain messaging is useful with pregnant women in these areas, the model will be simple in terms of their picking up the message to them.
The other thing that we really didn't touch on — people asked both of you a number of questions about diet and what is good and bad, but we are increasingly becoming aware of some scientific facts based on clinical-style testing. We're getting there, to some degree. This is a complex area.
Hopefully, again with your smartphone technology, there might be a possibility of moms being able to link directly to advice somewhere, that they suddenly get a product that they've heard about from friends, or it's labelled in a store or whatever, and that they could quickly communicate with a centre of advice.
One of the difficulties today for anyone in any socioeconomic area is getting access to good advice in a timely fashion. While industry has moved to just-in-time delivery, in terms of health advice, we are a long ways from just-in- time advice.
One of the things that seem to me to be a great opportunity in where you're going is that if you can link that to a quick-dialogue capability, it could have an enormously positive impact on pregnant women.
Ms. Adamo: I would like it if you would speak to CIHR about that. I say that because we submitted a randomized control trial last year to CIHR where we had a health coach embedded in the phone for exactly that reason — to be able to give advice to a woman when she says, "I'm at the grocery store. Do I buy the cornflakes or the Honey Nut Cheerios?'' for instance. We would want to be able to say in that moment to her, "I'm your health coach, and I say the cornflakes are the better choice when you're there.'' But CIHR did not understand the need or the benefit for this two- way dialogue, and they said that it could never be implemented. It wasn't scalable in our health care environment, so they really disliked that availability.
We're trying to convince them that either it's necessary or we have some sort of built-in dialogue that is virtual, that is not necessarily a health coach. But when they ask question X, the response from a health coach would be Y. That sort of real-time artificial intelligence is very challenging, as you can imagine, to build in. We did believe that this real- time advice from a health coach would be imperative for women, but funding agencies sometimes see it differently.
The Chair: I would urge you to continue along these lines. We are seeing in other health areas that the ability to communicate with a source of knowledge — for people who have certain heart diseases, if they are able to link directly to advice, there are very positive health impacts in these areas — home care, for example, which has a higher propensity for success than in-hospital care but requires a dialogue concept. We on this committee have been dealing with a wide variety of issues for which the electronic collection of data and the ability to communicate and have information available would very clearly make significant improvements and contributions in a number of areas.
I want to thank you both for your very dynamic contributions to us here today.
With that, I declare the meeting adjourned.
(The committee adjourned.)