Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 33 - Evidence - May 6, 2015
OTTAWA, Wednesday, May 6, 2015
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:15 p.m., in order to examine and report on the increasing incidence of obesity in Canada: causes, consequences and the road forward.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[Translation]
The Chair: I would like to welcome you to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I am Kelvin Ogilvie from Nova Scotia, the chair of the committee and I'm going to invite my colleagues to introduce themselves.
[Translation]
Senator Merchant: Good afternoon, my name is Pana Merchant, and I am a senator for Saskatchewan.
Senator Chaput: Good afternoon, my name is Maria Chaput, I am a senator for Manitoba.
[English]
Senator Raine: Nancy Greene Raine, British Columbia.
Senator Frum: Linda Frum, Ontario.
Senator Enverga: Tobias Enverga, Ontario.
Senator Stewart Olsen: Carolyn Stewart Olsen, New Brunswick.
Senator Seidman: Judith Seidman, Montreal, Quebec.
The Chair: I remind us all that we are here today continuing our study to examine and report on the increasing incidence of obesity in Canada: causes, consequences and the way forward.
I am very pleased to welcome our witnesses for today, and I'll welcome them as I invite them to speak. Since there was no battle for who would go first, I will call them in the order that they are listed on the agenda. In that case, I will first invite Dr. Heather Ross, President of the Canadian Cardiovascular Society.
Dr. Heather Ross, President, Canadian Cardiovascular Society: Thank you very much, and it's a pleasure to be here.
There is an epidemic in Canada; its name is obesity. As the president of the Canadian Cardiovascular Society and a cardiologist at the Peter Munk Cardiac Centre in Toronto, I see its damaging effects every day.
Last week a patient came to my clinic with severe advanced heart failure. He has a body mass index of 42. BMI is a weight-height calculation. A normal body mass index is 18.5 to 24.9 — above 25 is overweight and above 30 is obese. My patient is morbidly obese. He also has diabetes, so right now he's too high risk for a heart transplant. He's also far too sick to be able to lose the weight. This man, a 33-year-old father of two, is a casualty of obesity.
How many potential casualties are out there?
Here is what we know: one quarter of adult Canadians are obese; men and women are equally at risk; another 36 per cent of Canadians are overweight; and the problem is growing. The WHO says 2 billion people are overweight or obese, and the obesity numbers have doubled from 1980 to 2008. Since 2003, the proportion of Canadians who are obese has increased almost 20 per cent. Our youth are vulnerable too: 26 per cent of Canadian children and adolescents are overweight or obese.
There is more than one way to measure obesity. BMI is an important tool, but we should also capture waist circumference. This measures visceral adiposity. In simple terms, this is when fat is around the belly and the internal organs such as liver, pancreas and intestines, and it is associated with major alterations in cardiovascular structure and function. If waist circumference is a 102 centimeters or 40-plus inches for men, and 88 centimeters or 35-plus inches for women, then that is abdominal obesity.
In Canada, 29 per cent of men and 41 per cent of women are in that waist circumference category. The presence of abdominal obesity poses an added significant risk of adverse events.
Many factors contribute to obesity: genetics, age, poor nutrition, a lack of regular physical activity and sedentary lifestyles, socio-economic and environmental issues, including the design of our communities, education, and social patterning of obesity.
Whatever the causes, we must consider the consequences. Obese individuals are twice as likely to develop heart failure. Being overweight or obese is not only a risk factor for heart disease and stroke but also contributes significantly to diabetes, high blood pressure, cholesterol and some cancers.
A 2001 study from the Canadian Institute for Health Information, CIHI, and the Public Health Agency of Canada, PHAC, reported that obesity costs our economy $4.6 billion to $7.1 billion annually. That's in direct health care costs plus indirect costs, like lost work productivity.
This is not just a health care crisis but an economic crisis, and it's growing. We can measure that growth by the centimetre. A one-centimetre increase in waist circumference increases the relative risk of a future cardiovascular event by 2 per cent.
We must dispel the notion that overweight people actually live longer or even that obesity is somehow protective, the so-called obesity paradox. A recent meta-analysis suggested there is no healthy pattern of increased weight. Let's be clear: Obesity shortens lives.
How can we reverse the obesity epidemic? We can start by setting four clear goals. We can increase the proportion of people eating five daily servings of vegetables and fruit by 20 per cent, we can increase the proportion of people who are physically active by 20 per cent, we can decrease the rate of adults who are overweight or obese by 20 per cent, and we can decrease the rate of childhood obesity from 8 per cent to 5 per cent. Here's the challenge: These targets were proposed to the federal Minister of Health in the Canadian Heart Health Strategy and Action Plan back in 2009. The Canadian Cardiovascular Society, Heart and Stroke Foundation and Canadian Institutes of Health Research were the leads in this PHAC-funded report. The target for those bold goals was 2015, and we missed it.
Will we keep missing opportunities? Making changes in obesity requires actions on many fronts by many individuals, governments at all levels, health care professionals and institutions, and more. The issues are complex. For instance, the problem isn't just fat but where the fat is. Let's ensure that waist circumference is now incorporated into reporting by family doctors so we can better counsel patients.
Making healthy food choices is important for all, but we must pay special attention to children and Aboriginals, two populations at particularly high risk of obesity and its consequences. Sending the message isn't enough. It's simply too cheap and too easy to eat poorly. We should consider steps such as added taxes on unhealthy food and beverages and subsidies for healthy choices.
Finally, as we know, there is much focus on weight loss, but increasing physical activity is vital. We know that individuals of normal weight who are fit have the lowest health risk of any other category.
Even small improvements can make a tremendous difference. A 2014 Canadian study estimated that a 1 per cent relative reduction in the number of individuals with excess weight in Canada starting in 2012 would reduce the annual economic burden by $3.2 billion by 2031. That's far too late for the patient I mentioned at the start. He is going to die. Others don't have to.
By making an impact on obesity, we will reduce the incidences of many of our greatest health concerns and further both our physical and our fiscal well-being, respectfully.
The Chair: I will now invite Dr. Catherine Pound, who is on the Nutrition and Gastroenterology Committee with the Canadian Paediatric Society.
Dr. Catherine Pound, Nutrition and Gastroenterology Committee Member, Canadian Paediatric Society: Thank you for the opportunity to present at this committee.
The Canadian Paediatric Society recognizes the critical nature of the overweight and obesity epidemic in Canada. Canada has one the highest rates of childhood obesity in the developed world, ranking sixth out of 34 OECD countries.
According to the WHO cut-offs, close to 20 per cent of 5- to 17-year-old Canadians are overweight and almost 12 per cent are obese. These numbers are even higher in vulnerable populations, especially in children of Aboriginal dissent.
The issue of overweight and obesity places a significant strain on the health care system. In 2008, the economic costs of obesity, as Dr. Ross said, were estimated at $4.6 billion based on costs associated with chronic diseases linked to obesity. Pediatricians now see children developing co-morbidities that were once mostly seen in adults, including insulin resistance, Type 2 diabetes and hypertension. Excess weight in youth has also been linked to poor emotional health, decreased self-esteem and diminished social well-being. Our overweight and obese youth will become overweight and obese adults if we don't intervene.
Given the challenge of reversing overweight and obesity once it is established, it is essential to highlight the importance of preventive strategies.
The overweight and obesity problem is multifactorial. It is impacted by genetic, economic, cultural, environmental, nutritional and physical activity factors, and it shares correlation with the social determinants of health. Sustained changes to current behaviours and societal environments are needed to bring into balance the caloric intake energy output equation.
Few children consume the recommended amount of fruits and vegetables daily. Access to healthy food is challenge for children from low-income families as the cost of nutritious foods is too often prohibitive. Obesity and food insecurity are closely linked, and in 2012, 1.15 million children in Canada were estimated to live in households experiencing some degree of food insecurity.
The lack of physical activity also clearly factors into the equation. Ninety-three per cent of children aged 5 to 11, and 96 per cent of children aged 12 to 17 do not meet the Canadian Physical Activity Guidelines of 60 minutes of moderate to vigorous physical activity daily.
Similarly, fewer than 20 per cent of three- to four-year-olds and 10- to 16-year-olds meet the Canadian Sedentary Behaviour Guidelines for children and youth, which recommend daily screen time of no more than one hour for the younger age group and no more than two hours or the older one. This is important as children participating in over two hours of screen time daily were found to be twice as likely to be overweight and obese as compared to children exposed to an hour or less.
It is likely that significant change will require the input of multiple stakeholders with the aim to empower individual accountability. Such interventions are likely to include increased education and awareness of the impact of overweight and obesity on health and disease, as well as identifying healthy behaviours that will protect against the development of obesity. Important stakeholders need to include individual Canadians and families, health care systems, schools, work environments, the food industry and governments.
Preventive strategies need to be explored and developed. Policies and legislations have the potential to facilitate the development of healthy environments and communities, though such interventions have to be sensitive to customs and individual choice. Care must be taken to ensure that the policies and legislation do not impact vulnerable populations.
Strategies starting as early as the neonatal period should be encouraged. For instance, nationwide breastfeeding support programs should be considered given the protective effect of breastfeeding against overweight and obesity. Food and beverage advertising to children should be examined given its potential to contribute to childhood obesity. The development of programs aiming to increase physical activity levels and improving access to community recreational facilities need to be considered.
In addition, educational and social awareness campaigns are essential to disseminate the strong and unified message to the Canadian population.
The setting of goals and the implementation of monitoring programs to examine the impact of intervention is critical. Ongoing research on the determinants of overweight and obesity development, as well as on the effective solutions, should be strongly supported.
The Canadian Paediatric Society shares the hope that sustained, thoughtful and collaborative interventions will be developed with the concrete goal of decreasing overweight and obesity, as well as the burden of disease associated with it in our Canadian youth.
The Chair: Thank you both very much. I will open the floor to questions from my colleagues, starting with Senator Eggleton.
Senator Eggleton: Thank you very much for your presentations. They remind me that I've been hearing lately from some sources disputing whether people who are overweight or maybe even mildly obese are necessarily unhealthy. It may be more a matter of their dietary patterns as opposed to the fact that they happen to be overweight or obese. In other words, their health consequences are their dietary pattern, but not necessarily the weight. Can you comment on that?
Dr. Ross: It's an excellent question. For a long time, people have thought that being mildly overweight might be somehow protective. Some of this obesity paradox, as it has been called, has been called into question recently. If you are overweight and fit, you will mitigate a lot of your risk through fitness. For any weight category, a fitter person in the same weight category will be at much lower risk. There is a J-shaped curve to weight. You can actually be too thin and be associated with risk if the BMI is less than 18.5.
The most recent meta-analysis grouping all the studies together clearly shows that even overweight, not even into a full category of BMI over 30, is still associated with an increased risk. One of the messages we want to promote is that fitness clearly will abrogate some of the risk; but it's critically important that we don't leave people with the message that it's actually okay to be overweight.
Senator Eggleton: Do you agree?
Dr. Pound: Yes, 100 per cent.
Senator Eggleton: Dr. Ross, you mentioned in your submission a number of things you think the federal government could be doing, plus the fact that it missed the boat as you pointed out on some targets and strategies that were suggested to it at one time in 2009. I do not see any advertising and marketing. There have been some suggestions that there should be some federal control over those. Can you comment on that?
Dr. Ross: I would agree. Seven minutes is not enough time for me to put forward all the suggestions I would happily have mentioned; so your point is extremely well taken. As Dr. Pound has said, especially as it relates to advertising for children on sugary beverages, these are ways for us to try to change behaviour, which is really what we're talking about. Great inroads could be made in the area of advertising fast food and some of the unhealthy sugary drinks that we worry about on television and social media.
Dr. Pound: I agree. Children, as we know, are particularly vulnerable to this kind of messaging. If there was anywhere to tackle first, I would say that advertising to children and adolescents is absolutely critical. Other places have implemented bans on such advertising. It is probably too early to see if it has had a true impact on obesity and overweight. It is doable, and hopefully it will show some success over time.
Senator Eggleton: I'll go now to the issue of waist circumference. I'm glad you raised the point. I have always wondered about how effective BMI is. You raised it here, and you both can comment on this. Is this for all ages or just a particular age where you see this being implemented?
Dr. Ross: The evidence would suggest that it's all ages. BMI is such an easy tool because you just need height and weight. It gained favour because it was such an easy thing to measure. It's also quite easy to take a measuring tape at a visit to the doctor's office and measure the waste circumference. Some very elegant studies have clearly shown that waist circumference correlates on CT scanning and other imaging with actual visceral or deep adiposity. It's the deep fat around that leads to the metabolic syndrome that we worry about, which is especially prevalent in Aboriginals and South Asians, and the increased risk of diabetes. Fat is a very complex endocrine organ, which a lot of us have not realized. There is much that it secretes that causes these increased risks of diabetes and other things. Adding waist circumference — and I'm not suggesting that we CT scan people as it would be way over the top — will provide added information.
The other caveat is that you can have someone who is incredibly muscular. If you look only at the BMI and their weight and height, they may appear to be in an overweight category. But when you do their waist circumference, because they have such lean body mass, you find they are actually not. In some instances, the waist circumference will show a group that's at even higher risk; and in others, when someone is in an overweight category, it will show a group at lower risk because it is lean body mass.
Dr. Pound: If used in children, it may facilitate things as well because the BMI in children is lot more complicated. It is obtained in the same way, but the BMI thresholds constantly change with age.
Senator Eggleton: You could do it at home too.
Dr. Ross: You can do it when you buy your jeans. Most of us know what our waist size is.
Senator Seidman: Thank you for your presentations. Clearly with this we are hoping to make recommendations that are actionable in a confused field, as we are discovering listening to witnesses.
I'd like to ask you about diet because there is evidence to demonstrate that diet has an effect on obesity. Dr. Pound and Dr. Ross, you both mentioned the importance of preventive strategies and that we should focus throughout the life cycle on healthy behaviours.
I would like to ask you about Canada's Food Guide, whether you make recommendations on the use of Canada's Food Guide through your organization, whether you think it is a fruitful guide and whether you see other things we can do with the guide. I'd just like to talk to you about the importance of getting at this very early.
Dr. Pound: Certainly, we talk about it quite a bit in pediatrics. It's a bit difficult because the amounts of food change as the child ages. The most important thing we talk about is the importance of fruit and vegetables and increasing them, which is often an issue because we deal with children from various backgrounds in vulnerable populations. As I mentioned earlier, we know that the cost of these foods is prohibitive. As much as we can, we emphasize the importance of it and encourage our patients and families to go that route.
Dr. Ross: I agree. It's one thing to promote it, but how do we actually implement it? That's really where the challenge is. A lot of mathematical modelling has been done looking at the upfront investment and potential downstream benefit. One study showed that $1 invested in prevention as it relates to healthy eating is worth $5 in savings in terms of health care costs. They did a penny-per-ounce tax on sugary drinks evaluation and were able to show in the United States that it would result in $17 billion in savings and generate $13 billion in tax by taxing at a penny per once.
One of the biggest challenges that we both alluded to is the cost of eating well. In some areas in Canada, the food simply just isn't available even if you want to eat well. You don't have an organic market or a fruit store down the street.
Dr. Pound: Before we start talking about Canada's Food Guide, it's important to look at earlier food that's accessible to everyone, and that's breastfeeding. People don't necessarily realize how important it is and how much of a burden it is on the health care system that people don't breastfeed as much as they should. A recent study showed a set of siblings, one who was breastfed and one who was not. At the age of 14, there was a 14-pound difference between the two individuals. All other factors being the same, a child who is breastfed has this much advantage over people who are not, for many different reasons.
Senator Seidman: You're making important points about how we do this. We can say, yes, this is what we need to do, but, Dr. Ross, you said we need to increase the proportion of people eating five daily servings of fruits and vegetables by 20 per cent. How do we do that?
Some who have suggested that Canada's food guidelines are not working very well. There might be other ways to revise them, for example, or there may be other ways to guide people by changing up those guidelines and getting at different aspects. Do you have an opinion on that?
Dr. Ross: Labelling of food is one of the single most important things that have happened, because I think a lot of people don't actually realize when they're eating something that has a really nice healthy name that there's really pressboard and additives.
The progress in food labelling, which is growing in Canada, has been huge. I think all restaurants, in fact, should be required to label the content of the food. When people think chicken they may think it's actually healthier, but I think if we require publication of what is in it, it's not going to stop some people. I think it will make a lot of people who think they're eating a healthy chicken on a salad maybe think twice if they actually know what the contents are.
I think labelling is huge. Eliminating trans fat has been important, as well as looking at minimizing sodium in a lot of the processed foods. These are ways that I think are relatively — if you will pardon the pun — low-hanging fruit, and I think they should be done.
Senator Merchant: Thank you for your presentations, although they echo many of the things that we have already heard about food labelling and eating more fruit.
Because you are both physicians, I would like to start with what doctors can do, because you have concentrated on children and the behaviours that are adopted early that then determine whether a person may become obese or not.
To start with physicians, do you think that physicians are trained to counsel their patients? Is there enough time during a doctor's visit? There are also things that prevent them, maybe, from having enough time to speak because of billing practices.
You said education is very important. Can you say how physicians can help with pregnant women and young children to really instill in families and young mothers how very important this is?
Dr. Pound: I think we can always do more, obviously, and I think you make a very valid point when you say that there are time restrictions, but people have different types of practices with different amounts of time. But I think the key is prevention and the key is starting early.
When you see a mother who is pregnant for the first time, this is when physicians should start talking about prevention, about food, about breastfeeding, about healthy eating, about how they're going to plan and make this fit in their family. This is when a physician can start looking for resources for a family that may or may not have the financial means.
Physicians can advocate for their patients, make recommendations for changes and talk about subsidizing healthy foods, for instance.
Dr. Ross: I think those are all valid. On your point about do we get enough education on this in medical school, I went to medical school quite a while ago. I can tell you that at the time I was in medical school, the answer is no, we did not. There were a number of things that I think have turned into major issues that were not adequately addressed in medical school, and nutrition was definitely one of them at the time I was in medical school.
I think it's important that doctors walk the walk. Our patients often look to us as role models as well, and I think it's really important that we actually practise what we preach.
You are right about the time that a general practitioner, for example, might have in their practice to put aside, but resources are available. There are dietitians. I think if you're a physician and it isn't something that you feel comfortable addressing, although you should, if it isn't, there are resources. There are dietitians. There are ways to do this so that I don't think time should be a barrier.
Senator Merchant: Secondly, you have pointed out one remedy for eliminating junk food, let's say, from young people's diets is by increasing taxation. I'm just wondering, with vulnerable populations and First Nations populations, remote populations, increasing taxation makes it that much more burdensome for them to be able to afford food. It's a good solution probably, but it doesn't apply to the most vulnerable people. I'm just wondering what we can do, because we can make recommendations, how we can overcome that.
Dr. Ross: You're absolutely right, and I think the tools that have been shown to work best are taxation and subsidy as opposed to just taxation.
One of the concerns about taxation is that if you don't necessarily get all the things that should be taxed, they will just go to the thing that's still inexpensive that might still not be healthy. And we have to remember that they might be having something that's healthy, but the calorie intake, because there's still a calorie intake aspect to the equation, they may be eating or drinking things that are healthy but just too much.
So sometimes taxation on its own is probably not the way to do it, but I think you can look at subsidies, especially in areas of food insecurity and especially in the area of the Aboriginal population, which I believe is so dramatically at risk and already at risk for cardiovascular disease because of a greater likelihood of metabolic syndrome. I don't think taxes alone are probably the answer. I think it's a balance of tax and subsidy.
Senator Merchant: Is that something you proposed when you said you had proposed something to the health minister? Were subsidies one of the things you proposed?
Dr. Ross: That was part of what was addressed within the Canadian Heart Health Strategy, with a number a different aspects, including looking at better transit of food into the northern areas as well. I think another issue isn't just food insecurity but actual availability in some of the northern reaches of the country. That is contained within the heart health strategy.
The Chair: With regard to the senator's first question, I was just reading an article earlier today that purported to deal with the study trying to determine whether physicians make any — general practitioners in general — comments to children and/or their families with regard to weight issues, and the report suggested that it's minuscule, that most do not feel that that's part of their responsibility in terms of guiding in that particular area. That just happened to be a report saying that. In any event, it came out today.
Senator Enverga: Thank you for the presentations.
Health Canada is responsible for creating and promoting the food guide called Eating Well with Canada's Food Guide, and yet you mentioned we should eat more fruits, 20 per cent more of that and 20 per cent more of this. Is there something wrong with the food guide? Should we change it?
Dr. Ross: It's not that we should eat 20 per cent more fruit; it's that we should have 20 per cent more Canadians eating the five servings of fruit and vegetables. The problem is that the food guide outlines very well what we should be doing, but, as was mentioned, the penetration of that into actual practice for most families is still not at the level that it should be. I think really what we would like to see is more uptake of the food guidelines.
Senator Enverga: Is it possible for us to change the guide for kids and for adults and maybe for people who are obese? Do you have a suggestion to change it in a sort of way like this so that it would be appropriate for each individual or each age group?
Dr. Pound: I don't have a great answer to that. I think if we start changing the food guide for various populations there's no end to it. I think what's important to remember is the general guidelines. We want people to eat healthier food, and how are we going to get to do that. We can tell them to eat healthier food, but especially in Aboriginal populations — and I was working in the North a few years ago — the price is so prohibitive for fruits and vegetables. Before we talk about taxes on unhealthy food, I think the subsidy of healthy foods would be probably much more relevant, especially for those populations who have low income to begin with. The cost of living and eating healthy food is completely out of proportion to what it is for the rest of the country in the populations that are already genetically at risk.
Senator Enverga: It was discussed before that there's something wrong with labelling. People are not reading it well. I made the suggestion that maybe we should change the way people label food, especially for kids. If the calories are too high, we put an elephant on the label; for fewer calories, we put a mouse. Do you think that's more appropriate, especially so that kids would be able to understand?
Dr. Ross: I think honest labelling is critical. My favourite label is label per serving. You look at it and say that calorie count sounds pretty good. You look at the package and you figure that there can only be one serving, but you find out that there are four servings in the package. No one in their right mind is going to not eat the whole package, so you change the labelling on the package. You are left with the feeling that it is totally okay because it's only 180 calories and 8 grams of fat. However, anyone buying it is going to eat the whole package.
There are subtle intricacies with the way people get away with labelling. I think you're right; labelling needs to be honest. You can comment on the idea of the elephant and the mouse, but I think honest labelling really needs to be done, and it just isn't done.
Dr. Pound: I have a concern about the elephant and the mouse because of the message that it carries. Similarly, maybe red, yellow and green could be used.
Dr. Ross: For sure; kids would respond to it.
Senator Enverga: They may think all colours are nice, but the animals —
Dr. Pound: Typically, parents buy food for their kids.
The Chair: With the references to the food guide and the way the discussion unfolded, I think we should note that Canada's Food Guide makes recommendations for a number of servings for each category depending on the age, and so on. The point that you stated, Dr. Ross, is that you wanted to see a 20 per cent increase in the number of people actually consuming the amount identified in the guide.
Dr. Ross: That's exactly my point; correct.
The Chair: I wanted to get that clearly on the record.
Senator Tannas: Thank you very much for being here. Have you heard of any country where they're making progress on this? Is there anyone who has shrinking waistlines that we could look to, either in general or in a specific segment of the population, Aboriginal or children? That's number one.
I'll roll all my questions into one. Do you sense that the most effective program can be the use of spokespeople? I would be interested to know if you have had or seen any data around Michelle Obama's initiative and how much impact that has had versus taxes and subsidies. Could you comment on that and my first question?
Dr. Ross: Those are great questions. The U.S. is still a more obese country than we are. However, there are countries that clearly that have less obesity. The Scandinavian countries have had less. Their rates have stayed while our rates have done this. Rather than their tackling the problem and the waistlines coming down, I think they generally have less obesity than we do.
They seem to have promoted an ethos of fitness. In my travelling through Scandinavia, the ethos of fitness is incredible. People are out more than, as Dr. Pound said, in front of the screen. We can't dissociate the food piece from the fitness piece, because I think that the fitness piece is a critical part of what we've lost in this country in large part, I think, due to social media, Web viewing, TV, et cetera. I think there are countries that do a better job.
Regarding the spokesperson thing, I think you can't underestimate the effect of a spokesperson. You see all the athletes who are promoting energy drinks, which people think are healthy although many have a rather large calorie count. I think we can do a lot with spokespeople. We've seen it work with some of our sports people in terms of depression and in other areas. I think there can be some inroads there.
Dr. Pound: I certainly agree with that, especially in children and youth. Taking that publicity that we have right now for unhealthy foods and turning this into a spokesperson that is really going to speak to children — children are very receptive to this kind of messaging — would be a fabulous idea. It would work very well with kids.
Senator Raine: We all appreciate that there's no easy solution, but I want you to comment on what your organizations are doing to promote healthy activity in terms of getting physical activity, physical literacy, back in the schools, and perhaps also getting home economics, teaching people how to cook, back in the schools. Are you focused on that at all in your two organizations? There is no doubt that they took physical education out and put computers in, and I think it's got to swing back the other way.
Lots of studies show that a child who has been exercising aerobically before class learns better. Are your organizations engaged in that at all?
Dr. Pound: From the Canadian Paediatric Society's perspective, there's a lot of social messaging and campaigning advocacy. There are spokespeople who are always advocating physical activity, fitness and healthy eating. More than that, I'm not aware of.
Dr. Ross: The Canadian Cardiovascular Society, as a voice for cardiovascular medicine and research, is on the other end of the sharp stick, which is doing the research on the impact of obesity and messaging and the translation of the impact. A number of world leaders on the impact of obesity are Canadians, and we're involved on that side.
The arm that generally does the work into education on exercise is the Heart and Stroke Foundation, which is the partner arm of us. We're the physicians and scientists, so we don't per se have a platform on exercise other than what individual spokespeople do. Most of that messaging is done by the Heart and Stroke Foundation, but it's an excellent point.
Senator Raine: Are you aware of a program called Exercise is Medicine?
Dr. Ross: I'm not personally aware of it.
Senator Raine: It's a post-degree training program for physicians to learn how to prescribe exercise.
Dr. Ross: In that context, yes.
Senator Raine: There are a lot of doctors out there who know they should be prescribing exercise, but they don't know how to do it. They can't just write out a prescription. Some doctors do, but I think this is something that has to be done.
Dr. Ross: Again, we represent the cardiac rehabilitation group as well. That group looks at the role of exercise in rehabilitation from cardiac illness, heart attacks, stroke, heart failure, et cetera. We do a lot of that, but, to your point, it's not at the primary prevention level, and that's the problem. We have a huge role in cardiac rehabilitation and promoting that at the national level as an organization. But again, by the time we're doing that, the horse is out of the barn, although we can make major inroads by doing that, and we do it quite aggressively.
Senator Raine: I think it's fair to say that we are aware that there are jurisdictions in terms of delivery of education and health. At the federal level that's not our jurisdiction. But we can see the problem that comes when we've let it fall down now. If you look at the rising rates of obesity, especially among children, and look down the road, our health care is not sustainable.
How do we all work together and break down the silos and decide who does what? As national organizations, what do you see your specific roles being in doing this?
Dr. Ross: Part of the reason we were so excited to be here was to talk about and be involved in the dialogue. When we came together for the Canadian Heart Health Strategy and Action Plan, more than 1,500 people, led by Dr. Eldon Smith, who collaborated and provided input into that action plan. In 2009 when we presented that, we felt it was a plan that involved the Canadian Cardiovascular Society; the Heart and Stroke Foundation, which gets into the issue at the primary prevention level; and also the Canadian Institutes of Health Research, because we felt it was critically important that we actually try to move forward.
As it relates to obesity, I did share with you the four recommendations that we made. There were a number of other recommendations made toward heart health in this country that we had recommended, and each of those recommendations had a detailed plan attached to them. I would be delighted to share the report with you.
I think we are completely invested in trying to figure out how we go about addressing this issue. I have far too many patients like the patient I told you about. I have far too many patients who come in who have an illness that, if they had been enabled, they might never have come to see me. So, we are completely invested.
Senator Raine: Heart health is in a silo, but then there is diabetes, cancer, unhappy people and depression. So we have these silos, and somehow we have to figure out how to get the energy flowing out of that and wake people up that this is a crisis. That's the challenge, I guess.
Dr. Ross: I agree.
Dr. Pound: That's the advantage that the Canadian Paediatric Society has, because we are not looking at adults but the youth population. There are no silos for us. We are looking at the overall health of children; we're not focusing on just one organ but on everything. The Canadian Paediatric Society very much promotes the use of anticipatory guidelines with all of their physicians. Those guidelines that are used as well for baby checkups at the annual visits, physicians have guidelines to discuss those important topics of physical activity and healthy nutrition.
The Canadian Paediatric Society has already had successful campaigns and education on its website. It is distributing a lot of information to physicians and parents. It is continuing to disseminate this messaging about healthy eating, physical activity and the importance of all those things we discussed.
Senator Stewart Olsen: Your presentation is very frightening actually, and should be frightening for a good many Canadians.
I almost don't know what to ask because there is so much confusion. One of the things you said is that fat is an endocrine organ, which is a surprise to me. I didn't realize it was. I know it secretes hormones and things like that.
But your presentation seems to be asking people for motivational change — how to motivate people to change. I don't think we're there.
I have heard all my life about being overweight. Kids hear it all the time. Kids are shamed in school if they're overweight, and have been for years and years and years. That doesn't seem to make a huge difference.
I'm wondering, when you hear all the health — we hear all of that, and I don't think it's a lack of knowledge. I think people are very well aware, for the most part, that they are eating badly, and they do it anyway, that they are going to fast food places and they shouldn't, but they do it anyway.
I'm not sure if you would have any suggestions about how you motivate people to be healthy. I'd really welcome that, but I think that's where we're hung up on trying to go, plus the confusion around everything that was not healthy 10 years ago now it seems not so bad. There are all kinds of things like that. The mixed messages really confuse people. I'm confused.
If you have anything at all on how we motivate people, I think that would be a big help.
Dr. Pound: Education is key, and coming at it from various levels is necessary. What we are talking about is a culture change, completely, and it needs to happen everywhere at the same time. It needs to happen in the physician's office and in the schools, as well, where too often we see in elementary schools that the treats day is pizza day. Well, that's not healthy food. All of a sudden, it's rewarding kids; we are telling kids it's great. What about a fruit day? What about giving fruits and vegetables to all the children, every day or once a week, and making it a treat as opposed to pizza being the treat?
Programs that tackle that are important, as are changes at the level of the school and changes at the level of the advertising that we see.
It needs to be targeted at many different levels at the same time, because targeting it at one level at a time will not work. It will fail, because there are so many things happening together that we really need to have a collaborative approach. That's the only way to do it. It's not an easy way, but it's the only way to get any kind of success.
Dr. Ross: I also think that we have to add back the fitness piece. It strikes me that when we look at what some of the biggest changes are, when I grew up, we'd go out and play. Now "go out and play'' means that my thumbs are going.
A lot of what we're seeing is the plethora of food that is everywhere, exactly as Dr. Pound said — coming from all angles. We have to somehow engage people back into fitness. It's a major issue in children, but also adults. Fewer than a third of adults actually hit 150 minutes of moderate exercise a week. You're looking at an hour a day, and we are asking for 150 minutes a week and we're not getting there.
You can see what happens when you make it interesting like with the Fitbit, and how many people are wearing theirs. They get hung up now on doing their 10,000 steps. When they get home, they check. I've got patients now who are getting that competitive edge. "I'm at 8,261.'' They go around the block until they hit 10,000.
That type of motivation has gotten cool, and people always are coming in now and showing them off.
The hope is that if we can try to reinforce that type of behaviour, then maybe we'll make inroads. But I agree that it's got to come from — further to your point, it is isn't one thing; it's on so many levels.
Dr. Pound: There is a lot fear associated with it. We see that in young children and families. I remember when I was a child that it was okay to go play at the park by yourself. Now there's this idea that life is dangerous. If your seven-year-old is playing alone in the front yard, they are going to get abducted.
There needs to be education. This is particularly true in more vulnerable populations — areas of lower socio-economic status. People keep their children at home and are afraid of letting them go by themselves. I don't have a solution for that, but it's a big part of the problem.
Dr. Ross: There is the impact of urbanization, too, with the loss of green space in ways we didn't have. As we continue to build and expand cities, we need to think about how those cities are being built, so that those spaces people have been using over the years are not lost.
Dr. Pound: Another reason the message should come from all levels at the same time is because of the situation that we see too often in our clinics, where I have an overweight child and I give them a prescription for exercise and say, "You need to go and walk or do all these things.'' They come back and I ask them: "Did you do it?'' They say, "Well, no because my parents didn't want to come with me.'' This really clearly emphasizes the failure on my part. I thought, wow, I should have told the parents also that they needed to do this. I think it goes back to your point of working in silos. I treated the child and I didn't necessarily think of telling the families to do this. If the message comes from everywhere, at the same time, then maybe it can become a fun activity, where we go for a walk together as opposed to the child couldn't do it because the parents were too busy eating chips and watching TV.
[Translation]
Senator Chaput: Thank you, ladies. This is a difficult committee, as we deal with very important subjects that are so broad, while having to set goals at the same time. We cannot be everything to everyone.
Can you please tell me a little more about the situation parents find themselves in, who often, when having to prepare meals, will head to the supermarket? There, they may purchase fruits and vegetables, but they may buy canned tomatoes, tomato juice and many other types of canned food. You briefly mentioned the issue of sodium, but there is also the issue of sugar, as well as saturated fats as compared to unsaturated fats, which are much discussed these days.
What are we to make of all this? What is your opinion on fats, for example? What about saturated fats as opposed to unsaturated fats? Is butter better for your health than margarine? Is tomato juice better than tomato sauce?
Dr. Pound: That is not an easy question.
Senator Chaput: I see my own daughters grocery shopping to prepare food for my grandchildren, and that is their reality. They do not have a garden behind their house as we did years ago.
Dr. Pound: I think the best way to go about it, to begin with, is avoiding saturated fats as much as possible. A high intake of sugar is to be avoided as well. Of course it is always a good idea to buy fresh produce as opposed to canned fruits and vegetables.
As for parents cooking meals for their children, their task is made more difficult by all the allergies and food restrictions imposed by schools. However, the same recommendations apply: it is best to focus on fruits and vegetables, homemade food; the more commercial a product is, the more sugar and fat it contains, generally speaking. Ultimately, it is best to stick to food staples.
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Senator Chaput: Do you have anything to add?
Dr. Ross: The question of the margarine versus butter is probably one of my all-time favourites. There is really nothing wrong with butter. At the end of day, it's probably about how much butter. That's where we get into one of challenges. Sometimes we have been led down this path that something is not good for you and go all the way over here and then people think, "well that means I can have this much of it.'' Whereas, a small amount of butter, if you are doing the other things right, is not the end of the world.
One of my challenges is the Costco challenge, and I'm not meaning to single out any individual company, but people go there and buy and we are back in the issue of labelling and the size. How many of us have opened a bag of chips and not stopped until the bag was empty? The problem is that if the bag is this size, then that's what I eat. If the chip bag is from Costco, then that's the fear. This is again about the education, packaging, appropriate labelling and portion control, which we haven't talked about really today, but I think is really important.
We can eat all the right things, eat way too much of all of them and still end up obese. It's what and how much we eat. Foods that we've been told are bad for us, in moderation, are not so bad for us, which is really what I was raised on.
Senator Frum: Dr. Pound, I want to go back to the statistics that you gave us about how 7 per cent of children between the ages of five and 11 get an hour of exercise, and 4 per cent, ages 12 to 17, exercise vigorously for an hour a day.
It's really the same territory as Senator Greene Raine raised: If the recommendation is for a vigorous hour a day for children, then that has to be done with the cooperation of the schools because when else are we expecting that to happen? Don't you think so? Again, the problem is that we're the federal legislators here, and this is not in our purview, or your purview either, as you don't control the schools — but in terms of coming up with a strategy?
Dr. Pound: I absolutely agree that part of it part of it should come from the school, but again education is key because it can certainly come from the families as well. We are in a society where children are overscheduled. Those children leave school and do an hour of skating, swimming or an hour of this. When you're actually looking at what they are doing, they are standing on the basketball court talking with peers. They're not actually doing the physical activity. They're standing on the sidelines checking their phone. But the parent, at the end of day, feels good because they did that one hour of activity. They didn't. They stood there checking phones or chatting with friends. Part of it again goes back to the cultural change that we were talking about. Maybe instead of having them enrolled in 23 activities after school, they could be enrolled in five and the rest of the time they could play at home and run around and do what children do. They don't need a special class to run; they run. That's what they do.
Senator Ringuette: Unless they are fat.
Dr. Pound: That is true. If they were running before then hopefully they didn't get there. If we can somehow change the culture and get that message across through spokespeople or campaigns then, yes, they can get some activity at school. They do already get some activity at recess as they run around and they do all their things. I think it's not just the school's responsibility, but also the responsibility of the parents to make sure that happens.
Senator Frum: By actually doing less after school, they are more focused on play?
Dr. Pound: I think so, yes.
Senator Frum: That's fine. Dr. Ross we talked about the reasons why people don't eat well. We've discussed a number of them today. We have the staggering statistic you gave us about a quarter of adults being obese. Is there such a thing as food addiction, like there is with drug and alcohol addiction? If so, can we attack that problem the way we attack other kinds of addictions?
Dr. Ross: There clearly are a whole range of eating disorders that range from frank anorexia and bulimia through to more emotional or binge eating. I believe, without question, that there can be a dependence on patterns of eating. So you can go from a very serious and life-threatening illness, anorexia and bulimia, through to probably not an actual food addiction, but more of a behaviour pattern of dependence. Much as some people say, "I've have had a tough day, so I need a drink,'' which is a pattern of behaviour — I'm not espousing that, by the way — other people will say, "I had a tough day, so I'm going to get a chocolate bar.'' So yes, there can be.
Those are some of the things — having healthy alternatives. You're reaching and you can actually reach for the vegetable or fruit. It would be nice to see a way to actually have people, if they feel the need to have the hand-mouth action, put something healthy there. It's an excellent point. I don't know how to get at that. We have been spending a lot of time and effort on other addictions and we still haven't managed to figure those out. Those are addictions where you don't need them to live. Smoking is an addiction, but you don't need to smoke to live. You need to eat to live, so it's trying to find that balance between eating right and healthy to overeating or just eating unhealthy. You still need to eat. It's a great question, and I don't know.
Senator Eggleton: Senator Tannas asked about other countries where we might learn something from how they handle these issues.
You mentioned Scandinavian countries and an exercise ethos. There are a lot of people who have come and told us that, yes, exercise is important, but it's not as important as what you put in your mouth. We've also heard people like Dr. Lustig, who told us that sugar and added sugar are enemy number one, and we've heard others who say — this is perhaps a point to your last answer on addiction — it's the creation by the food industry of the bliss point, which consists of the additives of salt, sugar and fat, to make you to eat more than one potato chip. Would you agree that the balance is more on the side of what you put in your mouth?
Secondly, what can you say about other countries, Scandinavian countries or any other countries, in that regard? What did they do in those countries in terms of food consumption that is better? I take it it's going to be a combination of both exercise and consumption of food.
Dr. Ross: The only reason I believe fitness is such a critical piece is that there is a lot of work that shows that for someone who is overweight, even in the minor obesity category, if they are fit, you can bring their risk down substantially just by having fitness. That is a critical piece to lowering risk.
It doesn't mean I'm saying it's okay to be fat. That's not what I'm actually saying. If we only solve calories and fat and not fitness, we will still have a country that is full of cardiovascular disease. I think both are of critical importance for us to get where we need to be. That's why I want to make sure we don't leave fitness off. We know that a sedentary lifestyle, physical inactivity, is another crisis in this country.
Having travelled a lot, when you go into a grocery store in Oslo, and you go down the aisles and look at the number of aisles dedicated to pork rinds and chips and chocolate, it's — you can go Oslo, Canada, the U.S. for the number of aisles that are actually devoted to foods that are, generally speaking, not healthy. It's not there. It is not as pervasive.
I think, therefore, the dietary habits are different. There is more fish in the diet. There is probably less processed sugar. That's been my experience of travelling there, and I've been fortunate to have been there a number of times.
My understanding is that Australia and New Zealand also have less obesity than we do, probably also related to changes and differences in diet and also differences in exercise. Also, maybe the climate difference, which make exercise a little more accessible, although I'm a fan of winter sports.
Many Canadians find it difficult to get out in the winter. There is a cyclical pattern to weight in Canada. Weight tends to go up in the winter months. Everybody says they'll get to it, and they may, but they don't quite get to it enough. That's how you start seeing that general rise in weight as we age.
Getting back to the point that we have to look at all of these pieces, you can't divorce one from the other, because it's a multi-faceted problem. I think it will require a multi-faceted approach.
Senator Enverga: You mentioned earlier that one thing to promote here is to give some more activity to people. One of the things that the government has made possible for parents is for them to be able to have their children play soccer through the Children's Fitness Tax Credit.
My question is this: Because there are a lot of adults who want to go to fitness clubs and all kinds of diet programs, do you think it will help if we have something we call an adult fitness tax credit? Do you think it will help? And how effective are these lose-10-pounds-in-10-days programs? Do you think it would be good as a public policy or something we can work on?
Dr. Ross: I personally would love a fitness tax credit myself. That is a really interesting, novel idea.
I know we talked about larger companies providing access to fitness equipment and that that brought some improvements. Most people, once they have a gym membership, are more likely to go than if they have no membership at all. There are still many who have memberships and do not go, but if you have a membership, you are more likely to go.
It is an interesting idea. I'm not aware of its having been done in other places. I'm sure the gym industry would like it as well. I think it's a very interesting, motivational idea. I like it.
Dr. Pound: I think it's a great idea as well, but my concern is the same as is it is for the Children's Fitness Tax Credit in that it is leaving out a good chunk of the population who are vulnerable and at risk, because they still need to pay up front and can't. It is great for the people who can, but the people who are most at risk still can't benefit from that. There is a need to look at other things for those groups.
Dr. Ross: Although you could look at it as time. They wouldn't need a membership. There would be a fitness tax credit based on time. I'm just going with the idea because I really quite like it.
Dr. Pound: It is interesting.
Senator Enverga: How about a tax credit for those lose-10-pounds-in-10-days programs or something like that? Do you think it is a good idea to do that? Do you recommend those things?
Dr. Ross: As Dr. Pound mentioned, I think a tax credit for those in need, which is really getting at the vulnerable population, would be more the type of tax credit, from a food perspective, that I would be more comfortable with.
Dr. Pound: I worry about those lose 10-pounds-in-10-days programs.
Dr. Ross: You need a full on, rest-of-your-life lifestyle change. That's the only way to approach weight. You have to make a constitutional change that you have to be able to manage and do with for the rest of your life.
From the cardiac perceptive, the risk for people whose weight goes up and down is actually huge. What often happens in those dramatic programs is the weight goes down and then up, down and then up. There is a fairly significant risk to that. We want to change behaviour, and we want it to be sustained. I like the fitness.
The Chair: There are a number of places in this area where they do have prescriptions for gym memberships, activity and so on. There is a study I read again today following up on these, and it shows that within three months of the subsidy being removed, the person is back to where they were before. It has to be continuous.
Dr. Ross: That's absolutely true. That has been shown in cardiac rehab programs as well, unfortunately, that unless people have continued access, they will slip back into previous habits.
Senator Seidman: Both of you are here for national organizations, as you've said, that represent physicians in one way or another. In the case of the cardiovascular, also scientists and not only practising clinicians. In both of your societies' mission statements, it states clearly that you advocate for improvements to public policy.
We've talked about a lot of things here today and a lot of different ideas, but what I'd like to know from both of you is whether your societies have been involved in some kinds of interventions, be they prevention or rehab, that have shown to be successful in this particular area.
Dr. Ross: That's a great question. We are not a large organization. We are an organization of over 2,000 members. We pick an area, and we focus on that area with all of our might.
We have been before the Senate previously on the access-to-care issues, which is a priority for cardiovascular medicine, and, currently, we have a great deal of focus on quality care, quality improvements and assessing the quality of care as it is delivered across Canada. So we have a large program right now, in terms of our advocacy, that is addressing issues related to quality care.
We have chosen, as an organization, to highlight areas that we think are of critical importance and try to see them through to completion, in a way of doing a bit more of that than necessarily doing the breadth of many issues.
Having said that, we have a very large and vibrant cardiac rehab group, and we have written and, as an organization, published guidelines for cardiac rehabilitation and fitness post many different cardiac illnesses. But, on the specific area of obesity, I think we are interested and engaged, and that's why we're here.
Dr. Pound: As for the Canadian Paediatric Society, we routinely make recommendations on various topics related to public health in the form of physician statements. However, on that specific area of obesity and whether we've had positive results, I do not have a good answer for you, but I'm more than happy to look into it and get back to the committee with that answer.
The Chair: Getting back to the committee, would you communicate directly with the clerk?
Dr. Pound: I will, absolutely.
Dr. Ross: Along that line, we will forward to you the Canadian Heart Health Strategy and Action Plan, which was our hope to make inroads into the areas of obesity with the recommendations that we made in 2009.
Senator Merchant: With a little help from my neighbour and friend here, I'm going to ask a different question than the one that I planned to ask.
Could you maybe talk to us a little bit — because there have been conversations here about physical exercise, about memberships to gyms — about walking? How much walking is adequate, and whether our weather patterns have something to do with that? Because it's an exercise that almost everybody can do. Even if you're obese, maybe you can't participate in very vigorous activity, but you could in that. So could you tell us how beneficial simply walking is, and how long you would have to walk a day?
Dr. Ross: It's an excellent question. By and large, the vast majority of people can walk. The recommendation would be for 150 minutes of brisk walking, which we would qualify as moderate exercise with brisk walking, per week. So that is really not hard for an adult to do.
Generally speaking, with an exercise prescription and somebody with no cardiac risk factors, we would recommend that you try to walk for 15 minutes and then add five minutes every week to every other week, until you're up to 30 or 45 minutes, and try to engage in that, in a brisk way, five times a week.
That's how you get to your 150 minutes — 30 minutes five times a week.
For people who have cardiac risk factors, sometimes they need to be seen by their physician before they engage in an exercise program to ensure that it is actually safe for them to engage in an exercise program. So, for people with a strong family history, hypertension, hyperlipidemia, smokers and diabetics, often we will ask them that they see their family doctor first to ensure that it's safe for them to engage in a regular program.
Some of those would best engage in the program through cardiac rehabilitation, where it's a supervised exercise program. As they get their exercise prescription, which is what happens in rehab, it is done with monitoring of blood pressure and signs of any issues.
When people leave cardiac rehab, they leave with an exercise prescription, and I very much endorse what is told to them, which is that that prescription is really of the same importance as any other prescription. Most of us don't think about taking prescription medications that we pick up at the drugstore. An exercise prescription at cardiac rehab or from your family doctor or from your specialist should be treated in the same way, with the same degree of importance.
It is actually very easy to get into a walking program, and it can be done at low cost. You need an environment that's safe, which speaks to where you may live.
In Canada, there are really two extremes of weather that make walking potentially difficult for people with any cardiac history, and that is at the height of summer, on the days with humidity and humidex advisory. We don't recommend that people walk in that because that actually adds a strain. In the days of bitter cold, likewise, when there is a weather advisory, we don't recommend that you walk outside.
For people in urban environments, as I always say, it's 70 degrees and sunny every day at the mall, and many of the malls in urban environments have a walking program that you can go to in the morning, before the mall opens and you eat the wrong foods. So there are often ways to do it no matter where you live, but, in some of the more remote and rural environments, obviously, you have to be cautious about the weather. But I am a big believer in engaging in a walking program.
Dr. Pound: The same is true of children. I would also very much encourage children to walk. The guidelines recommend an hour of moderate to vigorous activity, so a brisk walk would be moderate physical activity, and, again, it's a great activity that they can do with the family and in this way engage every member of the family in the physical activity.
Senator Raine: I would just add to the last comment that when you go walk briskly with your child, they are going even more briskly because they have smaller legs, so it really does work.
We really live in an obesogenic environment, and it's coming at us from all sides. Would you recommend, number one, prohibiting the marketing of food and beverages to children 16 and under, for instance, saying that adults should be making those choices and that the advertising should be targeted towards adults?
Also, in school food programs, obviously, that's very important, and many jurisdictions have excellent programs. But do you think that's something that can be legislated? Obviously, we can't do it at the federal level, but is it recommended by your organizations?
Then my third question would be this: When it comes time to measure things, you really do need to measure, and, for BMI, most people can't do the math and figure it out. But would it be that for a certain height, a certain waist circumference would put you in the different category, so it would be simple for parents to do?
Then my final thing is, do you think it should be considered child abuse to let your child get fat?
Dr. Pound: Okay. I'll try to tackle all four.
I absolutely believe that marketing to children under the age of 16 should be restricted. I think children are extremely vulnerable to advertising, and they do not have the abilities yet to be able to discriminate. To me it's a no-brainer. Absolutely, it should be restricted.
I think school programs should be very much encouraged. They should be legislated, and the reason for that, in my opinion, is that school is the great equalizer. Every child has to go to school, except for the home-schooled ones, but most children end up going to school. Children from lower socio-economic status will go to school. Children who have more means will go to school, and this is the place where those children whose families cannot necessarily afford after-school programs or other activities and get their fitness tax credit back can participate in activities. So, absolutely, I think it should be very much encouraged to allow all children to participate in activities.
As for measuring children and having a specific measure, I think that would be a bit difficult. That's where I see the role of the physician. Most children will see their physician annually. The physician should be able to do the math for BMI or should be able to do the abdominal circumference, and this is where education becomes key for our physicians and encouraging physicians to discuss those topics with the family. So they should be weighing the child, and we do know that. It is in our guidelines. Pediatricians and family physicians are supposed to weigh and measure children every year and plot them on the growth curve and decide, according to the growth curve, which is really easy to read, whether they are overweight or obese. If they are, then they should make recommendations, and, if they're not, then they should still make anticipatory recommendations. This piece needs to happen at the physician's office.
Your last question is a little touchier. Is it child abuse to let your child get fat? The worlds "child abuse'' may be a bit strong.
Senator Raine: Is it neglect?
Dr. Pound: At this point, I don't know what the Canadian Paediatric Society's position is on this, so I'm just speaking for myself. It's like anything else in medicine: If a physician has given you a clear recommendation to get antibiotics for a condition and the parents don't do it, I think they are liable for neglect if there are negative consequences.
I see this as the same thing. If a physician gives a prescription for exercise and the parents disregard that recommendation, then yes, I believe there are grounds for neglect, assuming they understood the recommendations and just didn't do them. If they tried and failed, then I guess there's a role for more education and resources. Maybe the onus is on the physician to be a bit clearer. If the recommendations are clearly disregarded, then yes they are putting their child at risk of many illnesses and adding a huge strain on the health care system.
Senator Chaput: Is milk good for children or not good?
Dr. Pound: It's like everything else — good in moderation.
Dr. Ross: Some milk is good. This is one the biggest challenges, and we don't want to forget. We have been talking about quality of food, and quantity food is an important issue. There's nothing wrong with milk, but if you substitute two litres of coke for two litres of milk, you're going to add an awful lot of calories, and you still have to look at the calorie count. It's not just the quality of food, which I think is still one of the biggest challenges, but also the calorie content and clear calorie guidelines.
Dr. Pound: Milk can lead to a lot of issues if taken in excess. Any child who drinks more than 500 cc of milk per day is at risk of multiple complications, obesity and overweight being only two. I'm going to use the opportunity to plug breastfeeding because we're talking about milk. Breastfeeding is essential in reducing the overweight and obesity epidemic.
The Chair: On Senator Raine's question of child neglect, there is another report today with regard to obesity. There've been some court cases recently over a movement to have obesity included under human rights laws to prevent discrimination on the basis of obesity. A court case I read about today was about an individual who weighed nearly 400 pounds who was dismissed from a child care facility. The courts ruled that it was not grounds for dismissal. As you know only too well, a person of that size is not able to tie their shoes and so on and deal with small children.
We have here a societal view of what is acceptable, just as those statements that it's better to be overweight than underweight drove a lot of people to think that being overweight was okay. This idea of moving obesity into a protection under human rights acts of certain countries could well have a significant impact on society's view of the issue.
Dr. Pound, I was struck by the way in which you dealt with saturated fat. You had a kind of negative reaction to the idea of saturated fat. I assume you're referring to natural saturated fat. That was the interaction in which Dr. Ross came back with the butter versus certain alternatives. Could you expand a little on your views of saturated fat?
Dr. Pound: Again, I'm going to go back to what we were talking about: the moderation piece. Anything taken in excess is going to be bad. We know that a lot of saturated fat is bad for cardiovascular health, but healthy eating and consuming a small amount of saturated fat and small amount of sugar is not going to be terrible for anyone.
The Chair: As you know, the trend had been to dismiss saturated fats as being almost acceptable within a normal diet, which some have argued in publications, including book form. That drove people into the sugar end of getting your calories and the biological issue with regard to saturated fat is very different than that of sugar. As one of my colleagues knows, as a chemist I have very dim views of substitutes for natural materials; and the impact of those has been significant.
I'm with Dr. Ross on the butter issue. I remember the first time the great rave review of some — well, I'll just leave it alone. I don't have a very high opinion of the individual who has written many books and become very rich off various diets and downplayed butter as an issue; and then margarine came along. We found quickly that substitutes were likely to be worse than the original. During the course of my lifetime, we've gone through four periods of up and down on butter.
Dr. Pound: I very much hear what you're saying. If you're going to take away one thing, people are going to start using something else that has negative consequences. The key is to have a healthy diet; and moderation is key. Have a little of everything and emphasize the importance of healthy nutrition.
The Chair: Everybody has said today in prefacing their questions, and you have certainly indicated it in many aspects of both presentations and answers, that this is a complex issue. You referred to the changes in the way society operates. Particularly over the last 30 years, there have been substantial differences in the way we all move within the social environment. Consider children and how the amount of walking they do as part of normal social interaction has dropped dramatically. It has almost become a fear that children would move anywhere in walking from A to B within a community. Some school districts have regulations such that no child can be required to walk more than one kilometre to school, so anything above that requires access to busing and so on.
I am very grateful that I didn't grow up in that era. School buses were an unknown phenomenon when I was a child, certainly living in rural areas. The vacant lot phenomenon is a very simple issue. We all played various games in a vacant lot. A vacant lot today is highly marked off and immediately being made ready for some sort of development. I'm not going to go further on this but simply indicate that what we are hearing throughout the study is about the substantial change that has occurred in life patterns from a very early age and the overall impacts are compounded in these areas.
The final comment I would make relative to things that came up today is the business of dieting. Dr. Ross, you used a fluctuating model to indicate when people go off a diet and come back. Scientific studies show the reason is that the body becomes adjusted to a certain weight. A drop in that weight changes physiology, urging the body to consume more because the physiology recognizes the higher weight as the desired value.
We have a complex situation that we're dealing with. You have been very helpful in helping us to understand that. I'm not sure you have led us closer to clear recommendations to resolve this in three easy steps. We've had a wonderful dialogue today with all the interesting issues. You have been clear and articulate in your responses to us, and I thank you for that.
I declare the meeting adjourned.
(The committee adjourned.)