Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 34 - Evidence - May 14, 2015
OTTAWA, Thursday, May 14, 2015
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:29 a.m. to continue its study 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: Honourable senators, welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I'm Kelvin Ogilvie from Nova Scotia, chair of the committee. I'm going to invite my colleagues to introduce themselves, starting on my right.
Senator Seidman: Judith Seidman from Montreal, Quebec.
Senator Enverga: Senator Enverga from Ontario.
Senator Wallace: John Wallace from New Brunswick.
Senator Raine: Nancy Greene Raine from B.C.
Senator Cordy: Jane Cordy from Nova Scotia.
Senator Beyak: Lynn Beyak from Ontario.
Senator Eggleton: Art Eggleton, Toronto, and deputy chair of the committee.
The Chair: Thank you, colleagues.
We are here today to continue our study on obesity. Specifically, we are to examine and report on the increasing incidence of obesity in Canada: causes, consequences and the way forward.
We have two groups represented today and a witness from each. I'm going to invite them to speak in the order in which they are listed on the agenda. I will invite Mark Tremblay, Director of the Healthy Active Living and Obesity Research group at the CHEO Research Institute, to go ahead.
Mark Tremblay, Director, Healthy Active Living and Obesity Research - CHEO Research Institute: Thank you very much for the invitation to be here and assist with your deliberations. More importantly, thanks for taking on this important issue. I'm going to begin with a couple of comments to set the stage and maybe one clarification, which might be the wrong foot to start off on.
To the best of my knowledge, there is no current evidence suggesting that the incidence of obesity is on the rise in Canada. This might just be a terminology thing. The prevalence is high and likely or possibly rising. The incidence, which is a different meaning, we don't have any evidence to suggest that's the case. We can talk statistical definitions, if you want, but I think it's "prevalence" that you're meaning here.
Secondly, I think that the focus on obesity, if that indeed is the focus, is misguided. The focus should be on the behaviours that precipitate or prevent obesity or its related conditions. I think that's what you mean. Obesity is the surrogate indicator that we read about in the news all the time, and that's important, but it's the behaviours that get us to that state that are going to cause or prevent problems.
In the context of obesity there are really four entry points for your work. You have probably received this from other people as well. One is efforts to promote or facilitate healthy eating behaviours. Another is efforts to discourage or inhibit unhealthy eating behaviours. It is the same thing on the physical activity side — efforts to promote healthy movement behaviours, or efforts to discourage unhealthy movement behaviours. Those are your four entry points in the context of obesity. They're your only four entry points. Within that, it explodes to all kinds of things, the built environment and policy and things on an individual level that I'm sure you've heard about from other people, but for a framework, that's what we have to deal with.
There is increasing evidence in supporting an upstream focus to halt or reverse the current global obesity crisis, "upstream" meaning early or preventive measures. For example, the World Health Organization has established a high-level commission on ending childhood obesity, and it's doing its work right now. Their goals are very similar to those of this committee, I suspect: to prevent childhood and adolescents from developing obesity and to figure out how to treat those already with the condition in order to reduce the risk of morbidity and mortality due to chronic diseases, also the psychosocial effects of those, as well as — and I don't know how much this has been talked about — the transgenerational risk of obesity in the future. I'm going to talk a little bit about that because the situation is not contained to the individual but also their offspring, and even future offspring that aren't conceived yet.
Related to that comment, I need to disclose that I am a member of the World Health Organization expert group for that, but I have disclosed nothing and will disclose nothing here that is privileged. Everything I've said is in the public domain.
A central theme in the interim report, which I did send to the committee, is that a life-course approach needs to be taken, even intergenerationally, recognizing that this intergenerational transference or biologic imprinting — these are technical terms — are fundamental. The sperm and the ovum of a young couple already have predisposed conditions to that zygote and eventually embryo and fetus that hasn't even been conceived yet. I think that's important to understand when thinking about a life-cycle approach. The cycle needs to begin preconception, with healthy active living behaviours of the prospective father and the prospective mother. That needs to continue through pregnancy for a healthy pregnancy and especially during the early years, the first few years of life. That sets a child on a trajectory with a predisposition to good things coming out or bad things coming out. It affects not only them through their life course but also when they get to reproduction age and they reproduce again. You're already tilting it one way or another.
I also wanted to comment briefly on the economics of this. An important report came out of the McKinsey Global Institute late last year. I circulated it to the group as well. It's a very good and important read. It shows that the global burden of obesity is on par with armed conflict around the world. It's not a tiny issue. I'll just take a quote from it, because this is fundamental to my comments.
Based on existing evidence, any single intervention is likely to have only a small overall impact on its own. A systemic, sustained portfolio of initiatives, delivered at scale, is needed to address the health burden. Almost all the identified interventions are cost-effective to society — savings on health-care costs and higher productivity could outweigh the direct investment required to deliver the intervention when assessed over the full lifetime of the target population.
So there is no magic bullet. If you spend your time looking for the magic bullet, you're wasting your time. I can say that with extreme confidence from every think tank that I've been involved with over the last 25 years. There is no magic bullet.
Fortunately, we have a lot of good things going on. I've written ten years ago, five years ago and recently a manuscript called Major Initiatives Related to Childhood Obesity and Physical Inactivity in Canada: 2014 Year in Review. This is basically a year-in-review paper. The first two were published in the Canadian Journal of Public Health. The newest one is under review for publication there. I've circulated the submitted draft to you as well, where we highlight 15 promising initiatives, big things that are going on in the country, most of which have not been sufficiently evaluated so we're not positive they work, but they provide a portfolio of things that, if we did them and if we sustained them and if we scaled them, we've got a chance of making a huge impact, a big social change, which I think is what we're after here. I listed them in my notes that were sent you. I won't waste time reading through them. Some of the initiatives you've probably heard about or had people testify about. Some you might not know about and I'd be happy to comment on them.
The last three or four are related to measurement issues, which you may not think of as interventions. I very much think of measurement as an intervention. In fact, I think it's the most potent intervention. It certainly gets your attention, as people in politics, when you're accountable and measured, because what gets measured gets done. We know that. Transparent accountability motivates behaviour change at individual, organizational and governmental levels. So the results of a Statistics Canada survey can have a huge impact on all of our behaviours and on what we do. In fact, the construction of this committee is probably due in part to papers that Christine and I and others have written, because they have gotten your attention: "This is a big problem; we need to deal with it."
The Canadian Health Measures Survey that I list and the CAN PLAY Survey that the Canadian Fitness and Lifestyle Research Institute, which Christine works at, are examples of surveys that bring out information on obesity, on physical activity levels, on sedentary behaviour levels and on fitness that are strikingly important. The Active Healthy Kids Canada Report Card is a similar reporting mechanism. We now have replicated that process in 14 other countries, allowing for comparison and the creation of a global matrix of countries from around the world.
We're very constrained in environments like this with group think. It's the biggest barrier. In fact, rather than having me here, you should have someone from rural Kenya or Southern Brazil that is not constrained to our policies and our thinking, because that's where the answers lay. That's what the global matrix showed us. It showed us in Canada that we have built it, but people haven't come. Countries with the lowest infrastructure and the least developed policies are consistently the most active. We can disregard that, but that's what it shows.
My guess is that the tendency of this group will be towards building more, bigger and better facilities and institutions for this. This is not what we need. We need to get children back outside and reconnected with nature. That is a scalable solution. That is a solution that does not marginalize the already marginalized or the vulnerable. It's economically possible. We have the biggest playground in the world outside. It's fantastic and we don't use it because we convince people to go to their local community centre and get onto a treadmill in a room surrounded by granite. That's not viable. That's not what the active world does.
Let me summarize the main points I wanted to make. The focus should be upstream on healthy behaviours to prevent the problem in the first place. We want Canadians to be healthy, not a particular size or shape. We should take a life-course approach. It will take a portfolio of initiatives delivered at scale to make any impact on things. I believe that a back-to-the-basics framework is really what we need. It doesn't suit well to typical government portfolios or to the solutions that most of the leaders out there were trained in at university. That doesn't make it wrong.
Thanks for your time.
The Chair: Thank you very much. I will quickly reassure you that we have heard this same message virtually throughout; that is, it's not more arenas but there's a lot of other accessible infrastructure that we've heard about in terms of building things. I don't think we're likely to recommend many mausoleums.
It's my pleasure to welcome Dr. Christine Cameron, President of the Canadian Fitness and Lifestyle Research Institute. Please proceed.
Dr. Christine Cameron, President, Canadian Fitness and Lifestyle Research Institute: Thank you for the invitation to be here today. I'll talk a bit about the stats, which Mark talked about. We conduct quite a few surveys at the institute which I'd like to talk about.
Looking internationally at the rates of overweight and obesity, they have increased substantially in the past three decades. Although prevalence rates in Western countries have shown by some evidence that they're starting to stabilize, really the rates remain generally very high. Global prevalence rates of overweight stand currently at 39 per cent of adults last year, whereas the rate for obesity is 13 per cent. Worldwide the number of overweight and obese young children aged 5 and younger have increased from 32 million in 1990 to 42 million in 2013. Obesity during these early years, as Mark has indicated, may also lead to continued obesity into adolescence and again into adulthood. In Canada, it's estimated that the direct cost of overweight and obesity total $6 billion, whereby 66 per cent of this figure is attributed to obesity more specifically.
The current surveillance system and the research often focus on body mass index. As it's a measure to assess population level indicators of overweight and obesity, it's relatively easy to collect in population surveys. In fact, in Canada there are several large-scale representative studies, through Statistics Canada, which explore the prevalence rates of body mass index among the adolescent and adult populations. From 2009-11 data, 31 per cent of children aged 5 to 17 and 60 per cent of adults aged 18 to 79 were considered overweight or obese.
It's often recommended that body mass index be used in combination with other objectively measured adiposity indicators to assess body weight, like waist circumference. Research has shown that between 1981 and 2009 these measures have increased and Canadians have become at a higher risk of obesity-related health conditions over time.
As Mark has already mentioned, the contributing factors to obesity are multi-dimensional. Generally, higher levels of adiposity result from the imbalance of the amount of energy intake versus energy expended by an individual. Hereditability also accounts for estimates of body mass index. Understanding the determinants associated with obesity is important when developing public health strategies to combat obesity. These include a wide range of factors that either enhance healthy diet and physical activity behaviours or reduce unhealthy diets and sedentary behaviours. These should be considered within the influence of the individual themselves but also the social and physical environment in which they live, as well as the policy arena.
I'm going to look at these factors separately, starting with diet. According to the WHO, nutrition and diet is an important contributor to obesity among children. Research has shown that food preferences are learned in the early years and that these behaviours may track into adulthood. Increasingly, children are being exposed to multiple types of messages about food through a variety of mediums. The WHO has endorsed a set of recommendations introducing and strengthening policies on the marketing of food and non-alcoholic beverages to children.
Beyond policies for food marketing, the WHO also has developed a set of population-based prevention strategies for creating supportive environments for healthy diets, including nutrition labelling, food taxes or subsidies, fruit and vegetable initiatives, restriction of trans fat content in the food and also the provision of healthy food options in government institutions.
Turning to physical activity, there is evidence in the literature that shows the effectiveness of physical activity in the prevention or the management of non-communicable diseases, including obesity. Despite the known health benefits, we're finding that a relatively small proportion of the population is considered active enough to reap these benefits. Among adults, the population achieves an average of about 12 minutes per day of moderate to vigorous physical activity, so about one-in-five adults accumulate sufficient activity to meet Canadian physical activity guidelines. The majority of school-aged children and youth, which we find through Statistics Canada's data and also CFLRI data, are also not getting enough physical activity. Less than 15 per cent of children and youth accumulate at least 60 minutes of moderate to vigorous physical activity on a daily basis.
Physical activity participation is a complex behaviour in and of itself and is likely influenced by a host of internal and external factors. Effective strategies for increasing physical activity should be comprehensive, draw on behaviour change theories and also based on a socio-ecological framework, so those that include interpersonal, social level, the environment and policy-level interventions.
The literature does show that several interventions have been effective in promoting physical activity, such as informational approaches through community-wide campaigns, mass media campaigns and decision prompts. Social support within the community and work sites, physical education, classroom activities, after-school sports and active transportation are also recommended. The development but more the improvement of access to places for physical activity, urban design land use, active transportation and community-wide plans and policies that overcome these environmental or structural barriers are also important.
Lastly, I would like to take a quick look at sedentary behaviours. We find that longer bouts of sedentary time or low activity are also related to the development of obesity. The proportion of young Canadians who meet the Canadian sedentary behaviour guidelines also vary with age. Some of the stats show 18 per cent of 3 to 4 year olds, 69 per cent of 5 to 11 year olds and 31 percent of 12 to 17 year olds meet guidelines. Certain outcomes are found to be linked with specific sedentary behaviours in both children and adults. These can include obesity in television viewing in children and adolescents, and between certain types of sedentary behaviours with "all-cause mortality" and certain non-communicable diseases in adults.
In a systematic review, research has also shown that when we look at sedentary behaviours and physical activity separately and in combination for reducing sedentary time among adults, often the sedentary behaviour focus can have the largest reduction in sedentary time, whereas physical activity in combination may have slightly smaller reductions in sedentary time.
To sum up, diet, physical activity and sedentary behaviours are all recognized as modifiable risk factors for obesity. Given their importance for treating obesity and other non-communicable diseases, public health guidelines and recommendations regarding these factors have been developed and refined over time. Long-standing surveillance systems such as those through the Canadian Fitness and Lifestyle Research Institute as well as Statistics Canada have evaluated the progress over time to look at the temporal changes for the population prevalence rates for these behaviours but also the factors that are associated with enhancing these behaviours or acting as barriers. A comprehensive, multifactorial approach is warranted, especially given the research that shows a protective effect for achieving these recommendations.
The Chair: Thank you both very much.
I'm going to open the floor to questions, starting with Senator Eggleton.
Senator Eggleton: Mr. Tremblay, you talked about the incidence versus the prevalence; one was increasing but not the other. Can you explain that in more detail?
Mr. Tremblay: Incidence refers to the rate of new cases, whereas the prevalence is the accumulated rate. If 2 per cent of Canadians are becoming obese in a given time — usually a one-year period — and it stays at 2 per cent, but it used to be 1 per cent, then the incidence doesn't change, but your prevalence will go up because it used to be 1 per cent. The 1 per cent has fallen off the back end and the total area under the curve is increasing. That assumes that a lot of people who were obese don't become "unobese."
To show increases in incidence requires longitudinal survey designs, which we don't have in Canada. There's also no evidence, especially given that the rate of the prevalence has gone up dramatically in the last couple of generations. There's evidence globally that it's plateauing. Maybe it has flatlined or it's plateauing. It's not something to get excited about because they are at the highest levels they've ever been. It's not good. That suggests the incidence, if anything, might be going down.
In terms of clarity, in the name of the committee or the name of this particular initiative, "incidence" should probably be "prevalence."
Senator Eggleton: You're also calling it a crisis still.
Mr. Tremblay: For sure. It's the worst it's ever been. Let's not get excited about flatlining at the worst level we've ever been at.
Senator Eggleton: That helps to clarify.
Ms. Cameron, let me ask about a study that I think your organization brought out. It talks about physical activity and says that levels have not declined over the past 10 years but in fact have increased. If they've increased — and we've seen obesity going up at these astronomical rates, prevalence — is it really more a case of diets than of physical activity? As one person said, "You can't outrun the fork."
Ms. Cameron: For children, we're finding that using objectively measured data, the activity levels have gone down slightly over time. When we're looking at more objectively measured data, and Mark can speak to this a bit better, CHMS data from StatsCan, we're finding that the proportion of those who meet guidelines among adults is very low. They haven't really changed over time. We're seeing a very slight increase in self-report measures. They may be an over-representation of obesity levels at this time. But with objectively measured data, we're not seeing an increase. We're seeing "stable" and then in the most recent year, a very slight decrease.
Mr. Tremblay: As you dig into the information, it becomes quite complicated, and you've picked up on that. I can send you five papers that show no change, five that show increase and five that show decrease. I can do the same with "energy in," with diet, that we are actually eating less. How can we be more active, eating less and becoming obese?
When I was a DG at Stats Canada this was a tough thing to tell the minister. It's because of limitations in our data collection. You look for your most robust and hardest outcomes, and you trust them.
We would often then defer to fitness measures, which we can do quite accurately, in the gymnasium and in the lab. Stats Canada has done that on a sample of Canadians. It's much easier to determine a person's cardiovascular fitness or strength. You saw the news yesterday about grip strength predicting heart attacks. We can get these hard measures and they're pretty accurate. My grip strength today will be the same as tomorrow, and it's pretty accurate. If I ask you how active you are or exactly what you ate, the information will be all over the place because it varies a lot day to day and because you're limited by your memory about whether you walked farther — you don't remember any of your incidental activity.
If we look at temporal trends in fitness, which we've done in both kids and adults, we see dramatic and striking declines, consistent with the reason that you formed this committee.
I wouldn't get lost in the data that goes up and down. I would trust the strongest, hardest data, which are absolutely convincing. Like the prevalence trends in obesity, it's gone massively up. In the case of kids, it's tripled in one generation. Similarly, fitness levels have declined at a striking rate. In children, we're seeing a 20 per cent reduction in strength in one generation between 1981 and now. Kids that used to be able to climb trees can't climb trees, even if we were to take that approach.
Senator Eggleton: The statistics are different in terms of physical activity between adults and children. It's gone down in children and perhaps rising in adults.
Mr. Tremblay: I wouldn't be confident that it's rising in adults.
Senator Eggleton: Okay.
Let's go on to possible solutions, and there's a whole raft of them, such as nutrition labels and Canada's Food Guide. There's also the question of advertising and promotion to children. Quebec has a ban on advertising anything to children. Most of the discussion here has been relevant to healthy foods and beverages. Do you have any thoughts about those kinds of measures?
Mr. Tremblay: To me, that's low-hanging fruit. It's a no-brainer. What Quebec is doing is talked about. There's no downside to not advertising unhealthy food to children or to increasing the advertising of healthy food to children. Whether you can demonstrate empirically that it causes anything, it seems to me that it's a no-brainer to put in the portfolio of things that you have to do. There's no downside to it. There's a downside, I guess, if you're the shareholder of a company that can no longer advertise their sweetened cereal to children. Every group that I sit around with and talk about this, that topic rises to the top quite quickly. Why don't we just try to do that?
It's much more complicated, of course, because most of our exposure is on screens that Canada doesn't control. We watch American stations and stations from around the world, and the Internet isn't controlled. It's really hard to say, "That's designed for a 10-year-old child, therefore your company can't advertise there because we simply don't have jurisdiction over that." That's where the problem arises. Nevertheless, for the rest of the provinces in Canada to emulate what Quebec is already doing seems like a no-brainer to me.
Senator Eggleton: Further to that, should we make a distinction between healthy and unhealthy foods and how would we do that? Or should we just say, "No food advertising and no beverage advertising" as a means of getting around having to make those distinctions and setting up massive bureaucracies to administer it?
Mr. Tremblay: It's a good question and it gets discussed a lot. Some mechanisms are in place by the experts who can judge that. It's the same with vending machine policies that can only have healthy foods. Someone has to decide if the granola bar is healthy or not or that a beverage is healthy or not. There are long debates about that, for sure.
We want our kids to know what's healthy, so it would be a shame not to provide them with some exposure to that.
Ms. Cameron: It may be through public education as opposed to advertising.
Senator Seidman: Mr. Tremblay, you submitted a paper to us, as you said: Major Initiatives Related to Childhood Obesity and Physical Inactivity in Canada: 2014 Year in Review. In your conclusion, you note that many initiatives across Canada are currently underway that attempt to address the childhood obesity issue. You also mention that we need to focus on efforts that can be sustainable and scalable, words that you used in your presentation to us today.
My question to you is: Which efforts currently under way do you see as having the greatest potential to be successful by the criteria you've outlined?
Mr. Tremblay: I never fall into "what's the one thing we should do" trap. If we can do one thing, my answer is always "don't bother." Let some other department have the money because you'll have no impact. Every study shows that.
We need to change the built environment in our country. We need to change, probably more importantly, the social environment to one that allows kids to behave today like we did when we were kids, and that to me is the easiest solution.
The 15 initiatives are actually subcategorized in a few different ways on purpose, using a sort of portfolio idea that we can't just do one thing. Some are programs, and there are a number of programs. They come and go like crazy because you can get funding for one year or six months in one community to do something. It doesn't matter if it shows that it's fantastic or not; it dies and then you have to come up with a new program.
I wouldn't pick any one. A number of them are good. It depends on what age you want to target. My preference would be probably going for the earliest ages and things that get at the early years or pregnant families.
But there are also categories of surveillance, which is absolutely necessary. Senator Eggleton looked at the information, and it shows this and it shows that. We need to have very good information. The Statistics Canada Canadian Health Measures Survey is absolutely fundamental, groundbreaking and essential. Now, it does have A-base funding and is ongoing, but that sort of thing is absolutely essential.
To answer your question, I would pick a little bit from the different parts of the portfolio that have a chance of impacting things, like other social change initiatives such as what we've done with smoking. It wasn't just one thing. It wasn't just one program and it wasn't one target age group or just a program. It was stacked with social marketing, with education, with interventions and with measurement.
That's why I do that paper. I'm often criticized of being Captain Negative because the data are poor and I do a lot of the surveillance. It's not a great scenario. The data are bad. However — and this is why I write this paper and this is the third time I've done it — we're trying. We're doing a bunch of things. It's nowhere near resourced to the level that it needs. All sectors need to step up for that. We're trying to deal with a massive issue using pocket change, and I think that's where we're stuck.
I'm sorry; I sort of dodged your question.
Senator Seidman: No, you haven't. You put forward the point we heard from many witnesses and that is this isn't just one solution and it isn't just one target. It's multi-pronged, and it must be. The recognition that this is akin to what happened with smoking is quite apt because we all know that the public health approach to smoking was probably the best prevention, intervention program ever launched in this country, but it was decades long.
Mr. Tremblay: Sixty years, yes.
Senator Seidman: Exactly. So you have to start somewhere and you have to target short term, medium term, long term, and it has to be on a very large scale, as you say, targeted at many different systems, and I think we understand that. We've heard that.
This committee needs to make recommendations and hopefully we'll have a short-term, medium-term and long-term approach to it. My question to you really was to get at what efforts in all of your work — and you've spent quite a long time working in this area — from an evidence-based point of view seem to be most successful.
I might ask you, then, about reducing the intake of unhealthy foods and non-alcoholic beverages. In your research, have you seen interventions — and I'm not asking you for one — that have demonstrated themselves to be effective from an evidence point of view?
Mr. Tremblay: Most of the evidence for school-based programs or reducing sugar-sweetened beverages — it doesn't matter what it is. The reality is it's blended into a fruit salad and it's really hard to say, "The flavour that I'm tasting is just the pineapple," because it's all in there. That's the problem and that's what the McKinsey report told us.
This is a real struggle, as a researcher in the area, because you need to submit a grant to do something like reducing sugar-sweetened beverages in schools, and you test it and it doesn't show what you hope it would show. That doesn't mean it didn't work; it means that it's one little sliver of things. It is not just sugar-sweetened beverages, but is that part of it? My guess is probably. It's the same with other fast foods, the same with the lack of taking in fresh fruits, the same with too much sitting and not enough standing. So the struggle is to isolate that one thing, which is what people like you always want and it's what research agencies want. It's innovation because you can produce projects and say, "Okay, here's the magic bullet: If you wear this on your shoe it's all going to be better."
With all of the data, the meta-analyses and systematic reviews are somewhat disappointing, but they do give us hints. School is an important intervening spot. The home is an important intervening spot. The workplace is an important intervening spot. There just isn't one thing. It's like 1 plus 1 plus 1 plus 1 might still only equal 1, but if you add one more 1, it equals 23. We haven't reached that tipping point like we did eventually with smoking cessation. It was a couple of generations. That doesn't mean that the 20 years of previous work wasn't helping; it was setting the stage for success.
Senator Seidman: Dr. Cameron, in an early release of the Canadian Medical Association Journal, which will be public fairly soon, there is a piece titled "Active play key to curbing child obesity." Is focusing more on active play versus organized sport a direction your organization is advocating?
Ms. Cameron: What we've done is take a look at the research for both and the contributions of both because sport has its contribution for learning skills and that sort of thing, but we don't underestimate the value of unstructured play. We do see that children who participate in unstructured play during the after-school time period or play outdoors take somewhere between 1,500 and 2,000 more steps in a day than those who do not. Although we can't say directly it's because of that, the evidence does show that there is a contribution there and an important one to be made.
Senator Seidman: Mr. Tremblay, do you have something to say on that?
Mr. Tremblay: That paper by Dr. Ian Janssen is actually out now. This is what we found from the global matrix. We compared physical activity behaviours in African countries, South American countries and countries all over the world and it allowed us to think outside the box a bit and have a clean slate. It showed that we need a portfolio of behaviours. We don't just need super phys. ed. We don't just need super sport. We don't just need play. We don't just need active transportation. We need all of it. It needs to be embedded in life, as it was in previous generations.
The case can made about active play that it is probably the one that has declined the most. If you look at temporal trends in phys. ed. — organized sport is very good, actually, although probably marginalizes the most marginal, so it may not be the one to go to. If you have a portfolio there, regardless of your circumstance, if you live in the remote North you've got a fantastic outside environment. You might not have an ice rink right there or a wave pool, but that's okay because you have that piece and you may have to actively transport to school.
It's the portfolio approach. Active play has disappeared the most. Increasingly we're cocooning inside. Parents who allowed their kids to walk to the park are now going to jail, if you're following that story in the U.S.
Senator Enverga: Mr. Tremblay, you mentioned earlier in your presentation about the predisposed condition. If this happens from the very time of conception, there's already a predisposed condition. Are you saying that there is genetic predisposition there? Is there actually some research, some science? Maybe mothers taking antibiotics will result in more children being susceptible to obesity? What can you say about that? Can you tell me more?
Mr. Tremblay: It gets complicated. It's not genetics but epigenetics. The more we learn about our biology, the more we realize. When I started my schooling, it was very clear that you had genetics, which is immutable, unless you're talking about 10,000 years or something, and you had the environment. You can't do anything with that, so you spend all your time on this.
The more we learn about things, the more we realize those aren't two separate entities; it's a continuum. If my grandparent worked in an asbestos mine, that impacts on my health because he passed that along to my father, who got my mother pregnant, and that's part of me.
So, yes, there are actually changes to the epigenome that happen to predispose us, whether it's antibiotic exposure or your grandmother smoked, or, on the positive side, your grandfather was a marathon runner, they are predispositions. It's not like it's destiny, but they set you off either in a positive direction or a negative direction.
So the huge concern that we have and that the next generation of senators that are going to sit around this table need to worry about is that we have had a tripling of childhood obesity. In the current generation that had kids, the prevalence of obesity was not all that great. They were fundamentally active through a portfolio of things. They had to walk to school. They had to do some chores. They played outside because there was no TV inside.
This generation of kids does not have that positive deflection. In fact, they have the negative deflection. They are going to pass that on to their kids, even if we solve the problem today. We've created some debt there, and we're going to have to pay it back.
In the future, even if we figure things out, we have some debt to pay. So the biology would forecast a tougher time ahead. That's the same even with taste preferences, which get passed along.
Senator Enverga: So we have to approach each individual differently to prevent obesity.
Mr. Tremblay: I think there are big buckets that most individuals fall into. Like I said, you want to promote healthy eating and discourage unhealthy eating. You want to promote healthy moving and discourage unhealthy moving. Those are your big buckets. But even for these things like exposure to pesticides and, as you mentioned, antibiotics — although I don't think there is conclusive evidence on any of them — there is no doubt that they affect the human genome. Probably, when you mess with Mother Nature, there are problems down the road, and I think we're seeing some of that.
Senator Enverga: Thank you.
I have a question for Dr. Cameron, and maybe, Mark, you can also reply to this. We are talking about more activities for kids. You must have heard about the Children's Fitness Tax Credit. It has had some success.
My question is: Is it advisable to do a refundable fitness tax credit for adults? Do you think it would help? What do you think the effect of this would be? Since the government is trying to do something about this, could this be one of the solutions?
Dr. Cameron: We have looked a little bit at the Children's Fitness Tax Credit in some of research we've done. We were seeing some economic discrepancies in the proportion of adults who actually felt that the tax credit was useful or that it increased their child's participation in activities. We're seeing that those with lower economic status were less likely to respond to these types of questions. That was based on parental self-report data.
It's hard to say in terms of the adult population. We haven't done much research on that. Maybe Mark would be able to respond to that a little bit better.
Mr. Tremblay: We did do a paper, using Revenue Canada data, to determine who was utilizing things, and it is consistent with the other reports that have been out there. It seems to be of benefit more to the middle and upper class, people who have the $1,000 to spend. This is in the case of kids, and I suspect it would translate to adults. The vulnerable group, the one you're trying to get at the most, would need to have the disposable income and the inclination to spend it in order to get it back a year later.
I would say it's the fairly strong consensus of the physical activity sector broadly that the amount of revenue foregone associated with the Children's Fitness Tax Credit, which is in the $200 million a year range, could be better spent with other things.
I think the greatest benefit of it and where it falls into the portfolio of important things is that it demonstrates to the Canadian population that this issue is sufficiently important that we're changing tax law for it. So that, on a higher conceptual level, I think is part of the nudging towards the tipping point. Whether the actual dollars foregone and the opportunity cost of spending those monies in another way is the best way, I don't know.
Senator Enverga: Thank you.
Senator Beyak: I'm just a replacement on Senator Ogilvie's wonderful committee from time to time, but I have been privileged to hear expert testimony like yours.
I also share a concern with Senator Seidman with palliative care, and she is much more experienced and knowledgeable than I am. We had testimony from Dr. Robert Lustig and now from Dr. Ben Carson, presidential candidate in the United States, that each of us — old, young, fat, thin, healthy, unhealthy, male, female, any race; Dr. Ben Carson is African-American — will cost the health care system more in the last six months of our life, at any age — children, a woman with breast cancer, an older person dying with dignity — than all of these other issues, like smoking, obesity. We have to be concerned with them, obviously, because quality of life is so important. But how do we weigh that in the value for money for taxpayer dollars so we give that last six months the care it deserves as well?
The Chair: I'm going to intervene. That is a very complex overall issue, and we have a lot of questions to deal with the obesity issue itself.
If there was a comment that you could make with regard to obesity influencing that last six months in terms of cost, perhaps that would be the case, but I do not want you to answer the direct question that was asked because of the complexity of the issue and because it's outside of our mandate.
Mr. Tremblay: All I would offer is that in the obese individual, that six months is likely to be extended. There are a number of studies that show this, and Christine, I think, cited some of the numbers. An obese individual costs society more across their lifespan, whether it's in the last six months or the fact that that deconditioning makes that six months 18 months. In the context of obesity, it's just another reason to try to prevent it.
The Chair: Did you have another question, senator?
Senator Beyak: No.
Did Dr. Cameron want to respond?
Ms. Cameron: I would agree with that.
Senator Beyak: Thank you.
Senator Raine: I always enjoy hearing from real experts in this field because you've been at this for a long time, and we all know there is no single solution.
If we're going to attack things in all directions, from a public policy point of view, our delivery system, of course, is quite complicated in Canada because the responsibility for health and things like that falls in the federal budget to make transfers, but the delivery is done at the provincial level. There are federal-provincial gatherings that discuss this, and I know this is of concern to all provinces. But do you think there's a way to communicate the best practices that are taking place at the provincial and municipal levels from one province to another so that we don't have to always start from scratch and reinvent the wheel? If something is happening in one province, how does that get transferred to another province?
In your year in review you mentioned some of the items. I suppose you've done this for many years, so there is another catalogue, if you like, of successful things.
I share your concern that a lot of these programs come and go because of a lack of long-term funding. Could you comment on how long it will take before we can really analyze whether a program is working to the point where you want to roll it out all across the country?
Mr. Tremblay: Regarding the last point, I don't think we know. Certainly it would be in the decade range, not in six months or one year, which is the constraint with almost all government funding and most research funding.
You're really constrained and it is almost predetermined that a truly rigourous assessment is going to show it has failed. That's what happens almost all the time, so we throw the baby out with the bath water. You give it some traction, and it's sort of institutionalized within the country to have a chance, but we haven't given it a chance. It's a long-term investment where you continuously stack things on top of one another.
What I was promoting is going back to the basics, a simple "let kids be free again," which doesn't obviously fall within the jurisdictional framework that you mentioned, namely, the federal government sending health money or sport money to the provincial level. However, there are interesting barriers with that. For example, when I give talks to school board trustees, to the Canadian School Boards Association, they are totally on board with the need to let kids do more and let the playgrounds be used more, whether it's during school or after school. However, they are constrained by litigation fears and realities.
This is where the Solicitor General's office needs to intervene. I put this in my notes. There needs to be joint and several liability reform. If there are any lawyers in the group, you'll understand what that means. There must be mechanisms where frivolous lawsuits don't paralyze communities from allowing kids to play in the park. Yes, someone will fall and break their wrist. It has always happened and will always happen. Putting them inside our house and allowing them in front of a screen where a cyber-predator convinces them to kill themselves is not the answer. I'm sensationalizing it on purpose because the reverse gets sensationalized constantly to the point where we have vacant parks, vacant communities and people freaking out because an 8 year old is walking home from school by themselves. Every 5 year old from Bracebridge, Ontario, where I lived, walked to and from school every single day and we knew how to look both ways when crossing the street.
There is that sort of approach where you're trying to get at both the family and schools, and so on, but you've got to provide the legal structure that allows them to make the moves. The trustees say, "We completely agree with you, Dr. Tremblay, but we can't do it because of liability concerns," and so on.
Senator Raine: But that is something we could do.
Mr. Tremblay: That is absolutely something we could intervene on, yes.
Senator Raine: The messaging to parents about this is also important. Somehow parents think it's child neglect to let your children go and play in the park alone, but it's not child neglect to let them lie on the sofa, eat chips, drink pop and watch TV.
Mr. Tremblay: Precisely.
What is the education approach, the social marketing approach, the legal framework and the social change we need in the community? Going back to the global matrix, we can pick peer countries. In Finland, for example, the active transportation norm is extraordinarily different from here. It's cold there. It's dark there just like it is here. I guess Finnish kids are more robust. This goes back to reliving the 60-year-old Swede in the ParticipACTION commercials. Young kids will walk two or three kilometres. That is normal there; it is very abnormal here. It was normal in our childhood. How do we change that social norm? Like I said, there needs to be social supports there.
There are many organizations fighting against this. With some of the injury prevention and child protection services, the norms have changed. What used to be okay for a 5 year old is now not even okay for a 10 year old; or what is currently okay for an 8 year old in some parts of the world is nowhere near okay for an 8 year old in Ottawa.
Senator Raine: Which organization should be setting target standards? I heard, for instance, that it is your right to demand a school bus if you live one kilometre from the school. That's crazy.
Mr. Tremblay: It's less than a kilometre for young school-aged kids.
Senator Raine: But who sets those standards?
Ms. Cameron: School boards.
The Chair: It's all local laws.
Senator Raine: This is the social change you're talking about. Can we drive that from leadership at senior government levels?
Mr. Tremblay: I think there is a role to play in terms of changing laws and influencing things like that, for example, in terms of funding campaigns that will help people to change that and even interventions to show that it can work.
Senator Raine: If you don't mind me digressing a bit, I'll tell you about my community of 450 people in a mountain village. Many of the people living there are lower income people. They walk to school, but in the wintertime they ride a ski lift because the school is at the top of a lift. In the summer they have to walk up because there is no snow on the ground. It's very active, healthy living. If you want to use some of that in your research, I invite you to come to Sun Peaks.
Mr. Tremblay: Thank you.
Ms. Cameron: To address your original question about the sharing of information between provinces or federally, there have been attempts to develop either web hubs or portals to share that information. With funding, unfortunately there have been circumstances where it has been relatively short-lived to determine whether or not it was effective. They were not funded long enough to determine the ideal timing and funding was an issue.
Senator Cordy: My question has to do with the same idea, namely, changing the mindset. Kids have to play outside and it has to be unstructured. We know of a case in the United States where a 7 year old and a 9 year old were playing in the park unattended and the police were called. We know of cases where kids are walking two blocks to school and parents are being chastised and neighbours are calling the police about children walking to school alone.
When I was teaching at school and it was a cold winter day and there was a three-foot sliding patch, the kids slid during recess. It was great when you were on yard duty because the kids were all busy sliding. Someone occasionally fell and bumped their head, but the kids had fun and they had red rosy checks when they went in. You're right; school boards are now being pressured by parents that it's too dangerous to let the kids slide. It's too dangerous to have swings and climbing apparatus on the playground, and so on.
How do we go about changing that mindset? You referred to it as changing the social environment so you can do away with frivolous lawsuits. However, we still have helicopter parents who have to walk their kids. They can only have their kids involved in organized sports and their kids can't play in the backyard by themselves alone for any period of time.
It involves a whole societal change. How do you do that? Is it by advertising? I know you mentioned changing some rules and things, but the pressure for school buses to drive them half a kilometre to school is coming from parents. The pressure about no sliding on the ice at school is coming from parents. I did actually read that there was a parent group started that is saying enough already.
Mr. Tremblay: I think the movement has begun, and I think you'll be hearing a lot more about it in the near future, but I think you need to begin. It needs to be a portfolio of things and it needs to be long term.
The whole smoking cessation thing began when I was in school: the black lung and the nurse came around to your health class. At that point in time, 51 per cent of Canadians smoked. It was the cool thing to do when I was in high school. I never did but most kids did. It took us 30 years or so to make it uncool, and it took a whole portfolio of inventions, from health claims, to social marketing, to education, to restrictions, to laws such as taxation on cigarettes and you can't buy them until you're a certain age. I think we need to look at the whole arsenal available to us and I think it's going to take all of those things.
As a starting point, a strong foundation of evidence needs to be presented, and will be presented quite soon, I think, in a compelling fashion to really show parents the balance because — and some have mentioned it here — we think kids are safe when they're inside. There is compelling evidence from toxicology research that indoor air is much worse for us than outdoor air. These seats and this carpet are all protected with toxic fire retardant sprays that we are breathing in. No doubt they have epigenetic effects on us going forward. We are now exercising inside, so we're breathing huge volumes. Some people think active video games are the answer to the problem. We breathe more indoor air, we're close to the cookie jar, we've got our soft drink sitting there, and we're playing the active video game while sitting on the couch. It's just not viable. It makes no sense.
Present a balanced argument: "Did you realize that the chance of being abducted by a stranger outside is estimated to be 1 in 14 million and that it is somewhere between 100 and 200 times more likely that a cyber-predator will get at you, but we're okay with that? The average person does not know that. We need to present that balance and say, "Give your head a shake, parents." We need to reform parenting. We need some Parenting 101, so maybe community centres should be offering that to try to help parents.
I talk to parents all the time. The nostalgia comes out when they talk about their childhood with huge smiles on their faces saying, "I remember." We all remember that. We ask that same parent, "Do you allow your child?" They say, "No." We ask, "Why not?" The environment they live in is safer than the environment you lived in. We've lost that and we're agreeing with one another. We need to activate the entire arsenal we have to swing the pendulum back to where it belongs, where it's sustainable.
Senator Cordy: You said that it's difficult to determine what works, evidence-based, because we should be in it for the long haul; but government being government, it wants instantaneous results. So the six-month program or the rink built in the community works for government because the public sees a physical structure within a year or two or a program where the kids or the community is involved. How do we get beyond that in making recommendations? Would that indeed be a recommendation? Should we be doing long-term planning and programs?
Mr. Tremblay: You did it with smoking. Take a piece at a time. You can fund education and social marketing campaigns. You can fund pilot projects. You can fund research related to things. You can make declarations. We've got a new health and fitness day. We could have "Grass Stain Day." There are a number of ways to slowly start to change the pendulum back, as has been done in the past.
This isn't entirely a government thing. I think the Solicitor General's office and some of the non-traditional portfolios within government have roles to play because the litigation fear is absolutely paralyzing decision makers who are the key conduits to making the changes to allowing kids to play on playgrounds, instead of mowing over the play structures that kids play on. I do a lot of research in Africa and have seen the stuff that kids play on there. They have a ball and rarely get hurt. It would scare the heck out of you in the context of a Canadian discussion.
Senator Cordy: You really can't blame school boards for their decisions.
Senator Nancy Ruth: We keep hearing that knowledge is going to cause change — knowledge on diet, exercise and lifestyle change — and that it's going to make us healthier and less obese. I agree, but as someone who has struggled with this for 60 years, I ask: How do you see this being sustained over a lifetime? I come and go on this scale of being more obese or less obese, a healthier lifestyle, a less healthy lifestyle. I get caught up in my problems and I'm back at the bad place.
Over a lifetime there's all the education. I know most of this education about nutrition. So what? How do you see it being sustained?
Ms. Cameron: Well, in terms of physical activity, focus on say the community-wide campaigns or the mass-media campaigns like ParticipACTION that look at specific populations and that we know could have an impact. For example, mothers of young children. We have to look at the barriers or the enablers for those populations and then make it useful for them and provide the knowledge. As we evolve through time, what we perceive as barriers will change. As we become a parent, then we're suddenly concerned not only for ourselves but also for our children. Providing the information that is specific to population targets would be helpful. The same goes for nutrition as well.
Senator Nancy Ruth: Mr. Tremblay, did you want to say something?
The Chair: He looked like he had nothing more to say. This is one of those areas where it's dangerous to take an individual example and try to extrapolate.
Do you have another question, senator?
Senator Nancy Ruth: No.
Senator Raine: Canadians, for the last 20 or so years, have received well the messaging from ParticipACTION. Do you see this of value? You mentioned it, Ms. Cameron. I know they have a limited amount of funding. Should we be doing more of this kind of targeted advertising, which seems to be trying to get at the issues? Is it doing a good job at getting into the different kinds of information messaging, social media as well as traditional media?
Mr. Tremblay: I will disclose that I am the former Chair of the Research Advisory Group for ParticipACTION and was part of the group that brought it back with the current government. With that disclosure, this is a good example of something to sustain. If ParticipACTION stops doing or constricts what it's doing, you're just going to fund another group to do the same thing. They have a 45-year history of success. We have published more information on the success and the evaluation of the program than any other organization in Canada. Challenge me on that and I'll show you the information.
Does it do it alone? Can you have a campaign on TV? No, but it's part of the puzzle. If they had twice as much money, they would do four times as much good. If they had 20 times as much money, they might be able to have an impact.
You need a national voice. You need some social marketing like this. There's evidence in the U.S. from campaigns that had the type of money you should have to be able to evaluate these things. It shows that it has an impact. It's a piece of the puzzle.
This is what happens: Funding gets so tight and constricted, and that's why ParticipACTION disappeared for seven years and had to be brought back. It's interesting that government funding was cut by over 50 per cent in the previous budget. The organization is absolutely struggling. Active Healthy Kids Canada, which produces the report card that many of you will be aware of, is in the process of folding. Another group will be able to get funding because they're a new group, and they'll have to restructure themselves to do exactly what Active Healthy Kids Canada did in the past.
This is not what we should be doing. I would invest in the ParticipACTIONs of the world that have demonstrated success, that have 80 per cent recognition in Canada. Build off that; don't be frustrated by that.
The Chair: Ms. Cameron, any further comments?
Ms. Cameron: I agree 100 per cent.
Senator Beyak: With all due respect, the previous question was about funding and the witnesses were both nodding while I put the question. Dr. Robert Lustig told us clearly that if we don't focus on that last six months and the cost of that care, there won't be any money left for health and obesity. I wonder if you could elaborate on what you were going to say.
Mr. Tremblay: The health care funding issue is one that has been predicted for a long time, and you're seeing withdrawals of it in the provinces. The Children's Hospital of Eastern Ontario is laying off hundreds of nurses because there isn't enough money. Researchers like myself have known that this was coming for a long time. It's going to get much worse. It'll challenge our universal health care to the extent that it won't be that way anymore. It's the reality because we just can't afford it, in part because of what you said.
This is getting beyond the obesity thing. Maybe I'll stop there.
The Chair: I'm going to come to a couple of final questions. Dr. Cameron, I'd like to come to your presentation and see if I can ask a question to clarify a couple of things.
In the second paragraph you deal with the overweight and obese young children five years of age and under, and you indicate the increase there. I want to get back to the issue of the mother in this particular case. Do you have any statistics on what percentage of those obese children in that "five years and under" category was due to the mother's condition during pregnancy and at birth?
Ms. Cameron: I think that data is available. I just don't happen to have it with me. I could look into it, though.
The Chair: Dr. Tremblay, do you have any comment?
Mr. Tremblay: It's not as simple as the mother is overweight or obese, therefore the child will be, although that relationship is there. It can't be as simple as that because the generation that is having kids right now weren't as overweight or obese as the kids that they're having. With 23 per cent of "early years" children overweight or obese, a smaller proportion of the mothers are, but being overweight during pregnancy is a risk factor for your child.
The Chair: Yes, absolutely. We've had a lot of testimony on that, which is why I was trying to delve out the distinction between the pre-determined nature that the child will become obese to those who develop obesity because of other environmental factors in the home. I don't want to delve into that in great detail exactly for the reasons you both indicated.
Another thing suddenly struck me when I was reading your presentation. It goes to this situation where the proportion of young Canadians who meet Canadian sedentary behaviour guidelines varies by age. You talk about 18 per cent of 3- to 4-year-olds meet guidelines, less than one hour — the point is, it's a piece of data on screen time, that is, how much time they're spending in front of a screen. I've been wondering about this for a while. One looks at that and uses that as an indicator that children are becoming more inactive. In actual fact, over time, even prehistorically, when I was a child, kids read books and played board games. They spent a lot of time on things that were not running up and down trees. In other words, in my day, we didn't have television, but we had radio. There were great radio programs that families often listened to together.
My point is that it seems to me that a certain part of a day doing those things is a reasonable part of a normal life pattern. When I read things like "no more than two hours of screen time", I knew kids that read books for two hours at a time, and they were very active and successful overall.
Can you put this in perspective for me in terms of what you mean and how that relates to total sedentary activity by these various groups?
Ms. Cameron: That's not my area of expertise, but it is my document. I will say that some sedentary activities are beneficial, like reading and time spent in school or even sleep. We know sleep is an important indicator as well.
Mark has the expertise here, but I think the reason that we're looking specifically at screen time is the negative aspect it has in relation to physical activity. We admit that there are sedentary behaviours that are important and they need to be recognized as such. That's why the indicator uses screen time and was developed at that time with the guidelines, I believe.
Mr. Tremblay: Yes. Just to clarify, I'm not an expert on watching TV. I just want to be clear on that. I'm pretty good at it, but . . . .
There are a number of reasons for it. Guidelines are developed based on research evidence that exists. I led that research for the development of the guidelines in Canada. It's crystal clear that zero screen time is optimal for health based on the collective literature in the world. None is the best. We drew the line in the sand at two hours for school-aged kids and less than that for earlier kids because the evidence substantiates that. People told us that if you say zero, no one will pay attention to it. The scientific evidence says the best is no recreational screen time, by the way. This is recreational. This doesn't talk about homework. This is separate and distinct.
The reason that's different from playing board games and things like that is because you're prompted by screens, by TV, to eat and to drink even though you're not hungry or thirsty. From an energy balance perspective, it's a negative. When you're reading a book or playing Monopoly, a commercial isn't coming up. Your hands tend to be busier doing those things as well, which means you're not just eating because you're bored. There are other elements that come into play with that. Screen time is bad.
The Chair: I think you've given me an excellent response. What I was looking for it that it is a reasonable indicator. I totally understand the reasons.
Senator Raine: I think many of us around the table have read the book Salt Sugar Fat. I'm not sure if it's scientific, but there appears to be the ability to design snack foods that are addictive based on formulas and using brain scan technology to light up the bliss point in the brain when you eat these snack foods. My thought is that perhaps we could test snack foods. If they light up the bliss point, put a skull and cross bone on them or some label on the front warning that these are addictive foods. Does that make sense?
Supermarket aisles are taken over by snack foods now, and there are so many of them. It's very hard: Once you start, you can't really stop. There's a whole combination of needing to eat well, not eating these kinds of foods. Could you comment on that?
Mr. Tremblay: I'm not so sure we should be doing brain scans on everyone with everything that they eat, but there should be some mechanism. There are different ones that have been done by I think the Heart and Stroke Foundation and other groups to try to give you the health check, the green light, red light, those sorts of things.
On a more fundamental level, and I've always liked fundamentals, just going back to the basics, I try to picture what my dad or grandparents were doing, and things were better then certainly from a health perspective. We need to educate the kids, people, parents and so on so that they know when they're going to the thing that is disguised as something that's fruit and it's not. You need the words. You know what the labelling needs to be to differentiate juice from drinks or sugar from natural fruit, those kinds of things. I think it's a more fundamental level. I'm not an expert in nutrition, but I can go in those aisles and I can tell, because of my background, what's good and what's not. I think that's what we need to get across to kids.
The Chair: It occurred to me that we've had other examples here of how to label these things. Maybe we could get an elephant that lights up. That's an in-joke to the committee, so we'll leave that alone.
I'm going to draw this to a conclusion, but I wanted to comment on a couple of things that came up.
On the issue of laws, I think that's an exceedingly complex area that would be very difficult to get in the direction that we think would make sense. On the one hand, you're always dealing with the fundamental right of individuals to challenge for things that have happened to them, and, on the other hand, societies need to deal with it. But the issue of removing balls from play in all school grounds is just beyond the pale.
I started listening to a CBC comedy program one time when they were interviewing the first soccer coach trained to be able to train a soccer team to compete without a ball. It was a spoof, of course, but it was exceedingly well done in terms of the ridiculous extent of this tendency to try to protect people from any injury. The issue of law is a complex one.
The analogy of what was achieved in the area of smoking is a good one in terms of trying to learn lessons from it. It's a very different application, as we know, in terms of how to go forward. The key will be picking out concepts that might be applied in an area where you have to consume properly. It is an overall issue. As you both pointed out, particularly Dr. Tremblay, there were a lot of lessons learned there as it evolved.
I want to sum up by saying that you have continued to solidify the evidence we're hearing that this is a very complex issue, and it's going to require a lot of major change in terms of ultimately addressing the issue of how communities are organized and structured and the issue of ability of people to walk. There are a lot of people that would love to walk from somewhere to somewhere within their communities, but it's just not possible because there are no sidewalks, or in other areas because they're afraid to, for reasonable reasons, not just obsessive need to try to protect children. It is a very complex area, and we very much appreciate the information that you've brought to us today in terms of looking at these things. Hopefully you've given us insights that will allow us to come to some reasonable recommendations as we move forward.
(The committee adjourned.)