Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 35 - Evidence - May 28, 2015
OTTAWA, Thursday, May 28, 2015
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:30 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, senator from Nova Scotia and chair of the committee. I'll ask my colleagues to introduce themselves, starting on my right.
Senator Seidman: Judith Seidman from Montreal, Quebec.
Senator Stewart Olsen: Carolyn Stewart Olsen from New Brunswick.
Senator Beyak: Senator Lynn Beyak from Ontario.
Senator Wallace: John Wallace from New Brunswick.
[Translation]
Senator Rivard: Senator Michel Rivard from the Laurentians in Quebec.
Senator Chaput: Senator Maria Chaput from Manitoba.
[English]
Senator Merchant: Pana Merchant from Regina, Saskatchewan.
Senator Eggleton: Art Eggleton, senator from Toronto and deputy chair of the committee.
The Chair: Thank you, colleagues. I'll welcome our witnesses in a moment.
We are continuing our study to examine and report on the increasing incidence of obesity in Canada, causes, consequences and the way forward.
Colleagues, we have two sessions, with two witnesses for this first session. I will use the one-question-per-individual per round. We will have multiple rounds, hopefully.
Since they did not beat one another up to see who will go first, I'm going to invite them to present in the order they appear on the agenda. In the first instance, I have the honour to invite Mary Collins, who is now Director of the Secretariat for the BC Healthy Living Alliance. Ms. Collins, please.
Hon. Mary Collins, P.C., Director of the Secretariat, BC Healthy Living Alliance: Thank you very much, Mr. Chair and honourable senators. It's certainly a pleasure to be here today and have the opportunity to share with you some of our thoughts on the issue.
Your study on obesity has created quite a buzz among the health promotion community and we're very much looking forward to what you may report. I hope you're able to get the report done before too long — other events may intervene.
Thank you very much for inviting the BC Healthy Living Alliance to present and to provide our input into your report. The alliance is an alliance of NGOs committed to healthy living and the prevention of chronic disease, so we involve Canadian Cancer Society, heart and stroke and diabetes, plus the health authorities in British Columbia and the Ministry of Health of B.C. We look at the risk factors and inequities that contribute to chronic disease.
As you've already heard from many other witnesses, obesity — actually, we're concerned that sometimes "obesity'' has a stigma attached to it, so we talk about unhealthy weights — is a real problem in Canada. We know it is a risk factor for a number of chronic diseases. The evidence is coming out almost monthly about the connection of unhealthy weight to heart disease and to cancer — in fact, a big report came out just the day before yesterday about cancer rates — and to diabetes. Also, it has relationships to mental health and mental well-being, associated with anxiety and depression. New research shows that this can be further exacerbated by weight stigma.
We need to be sensitive as we seek to improve overall health, including both the physical and the mental well-being of Canadians, particularly those who may be at unhealthy weights or obese.
Fortunately, there are lessons on healthy living that apply to all Canadians of every age and size. Today I'm focusing this presentation on physical activity, as that's what you had asked us to talk about, and how this can be supported by governments as an important factor in what we call an "all-of-society approach.'' Physical activity supports both the mental and physical well-being throughout the life course. It's critical for the healthy development of children as infants — I have a new grandson nine months old and I'm already seeing how important this is — and to help them develop healthy bones, muscles and physical literacy skills that will serve them for life.
At later stages of life — and the evidence is increasing for older adults such as myself — physical activity is really important, such as getting out and walking and doing something. It really can have a dramatic impact on long-term health.
I think most Canadians have a pretty good idea about this, but the Canadian physical activity guidelines recommend at least 150 minutes a week for adults of moderate to vigorous activity and 60 minutes per day for youth and children. Recent evidence shows that every bit helps. Sometimes people say I can't make the 150 minutes. It's just too much. Okay, don't give up. Every little bit helps. Everything you do to keep active will have an important impact.
Recent evidence has also shown that mortality has been reduced by 20 per cent when people were somewhat active, even if they didn't meet the guidelines. Don't worry too much that everybody has to meet the guidelines, because some people will fall off that wagon.
British Columbia — and I notice we don't have any senators from British Columbia — and you probably know this — has some of the best rates of physical activity. Part of that relates to our weather. If you go to Vancouver, everybody is biking. It's amazing to see the resurgence of that activity in our community. What we also see is that it's not the same in northern communities, in populations of low socio-economic income and in small communities that are often rural. There are big differences and we have a lot of data on that.
I think there are parallels with populations that have an elevated risk for obesity and chronic disease. You see that same trajectory for low income, rural, Northern and First Nations groups. As we plan where we can make the most difference, we should be thinking about how we can prioritize action for those populations.
How do we overcome the barriers? How do we motivate people? There's no panacea. There's not one thing we can magically turn on that will work for everyone. We're doing some work at the moment with men in camps in the Yukon and Northwest Territories and northern B.C. It's really interesting to see the different approaches you need to work with those populations around healthy living and physical activity. We're learning a lot. It's a wonderful project.
There are a number of things we can do, but I do want to focus on a couple of areas where, perhaps, government can play a role. I know you think what's the federal government got to do with this; a lot of it is provincial and local? The federal government can play a role. We think one of the most important things is to invest in walkable and transit- oriented community design that supports active living. If people don't feel they can get out and walk or if they can't take transit, that has a huge impact on their physical activity levels.
A recent study in Metro Vancouver — and we have the big referendum going on at the moment — found that those who took transit were 22 per cent less likely to be overweight or obese than those who commuted by bike or on foot, who were 48 per cent less likely to be obese. That's a big difference.
There's the new program out for the big 2018 thing involving investing in helping communities to be walkable. We've done a lot of work in this area. Just little grants can help the smaller communities to redesign and have walkways or pathways — things that can encourage people to get out and walk. We also think we can provide opportunities for children and youth to develop active lifestyles by building physical literacy skills and programming in schools, as well as some of the things that the Public Health Agency of Canada is doing to support after-school initiatives. We would like to see that continuing, as well as increasing access to sport communities for low-income families. We want to talk about that later.
Revitalizing recreation centres and parks to better serve communities through some of the government programs and grants that are available is also important. In B.C., we know many of those need repairs and updating; I'm sure that's true throughout the country. Then there is working with First Nations and Aboriginal people to increase participation. We know the high rates of diabetes in that population.
Then, finally, we have been looking at nudging. I don't know how much discussion you've had about that, but it's about giving incentives to people, nudging people to do things. There are a number of new program ideas that are being developed around the nudge theory in Canada, which I'm sure you are going to be hearing about later.
We have to build on existing networks. Again, we think the federal government can play a role as a convener, as a funder, as a knowledge broker. You've got many levers and networks to facilitate an integrated approach to physical activity promotion. We encourage you to look at those existing networks where the federal government brings people together to see where there are opportunities to promote physical activity. For example, the Community Action Program for Children provides a really important audience and a vehicle for promoting physical literacy to preschool children.
I just wanted to conclude on a comment that Senator Nancy Greene Raine made:
. . . it's essential to get Canadians moving, and the stakes are high, especially for youth.
Investing in efforts to get Canadians active is worth it. Inactivity takes a toll on our economy. There's evidence that $4.6 billion to $7.1 billion a year goes into direct and indirect health care costs. Compared to an active Canadian, an inactive person will spend 38 per cent more days in hospital and make 5.5 per cent more family physician visits and 12 per cent more nurse visits. Again, we're gathering a lot more evidence about the economic impacts around these risk factors. Hans Kruger has done great work in that area. I want to assure you that the non-profit sector and local governments are your partners, but we do need the federal government to be involved and to make physical activity infrastructure and programs a priority. It's time to get beyond talking. It's time to get active.
The Chair: Thank you very much, Ms. Collins. I would just note that we do have a senator from B.C. who is unavoidably detained today, and, indeed, you quoted her. I'm not going to go beyond that because this is a televised meeting. But she is unavoidably detained and devastated that she is unable to be here today.
I will now have the pleasure of welcoming Dr. Jonathon Fowles, who is here today representing the core faculty with Exercise is Medicine Canada.
Dr. Jonathon Fowles, Core Faculty, Exercise is Medicine Canada: Thank you, Mr. Chair and the committee for inviting Exercise is Medicine Canada to appear before you to address this significant issue for Canadians. In beginning, I'll ask the committee: What if there was one medicine that could treat dozens of diseases, including obesity, diabetes, cardiovascular disease, depression and cancer? Would you want your doctors to prescribe it to their patients? Certainly, you would. That embodies the vision of Exercise is Medicine Canada. Strong, irrefutable evidence shows that exercise, when taken in the right dose, can reduce the risk and prevalence of many chronic diseases by 25 to 60 per cent and is safer and more cost-effective than most drugs. While this committee is examining and reporting on the increasing levels of obesity in Canada, the evidence clearly shows that physical inactivity contributes to the obesity epidemic and is a major contributing factor to the reduced fitness and declining health of Canadians.
A recent Canadian Health Measures survey showed that nearly 50 per cent of Canadians report meeting the Canadian Physical Activity Guidelines, but only about 15 per cent actually meet this target when measured objectively. You may ask: Why is this a problem? Because declining physical activity levels in every domain of what we do, from work to transport to home activities to our precious leisure time, has a major effect on our bodies and our health, and it is significant.
I am an exercise physiologist and a member of the Canadian Society for Exercise Physiology, which partners and supports the Exercise is Medicine initiatives in Canada. As an exercise physiologist, I am amazed when I see that the average daily energy expenditure of North Americans has dropped precipitously since the 1960s. I am shocked when I see the fitness testing data of Canadians showing that we are, in fact, rounder, heavier, weaker, less flexible and less aerobically fit across all demographics than we were in the 1980s. I am not surprised when I see that two thirds of Canadians are now overweight or obese when I see this low activity in a society of ubiquitous, unhealthy and processed food. More so, I am appalled when I see that there is so little being done to support and encourage the healthy, active behaviour of Canadians.
The committee is asking for a way forward, and my colleague Ms. Collins was referring to some of the evidence in this regard. Recent studies suggest that increasing physical activity and reducing obesity rates in Canada by a mere 1 per cent per year could save $5.2 billion in total economic costs per year by the year 2030. If 10 per cent of the Canadian population became more active, this would produce a net improvement in GDP of $7.5 billion per year by the year 2040, let alone the positive effects on personal and social and other well-being.
It's clear that a multi-sectoral, bottom-up, top down, side to side, everything approach is needed to solve the obesity and health care crisis in Canada. Exercise is Medicine is one initiative in this puzzle, but it is significant in that it is internationally recognized. It was originally developed by the American College of Sports Medicine in 2007 and is now present in over 30 countries worldwide. The Canadian Society for Exercise Physiology is the national licensee and primary promoter of the program in Canada but does so with essentially no external funding support.
EIMC has as its vision that physical activity is an integral part of the prevention and treatment of chronic diseases in the Canadian health care system. The objectives of EIM Canada are to increase the number of health care professionals assessing, counselling and prescribing physical activity and to encourage the recognition of and referral to qualified exercise professionals who support Canadians in meeting the Canadian physical activity and sedentary behaviour guidelines.
You may ask why this initiative is needed. Although lifestyle behaviors are responsible for roughly three quarters of chronic disease prevalence in society, including obesity, only a small percentage of Canadians receive prescriptions for a healthy lifestyle through their primary health care. Our current health care system, from training to practice, is very much entrenched in a corrective treatment model that is pharmaceutically and procedurally driven. There are significant barriers for primary care physicians and other allied health care professionals to prescribing exercise and many do not have the knowledge or the community resources, to support referrals for such an exercise prescription if one were made. So it's no surprise that more than 75 per cent of Canadian adults receive a prescription for medication to address the symptoms for their poor health, but only 10 to 15 per cent of Canadians receive a prescription for exercise to help prevent their health from declining. This needs to change right now if we're going to decrease obesity levels and address the health care crisis in our lifetime and in our children's lifetime.
You might ask: What is Exercise is Medicine doing? We are a multidisciplinary advisory council of health and exercise experts, working with organizations such as the Canadian Academy of Sport and Exercise Medicine and the College of Family Physicians of Canada, to bridge the gap between these two traditionally separate sectors and to implement strategies to promote physical activity in clinical care. But this ship is big, and our rudder is small. To turn the ship around, we need strong government and profession support at all levels, nationally, provincially, regionally, as was alluded to previously.
To further this initiative, we're asking for: one, support for Exercise is Medicine Canada to raise national awareness and to facilitate policies and training for Canadian health care professionals to actually prescribe and promote physical activity as part of health care to improve the health of Canadians — that's what health care is about — and, two, support, through lobbying and legislation, to make physical activity counselling and exercise prescription the easy choice in health care. This means initiatives to keep Canadians healthy, such as the nudging-type initiatives; policies that support health care professionals to assess, advise, counsel, prescribe and refer; and policies that recognize appropriately qualified exercise professionals as providing a valuable health care service in health care teams and communities across Canada.
In conclusion, we believe that support for Exercise is Medicine Canada would have a significant impact on obesity rates and the fitness levels of Canadians, and this would result in a major cost savings to the health care system and increase Canada's fitness and productivity as a nation. Exercise is Medicine could then be the message that helps make Canadians as healthy as or healthier than the average 60-year-old Swede. We are so familiar with the ParticipACTION commercials of the 1980s. Thank you for your attention and consideration.
The Chair: Thank you both very much. I will now open the floor to my colleagues for questions. I will remind them that this session will end no later than 11:30 and that the one-question-per-round rule is invoked.
Senator Eggleton: Thank you very much for your presentations. Welcome back to Parliament Hill, Ms. Collins.
I want to deal with a question we keep hearing about in relation to children; namely, inactivity, because they spend an awful lot of time in front of televisions or playing video games, using computers, et cetera.
Are there any particular best practices your organizations, or other organizations you know of, use to help combat that situation, to get kids out into more physical activity as opposed to spending an inordinate amount of time in front of screens — if you think this it's an issue.
Ms. Collins: Definitely, it's an issue. Perhaps I'll start. I think you heard from Dr. Tom Warshawski from the Childhood Obesity Foundation. A good program has been developed for the schools around screen time to educate children about screen time, certainly in British Columbia — I don't know if it's been used in other provinces as well. That is one step. It's not everything and it's not going to work for everyone because, again, not everybody reacts the same way, not even children. We think it's a good program that should be continued and supported.
Doing things for after-school, as I mentioned, to ensure there's physical activity is a good practice. There's also the work that the Public Health Agency is doing in that area. Working with parents, through parenting groups, to encourage parents to limit television time is another. Again, I think it's important to be doing that with people from the lower socio-economic income bracket who may not have the opportunities to get out and do other kinds of programming.
I think a lot can be done, but we're certainly not there yet. Who has kids? We all have kids. It's so much easier sometimes to park them in front of TV set or a computer. You see them in restaurants using iPads. They've become quite addicted to them. It's tough, as a parent, to get them off that. It takes strength and willpower to make sure they are getting out and getting involved in other sport or recreation activities.
Dr. Fowles: The evidence shows that children and youth spend 38 to 42 hours per week outside of school in front of a screen. That is a full-time job in front of video games; in front of their iPads. We have not necessarily an attention deficit disorder. We have a nature deficit disorder for kids, where they're not spending time outside. Mark Tremblay would say that for every hour a child spends outside, their physical activity level is dramatically greater than those who don't.
A number of things can be done. One is within schools. There are initiatives to promote laptops and the use of laptops, almost sometimes at the expense of phys. ed programs. My daughter is 6. I have kids who want to move all the time. I personally think that is the way they're wired. I cannot get my kids to stop moving unless I put them in front of a screen. That's what they want to do. They want to go out and play with their friends. They want to be outside and jump on monkey bars. But we've legislated physical activity out of everything they do. We've taken out monkey bars because there they're too dangerous. We've taken footballs away from fields because someone could get hit in the head with one. Well, they're playing. They're kids. That's what they do. We've overregulated play in Canada. We need to invite kids to play again, and, in so doing, we need to invite parents to play with their kids. My son, who is 4, non-stop asks me, "Dad, can we play baseball? Dad, can we play soccer?'' If I can't do it, who can? I go out and play with them. That's how I get a lot of physical activity, by being there.
As Canadians, we need to embody and support being active as part of our culture again almost. That can be what we build frameworks of families around; namely, being active as opposed to isolating. You see this all the time at restaurants, where each kid is on their own thing and the two parents are checking their text and nobody is talking to each other. You go to a coffee shop now and nobody is talking to each other because everybody is fixed on their technology. If there are ways we can be creative about embodying physical activity and the social construct of it as part of what we do, I think that would have a big effect on how people feel and what they can do.
Ms. Collins: I think it also relates to safety issues of our communities. I'm sure many of us, when we grew up, went out to play all day. Parents are fearful of doing that these days. We have to find some ways around that as well.
Dr. Fowles: We have to address the issue of fear — this stranger, danger, or whatever you want to call it. The availability of parks is high in Canada but people don't use them because they're afraid. Actually, most of the evidence shows that our crime rates are lower than 20 years ago, but people have the perception they can't go to a park and play, which I think is misguided.
Senator Seidman: Ms. Collins, in your list of what can we do about this you make reference to "we can look at ways to 'nudge' healthier behaviours.'' You said that you would get back to that. I'd like to give you the opportunity, please, to get back to that because it's of enormous interest. Also, you mention the U.K. and the U.S.A. It's always important to look at what other countries' best practices are in dealing with the same situation.
If you could, please tell us about what "nudge healthier behaviours'' means?
Ms. Collins: I think we're in the sort of early days of that, although I guess you could say perhaps some of the traditional ParticipACTION-type of advertising would involve some of that. Some of the new work going on now involves giving incentives to people. I don't know if you've had any presentations on that, but there have been some projects in Canada. In British Columbia a few years ago, with the Ministry of Health and one of the grocery store chains, if you bought fresh produce and did those sorts of things, you would get more points on your Canada Safeway plan. There is some work going on in that area to expand those types of projects and to see how they work. Again, not everyone is going to react in the same way. I think we have to be careful to say there isn't one solution.
Other ways are in the workplace, by having teams that will go out and perhaps do things together. I know AIR MILES has done a lot of work on this as well. Their employees go out walking at noon hour and there may be some prizes. We've been doing that at northern camps. We walk out of camp and there are prizes for people who do it. A lot of people are motivated when they can get something in return if they do something good. That's kind of what we're thinking about in terms of the "nudge'' factor.
Senator Stewart Olsen: It's going to be very hard to keep to one question, but I will.
I'm very interested, Ms. Collins, in the camps, but my question is for Dr. Fowles.
When you talk about exercise as a prescription, what are you talking about there? Most doctors that I know, nurse practitioners and people like that, see their patients and they say, "You've got to get out and walk.'' But that is not helpful. Either people will or they won't, but most don't. Or they say, "You've got to get more exercise.'' When you talk about a prescription, can you elaborate a bit on that?
Dr. Fowles: Yes; certainly. It is true that just telling people to exercise does not work. It's kind of like the January 1 resolution: I'm going to be healthier. Yeah, sure. Unless you have a plan for that — that is, what you're going to do, when you're going to do it, for how long, at what intensity, with whom and what supports do you need in order to make that action plan happen — it won't happen. That's where the recommendation to be active in health care is failing. Many health care professionals will say "Be active,'' but unless it comes with a specific kind of prescriptive thing, it can fall flat on its face.
One of the programs within Exercise is Medicine is an actual prescription pad where you can write down "30 minutes, three times a week, at moderate intensity,'' and it empowers the message. For example, if a patient goes to see their doctor and they say, "You should probably eat better and be more active, but here's your prescription for a medication.'' They walk out of that appointment with this piece of paper that says this is important, and the doctor talked about some other stuff but they don't really remember what was said. That prescription for medication empowers a certain message and disempowers the other message.
One of the initiatives that we have is to actually get them to write it down, and only 10 per cent, at most, of health care professionals actually write down a specific recommendation. Many health care professionals might talk about smoking with their patients, but how many of them actually say they should stop smoking? That's a big difference in what you're directing and helping your patient to do. You need resources to support the message, just like you need smoking cessation supports to refer that person to, but the empowerment of the message increases the likely adoption of that recommendation by over 50 per cent. For doctors who actually do write prescriptions in practice, it increases the physical activity level of the population that they serve by about 10 per cent. I do acknowledge that not everybody is going to respond to that. We did a recent survey in Winnipeg, just a health poll. When I did an Exercise is Medicine workshop for a group of local doctors there, CTV News came and interviewed me and did a little Web poll. They said, "If your doctor wrote an exercise prescription, would it increase your activity, and would you do exercise?'' About 800 people responded to this poll in one day, and about 35 per cent of them said yes. That's quite a big number, actually. Not everybody is going to directly respond to that, but, if 35 per cent of them are, that's a whole lot better than the 15 per cent of Canadians who actually need guidelines. I think there are some clear things that can be done in that regard.
Ms. Collins: Can I just add some comments because we've had some experience in this area as well. A few years ago, we ran a project with physicians' to do with prescriptions for walking, and it didn't actually work very well. We learned from the mistakes. There wasn't enough follow-up, and we didn't provide information to physicians about where people could go. Now, there's a physical activity line in B.C., which is very helpful. You can phone and get all of that kind of information. In British Columbia, we're just completing a new physical activity strategy that the ministry of health has led and we've been part of as the NGO community as have the physicians. This area is going to be part of that strategy. It will involve not only physicians because we've been very strong about saying all primary health care providers — your dentist, your physiotherapist.
There is one other thing I would suggest you look at: I was in Norway a few years ago, and they have some wonderful programs that operated on a similar basis. When the physician referred them, there was follow-up; people really had to check in. It wasn't just, "Okay here's a prescription; go and walk.'' They were getting some very good results from that approach.
Dr. Fowles: The other initiative of Exercise is Medicine Canada is to promote the referral to qualified exercise professionals for follow-up. For medication, you can go to see the pharmacist, and they will tell you how to take the medicine, with what food. But the referral has to be to somebody you trust. For example, somebody with diabetes or cardiovascular disease has to be referred to someone who knows what the prescription means, what intensity and what precautions you might need to take if precautions are needed.
Right now, in our society, kinesiologists are regulated as a profession only in Ontario. It's very new, only in the last two years. Across Canada, we need much greater support within communities so that people can actually go to get the help that they need to be more active.
Senator Merchant: You have been sort of answering my question. Obviously, from what you have said, there's a disconnect between the information and knowledge that you have and reaching the community at large. You say that at every level we are falling behind.
You may agree or disagree, but maybe we're not giving information that's clear and accurate and that people can really follow. For instance, we know that, on packages, labelling is mandatory. We have learned from this study that people don't really follow or understand labelling. Maybe it's the same with exercise. I read somewhere that exercise actually is a prescription for the failure of government to bring in programs because we simply say "exercise'' and that's supposed to solve the problem.
Maybe other countries are doing something to engage people, to make people understand that this is important. We say it's important. We pay lip service to it, but, obviously, we're not practicing it.
Mr. Fowles: Two things. One, now we have harmonized guidelines. The Canadian Physical Activity Guidelines of 150 minutes of moderate to vigorous physical activity are harmonized between just about every major chronic condition. If you go to the CDA guidelines, the cardiovascular society, the hypertension guidelines, they all have the same guidelines now. A few years ago, they didn't. That's one thing that will clarify the message. The other side of that is that it is true; there is no national strategy for physical activity in this country. There's a document, Active Canada 20/20, that basically has the blueprint and framework for how we can do this, top-down, multi-sectoral, to promote physical activity as part of communities, health care, schools, but there's no leadership for it. When I think of the Public Health Agency of Canada and how it can activate incredible resources in something like a SARS crisis or a Mad Cow Disease crisis or something like that, the number of Canadians dying prematurely from physical inactivity every day exceeds all of those crises put together, yet there's no emergency. There's no national strategy to promote physical activity and the health of Canadians in that regard. Why not, is my question.
Ms. Collins: If I can add to that, we were all involved in Active Canada 20/20, but it seems to have kind of fallen off the table. I don't even know where it is now. Again, people react differently. There are those who are active and biking and doing all of that stuff. A lot of people just resist it. I don't know how you all feel. I'm kind of like that myself. I don't like to be told to do something, so you have to be very careful how you message these things to really get at people who may resist.
One of the things we certainly find is people are social, and to get people together to do things is important. Get groups to go walking, older people walking in malls, workplace, lunchtime walks, where people do it together and don't feel so isolated.
The Chair: I'm going to tell my colleagues, I have a full list now, and we will end at 11:30. I'm going to get in a question before we end.
[Translation]
Senator Rivard: Dr. Fowles, in your text, you say that exercise is medicine, and you hope that Canadians are as healthy as 60-year-old Swedes. This applies to people who are 20, 30, 40 and 70 years of age. It is a good model because every time people talk about Sweden, be it the tax model, the climate or social programs, it is the perfect example. So we like being compared to Sweden.
To come back to health, which is our topic today, I am over 60 and I believe I have a healthy weight for my height and age. We work several hours a week and walk from office to office. What else could be done, taking healthy eating into account, of course? What else could be done for people like me, who are between 60 and 70 years of age? Besides walking, what exercise could be done regularly so that we can achieve what is desired in your program, Exercise is Medicine Canada?
[English]
Dr. Fowles: The health care tsunami in Canada is that diabetes incidence rates increase basically by decade. They go up like this. The other thing that we see is that there has been a doubling of diabetes crude prevalence rates every 10 years over the last 20 years. Over the age of 60, there's this major increase in diabetes. The major contributing factor is use of muscle. Walking is one thing. It burns calories, but what we don't do in today's society is engage our muscles in vigorous activity. The second part of Canada's physical activity guidelines is muscle and bone strengthening activities at least two days per week. That's because 80 to 90 per cent of blood glucose is deposited in muscle. With all the things we have in society, like snow blowers and riding lawn mowers, there's a convenience to reduce the amount of upper body work that we do. Doing simple things like resistance band training engages the muscle mass and can reduce blood glucose levels quite precipitously and reduce A1C levels and reduce the risk of diabetes.
We have a number of community-based programs in Nova Scotia that are run out of church basements and diabetes centres, et cetera, where a group of seniors get together to do resistance band training and go for a coffee together. Their new job when they retire is to exercise and take care of themselves. The ones that do that can do a good job of being healthy and vigorous and living a long, independent life. That's one thing that exercise does. It not only adds years to your life but life to your years, in the sense that you can maintain a high quality of life until something happens, not this long, slow decline. That's what exercise, particularly resistance exercise, can do.
Senator Frum: My question is along the lines of Senator Stewart Olsen's. Most Canadians see their doctors once a year at most. A lot of the focus of your presentation, Dr. Fowles, was on the role of health care professionals. I appreciate that they see other types, but in terms of trying to solve this problem through the doctor's office, it seems to me to be a bit of a vain hope because people are not always necessarily frank with their doctors. They make all kinds of promises to them and they only see them once a year. I just don't see that as being really that helpful.
Dr. Fowles: I acknowledge that the exercise is medicine and the initiative to get doctors and other health professionals to prescribe exercise as part of health care is one piece of a large puzzle. I acknowledge that and admit it. I think it's a valuable one in that 70 to 80 per cent of Canadians see their primary health care provider at least once a year. The big thing is that when you talk about health information and what constitutes the highest regard for health information, the information they get from their physicians is always ranked number one. That recommendation from a physician, or from another allied health care professional, has a powerful effect on changing behaviour if a person is ready to receive that message.
It doesn't work for everybody. For example, for a doctor to recommend to somebody to stop smoking, we would all agree that will have a significant improvement in their health. Adopting Canada's physical activity guidelines has a benefit that is equal to or greater than stopping smoking, if they achieve 150 minutes. A physician has to talk to between 50 and 120 people to get one of them to stop smoking. But if they talk to 8 to 12 people, one of them will get 150 minutes a week. When you talk about the resources that go into smoking cessation programs, one tenth of the resources could get as great or greater benefit. That puts it into perspective.
Senator Wallace: As I listen to your presentations, I think back to my own youth. I played a lot of competitive sports. I enjoyed it; I loved it. I remember the training camps and doing wind sprints — hated that; hated having to get in shape. But I loved the game. I loved the play, the fun and the camaraderie — the exercise, not so much. I was able to fool myself. When I was in the game I was getting exercise, but I was having fun so I wasn't really thinking about the health benefits.
Ms. Collins, you spoke about your grandson. My grandson is a 4 year old and is like a heat-seeking missile. I don't have to tell him what to do, he just does it. With that backdrop, it strikes me that at different ages different motivations are needed to encourage people to be active. For very young children, they'll find their own way; for 9 and 10 year olds and teenagers, that's something else again. If they perceive the computer to be more fun than exercise, that's what they'll do.
Dr. Fowles, when you talk about the prescription that's needed to encourage activity, regardless of age, at the heart of it is that people have to have fun and enjoyment in what they're doing? If they think, "I'm on this treadmill because I need half an hour of this,'' well, we've all done that, and many of us just get away from it. It isn't enjoyable.
Do we have to create facilities, circumstances and innovative ways so that at all levels it can be fun? Where can there be play in this so it's not work, it's play? Is that really not at the heart of it so we can fool people? You'll get healthy but you're not doing it because you're told to do it as merely exercise.
Ms. Collins: I would agree with you 100 per cent, Senator Wallace. That's certainly what works for me. Again, I realize that everybody is different, but that's a big part of it, namely to make it fun and social and interactive so you don't have to be alone. Some people love running alone, but a lot of people don't react to things in that way.
Yes, having those kinds of programs would be great. In social housing complexes, having a facilitator or motivator involved, getting people together to have fun and to do some physical activity and together with their families would be another way to do that. There are a lot of things that we could be doing.
We are not big advocates of advertising. It may have worked back in the 1980s, but we don't think it works terribly well now. I think you have to be doing things on the ground with people and, again, making it fun.
Dr. Fowles: I totally agree with you. There are different strategies for different groups. I agree that it has to be fun and social. Part of Active Canada 20/20, there's multi-sectoral involvement in sports and the long-term athlete development thing, schools and all the rest of it.
From my perspective, within Exercise is Medicine, it is true that if you tell somebody to do something, they will actually do the opposite. If you tell somebody to exercise, they will probably reduce their physical activity. That's what our workshops and training do. They teach what physical activity counselling is. It puts the patient or the individual in the driver's seat and lets them choose their destiny with how they can become more active. Again, that's changing the prescriptive model 180 degrees, which is to ask someone about their physical activity, ask them about what activities they enjoy and then ask them what they might consider doing to contribute to their health. The key thing is that the health care provider is empowering the message that being active will contribute to their health, fitness and social well- being. They're more of a guider, when done properly. Again, this is part of the problem. Many medical professionals do not receive any training on lifestyle intervention. That's another initiative of Exercise is Medicine Canada. Exercise is Medicine is on campus to change the curriculum in medicine schools and programs and to give training to let people know how to counsel people on physical activity in order to empower a message and empower a person to adopt a physically active lifestyle the way they would like it to be done.
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Senator Chaput: It is unfortunate that Senator Raine is not here because she would be very happy. There is no doubt that physical exercise needs to be part of everyone's life. We must normalize physical activity again. It was in the past, and some senators have given several examples of this, but it isn't anymore for all sorts of reasons.
We talked about schools. Don't you think it would be important to encourage physical activity in school curriculum programs — I know this comes under provincial jurisdiction — as in the past, so that all schools offer these physical activity programs to children?
There are also daycares. There are small children in these daycares. There weren't daycares 40 years ago, but there are now. What could we do to begin normalizing physical activity at that age, so children follow all doctors' orders? Small children are there to learn and want to learn. What should be done with these children across Canada who are ready to receive this kind of message and could develop better habits?
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Ms. Collins: Absolutely. In British Columbia we do have guidelines for the child care centres in terms of requiring them to have physical activity. It is the same thing with schools. They came in a few years ago. One of the challenges has been, at least in the school part, that the teachers don't necessarily know what to do and it has been a problem. The feeling has been that the guidelines really haven't been implemented that effectively in some parts of the province.
We have been emphasizing in the new physical activity strategy that that needs to be strengthened. We need to have the tools and resources so teachers know what to do to make the kids have fun while being physically active.
Again, it requires partnerships at all levels of government to help implement those kinds of programs.
Mr. Fowles: Two things. First, there was a big initiative 20 years ago to remove physical education teachers from the schools. I think that was a colossal mistake because you had math teachers, well-meaning instructors trying to do something to develop physical literacy, and it requires expertise to do it properly. A big thing is to re-introduce those teachers into the curriculum. Just like I said about going to a doctor's office where they give you a prescription for medicine, and they talk about other things, you empower one message but disempower another.
In schools, we empower technology. We are embracing technology and saying you need laptops and all those things, and we're shortening physical education times. We are shortening lunch hours. My daughter has 15 minutes at lunch hour to play outside because she has to get back into the classroom. Why? The evidence is clear that the more you exercise, the greater your memory, the lower your attention problems, the greater your attention in school. So why isn't lunch hour mandated to be at least a half an hour for every kid every day to increase their school performance and health?
Senator Beyak: Thank you for your presentations. I have an 11-month-old grandson, so I share your joy. I have the same line of questioning as Senator Wallace. My grandmother was 102. She was fat and fit and she never took any medication in her life. But she exercised every single day. She cooked and owned a tearoom at Yonge and Bloor. I wonder if you can comment on how to make exercise more fun. She stood up and exercised during every commercial when watching television. She danced around the kitchen and was a very happy person. How can we make exercise more fun, because most of us aren't downhill skiers — I wish I were — or into competitive sports?
Ms. Collins: There are lots of things to think about. We're all sitting here. Why are we sitting? Why aren't we standing? A lot of work environments have standing desks so people aren't sitting all day. They are getting up and moving around. It is things like dancing during the commercials. Say, "Let's dance while we watch the commercial.''
I think there are lots of things that can be done to make it more fun. As you said, you can be what people might perceive as being overweight but you can be healthy if you are also physically active and eating fruits and vegetables. We have been to be careful that we don't stigmatize people because of weight issues.
Mr. Fowles: It is true that fitness is a much better predictor of health than obesity is. The other thing about the fun is that Active Canada 20/20 is a multi-sectoral thing that would normalize physical activity for all Canadians, and it can be part of the social construct.
For example, I talk to parents and they say to get their physical activity in, they watch their kids play soccer. I ask, "Why are you standing there?'' The answer is, "Because all of the other parents are standing there.'' If you walked with the other ones around the field, you would all be walking together and then that would be normal. I started this initiative and in all these communities now, you see people walking around soccer stadiums, around hockey rinks. We built a walking track around the rink at Acadia, and now that thing is used all the time. It's normalized that this is okay, and the sitting is going to get less and less okay.
We need that support for a national physical activity strategy that makes it the norm.
The Chair: I'm going to ask some questions now. Maybe I can extend the questions a bit. Our next witness who is coming to us by video conference is currently on a subway train in New York City. We'll see how that goes. We're in communication, so to speak.
I was thinking that because all the kids are on their cell phones and using their thumbs all the time, maybe we are in a period of evolution and will become a series of thumbs. Maybe we're resisting evolution here with all this effort to change things.
I also wanted to acknowledge some of the activities that Dr. Fowles and his colleagues in the kinesiology department at Acadia are doing, which have had a tremendous impact and reinforce many of the things being said here, including Senator Beyak's comment and others. They have, for example, a heart-healthy program. This is for people who have had a heart attack or some reason to be concerned about their heart activity.
These people have taken to this program so seriously that when Christmas or summer comes along, they want to be able to continue and it has been going on for several years now.
The point is that with all the things you've been saying here today, if you can make something available, create an incentive to get people into it, provide encouragement and make it a group activity, a community activity, it will become an event for them. They look forward to it. They're largely retired. It's a very positive construct. To give Acadia a plug, it has a number of programs, from children through to these age groups. In fact, it's annoying when you're using the facility on your own that they're so successful it's cluttering up the exercise facility.
Dr. Fowles: That's a good problem.
The Chair: It depends on your point of view. It absolutely is. It's an absolute measure of a great success. I want to applaud you and your colleagues for not only preaching but practicing and getting all kinds of examples of success.
I wanted to come back specifically to the issue of the prescription concept. First of all, I want to say that I am entirely with both of you with regard to all of the things you've raised and focused on here today in a very constructive manner.
But, there is now some evidence arising with regard to the so-called prescribing or incentive issue for people to exercise. A Cambridge University study, which you're probably familiar with, recently looked at this issue. The issue is how long can you continue to, let's say, provide free access to a physical fitness program? How long can you continue to give a treat, so to speak? Maybe it's a chit to encourage people to continue. They did a study that says "bribing people to live healthily only works for three months before they fall off the wagon.'' That is what a Cambridge University study has found. I just gave you an example of one that has been enormously successful for years, so there are ways of doing these things.
I will direct this initially to you, Dr. Fowles. Getting that prescription from the doctor, the discussion, writing it down, whatever it is that you're able to succeed in getting the doctors to do or getting the individual to start some sort of activity, tell me what your experience is with regard to the follow-up and the long-term.
Mr. Fowles: A few things. First of all, Senator Seidman talked about nudge, how exercise is medicine, and the incentives within health care.
One of the things that we're also trying to promote is called the exercise vital sign or physical activity vital sign. One of the most important health indicators, like heart rate, blood pressure, temperature and breathing rate, is your physical activity level in that it is probably one of the biggest predictors of your overall health.
Get physicians to measure that with each occurrence. Then they write a prescription. Then they can write a referral or make a recommendation to a program. That's where there needs to be follow-up. Community resources and programs that are working need qualified exercise professionals running them that know what they're doing and know how to manage individuals and their individual needs. If somebody has a knee issue, a shoulder issue, et cetera, we can alter the program in this way.
Having programs in communities that can support people to be active in the way that they want to be active is important.
There is this nudging. There are different types of motivation: intrinsic and external. For some people who may have low motivation overall, an extrinsic motivator can help leverage things to maybe get moving. But it is true that it's a short-lived thing. An appropriate physical activity program builds confidence over time.
There are what we call stages of change or theories of behaviour that identify that people need more confidence in order to do more things. Resistance training, for example, requires a certain amount of confidence to know what exercises to do, how to lift the weight and in what way. I need knowledge, I need skills and I need practice doing it. Just telling somebody once to go do resistance training probably would not work. So we need to have a community program to refer them to, with an exercise professional who knows what they're doing. That part basically builds their confidence until they get to the point where they can do it on their own and they develop a high confidence level and an intrinsic motivation once they start seeing the health benefits of that work.
For example, the older Canadian might say, "I can move my arms over my head now. I never used to be able to do that.'' Or "I can go up a flight of stairs and I don't get winded.'' Now they start to get intrinsically motivated.
The reliance on an extrinsic motivator is ill-conceived, but it has a place. And that's where, for example, integrating the exercise vital sign as part of electronic medical records and the interaction with patient support can influence somebody who is at 50 minutes when they should be at 150, because we are looking at how we can work them up, and then passing it off to community resources would create the best combination.
The Chair: Our guest has arrived, so I'll bring this to a conclusion. It has been a wonderful session. I would also say that it's the students in kinesiology who work with the seniors. I think the seniors love having the attention of these young people. As someone who is now very long in the tooth, I would have to say, following up on Dr. Fowles' last point, that it's addictive. Now I can't be without it.
Dr. Fowles: And now you'll do it on your own, without anybody else. That's where we need to get people to.
The Chair: And it is the strength exercises that give me the greatest degree of motivation.
You two have been absolutely wonderful. You've put a very dynamic and constructive approach to this issue for us and helped us a great deal.
Colleagues, I'm pleased to welcome Nina Teicholz, an investigative journalist and author. She's the author of The Big Fat Surprise, and she's joining us from New York City via video conference. I think we're aware of her book. I've heard her discussing it on a number of occasions. I think we're in for a real treat.
Without further ado, I'm going to invite her to make her presentation, then I'll open the floor to colleagues.
Ms. Teicholz, please go ahead.
Nina Teicholz, Investigative Journalist and Author, The Big Fat Surprise, as an individual: Thank you very much for the opportunity to testify. As you said, I'm the author of the The Big Fat Surprise. I think the subtitle is also important to include, and it is Why Butter, Meat & Cheese Belong in a Healthy Diet. It was published last year by Simon & Schuster and was named a Best Book of 2014 by The Economist and The Wall Street Journal, among other places. It also received many strong reviews, including one by the British Medical Journal. I only mention this because it is important that its arguments have been taken seriously by experts in the field.
So what are the nutritional causes of obesity, diabetes and heart disease, health conditions that have risen so dramatically in Canada and the United States? Most experts will tell you that the public is eating too much junk food and not doing a good job of following official dietary advice. But what is the evidence for this?
Look at illustration 1. Hopefully you all have that. We can see that, on the whole, the public has followed expert advice. Canadians, like their American neighbours, are eating much more fruits, vegetables, nuts, chicken and whole grains. All those lines are up, some of them dramatically. At the same time, they're restricting red meat, eggs, butter, whole milk and other dairy. Note also that sugar consumption has gone down, which is a rough measure of junk food. I couldn't find any specific numbers on junk food.
This data does not appear to support the hypothesis that obesity can be blamed on the public's eating too much junk food and failing to follow the government's food guidelines.
Is it possible that Canadians are fat because they have followed the government's advice? After all, these epidemics of obesity and diabetes did begin almost exactly when the government started telling the public to restrict fat and move toward a plant- and grain-based diet. There is actually quite a bit of evidence for this hypothesis.
Why would the government's diet cause obesity and diabetes? You can see Canadians, in clearing their plates of meat, eggs and dairy, shifted to eating more carbohydrates, bread, pasta and cereals. You can see that in illustration 2. These were the 1992 food guidelines. You can see the big outer bit of the rainbow. It's all pasta, potatoes and bread. Those are all carbohydrate-based foods.
Illustration 3 is from the previous guidelines, which were pretty much the guidelines for all previous years, which show carbohydrates are much less emphasized and fully half of the foods recommended come from animals, which are dairy, eggs and meat.
What is the problem with carbohydrates? In your body, they turn into glucose. Glucose triggers the release of insulin. Insulin is a hormone. It is the king of all hormones for socking away fat. In animal experiments, it's virtually impossible to make animals gain weight without the presence of insulin and glucose. Chronic exposure to insulin over time exhausts the body's ability to process it. That leads to what's called insulin resistance and is the chief cause of Type 2 diabetes.
I don't think the scientific evidence currently supports saying that increased carbohydrates are definitely the cause of the obesity epidemic. There may be other factors. However, there is a bounty of evidence that exists to show that restricting carbohydrates is more effective than any other diet for weight loss, control of blood glucose — which is the crucial factor in managing diabetes — and for ameliorating key risk factors for heart disease, including HDL cholesterol and triglycerides.
One effective step that Canada could take in order to improve the health of the public would be to back out of that high-carbohydrate diet introduced in 1992 and return to a more balanced diet that includes all food groups, such as you had previously.
There is substantial clinical trial data now on this low-carb diet that indicates it should not be considered a dangerous fad diet but clearly presented as one possible option for people suffering from metabolic conditions, including obesity, diabetes and heart disease.
In the past, this low-carb diet had been thought to be dangerous and harmful. But the clinical trials, which have now been done on all kinds of populations — men, women, obese people, people with metabolic syndrome — and some of those trials lasted up to two years, which is considered the gold standard in clinical-trial research for showing any kind of ill harm — have demonstrated that it is highly successful for all those health conditions and shown to be safe.
Moreover, there's a huge body of evidence that now exists showing that the low-fat diet — the one Canada has been recommending — is completely ineffective for helping people lose weight or fight diseases, including diabetes, heart disease or cancer. That is why U.S. experts have backed off their low-fat diet recommendation.
There is no more language in our dietary regulations, the chief ones being by the USDA and the American Heart Association, on restricting total fat, and the vice-chair of our USDA dietary guideline committee said recently that there is no official low-fat diet recommendation because that diet provoked a dyslipidemia, which means adverse cholesterol markers.
Other than dyslipidemia, there have been other detrimental effects from our decades on this low-fat diet. First, it appears this diet is nutritionally insufficient. The current USDA dietary guidelines committee recently published a report acknowledging that all its current dietary patterns — which are virtually identical to the ones in Canada — do not meet adequacy goals for potassium, vitamin D, vitamin E and choline. The adequacy of vitamin A is borderline, and only by eating artificially fortified foods, principally refined-grain breakfast cereals, can these dietary patterns meet adequacy goals for calcium, iron and vitamin B12.
Secondly, in shifting away from saturated fats in animal foods, we've shifted over to unsaturated fats. Those are vegetable oils like canola, soybean and corn oil. These oils entered our food supply in the early 1900s. Previously, the chief cooking fats were butter and lard. The principal harm of these vegetable oils is that when they're heated at temperatures that don't have to be high, they degrade and oxidize, creating hundreds of oxidation products, some of which are known toxins. These are found in any kind of food fried in these oils. That's not the only health problem associated with them.
The solution would be to return to naturally stable cooking fats that don't oxidize when they're heated. Those are butter, lard, tallow and suet. McDonald's used to fry its french fries in tallow.
We don't use those fats anymore because they contain saturated fats. That's also why they think meat, butter, cheese and dairy are bad for us, but it turns out that restricting saturated fats has been a mistake. I say that because the evidence behind the saturated fats, as I talk about extensively in my book, was never strong. In the last five years there have been efforts to re-analyze that evidence. Two big meta-analyses by chief scientists in the field, including some from Harvard, Cambridge and University of California, Berkeley, looking at all the evidence, including some that was really suppressed and not included until more recently, have concluded that saturated fats cannot be said to cause heart disease.
Now the job of nutrition authorities is to recognize this science. Why would it be good to lift the caps on saturated fats and allow animal foods back into the diet? I'll go through four reasons.
One, these foods would allow the public to eat a nutritionally sufficient diet. The nutrients that are lacking in the current diet — iron, calcium and all the fat-soluble vitamins — are found most abundantly in animal foods and are also in their most bioavailable form in animal foods.
Two, these foods would allow people to eat a higher fat diet. If a low-fat diet is not successful, how do you eat a higher fat diet? Unless you're drinking bowls full of olive oil like an Italian peasant or making all your meals of nuts and seeds, it's hard to eat a higher fat diet without eating these foods. These are the foods in which fats occur naturally.
Three, these foods provide food options if you're going to back out of the high-carb diet. Instead of pasta, bread or rice at your meals, and other than just fruits and vegetables, you have the option of eating other kinds of foods. Otherwise, there are not enough foods in the food basket.
Four, fat and protein are uniquely satiating. Scientists don't understand why, but they know people do not overeat readily on fat and protein. People cannot overeat on steaks and pork chops, whereas they're likely to overeat on cookies, crackers, snacks, pasta and bread. In fact, there is one idea about the obesity epidemic: The reason we eat more calories now is that we're trying to fill ourselves up on carbohydrates. People overeat on carbohydrates. Having more fat and protein in the diet would help people control their calories naturally.
Finally, these foods are delicious and also part of nearly all traditional diets. They allow people to return to their own food cultures. Not everyone need be Mediterranean. These foods have been the mainstays of meals for thousands of years, until the 1960s, when nutrition scientists got the idea that these foods caused heart disease.
I believe it is of urgent importance to correct the last 25 years of mistaken nutrition policy. Clearly it has not been good for public health. Good science now supports the measures needed to make these needed reforms. I hope your government, in the interest of improving the health of Canadians, will have the courage needed to make these important changes.
Thank you again for letting me testify.
Senator Eggleton: Thank you very much for being with us and writing a very interesting book on the subject. You've certainly taken a lot of old assumptions and turned them upside down. I think a lot of that is for the good.
I want to come to the conclusion in your book about a healthy diet being high in dairy, meat, fruit and vegetables but low in carbohydrates. You don't mention fish in there, and I wonder how that fits in. You're arguing, of course, as you have today, that the diet would be filling and would not result in a high calorie intake.
A lot of these things are a little higher priced than some of the less nourishing foods that exist on the market. I mention that in light of the fact that a lot of low-income people rely on the less nutritious foods because they cannot afford some of the better foods, the meat or some of the better vegetables you talked about.
What could we do to make sure that people of low income are able to afford these kinds of things?
Ms. Teicholz: First of all, I think the question for our government ought to be to look at the total cost picture, because governments provide subsidies and do all kinds of things to support their policy recommendations. The cost of disease — obesity, diabetes, heart disease — on the population, is huge. Perhaps you could lessen that load a little bit by not subsidizing corn and soy, as we do in the United States. We subsidize those foods so they are cheap. Instead, there could be subsidies to ramp up economies of scale for, say, more dairy farms. The dairy farms industry has been annihilated in the United States.
I think you would see economies of scale as demand increased that could make that diet more affordable. Not everybody has to have grass-fed meat. I think the conventional kinds of options are just as good. They still provide the vitamins, minerals and fat that's needed.
I think the government has to take a long-term look, look at the total costs of living with this kind of disease load and figure out where to put its priorities. You have the power to do that.
Senator Eggleton: Where does fish come into this?
Ms. Teicholz: I'm agnostic on fish. I did a lot of research that didn't get into my book about omega-3s. They don't have a particular ability to prevent heart disease. I think fish are a great food, but right now I call it our only safe meal. It's the only thing that people feel comfortable ordering in a restaurant.
The oceans have been fished out. I think fish is fine. I just think we should broaden the spectrum of what we consider to be a safe meal and be able to eat other foods. That would take some of the pressure off of fish as well. We can't all be eating fish all the time.
Senator Seidman: Thank you very much for a great book and a great presentation.
You've suggested to us that perhaps the cause of our problem of obesity is that Canadians and Americans are doing too good a job in following national food guidelines. I'd like to ask you this: Given what you've presented to us, given the scientific evidence increasingly in favour of your theory, shall we say, what would you suggest that governments do to change their food guidelines?
Ms. Teicholz: I think the single most effective thing any government could do is lift restrictions on saturated fats, because that would allow people to eat animal foods again. Once people started eating more of those foods, their diets would become nutritionally sufficient. They would increase fat in their diet. That would be healthier. That alone would do more than any other kind of change, I believe, in improving the health of a population.
Secondarily, I would say that for the population that suffers from metabolic conditions — once you tip over into obesity, diabetes, heart disease, that means your metabolism sort of tips over — the low-carbohydrate diet, which has proven to be so promising, should be offered as at least one possible treatment for that population.
Senator Frum: I'm going to try to squeeze in two questions quickly.
My first question is: Are all animal fats to be considered equal? Part of what you're recommending so flies in the face of everything we've been told for 30 years it is shocking to me. I'm having a hard time with eating red meat every night, seven nights a week, but is that okay, or should I also be eating duck, chicken and all those things?
You mentioned this diet is beneficial to all groups, but you didn't mention children. Do these recommendations apply equally to children? Children do seem to need and crave carbohydrates more than they crave protein.
Ms. Teicholz: First, let's talk about children. We all crave carbohydrates when we're eating carbohydrates. I don't think there is any need for carbohydrates in the diet. I think for children, there is a far greater need for a diet that is nutritionally sufficient. For them, it is even more urgent to include milk, meat, butter.
In fact, before nutrition science got hijacked into the question of what would prevent heart disease for middle-aged men, nutrition scientists used to look at what would help growth and reproduction and what would reliably restore or reverse growth retardation in children, which was simply to give them whole milk, liver or butter.
For healthy growth for children, it is extremely important that they have enough fat and that they have the foods that give them a nutritionally sufficient diet, which are animal foods. It might seem like children are craving carbohydrates, but it's because in our country they're going to school and trying to survive on school meals, which are like a slice of baloney. They're starving by the end of the day.
The other thing is that if you don't have whole milk, if you have only skim milk, not only does that not fill you up as much, but you cannot absorb the vitamins or minerals in milk without the fat that comes with them, because those are fat-soluble vitamins.
Sorry, I'm blanking on your other question.
Senator Frum: Seven days a week. Is that okay?
The Chair: It was the quality of the fats.
Ms. Teicholz: There are different chain links for different saturated fatty acids. I basically think there's a paucity of good research to show the different effects of different kinds of saturated fatty acids. They've all been in our diet for millennia. It seems like they ought to be healthy. I have to say that there's no evidence that any of those saturated fatty acids cause any kind of disease. The only indication of some kind of problem is when they're eaten in the context of high carbohydrates, and then there might be some inflammatory effects. But basically, saturated fats of any kind have not been shown to be unhealthy.
I get the question: Is this a licence for me to eat meat and butter all day long? There are plenty of civilizations that eat far more of those foods than we do. Simply backing out of the extreme restrictions we have on them now would be an enormous step forward.
Senator Merchant: I have lived long enough now to become suspicious of any of these theories that are promoted, because every decade or every generation has its own writers and promoters. They all claim to be scientifically backed, and I think you can almost set out to prove anything that you want to prove these days.
I will pose my first question by way of a comment: I don't think that our planet can sustain a diet that is based on animals and animal fats. You said not everybody needs to have grass-fed animals, but it requires too much of the planet to raise the food in the way that you prescribe.
Second, what about all the antibiotics, hormones, the things that people are now beginning to look at when it comes to milk, cheese, animal fats? Those are my questions, although other issues come into all this.
Ms. Teicholz: I missed that last sentence.
Senator Merchant: Just answer it, please.
Ms. Teicholz: These arguments are very powerful right now in the United States, one of which is: Is this diet sustainable? I think that the question of environmental sustainability is a really important one.
First of all, I think that we need to figure out what diet is healthy. I spent nine years researching my book, and it's extremely important to separate out different scientific questions.
The first question is: What diet makes us healthy? Then it is: How can we make that diet sustainable? Or do we choose to have a diet that is unhealthy? Then we have to weigh it as a matter of policy. Let's say we decide to have a plant-based diet. But then we have to accept that that comes with a load of diabetes, obesity, heart disease, and we have to weigh off what those choices are. But first you have to separate out the scientific questions and ask: What diet is good for humans to live well on? Then we can decide if that's our priority.
The science of sustainability is a science really in its infancy, the question of whether or not animals are less sustainable than mono-cropping, which in its own way destroys all kinds of biodiversity and has its own lack of sustainability.
There are so many complex issues involved in that.
I think that, first of all, nutrition experts ought not to be making scientific evaluations of what is environmental science, and then I think environmental science has a long ways to go. Just as an example, cows are now considered a source of global warming. In the United States, cow stocks have declined by 30 per cent in the last 30 years, so how are they responsible for global warming?
There's a lot to investigate about these questions. Also, cows graze on land that cannot be used for crops in most situations. It's such a complex issue, and it cannot be reduced into something simple. If we give up animal foods, can we live on fish? Our oceans are depleted of fish. We need to think about these questions in depth and we need to separate them out from the nutritional questions.
About hormone and antibiotic use, there are a number of questions on how we raise our animals, what are best practices, what are the ways to do that so they are healthy and can supply the population of hundreds of millions of people. Again, I think that's an extremely important issue that is separate from the nutritional question. If a diet higher in animal foods is healthier, then you have to figure out how to make it healthy, sustainable and high quality. Those are questions down the line.
Senator Beyak: Thank you for an excellent presentation. I read your book; your research is incredible. I've believed what you've written for many years. I come from a long line of chubby healthy people who don't take medication and eat the way you suggest.
I have heard and read that many of the problems women my age are facing, over 65, such as loss of hair, poor skin and thyroid issues are because we've eliminated so much of that stuff. Salt is iodized; we need a little iodine. We need the choline and the vitamins. I wonder if you could comment on any of those issues.
Ms. Teicholz: I don't know about those issues specifically, but I can tell you that women have a different reaction to diet than do men. Until the late 1990s, there was absolutely no data at all on women, and all of the dietary recommendations were based on information exclusively for men. Any information that did come out on women was sort of suppressed.
There was actually evidence that women over the age of 50 with high cholesterol, the biggest ever risk factor studied, tended to live longer, but that information was never included in the papers or summary statements. Nobody talked about it, and how many women go to their doctors today and their doctors say, "Gee, you have high cholesterol? That's good. You'll live longer.''
Women on the low-fat diet that we have been prescribed — and this comes out of the Women's Health Initiative, the biggest ever study in the history of nutrition science — tend to have more adverse outcomes than do men, particularly with respect to heart disease. Their HDL cholesterol, or good cholesterol, drops more precipitously for women than for men. It drops for all people on the low-fat diet, so that indicates that the risk of heart disease goes up more for women. Women better adhere to diets. Women care more about the way they look; they try harder, so they have more assiduously been following the low-fat diet.
I'm not surprised by some of these other issues. One of the other huge problems for women now is osteoporosis, and that may be because they're not getting enough calcium. Absorption of calcium depends on getting your fat-soluble vitamins. If you're eating a low-fat diet and not eating a lot of animal foods, you do not get enough of those vitamins and nutrition. Nutritionally, our diet has been poor.
Senator Eggleton: Probably your book covers this question, and I suppose there may be a very lengthy answer to it. I would like you to give me a bit of a summary so we can get it on the record.
In your view, why has the low-fat diet persisted for so long, as much as 60 years, despite, as you say, the lack of scientific evidence? Could you summarize some of the mythological shortcomings of the studies that came to that conclusion? It has been prevalent for so long.
Ms. Teicholz: It really is an incredible story, and I'll try to be brief. It is as much about politics as it is about science. The hypothesis that saturated fat causes heart disease began formally in 1961 with the American Heart Association, and it was a hypothesis that became official dogma before the science was in. It became institutionalized by the big leading institutions, and it became encrusted with a kind of dogma; it became very hard to back out of it.
That is the principal reason, which is that there was a group of scientists invested in this diet. Then they controlled the research funding, they did the studies, they reviewed the studies and they sat on all the editorial boards. This is still true today. These scientists controlled the expert conversation. They all sincerely believed for many years that saturated fat causes heart disease, so they did not challenge that.
Secondly, people who did challenge it — this is why you have a journalist here today. I should be a scientist. There used to be scientists who objected and were skeptical of the prevailing dogma, but they saw their careers suffer and they lost their research grants. I document this over and over in my book, about how the critics were silenced. Then, by the mid-1980s, there was no more criticism. Then subsequent generations of researchers realized that they would not be able to be scientists if they opposed this official dogma, so the critics just disappeared.
Thirdly, there has been the hand of industry in the story of nutrition science in the last 50 years. It really started in the early 1900s as the big food manufacturing companies learned to organize themselves, and they influenced science at its very source. They quickly realized — and, again, this is also something that still happens today — not to try to influence senators or people like you but to get to the scientists themselves, fund their university departments and research centres, influence science where it is being done.
Particularly involved were the vegetable oil companies. Procter & Gamble was deeply influential in launching the American Heart Association, who then recommended vegetable oils instead of saturated fats. So the vegetable oil companies have been particularly powerful, but food companies overall have been quite powerful in this story.
These different factors, industry and big institutions that don't want to be flip-flopping and changing their views and the professional investment by generations of scientists — three generations of scientists have now invested in this, so I think it would be very hard to back out and why your leadership is needed.
Senator Eggleton: Thank you for the summary. It was great.
Senator Seidman: We're always asking for scientific evidence to support things like health behaviours, and there's no doubt that the case of this particular evidence came from one of the largest epidemiological studies, the Framingham Heart Study.
In your book you talk about the difficulties in using epidemiological theory to understand nutrition. We're looking for evidence all the time in this evidence-based society. I think Senator Merchant referred to it: Every few decades there's some new idea we have to subscribe to and it kiboshes whatever we might have believed in the past.
I know you're not an epidemiologist but you deal with this in your book. Can you tell us why epidemiological theory has created a problem in understanding nutritional data?
Ms. Teicholz: That is an excellent question, and it really is at the heart of why our nutrition recommendations have gone awry, going back to that very first American Heart Association recommendation in 1961 based on an epidemiological study.
What is the problem with epidemiological studies? They show associations but not causation. That's a critical difference. You can look at a population over a long period of time and look at the people who die at the end of that study, and then you go back and look at what might have caused that.
You can make all kinds of association. Maybe it was the fat. Maybe it was something you didn't even think of measuring. Maybe it was exposure to computers. Maybe computers are causing problems. The point is they're just associations. You need randomized controlled clinical trials to show causation. I won't get into the weeds and why all that is true.
Nutrition science is so hard to do. That is, it's hard to feed people and to get them into a controlled environment where you know exactly what they're eating, but that's what you need to do for a clinical trial. We relied instead on these epidemiological studies that are far easier to do. The biggest epidemiological studies just send out a questionnaire to people every year. Most epidemiological studies sample people's diet once at the beginning of 20 years and then check in 20 years later. Those studies are easier to do and have been extremely influential because there are huge data sets. There are so many numbers and they are so impressive that they have been responsible for our key dietary advice like vitamin E supplements and hormone replacement therapy. That turned out to be wrong, though. When a Stanford professor went back and looked at all the claims of epidemiological studies that he could find to see what was confirmed by randomized controlled trials, four out of five times they were wrong. Another analysis showed they were right zero per cent of the time. The second analysis looked at the epidemiological findings on nutrition and found that none of them could be confirmed in clinical trials when they were actually tested.
It's crucially important to rely on clinical trial data. It is far more reliable. A huge number of clinical trials were done in the 1970s on this hypothesis of whether or not saturated fat causes heart disease. Altogether, 15,500 people were tested for periods of up to 12 years. That body of randomized controlled clinical trials showed that saturated fats don't cause heart disease. Now, because that's so embarrassing — led by mainly the Harvard Department of Epidemiology and the Harvard School of Public Health; they have two of the largest epidemiological databases — they have repeatedly used that evidence to support the plant-based diet. However, there are no clinical trials on a vegetarian diet or a mostly plant-based diet. The closest we have is the Women's Health Initiative on nearly 50,000 women. That was the biggest ever trial on nutrition science and it showed that the diet you're currently recommending, namely low in fat, high in fruits and vegetables and whole grains, was completely ineffective for fighting any kind of disease.
The bottom line for you or for your food advisers, your expert communities, is to prioritize the importance of clinical trial information in your evaluation of scientific recommendations. In our country that is not currently what happens, and I think that is the source of a lot of our flawed advice.
Senator Seidman: I appreciate what you're saying. I just want to be careful, when we talk about epidemiology, that we're clear that there's population-based data, population health, but there's also clinical epidemiology and clinical trials subsumed within that. It's a different level. It's direct, evidence-based research with people as opposed to population-based data where, as you say, you follow a cohort over time but you have no evidence; it's merely correlation. I just think we need to be careful when talking about panning all epidemiological research as only population-based data and correlation research. It's not necessarily true. Otherwise, I appreciate what you're saying.
Ms. Teicholz: Can I respond to that?
Senator Seidman: Sure.
Ms. Teicholz: Population-based data is called ecological data. That is where I look at all Canadian health statistics over time. That's the poorest type of data because you don't have any individual information. Epidemiological studies of the kind I'm talking about are on an individual level. Any kind of epidemiological study can only show correlation, not causation. There is no causal inference that can come out of that data.
The Chair: Thank you very much. I found reading while reading your book that I had to be careful because I agreed with everything you were saying in it. I'm old enough to have covered that period of time and be familiar with some of these remarkable conclusions that were drawn over that period of time. I'm a scientist by background, so I had an additional curiosity factor in looking at it.
I wanted to ask you one specific question and then I want to make some observations.
There is one thing that didn't come up during the questions here and I want to raise it. What about the question that seems to be occurring that there's a correlation between red meat and colon cancer?
Ms. Teicholz: The data on red meat causing cancer, again, is epidemiological data, and the correlation with colon cancer is quite small. I think 1.29 is the relative risk. Any relative risk that does not reach the level of 2 is not considered worthy of real consideration because it's so small that it's considered that it's most likely caused by noise.
By the way, the World Cancer Report was just updated, actually. It's considered the most thorough review of all the cancer data. I was just reviewing their most recent publication. The risk they see for red meat is the same risk they see for fruit causing colon cancer. I think that data has to be taken with a grain of salt. The relative risks do not reach the levels that are considered worthy.
I know this might sound like something a conspiracy theorist might say, but there has been such a long bias in the field that certain findings are emphasized and others are diminished. We don't hear anything about fruit possibly causing colon cancer, but we hear a lot about meat possibly causing colon cancer. I think we need to look at that with fresh eyes.
The Chair: I wanted to get this matter on the agenda. Under our regulations, we must have things on the table during our hearings in order for us to deal with it. That is one issue that we wanted to get on the agenda. I'm delighted with your response.
Speaking of controlling agendas — and I really relate to your comments here today and, of course, they appear throughout your book — it is not at all unusual in any scientific area where there is uncertainty of the outcome or where there is more than one variable that is likely to be important to the ultimate conclusion to see people rising to the point of becoming gurus in the field. We can take things like the study of major diseases such as heart disease, stroke, diabetes, and so on, and it is similar to the issue that you identify throughout your book.
Ultimately, as you well know in terms of your research, the granting agencies are controlled by committees, and so on, and the influence of senior people in a given field can have not only a dominant but also, as in this particular case, an ongoing impact for a long period of time on where funding will go in any major effort. My experience is that the more uncertainty in the conclusions — that is, as we go from, say, a specific scientific chemical reaction off into the area of epidemiological surveys and correlations — the easier it becomes to have a dominant theory. I greatly enjoyed how you developed that issue throughout your book and the incredible impact that it had.
One of the issues that is easier to get at in so-called scientific study is whether there's any outside influence on the principal investigator with regard to drawing conclusions. In this particular case, in the studies that started with the case study, and so on, it is clear that modern concerns about conflict of interest, had they been invoked through a lot of that period of time, would have raised substantial concerns much earlier. You dealt with that carefully I thought, and it's there in your work as well.
Finally, I'll give a personal comment before I invite you to give any summary point that you would like to make to us. As I mentioned, I'm a chemist and I remember very early when butter was declared persona non grata in the diet and that we should all go to margarine. This was going to be healthy for hearts and so on.
First of all, as a chemist I wouldn't have touched margarine under any circumstance, but the idea that something as good as butter was going to be this mortal sin, I simply threw that out. As I look out on the course of my lifetime, butter has been in and out of favour at least four times by so-called studies that have related. That's just an aside. That's not something I'm putting to you.
I would like to come back, as a conclusion to this session, and give you an opportunity to provide us with any summary observations you would like to or to re-emphasize specific points you made today that you think are particularly important for us to consider. We heard you loudly and clearly, but I want to give you the final word.
Ms. Teicholz: Thank you. I didn't prepare a conclusion or a conclusive summary statement.
First of all, I salute you for having invited me. It is an extremely controversial issue, as you know, and you're taking on something that has huge institutional defenders. This will not be easy to change. It's not just the food industry that will resist at every turn. There is now a tremendous growing movement. The whole environmental sustainability movement has swung in behind the plant-based diet idea. Its defenders are some of the most esteemed, popular writers of our time. Michael Pollan, Mark Bittman and pretty much the entire New York press corps support these ideas. It is a tremendous challenge.
For me, it is seeing this past year the fact that there was a tremendous study re-evaluating saturated fats, saying they do not cause heart disease. I followed all the headlines on saturated fats for nine years when writing this book. Last year was a banner year. There were a thousand stories on how saturated fats might not cause heart disease whereas previously there had been none. Just when you think there will be some kind of liberation or shift in science, along comes this environmental gale wind, a tsunami of support for continuing to push away from animal foods and towards plant-based foods. There's nothing wrong with plant-based foods, but 80 per cent of the diet is a high carbohydrate diet and has been shown in clinical trials not to be good for health.
To the forces that you face, I would add the entire pharmaceutical industry because they are behind the LDL cholesterol hypothesis. The lowering of LDL cholesterol is done through a low-fat diet so they are invested in the low- fat diet. Those are the forces that are arrayed against progress, but I want to thank you again for inviting me and salute you for taking on this important issue.
The Chair: Thank you very much. With your last comments, I will note that one of the things one hears a lot, and I think it is absolutely clear in a lot of these cases, is follow the money. It seems to have a lot to do with the issues you've raised in terms of the fads that are being promoted and the causes and conclusions being drawn.
For your background, this committee just completed a three-year study on prescription pharmaceuticals in Canada, covering everything from the clinical trial process through to unintended consequences in the end. I'm very confident that this committee is unique in its capability to look at some of the important issues, or the way we look at issues as you presented them to us today.
With that, I'm going to thank you very much, first of all, for having written that book and secondly for your appearance here and the clarity with which you handled all of the issues that you've brought. They are of great importance to us. I thank the committee for their questions to you. With that, I declare the meeting adjourned.
(The committee adjourned.)