Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 33 - Evidence - May 7, 2015
OTTAWA, Thursday, May 7, 2015
The Standing Senate Committee on Social Affairs, Science and Technology met this day, at 10:31 a.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. I will invite my colleagues to introduce themselves.
Senator Seidman: Judith Seidman from Montreal, Quebec.
Senator Stewart Olsen: Carolyn Stewart Olsen, New Brunswick.
Senator Wallace: John Wallace, New Brunswick.
Senator Raine: Nancy Greene Raine from B.C.
Senator Chaput: Maria Chaput, Manitoba.
Senator Merchant: Pana Merchant, Saskatchewan.
Senator Eggleton: Art Eggleton, Toronto. I'm deputy chair of the committee.
The Chair: Thank you, colleagues. I remind us all that we are here today to continue our study to examine and report on the increasing incidence of obesity in Canada — it's causes, consequences and the way forward.
To help us in that task, we have two witnesses with us today. I'm pleased to welcome them, and I will identify them as I invite them to present.
By agreement, Dr. Jennifer Blake, Chief Executive Officer of the Society of Obstetricians and Gynaecologists of Canada, will present first.
[Translation]
Dr. Jennifer Blake, Chief Executive Officer, Society of Obstetricians and Gynaecologists of Canada: Honourable senators, thank you for inviting me to appear before your committee.
[English]
This is a very important topic, and we're pleased the Senate is giving it attention.
Honourable senators and committee members, it is a pleasure to stand before you and to be given an opportunity to speak on the issue of obesity on behalf of the Society of Obstetricians and Gynaecologists of Canada.
As the SOGC's mission is to advance the health of women, I will be focusing specifically on the causes and consequences of obesity for Canadian women.
A quarter of women in Canada are overweight and close to a fifth are obese. As you know, being overweight and obese is associated with many chronic diseases, including diabetes, heart disease and some cancers including breast and endometrial cancer. In fact, it is estimated that a third of all cancers can be prevented by eating well, being active and maintaining a healthy body weight.
In the press, although we hear, for example, that menopausal hormones cause breast cancer, or is associated with it, obesity causes an increase of risk of the absolute same amount, and yet that is not on anyone's radar.
Of course, diet is very much linked to these astonishing rates of obesity and the associated morbidities. Our Western-style diet is a significant contributor to excess body mass, as well as to obesity, type-2 diabetes and heart disease.
The key to reducing overweight- and obesity-associated morbidities is prevention and improving diet and activity levels, but a weight loss of 5 to 10 per cent can be very meaningful. Diet not only reduces the risk of obesity — and here I'm not talking about weight-loss diet, but healthy eating — but can also play a role in reducing other symptoms associated with women's health. For example, women in China, Singapore and Japan have arguably lower menopausal symptoms due to a low-fat and high-fibre diet.
Encouraging women to eat healthily, to increase their activity levels and to participate in regular exercise is not as simple as it may seem. Many factors contribute to a person's ability to provide healthy food to themselves and their families, including their physical ability, mental health, cognitive ability, dental health, poverty, cultural factors and patient preference.
Food security is a significant issue for many people in Canada, particularly those living in rural communities and in the North.
Similarly, external factors such as the surrounding physical environment can play a critical role in a person's ability to engage in a healthy lifestyle: the presence of parks, recreation paths and green space and secure spaces to be outside.
Social determinants of health such as housing, economic opportunities and food security are related to excess weight gain in pregnancy. When securing safe housing for the night and putting food on the table are significant concerns, nutritional content of that food may not be a top priority.
In addition, stress itself changes our metabolism of fats and increases our tendency to weight gain. Socioeconomic stress is a compounding factor in obesity.
Improving access to healthy food and reducing stress related to socioeconomic factors can improve a women's physical, psychological and emotional ability to eat a healthy diet. Addressing the social determinants of health is also critical to improving many pregnancy outcomes, including those related to a healthy body weight.
Given the many health impacts of obesity and the challenges associated with sustained weight loss, adolescence is a critical period for developing healthy lifestyle patterns. You've already heard that one fifth of Canadian children between 5 and 17 are overweight and 12 per cent are obese. In teenage girls, obesity can lead to menstruation irregularities, low self-esteem and slower development. Factors associated with overweight and obesity in adolescents include lower intake of fruits and vegetables, excess consumption of sugar-sweetened beverages, low fibre intake, skipping breakfast, eating out often and increased sedentary activity.
Many adolescents are moving into adulthood without having learned about nutrition and food preparation in school, where I wish that it were compulsory, or from their families. Fewer and fewer families eat meals together, yet research indicates that adolescents who eat meals with their family perform better at school, have a lower risk of substance abuse, demonstrate superior social adjustment and have a more positive personal view of their future.
In all women, overweight and obesity can have a significant impact on fertility. Overweight and obese women often have few or no ovulations, resulting in subfertility, as well as other health issues as to energy balance and altered hormonal functions . Obesity is associated with increased androgen levels, impaired glucose tolerance, menstrual irregularity and infertility. These symptoms are often seen in women with polycystic ovarian syndrome, something that was probably beneficial to women before food became available and superabundant.
Fifty per cent of women with PCOS now are obese. As with weight loss throughout the life span, a weight reduction of even 2 to 5 per cent can result in significant clinical improvements, including improved metabolic and reproductive function.
A third of women in Canada enter pregnancy overweight or obese, with a BMI greater or equal to 25. This puts them and their unborn babies at an increased risk of several poor outcomes, including gestational diabetes, caesarian delivery, large gestational age, high birth weight, preterm birth and congenital diseases. Babies born to women who entered pregnancy overweight or obese are less likely to be breast fed and more likely to be overweight as children. They are also at increased risk of long-term chronic health diseases.
Although many women may still believe they should eat twice as much during pregnancy, a more healthy recommendation is to eat twice as healthy. Increases in energy requirements during pregnancy are modest. No increase during the first trimester, and only 340-calories a day in the second and 450 a day in the third. Two or three Canada Food Guide servings a day is all women actually need in pregnancy to provide for their growing baby.
The amount of weight gained during pregnancy is largely determined by pre-pregnancy BMI, thus further emphasizing the need to achieve and maintain a healthy body weight in early life. Overweight women are three times more likely to exceed weight gain recommendations and healthy body weight comparators. And entering pregnancy overweight or obese, combined with excess gestational weight gain, further increases the risk for adverse pregnancy outcomes, including gestational hypertension, preeclampsia, gestational diabetes, Caesarean section delivery, postpartum weight retention, a large baby, increased risk of preterm birth and more.
These adverse pregnancy outcomes increase the risk of gestational diabetes, increasing the risk of hypertension, preeclampsia, Caesarean section, prediabetes, type 2 diabetes and then five to 10 years postpartum progression of retinal changes, fetal malformations, neonatal hypoglycemia, macrosomia, growth restriction, shoulder dystocia resulting in birth injury, high bilirubin in babies — this list is endless — neonatal mortality and then increased risk of that baby for obesity in type 2 diabetes.
This is one of the largest causes of increased risk of Caesarean section. Overweight women do not deliver well. I'm just back from the United States where obesity has been a major contributor to the doubling and tripling in maternal mortality rates that are being seen there. The increased health consequences from adverse pregnancy outcomes also means increased costs to the health system in additional health care resources for both the baby and the mother.
Research supporting the importance of in utero nutrition is growing. The body of research indicates that in utero nutrition may program the development, metabolism and risk of chronic disease during adulthood for the growing fetus. Babies born to mothers who gained excess gestational weight are more likely to be overweight as children and adults and have a higher risk of developing illness. It is a multi-generational risk.
Overall research indicates that excess weight gain now increases the risk for that child of overweight obesity by 30 to 40 per cent. In considering the way forward, it is important to recognize pregnancy and adolescence are two key intervention periods throughout the female lifespan, with high potential for reducing obesity and improving health outcomes, for not just the women before us, but for future generations.
From a public health perspective, we need a national nutrition strategy for adults and pregnant women. Pregnancy is a critical period for intervention to reduce these long-term intergenerational impacts. Women who are made aware of pregnancy-related weight-gain recommendations early in pregnancy and have access to information and support are more likely to gain the appropriate amount of weight during pregnancy. Gestational weight gain is also influenced by the living and working environments, by access to healthy food and by opportunities for physical activity, family and partner support.
Pregnancy is a key period during which to facilitate lasting intergenerational change. Facilitating access to education and reducing barriers to a healthy environment during this critical window should be a public health priority. Given the intergenerational impacts of pre-pregnancy weight and gestational weight gain, efforts to reduce obesity must start before women become pregnant. Adolescents need to be better educated about nutrition and food preparation.
If we can improve the nutritional health and knowledge of adolescents perhaps we can prevent them from entering pregnancy at an unhealthy weight and arm them with the knowledge and skills to improve the health of their future families.
It is also critical to address the needs of vulnerable populations in insuring food security for all Canadians. By doing so, we magnify our impact and improve not only nutrition and obesity issues, but simultaneously improve other pressing social health concerns.
Lastly, we call on the Canadian government to invest in the establishment of a national maternal health database, including mortality and morbidity reviews and surveillance. By having access to reliable data, we can strategize for more effective and comprehensive interventions. It is only by that process that the Americans have been able to identify that it is obesity that is now driving the increase in maternal mortality in that country. In the U.K., a similar robust process enables them to do meaningful analysis of these numbers.
At the SOGC we provide health professionals with key recommendations on how to consult to their patient's. We are currently working on a clinical practice guideline regarding female nutrition throughout the lifestyle. We also just launched a public education website on pregnancy so that women can access the evidence-based information from health care experts.
The International Federation of Obstetrics and Gynecology is also focusing on this issue stating that maternal nutrition is a public health issue because of its significant impact on women and future generations. They will soon be releasing international recommendations on adolescent, preconception and maternal nutrition. SOGC and its members are well placed to improve the intergenerational cycle of health that is passed from mother to child, but we cannot do it alone. We welcome an opportunity to work with your committee on this important issue. We applaud you for taking your time to learn more about the effects of obesity on the health of women and their families.
The Chair: Dr. Dent, if you would please begin your presentation.
Dr. Robert Dent, Physician, Canadian Association of Bariatric Physicians and Surgeons: I would like to thank you for inviting me. I'm really happy to see that this subject is being entertained by this group. I represent the Canadian Association of Bariatric Physicians and Surgeons. This is an organization that started in 2006. Its mandate is to bring together physicians and surgeons with a special interest in bariatric medicine and surgery: to advance knowledge; to facilitate and foster research; to provide and support continuing educational programs; to develop policies and innovative approaches in clinical care; to represent the views of bariatric physicians and surgeons of Canada; and to facilitate communication with the public, the medical community, the ministries of health at all levels of government to promote awareness of the health risks of obesity and severe and morbid obesity, the financial and health burden, and so on.
Dr. Blake has presented the statistics beautifully. There is no disagreement there at all. There is a disturbing trend, though. The disturbing trend is that the Canadian map showed a lot less prevalence of obesity in 1985. Then when we turn to 2004 and we see that the obesity levels are hovering around the 25 per cent mark. The overweight state is about half of this Canadian population.
The prevalence of obesity in OECD countries, from 2004 to 2008: we find we're about No. 4 in the world. The U.S, in this particular study, is No. 1; Mexico and New Zealand are apparently ahead of us; we're No. 4; and the U.K. is very closely behind us. When you get the actual colour version of this, you will see some of these are self-reported measures and some of them are weight measures, which are always higher than the self-reported ones.
So we have to face the facts: one in two Canadians are overweight; and one in four are obese. Obesity causes one in 10 premature deaths amongst Canadian adults, 20 to 64, when we shouldn't be dying. Obesity in children and adolescents has tripled over twenty years.
What's the status of bariatric medicine in Canada? I have attached a series of research that has been done by Marie-France Langlois in Quebec. This is a series, but the summary comes on the next page. It's that grid. It shows that we just don't have very much in the way of treatment facilities for weight. We're talking about something that is prevalent by 20 to 25 per cent. This makes it the most common chronic medical condition in this country. Yet our treatment facilities are really inadequate.
How did this epidemic come about? We have an epidemic. We have an increase in prevalence, and we go back to the old idea of energy-in versus energy-out. Energy-in is the food we eat; energy-out is the exercise and energy expenditure that we do.
Let's walk through this. Some interesting things start to fall out of it. First of all, energy intake in the U.S. has probably actually gone down from 1940 to the turn of the century in 2000. These are from population studies. Alison Stephen reports this in a humorous way. They do calculations where they calculate the food produced, they add to it the food imported, they subtract food exported and then randomly select garbage cans and see what's wasted and subtract that. And it's suggested the food intake is actually going down. This has also been done in the U.K. and the two studies are population studies showing roughly the same thing. So energy in is obviously permissive, but it may not be the sole cause.
What about energy out? Let us look at the prevalence of inactivity. Peter Katzmarzyk, when he was at Queen's, actually looked at the per cent of the population exercising less than 3 calories per kilogram per day. That works out to be about 210 calories per day. You'd have to walk about 3 kilometres to do that. He finds that more and more people are doing that across two decades, from the 1980s to 2000. So if you look at planned activity, it looks like it's going up.
So what's happening here? We have to look at some social history. I was in Mexico, it was an unusually rainy day and there were some old magazines around. There was a Life magazine from 1955 advertising the electric typewriter. If you look carefully at this politically incorrect ad — the woman secretary and the male boss — anyway, don't shoot the messenger — she's saying to her boss, "I'm delighted with my typing machine, and the IBM people tell me that it takes less energy to type all day on this than it does to type 20 minutes on a regular one.'' If you do the calculations, this person would gain four pounds a year if she didn't otherwise alter her diet. As we add pieces of technology, we see on the slides that the extension telephone, which is good for around two pounds a year; the garage-door remote, another two pounds; the TV remote, 10 pounds a year.
We're seeing this subtle syphoning of energy expenditure out of our society, and then it stopped being subtle with the invention of the personal computer. Then people were gainfully employed and worked all day long and would go home and be on it all night long, and there was almost no energy expenditure, other than the requirement to raise your body temperature about 10 degrees Celsius above ambient and keep your heart going. So there's been an amazing decrease in physical activity in our society.
Then the more important question to me is: Why are we not all overweight? The more interesting statistic there is that 75 per cent of us are not obese and 50 per cent of us are not overweight. This is the mind of a researcher thinking. This is my own research being as I'm personally interested in the genetics of obesity.
When we look at the routes into obesity, we see overeating, and decreased activity is a huge factor. We're seeing our genes. There are 600 regions the human gene map that have something to do with our weight. If we have one or two powerful ones, we will have to work so much harder than other people to manage our weight. And if we have a bunch of weak ones, the same thing might happen.
So we start talking, not just in terms of point mutations, but gene loads — genes that may be chemically altered so they don't do the same thing.
This happens in your field, Dr. Blake, when you have a mom who is starved, her fetus is going to develop very thrifty pathways, and that person will have a strong chance of being obese later on in life. So it's not just the overweight mother, but the underweight one or the smoking mother, who now has a placenta that doesn't work very well.
There are genes, and that's my favourite area but I will leave it there.
There are drugs; doctors prescribe drugs to people. Certain psychiatric drugs cause huge weight gains, and there are viruses that will do it. If anyone wants to explore that, we can do so.
The basic conclusion here is that obesity is not practising two of the seven deadly sins, sloth and gluttony. It's a complex issue. There are dangerous morbidity and mortality possibilities.
It's the last frontier for legal discrimination. You can be discriminated against because you're overweight. You may not get the job you want and that you're eligible for. It's a population issue.
The take-home message is that there are two problems: One is a patient issue, and that needs to be taken care of in a doctor's office. We need better tools there. Then there is the population issue. So we go back to our energy in and energy out. We turn the seesaw to the side, which is this last slide, and it shows all of these other things that are feeding into this epidemic. We have the biological things that are happening in individuals in our population, but we have a population that is being subjected to an environment that so conducive to weight gain.
Dr. Blake, you brought up some of these nutrition issues. You talked about stress. I think you also talked about safety issues and physical activity. It used to be kids walked to school. Now they get driven, because parents are concerned about them. There is a whole litany of influences in our society.
That's why I am so glad this subject is being entertained, because we as physicians have to deal with the obese patient, but you are policy-makers and you're the ones who are dealing with the factors that are going on in this population. A few have been done — those little grids on the backs of things you buy in supermarkets that tell you the calories and grams of protein and so on. And restaurants now are doing that.
I leave you with that.
The Chair: I will open up the floor to my colleagues for questions.
Senator Eggleton: Thank you both for being here and for your presentations.
Dr. Blake, I'm glad you mentioned the social determinants of health, such as housing, economic opportunities, food security, and the impacts these can have on a person in terms of their diet, exercise and their general lifestyle, and how that can affect people's obesity or overweight situation.
I haven't seen any statistics in terms of people in poverty or with low income — the Statistics Canada stuff is done on income quintiles. Do you have any information in that regard that you can give us in terms of whether there are higher impacts? I would expect there are higher impacts on low-income people, but are there any stats?
Dr. Blake: There are. These aren't Canadian stats because, as I alluded to, we don't have that kind of database and we don't do the confidential inquiries and the analyses done in the U.K. and the States, so I have to refer to their data. But it shows clearly that obesity — and I'm talking in pregnancy here, and I do think there is good and robust data to show that lower socioeconomic status is highly correlated with risk of obesity.
That is because of a number of factors: access to grocery stores, the pricing — it is well known that common foodstuffs are priced differentially in poorer neighbourhoods, so there is a price barrier to some of the healthful and fresh foods we might take for granted in our neighbourhood stores. In the States, they are seeing an increase in maternal mortality disproportionately associated with obesity and among vulnerable and identifiable minority groups, particularly cardiovascular disease. In the United States right now, the risks in some states are extremely high for women. You can look at maternal mortality and the contributing factor of obesity, and not only is it present but it's also shown by degree of obesity. So the more obese you are, the higher risk of maternal mortality related to cardiovascular complications.
This is also biological because of the impact of stress on cortisol and fat metabolism. So it truly is a vicious spiral downward that women find themselves in.
Senator Eggleton: In terms of our research in this, if we can get information about the obesity statistics as they relate to Statistics Canada's income levels, I wouldn't mind seeing it.
You also mentioned that from a public health perspective, we need a national nutrition strategy for adolescents and pregnant women. Has a lot of work already been done on this by your association or other associations? What is needed to get this moving forward?
Dr. Blake: There is work. We are in the process, and we'll be soon ready for publication, of putting together nutrition guidelines for women. We've focused on women. We have women across the lifespan. We are dealing with both adolescents and women. We can only produce a guideline. The barriers between dissemination and uptake really require policies and assistance throughout the levels of government so we can institute meaningful change through guidelines we've produced.
Senator Eggleton: Would this be a logical lead for the Public Health Agency of Canada.?
Dr. Blake: Logical and a great partnership potentially.
Senator Eggleton: Dr. Dent, you've given us an outline on why you think there has been this increase over the years, with some good charts and maps and an interesting photo of a cat too. As you point out, we're policy-makers. We're part of the policy-making regime. What policies do you think we should be looking at from a federal perspective or even advice to the provinces in terms of this issue?
Dr. Dent: I don't have answers for you. There are more questions. First of all there needs to be a lot more research into what's happening in our society. My own personal view, and there's a little bit of evidence to support it, is that those grids on packages in the supermarket do help. I think the early research on this has been kind of disappointing, but certainly for us, dealing with the treatment of obesity, it's a really nice way to teach people. I think you'll see improvement along those lines.
The restaurant menus containing not only the cost in price but the cost in calories and things like that are really important, as is anything that can be done to try to improve physical activity. Sometimes those things go well and sometimes they don't, but we really need to have some guidance on just what should be done about encouraging physical activity. I think ParticipACTION used to help somewhat. We don't hear much from that anymore.
There have been some tax breaks on hockey equipment and so on, but that may actually increase the problem because now parents are going there, sitting down and watching their kids play hockey. I wish I had some really good answers for you, but I have many more questions.
Senator Eggleton: Let me throw one at both of you here, and that's marketing and advertising directed toward children, television advertising, for example.
Dr. Blake: I'm not as familiar with that literature as some, but there seems to be pretty robust evidence that advertising works, which is why it's such a big industry. Unfortunately, it is much harder to gain traction with some of the public health initiatives that we do. I think there have been good initiatives such as reducing the advertising of junk foods to children, and I think that would be beneficial.
If I could piggyback onto the other things that can be done, we can look at building codes so there are accessible, welcoming staircases when you walk into a building instead of having to go off into the grimy corners and find a fire exit you can walk up if you would like to climb stairs. There are many things that can be done at a policy level that would facilitate activity. I want to emphasize Dr. Dent's point that it's not going to the gym that matters; it's incorporating activity in everything we do.
Dr. Dent: I have an example of that very thing at the Heart Institute. They have put lovely paintings in the stairways, they're clean. The Ottawa Hospital hasn't done that and the stairways are never used, whereas they're always used in the Heart Institute. These are related institutions. There are things like this that are quite important.
On advertising directed at children, again, this isn't my area. But children watch a lot of television, and trying to change the folkways and mores of our population will be important. I think children have been swayed the opposite way because while it was their parents who dealt with desktop computers, today they're using smartphones and things like that. But that can be turned around too, because we also have smartphones that track activity, and maybe there could be some traction there.
Senator Seidman: Thank you both very much for your presentations.
Dr. Blake, in your presentation, you talked a lot about diet, meaning healthy eating. Then you used language that I'd really like to ask you about on prevention, research, education of public and professionals. In fact, your society produces national clinical guidelines for both public and medical education on important women's health issues. To me, these are all very important aspects of this issue, based on what we've heard from previous witnesses.
When you talk about, for example, pregnancy and the importance of healthy eating and healthy weight gain, I think of all the prenatal classes that are given these days. What can you tell us about the guidance that your society offers to the public, to physicians on this count?
Dr. Blake: We do have a documented guideline on obesity and pregnancy. We are just about to publish our guideline on nutrition throughout the lifespan, which includes pregnancy. We have a public website that includes information on nutrition for women and we of course worked with the Canada food guidelines and Health Canada to derive many of those recommendations. This work has all been supported by the society, and yet I think it is in the public interest to be doing the work on nutrition.
What we are seeing, and I think we have to be very concerned about this as a society, are the more affluent moms being very concerned and very particular about what they're eating and scrutinizing every mouthful to the point of almost being anxious about everything, the potential harm. Then you see other segments of our society where perhaps mothers have little hope for themselves. So it's very hard in that situation to have hope for the next generation, where access to food is difficult, where fresh food is hard to come by. So we're seeing a real polarization in health status in pregnancy which, as a society, I think is a real worry.
Senator Seidman: Your society is obviously working in an evidence-based approach in this field, and you do make reference several times in your presentation to interventions that are supported by evidence-based research. You say that research has demonstrated that women who are made aware of pregnancy-related weight gain recommendations early in pregnancy and have access to information support regarding healthy eating and physical activity are more likely to gain the appropriate amount of weight during pregnancy.
Could you point us to successful intervention research that demonstrates that? Because in order to make actionable recommendations, you want to have some evidence, and this is the kind of evidence we'd be looking for.
Dr. Blake: Can I send that along to you?
The Chair: Yes, to the clerk.
Dr. Blake: I'd be very happy to do that.
Senator Seidman: Thank you very much.
Dr. Dent, if I might ask you about the bariatric surgical procedure itself. Talking about evidence and evidence-based practice, could you tell me, please, what research has been done that demonstrates that this procedure has any long-term impact on patients' weight stability and health?
Dr. Dent: Yes. First, there are many different bariatric surgical procedures. The one that is best studied is the Roux-en-Y gastroplasty. The top of the stomach is made smaller and severed from the main part of the stomach. It's joined up to the small intestine about a third of the way down. So people eat less, but the major way it works is they're bypassing that old stomach and about a third of the small intestine. They don't absorb as well. The third thing that happens is gut hormones change dramatically.
This is the most powerful intervention that we have. The expected weight loss, from the Swedish obesity study, is about 37 per cent of the initial weight.
The other advantage of this is its impact on Type 2 diabetes. It's essentially a surgical cure for Type 2 diabetes. With that procedure, the diabetes goes away in about 85 per cent of people.
Now, I don't have at my fingertips the actual bibliography of the research, but there is a very good evidence base that it is a good long-term solution. There's also an evidence base that there's a failure rate, and there's long- and short-term failures here. About 20 per cent of people do regain some weight afterwards. No matter what they do for the first 18 months, they're usually losing weight. They then stabilize and then there's a creeping up. For about 10 per cent of people, it doesn't work. If you'd like the evidence base, I can try to find that for you, but that's a synthesis of the evidence that there is.
The Chair: If you could send us a reference document or an appropriate website, that would be great, and again, to the clerk, please. .
Senator Merchant: Good morning, and thank you.
Dr. Blake, you suggested that one thing the government could do is to set up a maternal health database. First, have you approached the government to do that? I mean your organization, not you personally.
Second, what exactly would that involve?
Dr. Blake: We have had discussions with the government about this, and right now statistics are not shared nationally. It would mean each of the provinces agreeing to share their data, and it would mean using federal resources to compile the data. Also, the models that have worked successfully in other countries are to have the involvement of the professional society, as well, to help with the analyses.
It means sharing those data. It also means doing a review of the antecedent, direct and contributing causes for the loss of each mother's life.
In Canada, we are fortunate that we don't lose a lot of women's lives, but we are seeing the same trend we have seen. The data most recently released shows that not only have we slipped from 19th to 20th place in the world, it's not because other people got better; it's also because we got worse. We have a lot of factors that are contributing to that: increasing maternal age. Increasing maternal illness at the time of pregnancy and obesity are two that we're very mindful of.
We often think of increasing maternal age as a mother's choice. It seldom is. This is societal. We don't see many women who are choosing to defer having their babies until they're worrying about their last window closing. It's relationship issues, employment issues. There are many issues that contribute to this phenomenon, but it's not good for women's health.
If we aren't collecting those data and analyzing the causes, we're not able to impact it. If we're not measuring it, we can't change it, so this is an urgent need.
Senator Merchant: I understand that. Is that now relating directly to the study we're having on obesity?
Dr. Blake: It's a separate but related issue.
Senator Merchant: May I ask you whether new doctors are getting better training in informing women about the difficulties with obesity?
Dr. Blake: With obesity?
Senator Merchant: Yes. I refer to women who are to become pregnant or of an age where they might be thinking of having children — I think you mentioned that — or women who are pregnant. In the past, colleges did not really train physicians to be sure to inform women of all the adverse effects of obesity on their infants.
You identified two stages. I think one was during pregnancy; the other was adolescence.
Dr. Blake: In general, there is a greater awareness of the health consequences of obesity amongst medical students and trainees now than there was when you or I trained. I think we trained probably at similar times.
Does it happen in every interaction with every patient? There are so many things that are being discussed in short periods of time. Oftentimes, people are reluctant to bring it up because they don't want to be seen as lecturing their patients, and there are people who are overweight and can feel quite sensitive about how the issue is raised.
It's a sensitive conversation. You bring it up with a teenager who already has low self-esteem, and she now feels that you're also calling her fat. It can be very damaging.
These are not easy conversations to have, and they require skilled time and training and a trusting relationship in which to have them. It's not one person who is going to do that; it's an overall collective responsibility, I believe. It doesn't take away from our responsibility for our piece of it, but it's not simple.
Senator Merchant: Dr. Dent, we have been told that obesity is an epidemic. Is it an addiction? With other addictions, like alcohol, we have, let's say, Alcoholics Anonymous. We have organized ways in which people can seek some kind of solution or help each other. With smoking, I see ads for the patch or ways to help people.
You are interested in helping people who are obese. I know of the work that you do.
What do you think? Whether this is an epidemic or an addiction, I know you're trying to do something. You have developed a program. I see a lot of ads on television for diets that people are promoting, but you have a bit of a multi-faceted approach. It's not just a diet, but you deal with other things. Maybe you can tell us something about it.
Are we in need of developing something that people can avail themselves of? A few people can take advantage of your program, but what about the population at large?
Dr. Dent: First, about the question of epidemic, what we're seeing is an increasing prevalence. It's not an epidemic like an infectious disease would be. It is, rather, this removal of activity out of our society. I think most of us working in the area feel that that is the major contributor to the increased prevalence.
The next issue that you asked about was: Is it an addiction? Usually addictions are acquired. Yes, there's a genetic tendency to become addicted to alcohol or cigarettes or what have you, but they're usually acquired. This one is different.
Remember that 600 regions on the human gene map have something to do with our weight? About 70 per cent of those act centrally in the brain, and usually they have to do with problems with satiety. People who are thin may eat the exact amount and then feel full and not want to continue, whereas people with certain of the mutations will not feel satisfied until they've had a thousand extra calories, and of course they become overweight.
This then comes across in the public eye as an addiction; they're addicted to food. Or it comes across, in older language, as basic gluttony. But the problem is that it's a genetic thing, and these people cannot feel satisfied until they've eaten to excess.
No, I don't think it's an addiction. In fact, there's good evidence to say that it's not.
Then what about treatment programs? At the Ottawa Hospital I started a program in 1992 and it has grown into a combined program that uses all of the known long-term treatments to manage weight.
Remember, obesity is a chronic medical condition. It's very analogous to hypertension. People with hypertension know that their blood pressure is treated as long as they take the medication. Unfortunately, we're not as far advanced with obesity. Only as long as we keep up the intervention is the obesity managed.
So the only three long-term interventions we have would be learning lifestyle skills to compensate for the genetic factors or the other factors that are going on inside of us. So we're actually having to learn techniques to compensate for those. That's lifestyle modification with respect to food intake and physical activity.
Two would be drugs. We're just at the dawn of time when we're starting to get some. The Americans have four; we have one, which isn't quite on the market yet.
The third would be bariatric surgery, where we alter gastrointestinal physiology. So that, then, is the long-term intervention. Our clinic deals with all three of those long-term interventions.
There are other clinics around, which I won't mention, that look on weight as losing weight, and then there's nothing for the long term, and those I would be very critical of.
That's what we've accomplished there. It works. It's not very widespread. We were the first ones, I believe, in this country to have a combined program that dealt with all three of the long-term interventions.
Senator Merchant: You have pointed to the genetic factor. I am wondering whether that has changed. Because you have given us statistics that show that obesity is getting higher and higher. Has the genetic component changed, then?
Dr. Dent: Right. That's a very good question, a very sophisticated question: Has the genetic material that we have changed?
If you take a look at the base pairs, it hasn't. So changes there would be — I don't know — 30,000 years before we would start to see those actual genetic codes changing. But what can change is what's attached to them. If you acetylate or methylate them, they do something different, and that can be done in the environment.
This is where fetal malnutrition comes in. This was learned in the Netherlands during the Second World War, when pregnant moms were eating 400 calories a day, and it wasn't very nutritious; it was tulip bulbs. The Dutch, keeping very good stats, realized that, 25 years later, that segment of the population had an unbelievable prevalence of obesity, and they tracked it down. These are called epigenetic phenomena.
That's why this question is a very sophisticated one, because we're now starting to realize that those genes, even though the base pairs are the same, they can be changed so they do something different.
The one we are now starting to have questions about is smoking mothers. For the last two decades there have been real warnings on cigarette packages about pregnant moms not smoking. When pregnant moms smoke, that placenta gets damaged and it's no longer giving that fetus the right nutrition. We often refer to these as "small for dates'' babies. Those "small for dates'' babies are at real risk for obesity later on, and it's through this modification of our genes. Now, that has to be fleshed out more.
Dr. Blake: We know that these epigenetic changes are also caused by chemicals and other things in our environment and potentially in our food chain. Canada showed leadership in banning BPAs, which we know cause epigenetic changes, but there may be others in our food chain that we are unaware of.
The Chair: I think the important part of the answer is that the fundamental genetic character of the human structure in these areas is not known, but the epigenetic factors are the issues that they're emphasizing. I think it's very important for us to maintain that distinction.
Senator Stewart Olsen: Fascinating discussions. Thank you so much for this.
When we decided as a society that smoking was extremely harmful, we decided to take a very pejorative approach. In other words, we said smoking is harmful to your health. It's on all cigarette packages. It's everywhere. And it was pretty much the norm; smoking was pretty much the norm for people.
It's harder to do that with obese people or with people who are even overweight, because of the sensitivity. It was interesting that you mentioned we don't want to hurt people's feelings.
Do you think maybe we should go that way, that obesity is harmful; it causes this, this, this and this; show pictures; it's going to kill you? There's a whole school of thought out there too that says: No, it's not. It's fine.
Dr. Blake: I don't think we can say it's fine, but I also think it's very hard to say obesity will kill you, unless we have really good things to offer that we're going to do about it, and our tools are very limited. You probably know the data better than I, but apparently if you hit 18 and you're obese, the likelihood is that you will remain obese in spite of anything that we do.
These critical opportunities is when we have to intervene: during pregnancy, childhood and adolescence. If we wait until we end up in Dr. Dent's clinic, we're chasing the tail end of the bell curve, but we've missed the boat.
Dr. Dent: I wonder if I could add something to that. I would find that approach very favourable if we were all starting at the same starting line, but we're not. If you have a gene load to be overweight, heaven help you. You may never get to a normal weight, no matter how hard you work at it, and we've got to wake up to that.
Let me not criticize the smoking thing, because that has worked. In one of the supplemental slides, you see the very sexy ad from the 1950s of somebody smoking and how wonderful it was; and then you see the side, where somebody has to hide behind an architectural detail of a building to do that.
We can use some of those things, but I think we have to be kindly about it. Remember, obesity is the last frontier for legal discrimination, and I don't think we want to be discriminatory.
Dr. Blake and I are really on the same page there. You have been very careful about communicating the idea of how we have to be very compassionate and kindly to people who have a weight issue.
Senator Stewart Olsen: I would say, though, that we are compassionate and kind, and it's not working.
Dr. Dent: You have shown this by your action. You're here. But it may be that that model has to be altered.
Senator Stewart Olsen: The next question I have, which I found fascinating, is your small allusion to the viruses and also to changing gut physiology. Could you expand on that just a bit?
Dr. Dent: Sure. This is an interesting story from a research standpoint. There was an MD in India, whose name was Nikhil Dhurandhar, who was having a session with one of his buddies who was a vet, and said, "You know, there's a virus in chickens that causes weight gain.'' Of course, that became very popular in the agri-industry because now you could get chickens fatter sooner.
He started to look at it in humans. He did find the virus, adenovirus type 36. There are a few other related ones, and they affect the stem cells that can go into fibroblasts or whatever they convert to, adipocytes; and those people are much more likely to be overweight or obese then, and it's out of the blue.
He finally was able to get some of these papers published — because it was such a weird thought — and now he is head of the infectious causes of obesity at the Pennington institute in Louisiana and is a very respected scientist. But it's a wonderful story.
There are also issues of gut bacteria. There is a whole area that hasn't been explored and that is some of us can absorb food well in our intestines; some of us cannot. That is an untouched area — probably because it's difficult to work in that area and you have to deal with stool samples, which lot of people don't like. It's an untouched area.
Senator Raine: We appreciate your being here. It is easy to say don't smoke, it will kill you, but you can't say don't eat, it will kill you. We have limited tax dollars to spend on how to eat healthy and are up against massive budgets marketing unhealthy things. Do you think, as a policy, we should look at warning labels on empty calories such as sugar sweetened beverages? We did them on cigarette packages. We need to do something other than the label on the back of the product. We need to somehow help consumers avoid things.
Dr. Blake: Certainly labelling helps. It helps those who are interested and concerned, and you can never argue against that. Some grocery stores have started to put indicators on nutritionally valuable foods. They're the ones found on the outside perimeter of the store; that's been the story.
I'm a great fan of labelling. If I go to a fast food restaurant that has labelling, I'm more likely to turn on my heels and say I don't want anything. It is effective as a strategy.
Dr. Dent: This can be explored further. The Swedes have done it by putting a green symbol on healthy foods. I like the idea of a consumer-centred thing. That's why I like the idea of menus at fast food restaurants or labels at the back. There must be work on knowledge dissemination on those things. When people look at how effective they are, they come up with bad stats or see it as ineffective, but it's partly because the knowledge dissemination has not been there. I think there should be more work on that. I like the idea of putting these symbols on food.
We have to be careful. Remember, there are 600 regions in the human gene map, so we cannot generalize across obesity. A low fat diet might be fine for some people and a low carbohydrate diet would be better for another. Still, there are a bunch of foods that are pretty bad no matter what kind of genes you have.
Senator Raine: I asked about beverages because the WHO has said that no more than 5 per cent of your calories should be in the form of added sugars. It's currently at 10 per cent, but they're moving it to 5 per cent. I don't think we have a recommended level in Canada.
I don't think most people realize what happens if you drink a pop every day. Many people drink more than one. I think that, somehow, we need the tackle that. We have heard from the Canadian Beverage Association that they completely disagree, and science doesn't support a specified focus on added sugars in relation to obesity, looking at the information they gave us.
As public policy-makers, we are influenced by people whose business is to sell these products. The business case needs to come up with some response from science and the medical field to help us make these policy decisions.
Dr. Blake: If we look for any one factor to be the thing that will do it, it won't.
This is complex and we would be well advised to look at the complexity theory as a way of trying to figure out what we will do. It's intervening on many different factors with a deep understanding of the preprogramming that we have. We're programmed genetically to live in a time of food scarcity. We aren't programmed for the lives we have now. We are programmed to have to work hard every day of our lives to put body and soul together. We're not programmed for our modern lifestyle. No single thing we change will be the magic bullet. We will have to take many small steps and they will add up to a substantial difference. I'm convinced of it. That's how we got here. It would be the same process to get ourselves back to a better state of health.
Senator Raine: When I look back over my life, I've seen things change big time in our schools. We put computers in and took physical education and home economics out. We are now deficient in our education in terms of physical and health literacy. Are your organizations working toward lobbying for that? Some provinces do much better than others. The evidence is coming out, but we seem to be reluctant to move.
Dr. Blake: Absolutely. Why we're teaching calculus and not nutrition in school — I think math is important. However, you can teach a lot of math while teaching nutrition and fitness; you can teach a ton of chemistry, a ton of civics. The data is clear on keeping kids physically active: their brains work better when they are physically active. These should absolutely be integrated back into our school and we should be establishing those habits.
Dr. Dent: Ditto. Our organization is trying along these lines as well, but if we have a big, concerted effort it would be so good.
Senator Raine: Do you have any videos to show in schools, for example, bariatric surgery?
Dr. Dent: I'm not aware of them. We certainly do have with the Ontario Bariatric Network, which is a related organization.
Senator Frum: I wanted to follow up on something Dr. Blake said which is alarming and interesting, namely that if you're obese by the age of 18, there is a certainty or a high probability that you will be obese for the rest of your life.
Of the 25 per cent of Canadians who are obese, how many are obese by the age of 18? Should we be offering those individuals bariatric surgery right away, when they're 20, or 18, or 19 years old?
Dr. Dent: That's a difficult one. I do not know the time of onset of obesity in the 25 per cent of the population. I'm not aware of that being in the literature, but I haven't looked, either. I think this is a really good question and I agree with Dr. Blake on this.
The natural history of overweight, if you're overweight to start with, is to go up 2 to 5 per cent a year. So if you're overweight at 18, that will happen. Should we be looking at bariatric surgery? I don't think we should be looking at bariatric surgery at that point. There is a whole lot of research happening quickly in this field. I would think that within a decade or two we will be having medications that are direct and that work. I think the social initiatives and the policy initiatives will help. If you go into bariatric surgery, it's irreversible and you've really anatomically changed a young person. There is a lot of reluctance at this point with our present knowledge to do that. Certainly, if somebody is 400 pounds and they are socially isolated, you bite the bullet and you do it. That's the kind of thinking we have here.
We have to remember that bariatric surgery has a mortality rate that's cited across North America as 1 in 200 within the first 30 days of surgery and then it has a long-term mortality rate. The most common cause of death in the long-term mortality rate is suicide. Why is that? Maybe because we don't absorb tryptophan as well that is used to make serotonin. It may be a dynamic thing where we blame everything on our weight, the weight is gone and the bad things are still there.
We can't take bariatric surgery lightly. And the other thing is that it's expensive and doing it widespread on a population would be hard.
Senator Frum: I'm very impressed that a bariatric surgeon is arguing against bariatric surgery. That's a rare thing. It's a great thing to hear a doctor arguing against surgery. I appreciate that, but I am curious to know if you do feel that we have enough bariatric surgery in Canada, if we are the fourth-leading nation in obesity, should our bariatric surgery rates be equally comparable to that?
Dr. Dent: This is an important question. In Ontario, we're marginal with the availability of bariatric surgery. In Quebec, the wait time is about five years but it's still not terrible. In Alberta, there are at least some bariatric surgery programs going on, but when we look at the other provinces they're pretty far behind. So I do think there has to be an increased availability of bariatric surgery so that we're bringing it up to speed across the country, not just in Ontario.
Senator Seidman: There is no question you both made it clear that this is a complex issue and needs to be tackled on many different levels at once. There is not a simple solution. I do think it's also important to recognize that the approach to smoking was very much that, it was a public health approach over decades on many different levels in the system. I'm not saying we should necessarily tackle this the same way, I'm just saying that was the approach to the smoking issue because of its huge impact on health.
I would continue the conversation that Senator Raine started about education. That is a huge piece and that was a huge piece in the smoking issue.
Dr. Blake, you said from a public health perspective we need a national nutrition strategy for adolescents and pregnant women. If I think about that national nutrition strategy and about the witnesses we heard here and how confused the whole field of nutritional epidemiology is, and how many times guidance and advice has changed over the decades, I would ask you how is it possible to develop a national nutrition strategy? Is it possible? Would we use Canada's Food Guide as a means of education?
You deal with medical education in your society. How would you link that in? I would like to see that, if we think about a concerted effort in a systemic way, how would we do it?
Dr. Blake: I think we should set as a goal to have food and nutritional literacy and competency for anyone graduating from our high schools, and we may want to start in middle school for the kids who don't make it through high school. It is important to know the fundamentals.
When I was at the Hospital for Sick Children I had a teen pregnancy clinic. One thing we had to do for the girls in that clinic was basically help them figure out what's in a grocery store and then how do you take these ingredients and put them together in a meal.
However, that can be done in school and it can be fun. It doesn't need to be burdensome or a luxury. In fact, for kids who are struggling in school, to go to a class, maybe the old home-economics classes, and actually have fun cooking and learning about stuff and getting something nutritional to eat would be a really valued thing.
I'm reminded of a sign I saw in a little kitchen long ago, and it was an 80-year-old cook who ran this little kitchen and she had a big sign up that said, "Kissin' don't last; cookin' do.'' But when I talk to my patients very seldom do you talk to someone who is having a family meal, who is actually finding the time to prepare food at the end of the day and sit for a meal. We have lost this really basic skill, which is important to our health, it's important to our relationships and it's important to our families.
If we're not going to get it in the home because it's not being done in the home, with people taking something from the fridge and eating in front of the TV, we're not going to get that instruction in the home. I know the schools are feeling overburdened but I think that fitness, activity levels, nutrition and food literacy and competency need to be fundamental.
Senator Seidman: We do education in the schools but what about the parents, for example, who go to the grocery stores and buy foods?
Dr. Blake: We learn a lot from our kids.
Dr. Dent: I would like to emphasize something that Dr. Blake mentioned that I feel is really important and that's the knowledge of what a meal should look like. It has to be a defined meal; it can be defined by a lunch bag or a plate. We teach this all the time in weight management. But with so many kids both parents are working so they go to the fridge and if they're lucky there's something nutritious there, but there's no idea what a defined meal would look like.
The fast food restaurants aren't the best places to learn what a defined meal looks like. So I think there could be some focus on something really basic like that. This is what a meal looks like and then the cooking part of it so I just wanted to highlight that one.
Senator Seidman: Are you saying we could do something different or something more with Canada's food guidelines for example? That's what I'm hearing from both of you — maybe we could do something different, more basic or more relatable to, so that's a way to approach it; is that what you're saying?
Dr. Dent: Yes.
Senator Merchant: Because this is a complex issue and you are describing new advances all the time, do you think that BMI is still a reliable measure for judging obesity? It's something that I think people can understand and something that we can use at home. Is that a false prophet or is that a good, basic way to judge where you are? Is it still a useful tool?
Dr. Dent: That's another very good question.
BMI, body mass index, is simply your weight in kilograms divided by your height in metres squared. It's not bad for population studies. It's really bad for individuals. For instance, Sylvester Stallone, during the height of his career, had a body mass index of 35 and he wasn't fat. He just had this huge muscle mass and so that added to his weight in kilos, and his height was the same.
We really have to be looking at a person's body fat. Clinically, that's amazingly elusive. We have tree flawed ways of determining it. We have a body weight. That's not too bad for men because when they lose weight it's usually fat. It's terrible for women because women can follow a program perfectly and have a fluid shift in and they look as if they've gained weight.
If you simply look at the weight only then you've given this person flawed feedback that could extinguish the behaviour. You then go to the next one. We can do a weight circumference but with that there's a huge problem with precision. Measure two centimetres up and you might get something that's two centimetres greater. So there's a problem there. Then other things can affect the weight circumference.
The third is a device that you stand on or hold in your hands and it divines your body composition That's probably the worst of the three. It's pretty good for telling body water though so we do use it.
When it comes to research we have DXA scanning, CT scans and so on where we can learn what the body fat is but you can't use those clinically.
The answer is BMI is not bad for population studies. It's pretty bad for individuals. There is an inherent problem because the issue is body fat, not your weight.
Dr. Blake: In post-menopausal women it gets even more complicated because with the loss of estrogen women also lose muscle mass on an annual basis and women do struggle with weight. It's one of the primary concerns that women express in menopause, but women have to be very careful that they actually become sarcopenic, which means loss of muscle mass, and then much more increased risk of falls bone fractures and generally poor health.
The Chair: You have added to the complexity of the issue today, very nicely. You have even rendered more complex some of the standard features, like BMI. Congratulations.
However, the issues, when you look back at them more carefully, come back to some of the straightforward suggestions we had at the beginning that BMI is a good population indicator. Once that is identified for individuals, they should get themselves to their family physician for follow up if there are additional issues. It's clear that being able to measure BMI isn't going to cure the obesity issue. The debate is: Where is it going?
Dr. Dent, on the issue of deaths in post-bariatric surgery, you indicated there were short-term deaths. Are those usually due to infections and other such things? That's much more prevalent surgery in obese people who are much more prone to issues that wouldn't occur in less obese people — things like infection and so on.
Dr. Dent: The mortality is usually divided, the first 30 days and after. What happens in the first 30 days that could kill somebody? First, obese people are more likely to have clots of blood form in their legs, development of thromboembolic disease — a pulmonary embolism, and may die that way. This is the most complicated for gut surgery. There is suturing along a gastric lining that secretes acid, so that's hard to heal. You can get leaks that kill and hemorrhaging that kills. Then, you can get scarring down so you can't get food through. That's not usually a killer but a complication usually after the first 30 days. You have to be careful about interpreting the statistics because these procedures for the last seven or eight years have universally been done laparascopically with no big incisions, just five little holes to go in and do it with a laparoscope. That has drastically reduced the mortality. In the older literature, when the procedures were done open, you see much higher mortality rates.
The Chair: I want to distinguish between something like suicide rate, which is a phenomenon arising, as you suggest, possibly from changes of hormonal composition versus the issues that an obese person generally brings to the surgical table.
Dr. Dent: You see better survival with the surgery than without it.
The Chair: As a quick observation on education, we know that's not going to solve the problem. It hasn't solved any of the major problems absolutely. It's part of the issue in terms of improving things in many areas but the point is how to get the information to the individual such that it will have an impact. You used a term that I interpret as being a visual impact kind of concept. In Argentina, they provide visual images of good meals in the public domain. For example, there are five typical breakfasts dealing with indigenous foods that would be examples of a healthy breakfast. It's very easy for anyone of any educational level to look at that and identify with it and so on.
Many kinds of things are being thought of with regard to trying to get the message across in a way that the population as a whole can receive it. A person of any education level can relate to that very quickly. The complexity of trying to get restaurants to do a calorie content on food composition will be another challenge; so we may leave that to another era.
The contribution to obesity is clearly impacted there. I would like to ask: after you leave here, think if there's a study that gives a correlation between obesity and age, in particular the pre-20 age group, please provide it to us.
Dr. Blake, we know there are statistics with regard to pregnancy and the status of the mother during pregnancy. We have some stats there but if you have one in particular, that would be great. One of them might be more general and consider the pre-20 age group identified as obese correlated to how their life progresses. As that came up during presentations and discussions, it would be very interesting for us to hear about.
Dr. Blake, I liked your use of the term "complexity theory.'' We know it is used in many areas — a very sophisticated analysis of things all the way from military activity to the micro biome in terms of how it may nuance things down the road. With increasing computer technology, data mining, the cloud and so on, we may be able to use that in ways we haven't thought of before around these groups.
The other issue that you identified are the subsets of the population in this area. We know in every disease category from heart disease to whatever, there are subsets of the population with regard to their susceptibility to various factors that can contribute overall. It might be that down the road we can combine the overall observation of the population with complexity theory and computer capability to be able to do more in identifying subgroups and to give them general advice in this area.
However, I will return to the point where you definitely impressed upon us the challenge that we face in making recommendations that could actually lead to a positive direction. You have given us a number of ideas that we can look at. If there happens to be a correlation in that pre-20 age group that continued throughout life in addition to the maternal issue, it could be a very useful area for us to look at in terms of possible policy recommendations.
I thank you very much for a most stimulating morning on this fascinating issue.
I declare the meeting adjourned.
(The committee adjourned.)