Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 27 - Evidence - February 18, 2015
OTTAWA, Wednesday, February 18, 2015
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:15 p.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.
[English]
The Chair: Honourable colleagues, I'm Kelvin Ogilvie, Chair of the Committee. I'm going to ask my colleagues to introduce themselves, starting on my left.
Senator Eggleton: Art Eggleton, Senator from Toronto and Deputy Chair of the Committee.
Senator Merchant: Pana Merchant from Saskatchewan.
Senator Seidman: Judith Seidman from Montreal, Quebec.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I remind you, for the record, that we are continuing our study to examine and report on the increasing incidence of obesity in Canada: causes, consequences and the way forward. I am very pleased that we have two witnesses today appearing as individuals. I understand there is an order preferred so I invite Dr. Carolyn Gotay to present first.
Carolyn Gotay, Professor, School of Population and Public Health, University of British Columbia, as an individual: It's a pleasure to be here. I'm excited that the committee has taken on this challenge, because I think it's something that researchers, the public and all of us are faced with. I'm happy to tell you a little bit about some of my thoughts in this area.
One thing I do at UBC is direct a cancer prevention centre. I wanted to start out by answering a question: What do obesity and cancer have to do with each other and why care about this stuff? The reason is simple. Obesity is a strong risk factor for many cancers. In fact, following tobacco exposure, it's the second biggest factor for cancer. Certain cancers are heavily influenced by obesity, such as about one third of endometrial cancers, one quarter of kidney cancers and many others. In addition, obesity has a very important effect on recurrence and cancer mortality. As we know, obesity affects a lot of other diseases as well, diabetes, heart disease and lung disease among them. Certainly, with class II and class III obesity, we see quite a strong relationship with overall mortality as well. It's important for cancer and a lot of other diseases in addition.
I thought I'd start by talking about what's going on in Canada in terms of the prevalence of obesity if we look across the country. My team and I, a couple of years ago, published a paper where we looked at changes over the last decade or so in obesity rates by province and territory. We've updated that for the purpose of this committee meeting — you stimulated us to do that.
I can show you a couple of pictures that are projected for you. The data are from 2013. They come from the Canadian Community Health Survey. They're corrected for self-reporting because we know that people don't always report accurately compared to measured data. They show you colours that indicate what proportion of the population these different areas would be categorized as obese, based on BMI. You can see these are all for adults. As we look at the map, the darker colours are higher rates. In Nunavut and Newfoundland, we see more that more than 35 per cent of the population falls into the obese category.
If we look by sex, for women we see the dark red colours corresponding to Nunavut and Newfoundland and the high rates across the country. The only province where we see fewer than one in five women falling into the obese category is British Columbia. For the men, again we see the darkest colours for Newfoundland and Labrador, and some other darker colours in the Maritimes as well.
Obesity is a large problem for many parts of the country in particular, while it turns out much of the increase in obesity has happened since 2004. While there has been relative stability, rates are still going up in many parts of the country. The only place where we've seen a sustained decrease in the past few years is among women in British Columbia, where it's gone down about one percentage point a year during the last three years. It continues to be a problem. It's not going away.
I was interested to find out about other health behaviours. Do they also show this geographic gradient? Data available from this survey include physical inactivity, eating fruits and vegetables, smoking and binge drinking. Those are the four we have data on. As an overall conclusion, they follow the same pattern that we see for obesity in that B.C. is among the lowest on all these indicators, and Newfoundland and Nunavut are among the highest in all the indicators. It isn't only about obesity. It looks as though a lot of health behaviours follow a similar geographic gradient.
Even though B.C. fares relatively well in this comparison, there's a heck of a lot of room for improvement because fewer than 50 per cent of B.C. residents eat five or more servings of fruits and vegetables a day, which is what's recommended. There's a lot of room for improvement across the country.
What are some of the reasons why this might be happening? I think we need to look beyond Canada because these trends are global. It isn't just something that's happening in Canada. The increase in obesity rates has been found in the developed world for quite a long time and more recently in developing countries as well. More global influences have to be part of the reason for why we're seeing what we are, such as more processed food, more calorie-dense food, bigger servings, all coupled with inactivity. We're sitting looking at screens in both our work and our play, so those things are combined to produce a perfect storm with obesity being the wave.
There also may be some other factors that are at work. Socio-economic factors have definitely been shown in virtually all developed countries to be associated with obesity. People who have fewer resources tend to be more obese. In addition, social ties may have something to do with it as well. There's evidence that obesity can spread through social ties, and perhaps it may be when norms shift in a population. If everyone is overweight or obese, perhaps that becomes the norm and may reinforce some of the things we see in some regions of our country.
What do we do about it? When it comes to complicated and complex health problems like obesity, I find that the model called the social-ecological model is helpful, at least in structuring my thinking. The model really puts the individual in the context of social ties with family, friends, relatives, and then in social institutions like workplaces, churches, schools. They function in communities, and on top of that we have laws, regulations, taxes and things like that. All of those levels, going from the individual up to the highest level of governance, are needed if we're going to make a difference in addressing obesity. You can't do one piece and expect that it will have a profound and lasting impact.
The final thing I wanted to say was that this trend in obesity has happened in a pretty short period of time if you think about it. It has been several decades where we've seen such big changes. Something that happens that quickly has to be due to environmental causes. We haven't suddenly changed our human genome or anything like that. Things in the environment are making a difference. If something can be caused by the environment, then it can be reversed by the environment as well, which gives me hope that we can make a difference, get it under control and have healthier Canadians in the future.
The Chair: Thank you very much, doctor. I'll now turn to Dr. Laurie Twells, Associate Professor, Faculty of Medicine, School of Pharmacy, Memorial University of Newfoundland.
Laurie Twells, Associate Professor, Faculty of Medicine, School of Pharmacy, Memorial University of Newfoundland: I would also like to thank the committee for asking me to come and present today.
Hearing Dr. Gotay's work, we obviously have two extremes here, the lowest rates of obesity in the country in B.C. and the highest rates in Newfoundland and Labrador. Hopefully we can come up with some solutions today.
My background is in epidemiology and clinical epidemiology, so I study and look at the health of populations, not individuals. Over the last 10 or 15 years I've been interested in looking at obesity, the epidemiology in Canada and globally, and more recently looking at bariatric surgery in terms of a treatment for obesity.
As you may know, obesity is defined as abnormal or excessive fat accumulation that may impair health. This is important to note. The concern here is not about size; it's about health. Obesity is most often measured using the body mass index that, as you know, is a person's weight in kilograms divided by their height in metres squared. There are other measures that measure body fat better than the body mass index, for example, MRI, DEXA scans and water weighing, but these are typically not used at a population level and even clinically not used. They're expensive resources and only used in clinical research studies. But we do know that body mass index has a strong correlation with body fat, a .7 or .8 correlation, so we're all comfortable in using the body mass index to measure body fat in individuals and then extrapolate it to population-level studies.
It's also equally well used for both sexes and all age groups. There are different cut-offs for the body mass index across different ethnic groups and for the Caucasian group we typically classify a body mass index greater than 30 as the obese category.
There's extensive empirical evidence that has elucidated the relationship between increasing body mass index as a major risk factor for cardiovascular disease, high blood pressure, cholesterol, Type 2 diabetes, musculoskeletal conditions such as osteoarthritis and some cancers, namely breast and colon. It significantly impairs quality of life and increases premature mortality, estimated between three and eight years.
The estimated annual economic burden of obesity evidenced by direct costs related to hospitalizations, medication use, physician and emergency room visits and indirect costs related to reduced work productivity and increased absenteeism is estimated to be between $4.6 billion and $7.1 billion in Canada alone.
As I said, the classifications of BMI help us understand the health risk associated with increasing BMI and I've provided a handout, which you can look at on the back page, figure 1. What I wanted to show you was a classification, which I'm sure you're familiar with on this committee, in terms of increasing BMI categories and increased health risk. That is the table below the figure, which shows you that after a BMI of 30, your health risk for all the comorbid conditions I've mentioned start to increase quite dramatically. The figure above is one of many. This one in particular is from a study that was done, but it has been replicated many times, showing the relationship between increasing BMI and the relative risk of mortality in women. The curve would look the same for men.
The key thing to note here is that the curve is U-shaped or J-shaped in the sense that low BMIs also have the increased health risks associated with being underweight, whether related to eating disorders or terminal illness where there has been weight lost, but after a BMI of 30 or 31, the risk increases exponentially.
There's often a lot of media talk around the obese Class I. The risk is substantially lower than obese BMIs that hit 35 and up. The risk for comorbid conditions like Type 2 diabetes and cardiovascular risk increase dramatically after a BMI of 35.
As Dr. Gotay said, over the last three to four decades the prevalence of obesity has increased globally with a higher prevalence in developed countries, although the rate of increase in developing countries is concerning, where both obesity and malnutrition are population health challenges.
In Canada, obesity affects an estimated 20 to 25 per cent of adults on average, with significant regional variations as was just shown. From a low of 15 per cent in British Columbia to a high of closer to 30 or 35 per cent in Newfoundland and the Atlantic region, obesity tends to be lowest in the West and highest in the East. Having said that, Saskatchewan and Manitoba have rates that are quite similar to the Atlantic region as well.
In the last decade Canada has experienced a 200 per cent increase in obesity, from 5 per cent in 1985 to almost 20 per cent in 2011. The figure on the back of that page also shows some work that I published last year looking at Canadian rates of obesity since 1985.
The top graph is just showing you the prevalence rates, and this is using self-reported data from Statistics Canada surveys that hasn't been corrected for bias, as was just mentioned. These typically tend to be underestimating the rates by about 7 or 8 per cent, but they show you the prevalence. The bottom figure shows you what's most concerning, which is that disproportionate increase in the BMIs over 35 and 40. As such, the prevalence is a lot lower, and that's the increase we're seeing in both males and females, those top classes of obesity.
For example, once those increases occur, a lot of those comorbid conditions are very refractory to medical treatment and lifestyle intervention. In that particular group of people, the people that then look to access something like bariatric surgery, for example, all the lifestyle interventions, whether it has been diet or increased physical activity, pharmacological therapy, nothing works in these patients and it's that particular group of people who are then needing to access some sort of treatment.
This particular group, if you look at the next page, is made up of about 1.2 million people in Canada. The map on figure 3 shows you just obese Class II and III in a report that was published by CIHI last year on bariatric surgery in Canada. It shows you a rate that goes from about 3 per cent in B.C. to 8 per cent in New Brunswick and Nova Scotia, accounting for about 1.2 million people in Canada in that obese Class II and III.
Again, the graph underneath is also showing you the number of bariatric surgeries that are taking place in Canada. This is also increasing exponentially, as you can see, based on the demand. In 2006-07, only 1,500 bariatric surgeries were performed in Canada and now, by 2012-13, we're seeing 6,000, so an increase of about 300 per cent in bariatric surgeries as well.
I'm not aware of any success stories demonstrating that efforts focused on prevention and management of obesity at a population level have been effective in decreasing obesity prevalence, although there are some signs epidemiologically that there may be some slowing down or levelling off in some countries, as well as in some childhood obesity rates. This demonstrates the complexity of the issue. It is both the environment and our biology working together that make weight gain very easy and weight loss very difficult to sustain. Human biology is difficult to change, but the development of new medical treatments may be helpful.
Our global environment has been described by the World Health Organization as obesogenic, as it supports weight gain through passive overconsumption due to increases in access, availability and affordability of food, larger food portions, calorie-dense foods, processed foods, increases in sugar-sweetened beverages, and the marketing of junk food to children, especially at a young age, as well as a decrease in activities of daily living due in part to the sedentary nature of our work, technology, changing forms of transport and urbanization.
Obesity and its health consequences is a national and global health challenge that will require a collaborative approach, with leadership and action from governments and policy-makers. Thank you.
The Chair: Thank you both very much. I'm now going to open up the floor to my colleagues for questions.
Senator Eggleton: Let me start, Dr. Twells, with your charts and your commentary about BMI. We're hearing that obesity has always been with us, but in the last 30 years or so there has been quite an acceleration of it. Then there's some suggestion it has levelled off and may be starting to take off again. I'm not quite clear. Your chart indicates a bit of levelling off, but I'm getting conflicting comments from various witnesses about whether it is levelling off and, if it is, why it is levelling off. I would like both of you to answer that.
Ms. Twells: There have been some global reports published recently that have suggested there is some levelling off in some countries. Canada was not one of them. The U.K. was one, as were some Western European countries.
One of the things we need to be careful about is what we're talking about when we talk about obesity. Obesity, defined by the Body Mass Index about, is a BMI over 30. Once you break it down into different categories, different things are happening. There is some suggestion that the Obese Class I group, which is the BMI between 30 and 35, is sort of levelling off and not increasing as much as it was. It's the sort of higher levels, the bigger people, let's say, that actually those numbers are increasing and they're continuing to increase exponentially in both men and women.
Senator Eggleton: But you say not in the U.K. What is the U.K. doing differently, or is it just the way the measurement is done?
Ms. Twells: The measurement will be done the same. I think there may be some evidence that some things are happening that are working.
Senator Eggleton: Like what? So we can do it here.
Ms. Twells: One of the things I would comment on looking at European and the U.K. strategies is that they're national in nature. For example, even in the U.K., where it's a country of 65 million people, a national policy rolls out across the country.
Senator Eggleton: They don't have provinces.
Ms. Twells: One of the things we highlighted in this paper around obesity rates was regional differences. Coming from Newfoundland, I think about what's going on here. When health is a provincial jurisdiction, every province can do its own thing. As much as we all may have a focus on obesity, depending on the resources that are available in those provinces and the focus on prevention, management or treatment, there can be different things happening. For example, bariatric surgery is a treatment that is not offered in every province and only started being offered in Newfoundland in 2011. There are probably some regional differences as well and there will be some socio-economic differences, but I can't talk to what is working.
Senator Eggleton: Maybe we need to explore that a little more. Do you have any thoughts on this, Dr. Gotay?
Ms. Gotay: As far as rates going up or not, the big changes we've seen in Canada were earlier on. Now, whether they're levelling off or going up a little bit, we're not seeing the same increase that we saw early on. The specific numbers vary from year to year, and for some of it we have relatively small numbers. Some of the smaller provinces and the territories are seen to be bouncing around a little bit. I think that's just error of measurement, so it's hard to tell what's going on there.
I think there's much more public awareness. I would attribute some of the changes, if there have been real changes, to the fact that people are talking about it. We hear about children getting Type 2 diabetes that they didn't used to get. I think there's more awareness. It takes a while for that to actually make a difference, but I think people are concerned. It has got their attention, and that's a first step in making a difference.
Senator Eggleton: What do you think, Dr. Gotay, the federal government could do to help push that along? People are beginning to realize it.
One of the examples we've had here is that, yes, maybe people are reading nutrition labels much more, but they're not sure what they're reading. They're kind of confusing. It's not very difficult. The U.K. uses a red light/green light kind of thing. One of my colleagues has suggested animals. He'll talk about that.
What should the federal government be doing? You mentioned processed food. Again, what do you think we should be doing about things like that?
Ms. Gotay: It's interesting. Dr. Twells and I met at lunch today, so this is a good opportunity for us to develop connections as well. We talked about the light system. It could make a difference. We don't think the evidence is out there to show that it does make a difference, so I guess we're not positive that's the way to go. I think I can speak for her in saying we favour clear information that's easily interpreted that could help consumers make rational choices. That's a good thing.
If I look at tobacco as being in a way similar but in a way different to what we're facing here, the biggest single factor that made a difference was taxation. Really, what made a difference was the kind of comprehensive approach that I think both Dr. Twells and I have said is necessary. If I had to pick just one piece, taxation makes a difference. I do think some of the other witnesses have suggested maybe sin taxes.
Senator Eggleton: Carrot and stick approach? Up the taxes, down the taxes?
Ms. Gotay: It's possible. We are economic creatures and that is something to think about.
Senator Eggleton: I have one more question on BMIs. Dr. Twells, you used a lot of references to BMI. Here again, not everybody thinks that's the best method. I'm beginning to wonder about it myself. My height and weight have stayed the same, but my stomach has gotten a little bit bigger. Wouldn't the circumference concept of dealing with the stomach as opposed to this combination of weight and height be better?
You mentioned there are other things that could be done, but you mentioned all those expensive things like MRIs and stuff like that. Isn't there something simpler but more accurate in dealing with the question of what is obese and what is not obese than this BMI index?
Ms. Twells: I would agree with you. Many researchers and people I work with could sit at either ends of the table and debate the BMI. I could sit on the other side as well, but the reality is that it's what we have, what we're using and it's not going away.
The American Obesity Society has just endorsed BMI and our own clinical practice guidelines on prevention of management of obesity, which were published in the CMJA just a couple of weeks ago have said that the use of BMI is as good as it gets — not in terms of it being the best measure, because location of fat is very important. At a clinical level, you wouldn't expect to go in and see a physician and for them to diagnose you with obesity based on your BMI. There's no two ways about it. You would not expect that to happen. Individually, you're going to be doing your waist circumference and blood work. If you happen to be a bigger person but you don't have high cholesterol and high blood pressure, that's great.
The body mass index is an easy measure and the population understands it. It's relatively strongly correlated to body fat, point 7 or point 8, which is quite good. In terms of population surveillance, I don't see it going away any time soon. The question is whether we just sort of accept that and use it for these types of particular studies and measures. Again, clinically and individually there need to be other measures.
Ms. Gotay: It is what it is. It can be replicated consistently. It has that kind of validity and we can look over time. But it's the interpretation that is the thing where it may fall down. As far as an indication of what's happening in populations and comparing us with the world, I think it's not too bad.
Senator Seidman: Actually, I was going to ask you some questions about the BMI, if we could just finish the BMI issue. When did we begin to use BMI as a measure of population health?
Ms. Twells: Well, thinking back, was it the early 1900s? BMI was developed by Ancel Keys. The measure has been around for quite a long time. It's been batted around with other things, like waist-to-hip ratio and weight in kilograms divided by meters cubed trying to get an estimate of weight while adjusting for height. It's used globally and is a measure we all understand. There are some differences in ethnicity cutoffs, which show you there is still debate.
For example, in Asian populations, the BMI cutoff of obesity is 27 or 25 because they have a predisposition to more body fat, which increases their health risk earlier. There is always some debate around the cutoffs. In Canada, an obese BMI was 27 about 10 or 15 years ago. That was actually increased a little while ago as well. It's not perfect, but it is a useful measure. It tells us what's happening in the population.
We can look at average BMIs across the population, as well. We know, for example, that in Canada 20 years ago an average population BMI was 22 and it's now more like 25 or 26. We're moving into the overweight BMI range. We're all getting bigger. That whole population distribution is shifting to the right. As Dr. Gotay said, it tells us a lot about what's happening, so it's good for surveillance.
Senator Seidman: Indeed, both of you talked about the fact that you're using population health data, so we're not talking about clinical data but about population health data, which is critical to understand. I guess I'd like to ask you about the possible built-in biases in interpreting population health data. There is no question that risks are involved — potential compounding issues, accuracy, biases, measurement issues and difficulties comparing. Could you give us some indication of what those potential problems are in using population health data to extrapolate?
Ms. Gotay: I guess maybe the biggest one that I deal with is the fact that the best and most comprehensive data we have are obtained by asking people questions about how much they weigh and how tall they are. We know right away from studies done that women tend to underestimate their weight and men tend to overestimate their height, which means that everybody is underestimating their BMI a bit. Those are biases. Health Canada and other people around the world have done a very nice job of identifying those biases by having measured data compared to self-report data. That's why when I report I adjust according to what Health Canada recommends. That bias can be adjusted to some degree.
The BMI does not suit certain people, who have a musculature of a certain range. As you pointed out, ethnically it may not be perfect. Those are biases that affect the interpretation.
I would not generalize what I would be looking at to non-population health applications either, because, as Dr. Twells said, in a clinical situation you're talking a completely different ball game.
Senator Seidman: You can't make any causal statements about population health data. Is that correct?
Ms. Twells: I think you probably can — you mean just body mass index and health risk. We know the epidemics of diabetes and obesity and the chronic disease sort of epidemics. They're all occurring at the same time.
Senator Seidman: They're correlations. They're not causal relationships.
Ms. Twells: In terms of clinical data, for example, I can speak quite clearly to this in terms of bariatric surgery parents. When patients come in with BMIs of 40 or 45 with five or six comorbid conditions, such as hypertension, high cholesterol, diabetes, within that first year of losing between 50 and 100 pounds, those conditions go away. There's no doubt that there's a clear link between high body weight and chronic comorbidities.
Senator Seidman: Okay. Can I just ask you something about the Fraser Institute and OECD? You're probably familiar with the reports they have put out recently. They clearly say in the Fraser report that measurements of overweight and obesity among Canadian population from Statistics Canada suggests that the contemporary Canadian situation largely lacks a negative or disconcerting trend. They say that among Canadian adults, there's been no statistically significant change in the rate of overweight using body mass index among the population between 2003 and 2012. Among Canadian adult males, it has stabilized or even begun to decrease. However, for females there's been a steady increase in the prevalence of obesity since 2003. For youth aged 12 to 17, the rates are largely unchanged between 2005 and 2012.
The OECD, by the way, puts forward a very similar statement that the rates have grown very modestly in Canada, Korea and Spain in the past years.
I guess I'm putting forward the same kind of confusion that Senator Eggleton put forward to you, that when you look at these issues, you're not certain how to understand the concept of a growing epidemic of obesity, which is what we keep hearing.
Ms. Gotay: I don't know what data they're using as I'm not familiar with that report so I can't speak to it; but it does not reflect what I've observed. Actually, on a population basis, even an increase of about 1 per cent is statistically significant, which is a term that they've used. When you have very large sample sizes, things become statistically significant; so I don't think that's completely accurate. The 12 to 17 age-group data are very confusing, because it's difficult to pull out overweight from obese in those data. I would suggest looking at obese would be more significant than overweight, but I have not been able to find any source that allows me to do that. So a couple of things in there raise questions for me.
It would be really interesting maybe to have a roundtable of everyone who has looked at these to see where there are differences. You have a table of data in your packet that we prepared for the last three years. You can see that there certainly isn't a trend going down in men or up in women. That's actually not what we observed in these data for the last three years, much less the last 10. I don't quite know what to say.
The Chair: Do her comments or quotes reflect your experience?
Ms. Twells: I'm not sure what data they're using, although I suspect it's Canada Health Survey data, because we don't have any other data in this country that you can use, but they're drawing different conclusions.
The rate of increase I would say has sort of slowed down, but doesn't mean there isn't an increase. The latest global report, one of which I have here, has said that in Canada there's still a rate of increase. It may have slowed down a bit, but it's still increasing.
In terms of men and women, men tend to be more overweight and women tend to be more obese, but when you look at overweight you have to be a little bit careful. In the graph that's in your packet as well, you also have to understand that people move through these categories. Overweight looks like it never changes, but the prevalence of normal weight in this country is going down. People move into overweight and then they move on to the next category. There are some very good statistics that show the movement through our longitudinal data, which is one thing that is important to keep up. I know they're reducing that, but it's actually following people through the life cycle.
We know quite clearly that less than 10 per cent of people, once they reach overweight, ever go back to normal weight in terms of adults, but people move through the categories. So, if you're overweight you move into obese Class I, and then Class II and III. So the overweight looks like it's not moving, but it's the category that people come through.
The overweight category is probably the largest predictor for them becoming obese, so it depends how you interpret the data, I suspect.
We've seen the biggest increases in the last 10 years. The rate might be slowing down, but it's still increasing and is of concern just because of the number of people that are obese.
Senator Stewart Olsen: Thank you for your presentations. They're just adding to my overall saying that I don't know what's going on here, but you made one interesting statement. You said that the real increase in female overweight rates happened quite some time ago and has levelled off a bit now. So what was the cause? What did people attribute as the cause to that big increase at that time? My question is that right now we're citing a whole bunch of things, like more processed foods, et cetera, whereas I don't know if they were available at that first stage. Do you have any data on what would have caused the big increase at first?
Ms. Gotay: I did put that in my written remarks with some trepidation.
Senator Stewart Olsen: It gave me hope.
Ms. Gotay: In 1977, the U.S. released new guidelines for low-fat foods, citing that fat was a significant concern, and I think that resulted in changes in the food industry and low fat. It really was low-fat food, but the problem was that it was high in carbohydrates. That may have been part of what went on to have that spike as those regulations and new food formulations came into effect.
It seems since that time people have re-examined some of the evidence that led to those recommendations and it wasn't as strong as had been thought at the time. You're asking me to go out on a limb and I'm not comfortable being there, but it may have been the implementation of new food formulations that had an immediate effect and it has kept on going since that time, but I don't know about that.
Ms. Twells: I think you're right. One of the things we need to keep putting in context is that the rates of obesity started to increase globally almost at exactly the same time, through the 1970s and 1980s. We can't look at any one country or any one place. It was a global issue and, if you read the reports written about global drivers — and there was a nice series done in The Lancet a couple of years ago — there is more and more pointing to the global food supply, whether it's access and affordability, processed foods, high-calorie-but-low-nutrient foods.
The availability of food just kind of skyrocketed. That is one thing going on, as well as the other issue around low fat, which has really come up against major debate now. There are a number of papers and scientists looking back at that research saying it was all related to high fat causing cardiovascular events, but the more they have looked at that data, in fact, that wasn't true. So it was a whole move in the global food industry that moved to low fat and that's hard to get out of people's psyche.
Supermarkets are still full of low-fat/high-calorie foods. We took fat out of the diet and put in carbohydrates, primarily sugar. The sugar debate is a big one right now as to whether that is helping people gain weight quite easily. It's not that we're eating more food, but we're eating a different composition of food.
Senator Stewart Olsen: You understand my trepidation. This is the latest thing that we're saying is bad for you, and 10 years down the road I wonder what that will be.
I have one short question on the bariatric surgery. It's really kind of new to have this number of bariatric surgeries, but do you have any data as to the success rates of the surgery versus other lifestyle change?
Ms. Twells: When it comes to surgery for the treatment of morbid obesity versus anything else, there is nothing else. I can provide you with a lot of data. In Canada, as you can see from the numbers, they're just picking up. In other countries, bariatric surgery has been around quite a long time. Certainly in the Scandinavian countries it has been 20 or 30 years and in the U.S. a lot longer as well.
But in terms of being able to lose weight with the surgery and then not gain weight back, with lifestyle and intervention, most people — again you'd only be talking about 5 to 10 per cent of the population — might lose 5 to 10 per cent of their body weight or 3 to 5 kilos, and most will gain even that back, apart from maybe one in 20.
With bariatric surgery, you will be losing 30 per cent of your body weight, so 100 pounds in a year would be quite normal, and even with some of that weight regained, you are still averaging out at 70 or 80 pounds lost after surgery, if not more. The weight loss is not comparable. This particular group of patients is one that I feel quite strongly about and advocate for because this is a group of patients that needs to be treated.
We also have to understand that we're not necessarily going to decrease the prevalence of obesity by treating these patients, but we will reduce the burden on the health system substantially because this is the group of patients accessing the system a lot more than even a regular obese population.
Senator Enverga: Thank you for the presentations. I'm looking at all the statistics and graphs, and it looks like there's not much difference from your stats on this one. I can see that in B.C. there are fewer and then if you go to New Brunswick or the Maritimes, there are more obese people.
I was just thinking, and perhaps you might have considered this, could it be that the people have just naturally adjusted to the cold weather? Maybe it's a climate change that's causing these things? The colder it is, the more fat you need to make it hotter for you. Don't you think it could be one of the causes? Have we evolved into a different kind of person as we grow? It doesn't grow that much, but if we look at the demographics and the geographical location, would it be something that we could look into?
Ms. Gotay: I think many people believe we are in a climate of global warming, which would work opposite to your hypothesis if that was the case. I don't know how that fits in. The problem is we're seeing increased diseases as well. It's not something that's adaptive and healthy. It's not that people in Newfoundland are doing really well even though they're larger. There are higher rates of all cancers and many other health conditions. I don't think from the health perspective it's something that's adaptive and healthy.
Ms. Twells: No. That's one of the things I'd like to understand because, in a country that prides itself on being a developed country, having such large regional variations is a bit concerning. There hasn't been a lot of research done on the interprovincial variations, which is something I think would be useful to do. There's quite a difference in the make-up of the ethnicity. Newfoundland is 99.9 per cent White Caucasian. So we don't have a large mix of ethnicities, which can be less likely predisposed to obesity.
There are cultural differences. There are differences between rural and urban regions as well, as rural regions tend to have higher rates of obesity versus the urban areas in Newfoundland.
But even that is all questionable. It's not clear why even in a country you have those big variations, but then again, even comparing Canada to the U.S. and the U.K. in places, there are differences as well. I don't think we really understand why, whether there's some genetic predisposition, which could be possible.
Senator Enverga: Talking about ethnicity, many provinces get a lot of immigrants. I'm wondering if you considered ethnicity. Some people are a little bit wider. Some people are not as wide. Have you considered that in your statistics?
Ms. Gotay: It would be wonderful if part of our national data collection exercises included ethnicity as part of a data element. It's hardly ever collected. It really ties our hands to examine questions like that. There are some special studies in some areas with regional variations, but ethnicity is simply not one of the things that's collected in virtually any data set, including the tumour registry, which is something I work with, which really impedes our progress to understand some of the causes of cancer. It would be a wonderful idea, but it would mean a change in how we collect data in Canada.
Senator Merchant: In much of what we study here, we point out education as one tool to help us make advances. It seems to me that there's a plethora of information. Every magazine you pick up says something about dieting. The newspapers have people who are concerned with food. There are articles everywhere. The television is constantly about diets. I'm not sure what sort of education we are talking about when we are talking about obesity. What kind of thing can we do? Every container has information about calories on it. Restaurants have introduced menus with reduced calories. You're experts in this. What kind of education do we talk about?
Ms. Gotay: Education is just one piece. I think that's part of the whole puzzle, but it's not going to do it by itself. You're getting, on one hand, advertisements about diet and, on the other hand, advertisements about the best new doughnuts out there. We are bombarded with conflicting pieces of information and I think it's hard to sort those things out.
People have sometimes so much information they don't know what to do with it. A lot of the labels on the side, I agree, are there, but they aren't necessarily expressed in terms you can understand. With serving size, when I try to figure out the calories in a bag of chips, it turns out it's like one and two thirds servings, or something like that. How many chips is that? I don't think it's communicated as clearly as it could be.
Health literacy is not super-high in our population. I don't know that people necessarily understand as much as they might. Maybe it needs to start at an early age and continue throughout our lives.
Ms. Twells: I'd agree, actually. Years ago, there would have been much less choice. We both have children. You can't get more educated than us. We find these things difficult. Certainly, marketing to children, fruit roll-ups and things that call themselves 100 per cent juice and this and that, if you look at the ingredients you can't pronounce any of them because they're all chemicals. This is what kids are eating and they're bringing to school.
The education piece is difficult. I think the health literacy piece is going to be a challenge. Labelling the calories is a simple one, and there has been some evidence and research to show that when people go in and see the calories, they still eat out, but they're making different choices. You always used to purchase some sort of pasta. You didn't know how many calories it had. You find out it has 1200, then you see a different one that has less; you're actually more likely to choose the one that has less. It's not stopping people from going out, but they're making informed choices.
There's also talk about a walkability index, which seems to have a little bit less success and a bit of debate. Instead of calories on a menu, it tells you how long you would have to walk to actually burn off what you've just eaten. Of course, as most people know, to burn off 1,000 calories you would have to walk 10 miles. You're probably thinking that's not going to happen.
These are some of the experiments that we're now working with, how to educate people, but the whole population, not just the super-educated. Everybody needs to be able to understand. These are the experiments that we're now running with the labelling, the traffic light system, and there might be something better.
Senator Merchant: On the other hand, who is in charge of managing a person? Is it your family doctor who suddenly tells you that you need to do a variety of things? Are doctors educated in our medical schools in a manner that gives a lot of emphasis to this one very concerning epidemic? Are there many other changes that we need to make?
When do you start? How do you start out? How can we help people, not just with labels, but even professionals? How can we channel people in a manner that they know that they need to go and get some help, and where do they go?
Ms. Gotay: I don't think physicians get a lot of information about this in training, and they don't get a lot of reinforcement in payment for doing this kind of work as part of their everyday activity. Some do it anyway because they think it's very important. If I had to pick one thing they need to focus on, it would be smoking. If they can only do one thing, talk about smoking with their patient, but obesity would probably be following soon after.
Probably you need to have a health care team. There need to be the nurses and the other people who are part of that team. This can't all rest on the physician's shoulders, because they simply don't have the time. But I do think our health care system is not oriented toward prevention and lifestyle modification as much as it is treating a disease or injury.
I completely am in favour of what you say, but I think it would take a reorientation of the way we think about health care to make it really health care as opposed to illness care.
The Chair: We have to get real here. Getting access to a family physician for a serious problem is not easy in much of this country. The idea that they're going to manage your lifestyle is beyond belief at this point. This concept of turning the health care from treatment to prevention is a bigger ship than a continent. I think we have to keep those things in perspective as we look at realistic possibilities.
Senator Raine: Thank you very much for your presentations.
Honourable chairman, I have to say that what you just said is kind of like throwing in the towel.
The Chair: It happens to be the truth.
Senator Raine: It happens to be the truth. I agree; this is probably not a job for the doctors. But in our health care system, who should be doing this? If somebody doesn't do this prevention-type of lifestyle counselling, it will just keep getting worse.
That would be my first question. What is the difference between British Columbia and Newfoundland in terms of how health care prevention, perhaps, is being delivered, where there are some differences being shown?
Ms. Gotay: I'm not sure that it's about health care. The differences between British Columbia and Newfoundland have been around for quite a long time and have something to do with people who choose to live in these environments as well. People move to British Columbia who want to climb mountains and ski and good stuff like that. I think there is some choice for people who are already more interested in a healthy lifestyle to locate in British Columbia.
Health care system-wise, of course, there are differences between B.C. and other places, but I'm not sure that the emphasis on prevention has been at the front and centre of what's done. They go together, though — non-smoking, physical activity, people who like to bike, bike lanes and all of those kinds of things together create the atmosphere. I've been to Newfoundland and thought it was wonderful, but I can't speak to what Newfoundland's health care system might have.
Ms. Twells: I'm sure they're not that different in terms of access. I don't think any of our system is oriented towards prevention, as many of us know, especially in a fee-for-service physician model. There's not time. Certainly, some initiatives are under way to get physicians to buy into starting the conversation — even, for example, going through a sort of process of asking a patient whether they'd like to talk about their weight and then weighing them. Sometimes that can be a wake-up call. There has been research to show that people who have gained weight over time don't realize they've gained that much weight. Sometimes a wake-up call says, "I need to get back to what I was doing;'' or "I've stopped doing what I was doing and I need to start again.'' That can be helpful.
I half agree in the sense that the health care system cannot look after 60 per cent to 70 per cent of the population — it's just not feasible — in terms of overweight and obesity. Other things have to come forward in terms of government intervention, policy, programs and initiatives.
I live in Newfoundland. It's an active place; so it's a mystery. There are as many people outdoors doing things in Newfoundland as in many other provinces. Again, the idea that you think that potentially people who have higher rates aren't doing anything is probably a myth. Often how we see obese patients is that they're not actually doing anything. In fact, that's not true.
Again, it's hard to know. Some of it may be cultural. Some of it is based on a resource-based economy, such as fishing and farming, and pulp and paper, where people traditionally probably eat more and could eat more. Some of it is access to activities.
You often talk about winters and cold, but Australia has some of the highest rates of obesity in the world as well; and they have a fabulous climate. What's going on there?
Again, I don't think there are simple answers to what's happening in the differences.
Senator Raine: I agree with your observations. Do you think that we should be moving to regulate against the advertising of all food and beverages to children 16 years and under?
Ms. Twells: Yes, I would be in agreement with that.
Ms. Gotay: I don't see the downside, so yes.
[Translation]
Senator Chaput: As you know, our committee is currently studying the increasing incidence of obesity, and we have heard from a number of witnesses on this issue. We have heard conflicting evidence regarding the link between obesity and health, as well as regarding the definition of obesity. Witnesses have told us that the Public Health Agency of Canada should promote healthy living rather than focus on body weight.
In your view, what should the focus of these messages be? How should the Public Health Agency focus its messages, and what should its strategy be? Should certain people be targeted? How can we make Canadians accountable? Ultimately, it is a question of personal choice and individual responsibility. So what should the message be?
[English]
Ms. Gotay: On your final comment, it is personal choice and responsibility. Each one of us decides what we're going to eat; but it isn't always completely up to us in terms of what we have available and what we can afford. There are a lot of pressures in our social environment. It's not about the individual alone. Certainly, we want to do things to allow that person to live as healthy a life as he or she can.
A great deal of information indicates that people who have a very high BMI, especially the class II and class III, are not going to be able to benefit from just public health messages without taking account of their weight. Some people can be very healthy at a very large BMI, but that's more unusual.
Targeting public health messages to people who are apt to have problems because they're too heavy to take advantage of many of the opportunities others have is a reasonable public health strategy. While knowing just about every public health message, I can say that they don't apply to every single person in the population but to most of them. It seems that we should make sure that people understand that having a healthy weight is an important way for them to improve and maintain their health.
Senator Chaput: Who would you target if you were responsible for the message? What would you put in that message, and to whom would it be targeted?
Ms. Gotay: I think it has to be targeted to the population. If we're going to make a difference, we can't target the message to, let's say, the obese adolescent without having his or her parents involved. We can't really talk to the wife without knowing what the husband is doing at work. I see it as interconnected. I would rather have broader messages that everybody can find themselves in. We're all in it together. We don't have to segment people as much as we have to realize it's an issue that affects everybody, one way or another.
Ms. Twells: I would agree. The messaging is difficult to target from a public health perspective. Clinically, the severe obese group is a totally different group of population. We're talking about a group of people that need treatment; so you're not targeting them for lifestyle change. They actually need medical treatment, whatever that might be. Right now it's surgery. At some point it time there might be some pharmacological treatments as well.
One thing I notice when I go to conferences is that different provinces are taking a different tack in terms of their strategic health plans. For example, some provinces are specifically targeting obesity reduction plans or obesity strategic health plans. Many other provinces are aimed at healthy living, so all the behaviors, for example. I know B.C.'s plan is more about healthy living and behaviors. Newfoundland's is actually more about healthy living and behaviours. Other provinces, like Alberta, are aimed at obesity reduction because it's an outcome that's measurable.
Obesity is the consequence of behaviours and lifestyle. We have to target those behaviours and lifestyles with initiatives that will then hopefully result in a reduction in body weight. If they don't, they will still result in an improvement in health, because we know that physical activity levels will impact health regardless of body weight.
The physical activity guide, for example, is something that I don't think many Canadians know about, the fact that children should be active at least one hour a day and adults should be active 150 minutes a week. We hear that all the time because we live and breathe in this world, but when I speak to colleagues and friends of mine who don't work in these fields, they've never heard of that. Maybe it's some of the translation of the evidence we already have and getting it out there in the public health messaging, whether it's advertising on TV or campaigns, but generally at the broad population is better than individual groups.
Senator Chaput: Is it possible?
Ms. Twells: Broad population? I think it is. Other countries are doing it. The United Kingdom has broad public health messaging on TV. I've seen some nice, animated commercials around active living and getting children and parents active. I think the sort of broad public health messaging is possible.
Senator Chaput: Can you evaluate the impact of such a message?
Ms. Twells: Evaluation will come with the changing figures over time.
Senator Frum: Dr. Twells, can I ask you about your chart on the bariatric procedures in Canada? You say there's a 300 per cent increase from 2006 to 2013, and that represents 5,989 procedures.
I'm interested to know about the general accessibility of these procedures across Canada province to province. Are they fully publicly funded? You spoke about them being a net benefit to the overall public health system, so that it's in the larger term interest of the whole population. Everybody who needs one of these procedures gets one. Is that what's happening? Does that number represent full service?
Ms. Twells: No. If you looked at that map above here, it would show you the eligible population that could potentially access surgery. In Canada, that would be 1.2 million people. The criteria for bariatric surgery are a BMI over 35 with comorbidities or BMI over 40. Approximately 60 to 70 per cent of that 1.2 million will have comorbid conditions. Not everybody, but the vast majority will. At this point in Canada, probably the eligible population is about 1 per cent.
For example, the average wait time for bariatric surgery across Canada is five to seven years. In Newfoundland, for example, it's seven years. In Nova Scotia, I think it's about 12. Other provinces have some shorter wait times. They've increased investment into bariatric surgery, but the wait times are fairly substantial.
We've just had a case recently where if the average age of bariatric surgery across the country is about 45, you will have people in their 50s and 60s who can benefit immensely. If you come in looking for bariatric surgery at 65 and you have to wait for seven years, the question is: Is it worth it? Surgeons are asking themselves if it is worth doing surgery on older people because they have to wait so long.
Many of these patients are then accessing bariatric surgery elsewhere, in Mexico and Thailand. There are paying for it. There are some private clinics in the country, but then there are issues with follow-up back in their home province. In Ontario, that was an issue recently, and they invested more money to solve that problem of people going south or elsewhere and then coming back to be looked after. There can be complications, and sometimes there needs to be revisions or changes with bands and things like that. I would say there's a very inadequate provision in Canada for bariatric surgery.
Senator Eggleton: Sugar and salt also get a fair bit of attention in this subject matter, particularly in regard to processed foods being more the villain than the bowl of sugar on the table or the salt shaker. We've heard about the bliss point, where the manufacturer of these processed foods tries to get it to a stage where you're not going to have that only one chip but you'll go back and have the second and third and on and on. How much is that a part of this whole problem?
Given that there have been some "efforts'' by the industry to rein some of this in — I don't think any of that succeeded at all, although they're coming tomorrow to tell us how wonderful they are — should we be making it compulsory? Should we have compulsory guidelines to reduce the amount of sugar and salt in processed foods?
Ms. Twells: Simple answer: Yes, from me.
Ms. Gotay: I think so. I'm not a nutritionist who could give you what those levels would be. I think that would be one of the challenges, to know what that cut point would be. But if people can agree on that and they're empirically validated, yeah, I think so.
Senator Enverga: My question is more in regard to my last question. You compare B.C. and Newfoundland, and you mentioned too that it's sort of worldwide. It's a global issue. Have you looked at the differences between Asian countries, Taiwan or Korea, and the European countries, or even Canada? Have you made any comparison with the BMI index?
Ms. Twells: Globally, you can see the figures. They are published every couple of years through the WHO or OECD. For those countries, their prevalence rates are much lower, but they're still going up. In terms of why, I wouldn't know. The diets are quite different. I wouldn't know what was going on between the differences. I don't know if you would.
Senator Enverga: Would it be genetics? How much genetics are we having here?
Ms. Twells: The genetics are not strong. There are a few specific cases of genetic mutations and defects that cause obesity. There are a few syndromes. I'm familiar with and know a few people working in this field. There are 300 or 400 genes associated with obesity. There is not specifically one or two genes. I'm not a geneticist. It's more multifactorial. There's a lot more going on than one gene causing obesity.
The Chair: Just as a quick comment on that, I saw a report that in China, where there's been major change in the last while, the obesity rates are much higher as affluence goes up, which is kind of interesting because there's often the thought about lower socio-economic effects, but there it's due to apparently very dramatic changes in normal lifestyle.
Senator Merchant: You made mention of another prong, and that is to indicate to people the activity level that it would take to lose X amount of weight. Instead of doing that, what happened to a program we had a few years ago called ParticipACTION? Instead of trying to figure out how many calories you can walk off in five or ten minutes, why not introduce a program that people can understand? Just get active. What happened to that? Was that not a successful program? Why has it been dropped?
Ms. Twells: It's still there.
Senator Merchant: I don't see any ads on television. But it's still there?
The Chair: On that one, our understanding is ParticipACTION is coming back, and we're going to hear from them in the session. I think probably we had better just wait for that, if that's okay, senator.
Senator Merchant: That's fine. I didn't know that.
The Chair: That's why we're doing this study.
Senator Eggleton: We had a little bit of dialogue earlier with my colleagues on this whole question of focusing on reduction of body weight versus just healthy lifestyle, healthy living, weight-focused or lifestyle-focused. I'm not quite clear what the difference is. If you're going to improve your lifestyle or health, you might have to lose some weight. It seems to me the two are quite inter-linked here. Do you see any difference in the two?
I'll make this a two-part question. The second part of it is that you talked about public health and public health messaging. We have an entity here we haven't heard from recently called the Public Health Agency of Canada. Would you have any thoughts about them being the leader on this kind of an endeavour?
Ms. Twells: Well, the second question, absolutely. With the Public Health Agency of Canada, I would expect that would be one of their roles. Health promotion and health of the country falls under the Public Health Agency of Canada. Health is a provincial jurisdiction, but the health promotion piece is meant to be national. When we deal with epidemics and that type of thing, they're in full force. For prevention and healthy active living, I would have thought it would fall under their remit, but I don't know if it does or not.
In terms of the activity piece versus the weight, you raised a good point and this is where some of the debate and confusion sometimes comes from. You will get health benefit from just increasing your activity levels; forget weight altogether. We already know that if obese people — not really big people because it's difficult for them to do much — increase their activity levels, their cardiac risk factors will go down, health risks will diminish and they can be healthier than a normal weight person who does nothing. The idea is that in some ways you can be fat and thin in terms of health risks.
You may not lose weight though. You may just become more fit. That shouldn't stop us from giving the message that we need to be more active. What you'll find is that in populations where groups — whether this is friends and they've shown it with some clustered activities — become more active, other behaviours change as well.
In the short term you may only see some physical health benefits, but as people become healthier their stress level goes down, they sleep better, and they make different food choices. There is a whole bunch of activities that go with making one or two choices to do something different.
You don't find people who are healthy and active who are smokers. They don't eat out at fast food all the time. They don't have less sleep. They're not stressed. There's healthy active living you would do that could be the cluster of activities, and all those benefits would accrue from those activities.
The Chair: Do you have anything to add to that?
Ms. Gotay: I agree with that, but sometimes people need a place to start. That's what I find often when we talk to community groups. They have a multiple issues. They're overweight, they're not physically active, they're smoking and sometimes it helps to start with something and get that under control, then the other health benefits ensue. Sometimes if you try to tackle everything at once that can be overwhelming.
Senator Raine: I want a point of clarification on this table here. These are the average BMIs for the different age groups?
Ms. Gotay: Yes.
Senator Raine: So this percentage shouldn't be there in that top? I think these are average BMIs.
Ms. Gotay: Yes.
Senator Raine: So that percentage on the top header —
Ms. Gotay: I see what you mean. Yes.
Senator Raine: Okay. That's clarification.
The Chair: Is that clarified, Senator Raine?
Senator Raine: Yes.
The Chair: I would like to ask you a question related to testimony we had with a previous witness. If I recall it correctly, it was roughly the following: Obese people have a higher risk of disease in the categories that you've outlined, but this individual said they have better overall outcomes in those disease categories.
I know you're not necessarily studying these particular issues. Do either of you have any experience where you could comment on that? Dr. Twells?
Ms. Twells: I think what this individual was referring to is potentially something called the obesity paradox, and that would be in relation specifically to cardiac issues, no other chronic disease that I know of. If you've had diabetes forever, you're not doing well compared to someone else who has not, because you're dealing with glaucoma, kidney disease, amputations and things like that.
The obesity paradox related to cardiac conditions is a controversial area under study. I don't have a strong view on it and I don't think many people do. The research is still a little bit out. The jury is out. People are looking at the data and trying to piece through it to see if that's happening or if we have a selection bias going on here in terms of people we're studying.
In recent presentations I saw last fall in Boston, there was a lot of skepticism around the obesity paradox. I don't think it's something to focus on from a public health perspective, choosing that 1, 2 or 3 per cent that might do better. They may have the genes for doing better, just like your grandmother who smoked a pack a day and lived to 98. I don't think it's something that people should get caught up in. If anything, it is an interesting research area to potentially elucidate or examine closer, but it's not something that should influence a public health debate to say there's a small group of individuals, from a small group, who might do better.
The Chair: I agree with you, but it was an interesting —
Ms. Twells: People like to raise it.
The Chair: It was an interesting set of curves he was presenting and I just wanted to ask because you've been very frank with your comments.
I want to go back to the BMI issue. All the things I have read in this area over a number of years indicate roughly what you and all the experts say. They say it's not the ideal perfect situation to deal with each individual, but, as you have clearly said here today, it has a very high correlation factor. Therefore, as a first cut it is an excellent way to look at it. But then, when you get to the individual out of that 100,000 people, you have to look at it on the basis of the actual character and health of that one individual.
It is a useful first-cut evaluation and a useful generalization category. Is that a fair summary of what you have clarified today?
Ms. Twells: I think so.
Ms. Gotay: The comparative value of it over time, over countries and so forth is something that helps a great deal in understanding what's happening.
The Chair: Exactly. That's the point I was trying to make.
You both would know far better than I, but from my reading of the issue, education in people's behaviour is suggested to be highly overrated in terms of its impact. On the other side of the issue, there are some general observations that if people can quickly discern significant differences in things they're dealing with — in this case we're talking about food — and easily distinguish a character of foods in a category, they will be influenced by that.
Now I'm speaking from my own observation. The problem is that if I walk into a grocery store and begin to look at the things on the shelves, it is absolutely not going to happen that I'm going to spend lots of time reading all of those labels on the back unless I'm looking for one specific indicator, a particular component, something hazardous or something of that nature. To expect the general population to do that is simply, in my opinion, not on.
This idea, whether it's mice to elephants or a stoplight system where on the front of the package there is a little bar label with things like sugar and salt that are quickly discernible, and there's a red, orange, or green light below that in a general character, in my opinion, people will see that very quickly.
Having said that, I recognize all of the issues that are being brought out before us as to how you can genuinely label a particular food green, orange and red, but from your experience, do you believe that the simpler and more easily identified the label with regard to transferring a significant piece of information like that is far more important than where we're moving to, which are very complex tables? The labelling being proposed for beverage issues will require us to have a box with all the label on it and somehow the 500 millilitres of beverage contained within that large box. Can you comment on the question of the importance of the clarity, simplicity and quickness of identity of the label, or do you feel it should be much more complex?
Ms. Twells: You said a lot of things there. I agree with you about education. Education is not going to solve the problem. Purchasing food and eating food often comes down to habits, so we have to try to subliminally change those habits.
I think the simpler the message, the better. The thing with labelling that I agree with is the accountability to the food industry. They need to be honest about what's going into the foods. Sugar is never produced on a label; we don't know how much sugar is in products. I think that is important. Having said that, I don't think that's what consumers are going to be looking at. I won't, just like you. But I will go in and if I can trust a source, whether it's the traffic light or the little checkmark, and that is a source that I've been educated to know is trustworthy in terms of low levels of sugar or high levels of fibre, there are standards that we know we can look at that would be on the label, but if that checkmark is easy and it's a little blue checkmark that's Health Canada's or PHAC's, given the choice I will choose the checkmark, and I think most people would.
I would be much more in favour of a simpler method. I know there are many advocates out there for the labelling, and I think the labelling is good but more from an accountability perspective. I don't think consumers are going to be looking at labels. Personally, I don't.
Ms. Gotay: I think it's an empirical question. Before something is rolled out on a national level and we change everything that happens with food labelling in the country, we should try it out in a smaller market and see what happens. That is not my great expertise, but what I have seen isn't clear enough to say we know this is going to work, let's do it, and put all of the work involved in setting up a system. I think some type of a test market should be identified to see, because we'll have a better sense when we see what real people do.
The Chair: Just a simple example, I'm aware that a lot of people that I've encountered think that these juice packs, orange juice, apple juice and so on, are really healthy for their kids, rather than soda pop, and yet the sugar concentration is in some cases higher. But if a parent could look on a juice pack and see that there is a red light on that with regard to sugar, they could discern that very quickly and would overcome the instinctive thought that juice from a quasi-natural source is better for you. That was in the back of my mind with regard to these issues.
The other issues that you've dealt with, I think the B.C. situation is an interesting one, and I think there are some fairly significant sociological factors there in terms of total lifestyle, access to lifestyle, and all of those things going on.
With regard to the idea of the overall temperature, if you look at the Maritime provinces versus Manitoba and Saskatchewan, Manitoba and Saskatchewan have much more dramatic ranges — far colder winters and far hotter summers. The Maritime provinces tend to be more moderate overall, and yet they have identical overall obesity factors. There seems to be something much more complex there. Perhaps if we can get Senator Greene Raine to build us ski resorts in all the communities in Nova Scotia, we might stand a chance of catching up to B.C.
I want to thank you for the clarity of your responses and the knowledge base that you bring to our discussion on this, and the very realistic way in which you've tried to help us with these very difficult issues.
We are trying to see what were the major factors in that significant increasing rate of obesity. Whether it's levelled off now or levelling off isn't the issue. It was a very substantial change and, even if it reaches that kind of steady status at a higher level of obesity, the real issue is what got it up there and possibly changes can help deal with that big rate of change.
On behalf of my colleagues, I want to thank you both for being here.
(The committee adjourned.)