Download as PDF

Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 22 - Evidence - October 30, 2014

OTTAWA, Thursday, October 30, 2014

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:28 a.m., to examine and report on the increasing incidence of obesity in Canada: causes, consequences and the way forward.

Senator Kelvin Kenneth Ogilvie (Chair) in the chair.


The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.


I'm Kelvin Ogilvie from Nova Scotia, chair of the committee, and I will invite my colleagues to introduce themselves.

Senator Seidman: Judith Seidman, Montreal, Quebec.

Senator Stewart Olsen: Carolyn Stewart Olsen, New Brunswick.

Senator Enverga: Tobias Enverga, Ontario.

Senator Cordy: Jane Cordy, Nova Scotia.

Senator Merchant: Pana Merchant, Saskatchewan.

Senator Eggleton: Art Eggleton, Ontario, deputy chair of the committee.

The Chair: We are in our order of reference from the Senate of Canada to continue our study on the increasing incidence of obesity in Canada, its causes, consequences and the way forward.

We have two witnesses with us this morning. I will introduce them as I invite them to speak. Following their presentations, I will open the floor up to questions.

At the outset, I invite Dr. James DiNicolantonio, Doctor of Pharmacy and Cardiovascular Research Scientist, who is in the Preventive Cardiology, Saint Luke's Mid America Heart Institute. We are delighted to have you with us, and I invite you to make your presentation.

James DiNicolantonio, Doctor of Pharmacy and Cardiovascular Research Scientist, Preventive Cardiology, Saint Luke's Mid America Heart Institute: Thank you. My name is James DiNicolantonio. As you said, I'm a cardiovascular research scientist in the Department of Preventive Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri. I'm also a doctor of pharmacy. The topic today is refined carbohydrates and added sugars as principal drivers of obesity.

Most of us are familiar with the prevailing dogma in regard to the cause and treatment of obesity. It focuses on calories. We eat too much, we don't exercise enough. This puts us in a positive caloric state, which leads to obesity, and thus the treatment for obesity is that we need to restrict calories and we need to work out more.

The problem with calorie-focused thinking is it supports the notion that in order to lose weight, you have to eat less calories than you burn and that all calories are the same. It does not matter what foods you eat. If they're mainly fat, protein or carbohydrate, it doesn't matter. If you eat 1,000 calories of salmon or white rice, as long as you restrict calories, you will lose weight. Of course, when you restrict calories, your metabolism slows down, thus defeating the purpose of restricting calories in the first place. Additionally, fat promotes satiety, whereas refined carbohydrates and added sugars promote hunger. So calorie-focused thinking doesn't take these metabolic considerations into account.

There is now an overwhelming body of evidence that shows that when you restrict carbohydrates without restricting calories there is prolonged weight loss and more importantly most of that weight loss is fat loss. The classic example is from Dr. Alfred Pennington in 1949. He took overweight DuPont executives and put them on a low carbohydrate diet. These individuals ate over 3,000 calories per day, and while restricting carbohydrates they were able to lose approximately two pounds per week.

An alternative view on obesity is that the consumption of refined carbohydrates and added table sugar as well as high-fructose corn syrup alters our physiology and our hormones, leading to a state of internal starvation. And it is this internal starvation that causes us to eat more and exercise less. In essence, eating more and exercising less is not the cause of obesity; it's a side effect of over-consuming these types of foods.

An example of hormones driving such problems with our storage of fat would be that these refined carbohydrates and added sugars cause insulin resistance, raising our hormone insulin. When this occurs, if you take two people and one has a higher level of insulin, they will store more fat than someone without a high level, even if they are consuming the same amount of calories.

A perfect example would be an adolescent going through puberty. They are going to grow at a faster rate because of their altered hormones. Is it so hard to believe that our food can alter our hormones to cause us to become fatter?

Another example of how these foods cause us to store more fat is that the higher insulin levels store fats in protein so our body cannot liberate the source of energy for ourselves to use and thus we are in a semi-starved state. Additionally, the insulin resistance does not let glucose into the cell as readily, and our cells are literally semi-starved, and that's why we are over-consuming.

Another point with higher insulin levels caused by consumption of these foods is that they reduce the burning of fat, and hence we become fatter. Lastly, a high level of insulin causes lepton resistance. Lepton is the hormone our fat cells release, telling our brain we have enough energy, we can stop eating; we can start exercising. That pathway is blunted when you over-consume these types of foods.

Now we're going to discuss how we got here. Approximately 200 years ago we only consumed 4 pounds of added sugar per year per person. We are now consuming, in the United States, up to 151 pounds of refined sugar per year. Our bodies are not equipped to handle such a high amount of sugar.

We have countless amounts of data including the National Health and Nutrition Examination Survey (NHANES) data that clearly indicate that the rise in obesity and diabetes in the United States from 1960 onward was almost 100 per cent driven by an increase in carbohydrates. During this time, saturated fat was not increasing. We had an approximate intake of 375 grams of carbs in 1960, which jumped above 500 grams after 1995. During this period of time, obesity doubled from 13 per cent to greater than 26 per cent.

We have association studies showing that sugar-sweetened beverages increase body mass index as well as obesity, and a prospective trial following 548 children, for each additional serving of a sugar-sweetened beverage, BMI increased significantly and the frequency of obesity significantly increased.

When we look at trials of basically free-living people, this is what is happening in the real world, they are able to eat and drink whatever they want and as much as they want. If they are supplied with sugar — in this particular study, they were supplied with soda — that group increased their body weight significantly, whereas those that were not provided soda or those provided artificial sweeteners lost body weight. All patients received three interventions, either being provided soda, diet soda or no soda for three weeks.

If we were to provide 500 calories of chicken, would we see an increase in weight? The point of this trial is when you give someone access to sugar and soda, they will increase their body weight.

In the same trial, when these individuals were provided with soda, their calorie consumption was almost 400 times that of when they were not provided soda. Their calorie consumption throughout the day was over 500 calories more than those provided diet soda. Bottom line, when we increase our intake of sugar-sweetened beverages, there is an increase in total caloric intake, thus sugar-sweetened beverages drive us to consume more calories.

Those who argue that sugar is no more harmful than any other type of food when matched for calories, which is also untrue, are missing the point. If a calorie is a calorie, it should not matter what was provided. Overall intake of calories should be the same throughout the day, but when men and women started consuming soda, they started consuming more calories.

Another trial supporting this is an ad libitum study in free-living population; they could eat and consume as much as they wanted. When they were provided sugar, they had significant increase in body fat and fat mass. They gained 3 and half pounds in just 10 weeks, 3 pounds of which was fat, whereas those provided artificial sweeteners lost weight.

How did this happen in this trial? Those provided sugar significantly increased their total caloric intake from baseline. They began to consume over 350 calories more per day. They increased their intake of calories versus the artificial sweetener group by over 600 calories per day. This is what happens in a free-living population. In essence, someone who used to consume 2,350 calories, once they are provided with sugar, they now eat 2,700 calories per day.

These studies are not outliers. In a 2012 meta-analysis in the British Medical Journal, produced by Lisa Te Morenga and colleagues, they gathered 15 randomized, controlled trials of ad libitum studies, clearly showing when sugar is increased, body weight is increased. When you reduce sugar, body weight is reduced.

Now we are going to discuss conflicts to the food industry. This was a systematic review of systematic reviews, meaning they combined all the trials they found, and when they looked at all the trials with financial conflicts to the food industry, 83.3 per cent found insufficient support of a positive association between sugar-sweetened beverages, consumption and weight gain. However, when they looked at the trials without conflicts of interest to the food industry, they found the exact opposite — 83.3 per cent found a positive association with weight gain.

In summary, conflicts to the food industry significantly affect the association of sugar-sweetened beverages with weight gain.

That concludes my presentation. Thank you.

Timothy Caulfield, Canada Research Chair, Health Law Institute, University of Alberta: Thank you for the opportunity to speak to you today. I think this is an incredibly important topic and I'm thrilled that the Canadian government is taking it on.

I will talk largely about policy options and what the evidence says about policy options.

I propose, as outlined in my brief, three tentative steps forward and three things that I feel can be de-emphasized and reasons that these three things should be de-emphasized.

As you probably heard already and probably know, this is a very complicated issue that's going to require a multi-pronged approach from a policy perspective. It's going to require coordination among federal, provincial and regional governments and it will require a variety of different legal tools.

History has told us that legal tools can work in this area if we look toward things like smoking and alcohol. Legal tools have been shown to be effective. Unfortunately, again, as I'm sure you've already heard, I think obesity is a much more complicated situation as compared to, say, smoking. We all eat, we all need to eat; it's a culture thing and, therefore, it can be difficult to actually change people's behaviour in this regard.

In addition, I'm an evidence-based person. I believe in evidence-based policy. It's at the core of what I do as a health policy expert, so this area is very frustrating for me because the evidence around what legal tools really work is pretty thin.

As a result of that, I do find it difficult to make definitive recommendations about what type of regulatory tool would be best. But, again, as everyone in this room knows, this is a severe problem and we need to take action. Therefore, I think that the recommendations I am going to make right now do have evidence to support their move and in addition to that, the unintended consequences of these policy moves would be beneficial regardless of whether they actually resulted in weight loss on a population level.

In addition, it's important to know, and this builds on things you've already heard, you probably know the data on weight loss is grim on a population level. It is very difficult to get populations to lose weight. A recent study in Lancet found that virtually no country has been successful in driving down population level obesity rates. Nevertheless, I feel that we need to move forward.

There are many recommendations that we could put forward, as I say in my brief; these are just to get the conversation started. The first recommendation is a solid one and has evidence to support its implementation, that is, the restricting of marketing to children of food and particularly of junk food.

There is a solid body of evidence that has demonstrated that advertising does impact children's preferences for food; it does impact what families eat. That body of evidence is very solid. There is also some evidence that restricting advertising can impact those preferences, even evidence from Canada.

One of my overall conclusions is that these policies should really point Canada toward a healthy food culture, a healthy lifestyle culture, and even if this does not have a dramatic impact on obesity, this is a wise decision for children.

The second recommendation, and this builds very nicely on the last presentation, is taxing sugar-sweetened beverages. As you heard, there is ample evidence to suggest that the increase in the consumption of sugar-sweetened beverages is at least correlated, associated with weight gain. This is one where I struggle because there is conflicting evidence about the utility of attacks on sugar-sweetened beverages. The data is somewhat conflicting, but I think in the aggregate it signals in a positive direction. There is relatively recent data from Mexico, which implemented a 10 per cent tax on beverages, that it can have a positive impact on the consumption of beverages.

Now the problem, as many of your witnesses may have already noted, is that we don't know if that will really have an impact on obesity rates. We just know it has resulted in a reduction of the consumption of beverages. I like to be optimistic. I like to believe it will eventually have that long-term effect, but we don't know yet. There is also concern there may be compensation behaviour so people turn from drinking soda to some other unhealthy beverage. These are things we need to monitor.

My third recommendation — I'm cheating here because it's a little bit of a catch-all — we need to develop policies. And this is where we need coordination between all levels of government. We need to create a policy where we have healthy food environments. That means everything from hospitals to schools to universities where we are promoting access to healthy food, and if we can't do it at the government level it becomes very difficult to implement this at a broader societal level.

Again, there is some evidence about the importance — and this builds on the last presentation — of having easy access to healthy food. There is some evidence that shows if you have that access people are more likely to make healthy choices. This builds on the whole research around the nudge kind of mentality, and this is an important way forward.

As I said at the beginning, what we want to promote globally is a healthy lifestyle, a healthy approach to lifestyle. Whether people lose weight or not, I think all of these suggestions, and I have others, make sense.

I now turn to three more controversial things that we can de-emphasize. I am concerned that the promotion of these three messages can confuse the discussion and policy debates around obesity.

There are so many myths out there about our food culture. It's ridiculous, and I get frustrated about it. There are so many myths; there are so many crazy diets; there are so many myths about how best to lose weight, and the government needs to promote a simple, actionable message around how Canadians should eat.

The first one is the idea that we can use exercise as a primary weight loss strategy. This again builds nicely on the last presentation you heard.

Exercise is simply one of the most important things you can do for your health. There is no doubt about it. In fact, I would say exercising and stopping smoking may be the single two most important things you can do for your health, but there is not a lot of evidence that exercise works as a primary strategy for weight loss. We can talk about this. This is a bit of a controversial statement. I don't think it's controversial in the academic literature; it's more controversial in the pop culture literature, because there is this assumption it's the way we should lose weight. One of the reasons I think it is so important is that the food industry can use the idea that you can lose weight through exercise alone as a way to maintain the consumption of things like Coke. Exercise for half an hour and have a Coke is the kind of messaging that can stay alive if we don't do something about this myth.

The second one I also think is controversial. This is the idea that we use genetic information, genetics and high-tech solutions to fix this problem. There is a big push right now to personalize medicine. I think it is a fantastic move. There is a lot of exciting research going on in this domain, but there is very little evidence to support the idea that we can use high-tech solutions like genetics to solve the obesity problem on a population level.

First, there is very little evidence currently to suggest that genetic testing is very predictive of future obesity. Absolutely, obesity has a genetic component to it but given the current technology it is not terribly predictive. Second, and probably most important, there is very little evidence that people change their behaviour based on genetic risk information even though people often believe they will.

The last is what is most important here. I am concerned that an emphasis on these high-tech solutions on things like genetics de-emphasizes the need for social change.

The third one I will highlight is the spread and constant mention of special diets, supplements and gimmick diets. This may seem like it does not belong as a discussion topic for this committee, but I think it is important. Governments around the world can get more aggressive through truth in advertising, for example, to tackle the kind of misinformation that flows from the diet industry as to how to lose weight. There is evidence that shows that when people are bombarded with all this conflicting information about diet and nutrition, they stop listening.

This brings me back to a point I made earlier. I do think the Canadian government needs to pass on a clear, consistent, simple message about how to eat a healthy diet and what a healthy lifestyle looks like. That should be the global goal: the promotion of a healthy lifestyle.

I will end there and look forward to your questions.

The Chair: Thank you, Mr. Caulfield.

Senator Eggleton: Thank you, both, for your presentations. I will start with Mr. DiNicolantonio, who I see is from Kansas City. I hope there is not too much grieving going on there after the baseball game last night. They had a good year, better than my team in Toronto.

I gather what you're saying is that not all calories are the same. With certain calories, you're not going to lose weight, and other calories could be a help. You talked about the low carb factor in all of this, which sounds to me a lot like a number of diet plans, like Dr. Atkins and some of the others that followed on after him. Is your essential message that you can't just watch calories but you have to watch what the food substance is?

Mr. DiNicolantonio: That's correct, these rapidly absorbable carbohydrates. I'm not referring to legumes and lentils and healthy real food that is high in natural carbohydrate that is broken slowly and comes with fibre and all these other healthy vitamins and minerals. I am referring to rapidly absorbable carbs, including beer, but particularly I am referring to substances likely honey. Fruit juice is not off the table either, and neither are syrups like agave syrup if they contain fructose. Fructose is a molecule that not only causes insulin resistance in the body but is highly addictive. If you look at studies in animals, they prefer sugar over nicotine and cocaine. If they're eating a diet and are totally fine, and then you introduce sugar, many studies have shown they will malnourish themselves to death by over-consuming sugar. Sugar acts like an addictive substance and causes us to over-consume. My child asks for sugar, not protein or fat. It causes us to crave the substance, and it leads to withdrawal and symptoms of substance abuse. These types of substances are being infused into our drinks and our food supply, and 80 per cent of the supermarket has added sugar to it in the United States, so this is a serious issue.

Senator Eggleton: Thank you. That's very clear.

Both of you used the terminology ''sugar-sweetened beverages.'' That suggests to me that you are talking about not only beverages sweetened with sugar but the artificial sweeteners as well. Are you including both? Of the sweeteners that are out there, are some safer than others? We've had some that have come and gone, and now the latest craze seems to be Stevia as a substitute for sugar. There is not a clear consensus that all these things are safe. What is your take on this?

Mr. DiNicolantonio: In regard to safety, I don't think we have the studies long term to say what is safe and what is not. When I'm referring to added sugars, I refer to sweeteners that contain the substance called fructose. Table sugar, also known as sucrose, is 50 per cent fructose and 50 per cent glucose. If it has fructose in it, it causes insulin resistance and all these metabolic side effects. Fructose is primarily metabolized by the liver, and the liver simply cannot metabolize it without eventually being a fatty liver. Glucose can be metabolized throughout the entire body. When I talk about sugar-sweetened beverages, I'm also referring to sports drinks like Gatorade and lemonade-type beverages that have this sugar, the high-fructose corn syrup, in them. It is not just soda but anything that contains fructose.

Mr. Caulfield: I think this is a great question. I will look at it from the perspective of policy. It does create a real challenge for policy because so many of the policies focus on pop, or soda in U.S. language. The problem, as just noted, is that fruit juice has the same impact. I think fruit juice is largely pop without the fizz. In fact, I think that, as also noted by Dr. DiNicolantonio, liquid calories are generally not as satiating. They don't make people feel as full. From a policy perspective, it does become challenging if we're talking about taxing these beverages because I personally think a sports drink is as bad as a coke in this realm. We need to think more broadly than just pop. We need to think about the social impact of liquid calories in general.

Senator Eggleton: I'm also struggling with what the best measurement is. BMI gets used more frequently than others, and some say waist circumference should be the measurement of who is overweight and who is obese. What are your thoughts on this?

Mr. DiNicolantonio: I can start by saying that if you want something easy, the waist to hip ratio is going to be better. However, what we're really talking about is fat around our organs as the issue, not subcutaneous fat. We clearly know from trials from Kimber Stanhope that fructose causes visceral adiposity. That is the fat that you cannot see. It is underneath your abdominal cavity. It is contained within the peritoneal cavity. You can only see it on an MRI.

We are talking about body fatness, but we can't see it. We're getting fatty livers, and our kidneys and pancreas are becoming fat. Our muscle is becoming fat. How can we monitor this? When we look at body weight, we can gain muscle, and we are gaining weight but we're healthy. We can lose weight, but we can be becoming more fat and could have less muscle. We really don't want to look at it from the standpoint of pounds. BMI is also a terrible measure because you could be muscular and short and very fit, and you would be considered unhealthy. We need to look beyond BMI. Waist to hip ratio is a little better. Waist circumference is somewhat of a marker of visceral adiposity, but not necessarily. Of course we are not going to put MRIs to everyone to see how fat they are, but that's the issue. It's called thin on the outside and fat on the onside. That's what fructose causes.

Mr. Caulfield: You will hear a lot of the same messaging, and it's great when you hear a consistent message. I think again the doctor would agree that there is a building consensus that it's not a great health measure on an individual level. BMI remains when you're doing population health research, and it's a useful metric when you're comparing countries, comparing populations, and perhaps even when you're measuring the effectiveness of a given policy implementation or given policy strategy. I think BMI remains useful on a population level, but increasingly the research community is recognizing it's not that effective as a metric of individual health.

The example I always use is you could go to the Olympic Games and watch the start of the 100 metre final, with some of the fittest human beings on planet Earth, and they are probably all, from a BMI perspective, either obese or overweight. On an individual level, there are different metrics to use. BMI remains useful as a metric on a population epidemiological level.

Senator Stewart Olsen: Dr. DiNicolantonio, I want to clarify something that is maybe a bit confusing to our viewers here, and that's your use of the word ''soda.'' On some of your slides, it's just the word ''soda.'' Are you talking about the sweetened colas and soft drinks? I know you mentioned unsweetened or diet soda.

Mr. DiNicolantonio: That's actually the terminology that was used in the trial, but obviously what I'm referring to is any type of liquid calorie that contains fructose. That is really what the issue is.

Senator Stewart Olsen: Professor Caulfield, I think this is going to be one of the most depressing studies that we have ever done because for some people, the only joy they now have is eating.

I'm trying to figure out how we can possibly impose regulations on what is essentially a basic need. People will resent that — the freedom of it. I know you support it, but I think it's difficult. Do you have any ideas?

Mr. Caulfield: You're right. Whenever these bans or regulations are put forward, you do hear cries of ''liberty'' and ''nanny state.'' You saw that in New York, and probably today in California, where they're debating their soda tax. You even saw it in Mexico, where there was resistance to it.

Throughout the world, there have been focus groups and surveys done. In general, people are tentatively supportive of these kinds of measures. That's one of the reasons I'm so concerned about things like the ''genetic myth.'' There is a study from Yale that showed that if you cast obesity as an individual problem, or as a disease, people are less willing to accept a government intervention or a government strategy. It's called the framing phenomenon. If it's framed as a broader social problem, then people are much more willing to accept it.

In this realm, there is tentative broad support for government intervention and there have been specific studies on things like the banning of marketing to kids. There is generally really good acceptance of that. Also, there has been some acceptance for taxes. The resistance becomes greater when you say that you can't have this, when it becomes an all-out ban, or when the government says you can't eat this anymore.

It is a challenge, but currently there is tentative and broad support for government getting involved in this area, particularly where you are trying to nudge the population in a direction, you're trying to promote healthy choices, and you are not saying, ''You can't have this substance.''

Senator Stewart Olsen: We're starting to hear two messages: we don't want to stigmatize people who are obese, but we want people not to be obese. That's a real difficulty. This was tried when we taxed cigarettes. That didn't work. The only thing that really worked with smoking was peer pressure and people saying, ''Don't breathe that in my face.'' I'm not sure how we can sort that out.

Mr. Caulfield: This is a superb question and I'm smiling because I had a section in my brief on weight bias. I took that off because I didn't want to give you too much and I wanted to keep my message simple.

You are correct. The weight bias issue is one reason, amongst many, that makes it such a challenging area. You don't want to blame the individual, but the individual is part of the story. The choices they make are part of the story. It is a real challenge. There are also studies that have shown that increasing stigmatization, such as increasing weight bias, makes it more difficult for people to lose weight.

Senator Stewart Olsen: Absolutely.

Mr. Caulfield: It is a phenomenal challenge. That's why I think a healthy lifestyle needs to be promoted. I think the government can play that role.

There is data on the fit-fat debate, and Dr. DiNicolantonio could comment on this, that if you adopt a healthy lifestyle, whether you lose weight or not, you are going to be healthier. If you're being more active, eating more fruits, vegetables and whole grains, then you will be healthier whether you lose weight or not. The country will be healthier. I always gravitate towards policies that promote that global healthy lifestyle, hoping that it will also have the effect of reducing obesity.

The Chair: Dr. DiNicolantonio, do you want to add anything to that?

Mr. DiNicolantonio: I would like to comment on health policy. Why don't we give food companies an incentive to grow and produce real and healthy food? Can we subsidize healthy food?

The Chair: We have noted that suggestion. Thank you very much.

Senator Merchant: Thank you to our guests. I'm a little conflicted because I don't think that the government can really tell people how to live their lives. People should be in control of that aspect themselves. You can give information, as you have this morning. Mr. Caulfield, you are more interested in a healthy lifestyle, as opposed to being interested in losing weight. This is a study about obesity.

I'm not sure that we, the government, should be telling people exactly how to live their lives. I find that difficult.

Could you tell us about some healthy foods that people should consume? For instance, you talked about fruit juices, but what about fruit? What is the sugar level in fruit? Can you eat too much fruit?

Mr. DiNicolantonio: I think fruit and vegetables are healthy. Anything that the hunter-gatherers could pick or if you can grow it, then it is healthy. Almonds are healthy. Can your government afford to have a population that is sick? We say that we can't control people. Will there be enough government funds left, if everyone is sick? If we do not get this under control, it's going to affect everybody. I think healthy food includes things such as animals that are set to pasture. There is no problem with eating saturated fat, if it comes from an animal that has been eating grass. That's a common myth.

There are tons of populations that are eating real whole food, if they eat animals that are grazers, such as the Masai in Africa, the Native Americans, the Eskimos that ate mostly caribou, seals, and things of that nature. If it has a food label on it, then it's not normally healthy for you. If there are more than a couple of ingredients on the food label then you can assume it's probably processed and therefore not healthy.

Mr. Caulfield: I sympathize with the idea that the government shouldn't be interfering in individuals' lives. It is a real challenge. As a law professor, this is at the core of some of the work that we do in this area. The government always tries to promote healthy things. We have rules about traffic, smoking, about kids going to school, and how restaurants can operate. I could go on and on.

This is clearly a tremendous issue for the developed world. Some people have argued that it is the number one public health concern on planet Earth right now. Some kind action needs to be taken.

When I said that I want to promote a healthy lifestyle, I meant that. I also think that we do need to think of strategies for weight loss. One reason is because we have such a level of evidence of how we can make populations lose weight. I think we should adopt policies with the goal of helping populations lose weight, but also include the broader impact of promoting a healthy lifestyle, which will make populations healthier.

The other thing I haven't emphasized is the importance of childhood obesity. We want to make sure the next generation is healthy, in that it has a healthy weight, a healthy attitude towards food, and understands what a healthy diet looks like.

I think the government needs to be involved and there is support in the Canadian population for that.

I also would like to talk about a healthy diet. Again, I look at this from a 30,000-foot view. I think the message needs to be simple and clear: fruits and vegetables, whole grains and lean protein. It needs to be a simple message. The only diet that really has solid clinical data to support it is the Mediterranean diet or some variation of it. We need to keep the message simple.

Senator Merchant: I'm glad to hear that. I was wondering where I can buy these very healthy foods. Where can I find the meat that the Masai eat? For families we have to be realistic. Where will families shop? Meats are full of antibiotics, and vegetables are full of fertilizers and things that are detrimental to the quality we want. Organic farming hasn't really taken off. It's expensive, and not everybody can afford it. Where would families who want to support your ideals and are concerned about their children shop? Of course we want everybody to be healthy because health costs affect every one of us. How do we put this into practice?

Mr. Caulfield: I feel very strongly about this. Your comment is a wonderful reflection of one of the last points I made in my presentation. We have to avoid this confused messaging. We need a simple message for the Canadian public: Eat lots of fruits and vegetables, eat whole grains, and eat a balanced diet. I think all of these things, GMOs, organic, and so on, are at the margins. When we're speaking to the population level, let's get the basics right. Get people eating more fruits and vegetables, more nuts, and healthy proteins. Keep it simple and we could cause a sea change. Then we can start worrying about whether it's organic.

I just wrote a piece on organic food, and there is no solid evidence that organic food is more nutritious. When we move on to whether it's less safe and there're more pesticides, I think the data becomes more questionable. There is still no evidence that conventional food has unsafe levels of pesticides. The concern and focus should be eating an appropriate amount of fruits and vegetables, not whether they have pesticides and whether they are organic.

The impact of organic versus conventional on the environment becomes even more controversial, and that is not the topic for this committee.

The Chair: Do you have any additional comment on this, Mr. DiNicolantonio?

Mr. DiNicolantonio: I agree, in general. Let's keep it simple and focus on something as simple as eating more fruits and vegetables. With regard to organic, I recently published an invited commentary on the large meta-analysis in the British Journal of Nutrition, which combined 350 studies and showed that organic crops had 50 per cent less heavy-metal cadmium toxicity, fewer pesticides and more phytonutrients. It comes down to the soil, so organic crops are not inherently healthy. I agree that we need to make it a simple message. Eating real food is what needs to occur, and subsidizing healthy food is a good start.

Senator Seidman: We might just head into the confusion of consistency of nutritional guidelines and indices that are used to measure them and the whole issue of labelling. I would suggest, Dr. DiNicolantonio, that as a cardiovascular research scientist you might understand that the cardiovascular research field might have been responsible for a gold standard paradigm in the Framingham cohort study that led to the development of nutritional guidelines that lasted decades and decades. It focused on the whole aspect of saturated fat and didn't deal with issues of sugar.

With respect to nutritional guidelines, indices, what they're based on, their consistency, and what we can do for Canadians, I would appreciate hearing something from both of you. You have both talked about basic, simple guidelines but the fact is we don't have basic, simple guidelines. We have indices and label usage. How can we help Canadians understand the important issues, both with nutritional guidelines and correct labelling?

I would like to mention, as you both made reference to Mexico, the fact that this year they put a levy of 8 per cent on food with an energy content exceeding 275 kilocalories per 100 grams. What is your reaction to that in terms of what scientific basis they may have used for that and how valid it would be?

Mr. DiNicolantonio: Taxing foods that are high in calories is the wrong approach. We know that satiating foods have more fat and contain more calories per gram. We don't care about how dense the food is in calories at that point. We care whether that food substance will drive continuous consumption of food. It is generally the lower calorie foods doing that — higher in sugar, lower in fat.

With regard to guidelines, I would follow the American Heart Association, which recommends no more than six teaspoons of sugar for women and no more than nine for men daily; or follow the World Health Organization that recently dropped their recommended added-sugar intake to less than 5 per cent for ideal health. This conflicts with the Institute of Medicine, which says you can eat up to 25 per cent of your calories from added sugars. I would go with the more consistent message of reducing the total caloric consumption of added sugars to less than 10 per cent of total calories.

Mr. Caulfield: I'll start with Mexico. As I said in my introduction, it pains me to recommend taxing sugar because I am an evidence-based person and I don't think that there is a definitive evidence base behind it. A 2013 meta-analysis of existing data suggests that it may lead to a reduction in obesity; but I'm not totally sold on that. I think it will lead to a reduction in the consumption of these kinds of beverages but I'm okay with that. As I said, it may lead to a healthy lifestyle and hopefully to a culture that eventually lowers the obesity rate.

With respect to food guidelines, I completely agree with you. The Canadian food guide is incredibly confusing. For one of my books, I tried to follow it. I get lost in portions so it was very difficult. I actually like the ''my plate'' approach they have in the United States. It's much simpler and when I'm speaking to the general public, this is the approach I take. Think about what you're going to eat in a day as a daily plate: 50 per cent should be fruits and vegetables, one portion should be whole grains, one portion protein and a little sliver for junk. That's much easier for people to think about on a day-to-day basis.

I really believe there are five or six things that human beings can do that will take them 95 per cent of the way to a healthy life. Everything else is on the margins. Don't smoke; exercise regularly with a little bit of vigorous exercise; eat real food, as has been mentioned; try to maintain a healthy weight, which is very tough; and take some preventive strategies, such as wearing a helmet when you ride a bike, a seat belt when you drive a car, and try to get a good night's sleep. The other thing is to have good relationships and love someone. If you do those things, you are 95 per cent of the way to a healthy lifestyle. That's a message that the government could get behind.

Senator Seidman: Neither of you has said anything about labelling. I know that doesn't necessarily fit with your message, in a way, because you are presenting very basic elements about how we manage our dietary intake. Labelling is a fact of life in our society, and we all go to grocery stores. I'm sure it increases my time spent in the grocery store by at least an hour trying to understand labels because they're so complicated and confusing.

Is there something that you could recommend in terms of simplifying this? You're for simplifying and I totally agree with simplifying labelling.

Mr. Caulfield: Yes. One of the reasons I didn't emphasize labelling — and I mentioned it briefly in my brief and I think Dr. DiNicolantonio would agree with this — is that real food doesn't need a label. Fruits, bananas and asparagus don't need labels. In addition, there is some evidence from Australia that a simple message like the stoplight message may be best where you give these broad recommendations.

Colleagues of mine at the University of Alberta have also produced a stop-light approach. Green is really healthy, orange is not very much and red don't eat or eat less of. The problem then is what you put in those categories. I think there would be a lot of disagreement. I disagree with a lot of things that are in the yellow, I think they should be in the red, but beyond that challenge I think a simple messaging like that is probably best.

Mr. DiNicolantonio: I have two additions to that. I would say stop highlighting calories in bold, big letters and start highlighting added sugars because, as I said before, for highlighting calories, now we're avoiding high fat calorie foods that are satiating and eating lower fat, higher refined carbohydrate and foods higher in added sugars.

Let's start highlighting added sugars and decreasing emphasis on the calories because the quality of the food drives our total calorie consumption throughout the day. We want to look at quality drives quantity, not looking at quantity calories on the label.

Senator Seidman: With regard to what you're suggesting about labelling, are there any international standards? There will be a big issue between what's healthy and what's not. I agree Mr. Caulfield that there are serious questions about that.

Is there anything that you could recommend to us in terms of international guidelines or other countries that have successfully tackled this issue?

Mr. Caulfield: There are research protocols going on around the world. Even in Canada there have been some research protocols. Australia is a good example that you can turn to. I believe in the U.K. they have also used different kinds of labelling approaches. I think there are places that we can turn to. Even there we see there is a great variance in how it's labelled.

One of the concerns I have with labelling and it does go back to something I said before is it does kind of push us away from eating the real foods because things that need to be labelled are generally processed or packaged and there should be an emphasis. Again, this is something the government can help with moving towards is eating things that don't necessarily come in a package.

Senator Seth: I can see that Professor Caulfield and Dr. DiNicolantonio have been suggesting a dietary problem containing a high level of carbohydrates under the policy and we have an increasing rate of obesity. Have you thought about the fact that in 2014 the OECD also states that there is a link between excess weight and education levels? In addition, the OECD indicates that physician and dietitian counselling has the biggest impact as a preventive strategy and extending the life expectancy.

In your opinion, do you think Canada should focus more on funding education and raising education levels as an obesity prevention tool and also expanding the ability of physician and dietitian counselling? Would that help?

Mr. Caulfield: These are excellent questions. I think it really speaks to the complexity of the problem. There is absolutely a socio-economic dimension to obesity and the populations that are obese. There is also evidence that, for example, when you take people and they are in a healthy environment, like a school environment, they are more likely to eat healthy. There is depressing data that kids put on a lot of weight in the summer, for example, because they are outside of an environment where what they eat is more monitored.

If I heard you correctly, education has to be part of the solution. Also, I think that starting even in our elementary schools we need to start educating kids about how to cook, about healthy food and about eating habits. I don't think that happens as much as it used to and I think we could introduce that. A colleague like Yoni Freedhoff from Ottawa is someone who really advocates this. He thinks part of the problem is this disconnect people have with food and we need to make food preparation more part of our culture.

I'm not sure if I answered your question completely, but I do think education and promoting education is part of the story.

Mr. DiNicolantonio: I agree, but I think we need to promote the right message. I think the wrong message has been promoted since the 1970s that it should be all about low fat. I agree with point one but I think we need to promote the correct message now.

Senator Seth: How do we do that?

Mr. DiNicolantonio: I believe we need to focus on reducing rapidly absorbable carbohydrates and added sugars as the main dietary villain causing obesity and metabolic syndrome, and it's not necessarily fat. That's what I think the key message is.

Senator Seth: Today I learned something from you when you told us about soda. A lot of people are unaware that soda has lowest calories and now it is a variety of the soda you get. This kind of awareness is very important in the public. How should we give the message? I'm sure in most of the population people do not understand. These are the important points of how should we counsel dietitians and giving awareness about the diet.

Mr. DiNicolantonio: I think there's confusion even in the ADA in the United States. They tell diabetics that they need at least 120 grams of carbohydrates because they think the brain needs that much glucose. They're wrong and they're right because fats and proteins can be turned into glucose in the body, so you don't need any exogenous carbohydrate to live. You can consume pure fat and pure protein and be totally fine. Seventy-five per cent of the brain can function on ketone bodies from the liver producing fatty acids. The other 25 per cent is from endogenously produced glucose, which does not require exogenous carbohydrate.

Most people do not get that message and the ADA is still promoting carbohydrates because of this common misconception that we need to be consuming carbohydrates or our brains are going to die, and it's just simply incorrect.

Senator Enverga: We are talking about food labelling, messaging, and we have to deal with advertising. What I was thinking is maybe there is something wrong with how we define people. How will you tell if you're just fat or just overweight or when does overweight become obese? Is there a way for us to tell everybody about that so that they will be able to control their intake?

Mr. Caulfield: This is one of my favourite topics, actually. I present on it all the time.

Human beings are terrible at evaluating themselves and knowing what they look like, how much they weigh, and they're also really terrible at evaluating their children. There have been studies that have shown that a very large percentage of parents who have obese kids think their kids are of normal weight. People often think that they are a normal weight when they're obese.

When I present it's a funny presentation and forgive me for my flippant remark but I think it makes a point. I often stand up and say most men — and I present data to show this — are shorter, fatter and uglier than they think they are and there is data to support that.

We all have these powerful cognitive biases that come into play here. There are cognitive biases about what we look like and cognitive biases about how much we eat. We all think we eat less. Has anyone ever tried a diet diary? It's incredible. I did a diet diary and I ate 40 per cent more than I thought I did and people lie to themselves on diet diaries by about 20 per cent, even when they think they're not doing it. People think they burn more calories when they work out. There was a study, recently, that showed that, often, it's four times as much as they actually burned. People are terrible at guessing the calories in foods. They underestimate the calories in restaurant food by 100 per cent. If you go to a restaurant and think something is 400 calories, it's 800 calories. We have all of these cognitive biases. It's very difficult to fight these cognitive biases, but just becoming aware of them is a step in the right direction.

Mr. DiNicolantonio: I think this is a great topic because you can certainly be fat and fit, and you can be thin and unhealthy. Being thin and unhealthy is also known as metabolic obesity. How do we identify those who look thin but are unhealthy? A really good marker is high triglycerides and low HDL. Basically, that's just a marker of insulin resistance. Insulin resistance is driving high blood pressure and obesity. What can we do to try to figure out the people who have metabolic obesity? High triglycerides and low HDL is an easy way, versus just looking at someone and asking, ''Are they thin, or are they overweight?''

Senator Enverga: What you are saying is that there is no real way to find out where you stand, whether you should stop this or when to stop this. When do you need more nutrition? There is no way, right?

Mr. Caulfield: There is no magical test, and that is one reason why I think getting a battery of tests is not the way. I don't think that all Canadians need to get screened, for example. That's why, again — I know I sound like a broken record — a healthy lifestyle needs to be promoted. If you take those elements of a healthy lifestyle, you are going to become healthier. Having said that, BMI, waist circumference and these other things are ways that individuals can start to do a check on themselves.

Most men — I always like to pick on them because they are simpler creatures — generally put on weight right from university. Most people do. Sixty per cent of the population is overweight or obese. This is a broad problem, and I think the messaging can target the population. It doesn't necessarily have to target individuals.

Senator Enverga: Can we possibly make a guideline, say ''If you are 10 pounds more weight than this?'' Is there a way to do this that will help our population to do this?

The Chair: A quick answer to end this. I think both of you have answered the whole issue, overall, with regard to the issue of healthy lifestyle versus being able to specifically identify. I think they've both said very clearly that you can't do what you are asking for.

Senator Enverga: But we should. We should have some standard for everybody.

Mr. Caulfield: The hope was that BMI was going to do it, but BMI is flawed.

The Chair: We will fight that out in committee after we have had the study, senator.

Senator Cordy: Your comments today have been most interesting, so thank you.

I'm interested in the restricting of marketing to children of unhealthy foods, particularly those high in sugars. It seems like a pretty simple thing to do. I guess until government gets involved, and then we complicate it.

Has this initiative been successful in any other jurisdictions? If you are looking at restricting the marketing to children, would you do it certain hours of the day, like Saturday morning or between the hours of four and eight or nine o'clock in the evening, or would you do it related to children's programming specifically, which might be more challenging because you'd have to examine every channel. Have you thought about how it could be done?

Mr. Caulfield: It is going to be very difficult for a number of reasons. First, there are so many different ways that you can advertise to kids now, like social media. Throughout the Internet, there are Internet games that market to kids. So we have suggested — and colleagues like Kim Raine at the University of Alberta have suggested — a blanket ban on advertising towards kids of junk food. In other words, all advertising to kids should be banned. That will be very difficult to implement for some of the reasons that have already been highlighted here, but I think it is a starting place.

The other challenge, of course, is the leakage from other jurisdictions. So much of our media comes from the United States and kids will be exposed to that. I do think that whatever has to be done has to be relatively broad, given all of the reasons I've just said.

There is some evidence and, again, most of the evidence is suggestive of a reduction of exposure to kids of bad advertising. The evidence, in other words, says that, yes, if you put these bans and these kinds of restrictions in place, it does reduce the amount of exposure that kids get to this kind of information. And that could be a good thing because we know this exposure does have an impact on food preferences. What we don't have a good sense of is whether, over the long term, it will reduce obesity rates.

My fall-back position is that, even if it doesn't do that, it's still a good policy because it will promote healthier eating, the reduction of food with added sugar, et cetera. Yes, there is a little bit of evidence, and I think that the ban needs to be broad.

Senator Cordy: Is there any jurisdiction where this is already taking place?

Mr. Caulfield: Quebec.

Senator Cordy: You are correct because so much of our media comes from the United States, so it would have to be in conjunction, I would think, with both areas.

You both spoke about simple messaging and healthy lifestyle, which, I think, is definitely the way to go. I think the advertising on the amount of sugar in soda is starting to work because there is a decrease in sales of soda. The most effective thing for me was the picture of how many sugar cubes are actually in a can of soda. Rather than anything that would be on the label or reading anything about, it is the actual visual, seeing that, I think.

Should we be doing simple visual advertising to show that? I think people are getting that it's in the soda. I don't think they are getting the fact that it's in sports drinks and juices.

Mr. Caulfield: I agree with you. I personally think we should target all beverages with added sugar, including sports drinks. There is no evidence to support the consumption of sports drinks, even for athletic performance. The evidence is very thin that people need these drinks at all. I absolutely think it should be targeted that way. There was another interesting study that demonstrated the degree to which people are confused. There was a study from the United States that was trying to explore the amount of confusion that people have around how to eat in a healthy manner. It found that people thought that doing their taxes was easier than determining what they should eat. If we are in that situation, it is grim.

My colleague, Arya Sharma, did a similar study in Canada — maybe you've heard about it — with the same results. People are very confused. Let's get a simple message, start with the basics and build from there.

Mr. DiNicolantonio: I completely agree. Let's say we look at a 12-ounce can of soda, and it says 39 grams of sugar. Most people are not going to understand what that means. When you can visually put, let's say, the amount of teaspoons, showing level scoops of sugar — let's say you put that there are 10 teaspoons of sugar in a 12-ounce coke — that makes sense visually, and it is easier for everyone to understand how much sugar is in these types of foods.

Senator Cordy: There is confusion. When I'm shopping in the grocery store, I see people taking a can or a package and looking at the ingredients on the back. I'd been looking for a while and would pick up a product that would say low in sugar. Then, when you read the ingredients, it's sky high in sodium. The confusion is a reality for Canadians or Americans, for consumers in general. That's what I found when I started looking at packages. Sodium is not great for you either. Senator Eggleton raised a question earlier related to artificial sweeteners. From what I've heard about aspartame, it is not something that I want to have in my body, so, are we going to take people from drinking a regular soda to a soda filled with aspartame? I don't know anything about stevia, but that's the new one coming out. What do we do about that?

Mr. Caulfield: Again we have people looking at labels. One of the other problems is this idea of a health halo. Perhaps people have heard about this already. When things say sugar-free, fat-free, organic, gluten-free or GMO-free, people assume it is healthy and will eat more of it. This goes back to the idea of simple messaging that will talk about the key components in a product.

With respect to artificial sweeteners — and I believe the doctor mentioned this earlier — the data on harm is equivocal. There is no strong data either way on the harm associated with it. I think there is some on both sides. I'm not concerned about the harm; maybe I'm being naive. I think you should avoid those kinds of drinks altogether. Correlation data suggests that these sugar-sweetened beverages increase your appetite for some of the reasons noted and it is correlated with weight gain. The problem is that these are association studies; we don't have causation why that might happen. I'm skeptical of artificially flavoured drinks for those reasons, but I'm waiting for more data to accumulate. The doctor may be able to help us.

Mr. DiNicolantonio: I agree that we need to keep the message simple. We also need to realize the unintended consequences of these types of recommendations of reducing the consumption of sugar-sweetened beverages. We don't want people consuming more diet soda. I don't think it is healthy. It may promote increased intake of food and an altered, harmful microbiota that may lead to insulin resistance as well.

The jury is still out on diet soda. We don't want people to switch from sugar-sweetened beverages to diet soda; that is not the point. We want them to eat real food. The message needs to be that we should be reducing our consumption of sugar-sweetened beverages because right now I have seen stats that state consumption is 40 to 50 gallons per person per year. Clearly we are over-consuming these substances. As noted before, liquid calories aren't as satiating, so the unintended consequences of reducing sugar-sweetened beverages are going to be a lot less than the benefits gained.

Senator Nancy Ruth: I'm someone who reads salt and sugar labels regularly, especially if I don't have to take my magnifying glass out to read them. Labelling is a huge issue for me and there is no reason they could not enlarge that stuff.

I wanted to ask about being satisfied with what you eat. For instance, if I ate a banana I would not be as immediately satisfied as if I ate an apple because an apple takes a lot more work to chew. When you want this framework of good foods to eat, are you concerned about those that one can eat quickly, like a banana, rather than those that take longer to eat, like an apple?

Mr. Caulfield: Again, there is some evidence to support this. I'm not a big fan of the smoothies and the juice craze. These are liquid calories that are easily consumed. When I talk to the general public, I say imagine the fruit that's in a smoothie and you have to eat that fruit one at a time. You will feel much more satiated for a lot of reasons in addition to those pointed out by Dr. DiNicolantonio, namely that, from a biological perspective, they are more satiating. The process of eating it takes longer and there is evidence to support that idea.

Let's keep it real food for now and worry about the details of banana versus apple for down the road. Let's keep it big and real for the general public right now. If we get anywhere near where we want the amount of real food consumption to be in Canada, we can worry about those details later.

Mr. DiNicolantonio: I have no further comment; I completely agree.

Senator Eggleton: I'm down to water now. We're making progress here.

I've read publications both in the United States and in Canada about how the industry can trick people into believing things are healthier than they are. I'm getting at the whole point of advertising directed at children. The cereal boxes say there is some fruit in them, but really there is a lot of sugar. The industry got together and said they would stop directing advertising to children. Some said they would stop doing it; others said they were only going to stop doing it with respect to approved foods, whatever that is. Some of the biggest names — Coca-Cola, McDonald's, you name it — were all involved. This was only about a month or so ago.

Is that something we can — I hate to use this word — ''trust''? What do you think about that? Will that fool people into thinking that they are really going to stop targeting kids when they will just find some other way of doing it?

Mr. Caulfield: I think the industry is tremendously nimble and will figure out ways to advertise to kids, full stop.

An example I often fall back on ties into the exercise point that I made. This often happens around the time of the Olympics or other sporting events. That is, they will have advertising for the Olympics and then an advertising campaign with a kid playing with their father and having fun and then having a drink afterwards. Is that an ad aimed at a child? I don't know, but the message is be active, be healthy, and drink a Coke when you're done.

I remain deeply skeptical. Studies have shown that these voluntary bans or rollbacks have not been overly successful. They have to figure out a way to get to kids and they want to create brand loyalty. There is evidence that that brand loyalty works. If you get someone who is a fan of Coke as a teenager, they probably will be a fan their whole life. I know my son is. That is a real challenge.

I do think the allusion of healthy food is a real problem. There are cycles of it. One right now is gluten-free products. Something is gluten free and, therefore, somehow it is healthy when there is no evidence that is true. Often, it has more sodium and other kinds of substances that are not healthy in it. This whole idea of a health halo and finding ways of projecting this image of healthiness is problematic.

Senator Merchant: We talked about sugars this morning and carbohydrates. Can you tell us something about fat? Can we consume too much fat? You seem to indicate that low-fat diets have failed. Could you tell us a bit about eating too much fat?

Mr. DiNicolantonio: Sure. We're cooking with fats. Some people cook with butter, or with olive oil, or with the omega-6 polyunsaturated fats. And that would include corn, safflower, cotton seed — soybean has a little omega-3. But saturated fat is hard to oxidize. That means there are no double bonds and it is not susceptible to oxidation, whereas the polyunsaturated fatty acids, like soy, corn oil and safflower oil, which have been infused into our diet since 1920, are unhealthy. The most recent meta-analysis in 2013 from Chris Ramsden and colleagues in the British Medical Journal showed that when you replaced saturated fat, even if it contained trans fat, with polyunsaturated fats like corn oil and safflower oil, there was increase in mortality and increase in cardiovascular death. It seems that these omega-6 fats are highly susceptible to oxidation and they're being used in restaurants. We are switching now from trans fats to these easily oxidized polyunsaturated fats instead of sticking with the beef tallow or the butter that is not easily oxidized. That is a huge issue with respect to cardiovascular health and potentially cancer because of the oxidized stress that these omega-6 fatty acids are inducing. It is also extracting these seed oils with hexane, or other chemicals, which oxidizes these oils. They are being infused into our products and are considered healthy because they might lower cholesterol. We are not looking at if they are oxidized or not. I think there is a huge misconception with saturated fat. We think that it's unhealthy when in my personal opinion I think it's extremely healthy, whereas we think these omega-6s are healthy because they lower cholesterol, and yet randomized controlled evidence indicates the exact opposite.

Senator Enverga: We talk about all kinds of foods, healthy foods and all those things, fruits, vegetables; however, my question is about processed foods. Are they generally good or what do I have to look at for this?

The Chair: Okay. We don't want an entire analysis of the processed food industry. If you have a quick comment, please. If not, we will move past it.

Mr. Caulfield: Simple messaging, I think we should try to avoid processed food.

Mr. DiNicolantonio: Agreed.

The Chair: This is been a great meeting. You have both been extremely clear on issues. Your messaging has been very clear, with one exception. Professor Caulfield, when you brought beer into this, you lost me completely.

Mr. Caulfield: I'm guilty here too because I drink black coffee, water and beer.

The Chair: We are in the same what we call ''diet range'' here. I must say that I have been very pleased to hear you both helping us with regard to the fact that you said there is no simple way of dealing with who is obese and who is not just on the basis of these simple indicators. You have both illustrated that certain indicators are useful in maybe a general way, but then you have to interpret it back to the individual. The reality is, if you want to get to scientific analysis, you have to go internally, look at your organs, each one, and that will not help the average person on an average day do anything.

We have to come back to the messaging with regard to lifestyle. That seems to be a trend we are moving toward here. That's understandable. It's easy; it fits into the pattern that you both have indicated and fits within a collection of items that are simple to understand with regard to a healthy lifestyle.

One issue again is emerging, and of course it has been emerging in the literature and various industries have been fighting one another over, whether it's sugar or fat, though the sugar industry does not like the idea that we are moving to the idea that it is really sugar that is the major issue. In terms of simple labelling, you use the Australian indicator of the traffic light, but it covers a number of things in getting to there.

If sugar is really the big baddy, why not use a traffic light that shows the level of sugar per unit in that food? If we come down to that, the idea it is really sugar, why do we not have a simple, clear, family-oriented label that indicates the amount of sugar per whatever in a given food?

Mr. Caulfield: I don't want to end our terrific discussion on what is potentially a disagreement, but I do think sugar is tremendously problematic for all the reasons you heard. I think at the government level we need to keep the message simpler and not focus necessarily on a particular substance. This is the messaging to the public, but having said that, I agree with everything that has been said. I think we need to try to concentrate on communicating with the public what a healthy nutritious diet looks like, and a healthy nutritious diet doesn't have a lot of added sugar. If we do that, I think it makes it more consistent and more sustainable, and I also think we're more likely to have the public internalize that message.

Mr. DiNicolantonio: I agree. But I also agree that it makes sense as well to somehow include added sugars in the category of creating this traffic light because most of the population doesn't understand the harms of added sugars. If we could somehow put that on a label easily, it just makes sense; but of course the simpler message is eat real food, right? Day to day, when people are going to be looking at the label, we need to give them something to direct them, and that is a beautiful way to do it.

The Chair: I also agree with Professor Caulfield with regard to the artificial sweeteners. I mentioned yesterday I'm a chemist, and I can tell you I wouldn't consume any one of those for a number of reasons, understanding both what their structures are and also the past issues.

I rarely ever bring myself into these kinds of things in a personal way, but I can tell you that I've worked out my entire life, and according to the BMI indicator my entire life I have been overweight. I do not think any other measure would indicate that would be the case. We do have all of these issues that you both have so well illustrated today in terms of the complexity of issue but the importance of bringing it back to some simple issue that will give guidance in some way to our society.

On behalf of our committee, I will repeat what I said at the outset of my remarks: You have been remarkably clear in your presentations and in your answers to us, and I can't thank you enough for your appearance before us today.

(The committee adjourned.)