Health Committee on Sept. 26th, 2006

[The Chair, Conservative, Rob Merrifield]

We will call the meeting to order. I think we are all set to go. If the vice-chair would just get control of her group, that would be appreciated.

We have a very interesting panel. At the last meeting we had an opportunity to hear from the department. It was very energetic, we were very interested in what they had to say, and the questions were very good. We have an equally exciting panel before us today.

From the Canadian Fitness and Lifestyle Research Institute, we have Cora Craig. It's good to have you here. From Active Healthy Kids Canada we have Dr. Mark Tremblay. It's good to have you here. And from Queen's University, we have Dr. Ian Janssen.

We will take your presentations in that order, so we will start with Ms. Cora Craig.

[Cora Craig, President and Chief Executive Officer, Canadian Fitness and Lifestyle Research Institute]

First of all, thank you very much for inviting us here to talk about this really important topic. I'm going to start with just a couple of words about our institute and then I'll be presenting data and some recommendations.

The Canadian Fitness and Lifestyle Research Institute has been informing policy at the federal level on physical activities since 1981. More recently, we've been working very closely with our provincial/territorial counterparts who are responsible for active living and sport. We do that by looking at the scientific evidence, the capacity of the system to act, looking at things like national strategies that are being developed. We've been involved in the development of the pan-Canadian physical activity strategy and advised on the healthy living strategy and so on. But more importantly, what I'm going to talk about today is the current situation in terms of population statistics and then what we know is happening in municipalities and schools.

The data I am presenting is from our physical activity monitoring system, which covers a range of indicators from policy and practice in various settings through individual factors that would influence behaviour, such as attitudes, supportive social roles, like parents providing supports for children, and what goes on in settings and communities. We have been collecting this data regularly since 1995 on a five-year cycle and we are most of the way through our second cycle. The data that I'm going to present will probably be touched upon a bit by Dr. Tremblay, as well. Some of it comes from the Canadian community health survey. The remainder comes from our own surveys--the physical activity monitor, our school survey--and municipal surveys. I just want to mention that, although we've been involved in this since 1981, we've been mainly tracking adult leisure-time physical activity patterns, with a focus on children really starting in 2000.

The Canadian community health survey shows that about 70% of our children are getting about the equivalent of 30 minutes walking daily. That is much higher than adults. However, from other guidelines that are presented internationally that would recommend around six METS, or the equivalent of an hour walking, we see that only about 20% of our teenagers are reporting that level of physical activity in their leisure time.

More recently, we were interested in looking at objective measures of physical activity for children and youth from ages five through 19, and we've just completed a study of 6,000 children wearing pedometers and counting the steps they take every day. That includes leisure-time physical activity, walking to school, phys. ed. classes, recreation opportunities, etc. What we see is that boys, on average, take more steps than girls--around 12,000 steps daily--compared to about 10,500 for girls. There are differences across the country, with children living in B.C. and the north taking more steps than children in the east, and that is consistent with what we've seen from the teenage leisure-time activity results from the CCHS, or the Canadian community health survey. The other thing we see is there's a sharp decline by age for both boys and girls, looking at five to nine-year-olds through teenagers. If we look at five-year-old to ten-year-old boys, they're accumulating about 12,500 steps a day, and it goes down to about 10,000 steps with teenage boys. For teenage girls, it's a little sharper decline.

That sounds like a lot of steps. So, is that good enough? It's really hard for us to answer that question. There are many different guidelines at the moment that are being explored. One of them is by researcher Dr. Epstein, who says 120 to 150 minutes of total activity over the whole day, so it would correspond to our step data. And if we try to translate that into a cut point for steps, it's about 15,000 steps. If we look at that, there are only 15% of our children who are meeting that requirement. And again, there are sharp differences between boys and girls, and there is quite a sharp decline across the age groups. So what we see is about 20% of five-year-old to ten-year-old children who would reach that level and it's down to about 9% in teenagers.

If we look at the preferences of children, what they'd like to do during their recreational activities, parents say that most children prefer different kinds of characteristics in their recreational activities. That's the majority. We see, for example, that about a quarter of children who do have a preference say they would prefer more active types of activity. That is down for teenage boys compared to five years ago. Where there's a difference between unorganized and organized activity, the preference tends to be toward unorganized. Between vigorous intensity or moderate-intensity activity, there is no difference, and between non-competitive and competitive, non-competitive tends to be preferred.

If we look at what parents are doing to encourage and support children's activities, about a third of parents say that they play active games with their children, but about a third rarely do so.

The good news, perhaps, is that currently, unlike five years ago, parents of girls are more likely to say that they play with girls in active games. That speaks well to some of the strategies that have been put in place to encourage physical activity among girls.

Parents also could provide transportation to events, and about 55% of parents say that they do that, but that's down from five years ago. Similarly, parents volunteer at school or in recreation and sports activities, and about 40% of parents, roughly, do that. But again, that's down from five years ago. Also, two-thirds of parents provide some form of financial support to encourage participation among their children.

Most municipalities provide special programming for children. About 66% say that they do so for children at risk, and about 65% of municipalities provide discounts for low-income families, so there is still room there for some movement.

There are barriers to being more active. According to about a third of parents, there aren't enough programs and facilities nearby for their children to be active. Also, about one-quarter say that the hours and class times don't meet their children's needs.

Another setting where we're trying to encourage physical activity is in the school system. Fewer than one in five children have daily physical education at school, yet parents think that's a good source of physical activity for their children and where they're active.

Fewer than half of children say they really enjoy physical education classes, or their parents say they really enjoy them, and an equivalent number, about 40%, say that those opportunities actually meet their children's needs.

What does the literature tell us we could do to increase physical activity? One thing it says is that we could hold mass events. There are a number of programs, like Go for Green's walking school bus, that are going on in Canada. Others are social marketing campaigns. There is a good example in the United States, the VERB campaign, which has shown increased awareness and a change in attitude among children and youth. The evidence there is that a single, clear message is effective, not multiple messages.

School-based programs to increase physical activity, and physical education classes and social support from family and peers, have also been shown to work.

Community programs and environmental-change strategies, like making our environment safer for kids to play, are promising areas, but there is little research done at this point to really underscore how effective they are.

One thing we do know, though, is that if children play outside after school, they tend to be more active than other children, but we don't know if those children who didn't play outside were then put outside after school they would play more. Nonetheless, it looks like a promising approach.

Our real challenge is to re-engineer physical activity back into children's lives and make activity the social norm for children.

What we need to do is make the environments where children live, play, and learn ones that support physical activity. In order to do this, we really need to emphasize the needs and preferences of children. I would say particularly for girls and low-income children, we need to see what challenges there are.

We recommend that there be a social marketing campaign that reflects the needs and interests of children. It should have a single, clear message. There's a lot of concern about obesity, but I do not believe that an obesity campaign aimed at children is the solution.

We need to look more at the root causes and look at a diet or a physical activity campaign. In particular I would say that we shouldn't combine those messages. We should think again about a single, clear message. We might have multiple campaigns, but each campaign should have a clear message. Also they need to continue over time so that they reinforce each other. They won't have an immediate effect.

We also need to look at environmental changes to increase physical activity, and think about things like physical activity trails, bicycle lanes, and physical activity facilities, and how to encourage their use.

We also need to look at policies that encourage mandatory physical education in schools. We need to tie them to curriculum outcomes so that they really are mandatory and have the things we are trying to achieve clearly associated with them.

We also need to overcome some of the societal barriers, because I really believe this is a societal and systemic problem. We need to look at our transportation systems to encourage active transportation for children and address safety concerns. And we need to look at things like screen time amongst youth.

I'd also recommend that we allocate 15% to 20% of all budgets to programs for evaluation, so that we can really understand better what works and what doesn't work, and why it does and why it doesn't. We then have to disseminate these evaluations, both to help shape the scientific literatures so we can add to the knowledge, and so we can share from community to community what works.

Thank you.

[The Chair, Conservative, Rob Merrifield]

Thank you very much. I appreciate your comments.

We'll move on to Active Healthy Kids Canada, with Dr. Mark Tremblay.

[Dr. Mark Tremblay, Chairman of the Board, Active Healthy Kids Canada]

On behalf of Active Healthy Kids Canada and the pediatric exercise science community in Canada, thank you for the opportunity to be here and thank you to this committee for tackling this important issue. We look forward to working with you to help advance the resolution of this problem.

You should have a package of slides. A lot of them I will go through quickly, and that explains why you have the other items to help you digest the material later on.

You have a short-form report card, which I will speak to in the second half of my presentation, and a long-form report card, which provides all of the scientific background and explanation for how the grades for the short-form report card got there. So I won't spend a lot of time going through that in detail. That's all there for your reading.

You may also have a sheet that draws you to our web page, where this information in both languages is available for download if you need other copies.

So I'm going to go through the slides if that helps you follow along. There are four main points.

The first point I want to get across is that often institutional-based and somewhat ecologically invalid or artificial approaches to dealing with a problem are probably not sufficient in order to optimize the health of children and maintain healthy body weights. I'll elaborate on that a bit.

My second point is on data quality, and Cora spoke to a fair bit of data. Ian will also speak to data, some of which is either contradictory or doesn't seem to make much sense in the world we live in. So I want to draw a few examples about data quality and about how our frame of reference as it adjusts over time affects our data quality.

I want to present the Active Healthy Kids Canada report card findings, which I believe consolidates the information that you're looking for in this committee into one tight package, and then go through some recommendations.

Nature deficit disorder is this concept that our younger generation, and increasingly ourselves, are drifting away from the outdoors, and that has implications because it makes us less active. This is captured nicely in a quote from Last Child in the Woods: “I like to play indoors better because that's where all the electrical outlets are.”

This is a different frame of reference for kids today from when I was a child, certainly.

And continuing on:

Ironically, the childhood obesity epidemic has coincided with a dramatic increase in children's organized sport. This does not mean that organized sports contributes to obesity, but that an over-scheduled, over-organized childhood may....

From a different thought leader:

Recreation has gone from spontaneous to organized and regimented activity: parents exercise at the gym while the young play soccer and hockey in leagues with schedules rather than in the backyard or the street in front. More time is often spent preparing for and getting there rather than on the activity itself.

Perhaps we've lost touch a little bit.

To try to investigate this experimentally in my lab, we've tried to look at groups that have preserved traditional agrarian lifestyles, and compared them to contemporary-living kids. We've studied Old Order Mennonites and the Amish populations that exist in Canada. When we do this we find remarkable differences: about one-eighth as much prevalent obesity in the Amish as there is in our kids; one-quarter as many are overweight. This is very reflective of what life might have been like in the late 1800s among contemporary society in Canada.

If we look at their physical activity levels and monitor them directly, minute by minute, by putting accelerometers on kids, we find that probably not too surprisingly to you, Old Order Mennonite and Amish kids are much more active than your kids and my kids, no matter what variable you look at. They achieve this despite the fact that they have no physical education in their school structure at all, they have no institutionalized sports structure in their community, and many of them live below the poverty level.

If you were to attend a think-tank on childhood obesity, those would be the first things that will come on the table. We need better physical and health education, I agree. We need better infrastructure for municipal sport, I agree. And it's an issue of income. Well, these segments of society that reflect life of a time gone by, before nature deficit disorder, before we've withdrawn from the outdoors to the indoors, were able to prevent the problems we are dealing with today. This is something to reflect on.

I've also provided a slide on step counts that we've done on these kids as well. If you recall the numbers that Cora was presenting, the numbers from the Amish kids are remarkably higher than the numbers of typical Canadian children.

I will add that in early May, when we did this experiment and were testing these kids, it happened that we had a freak week of snow. Despite the fact that weather was working seriously against that study, it showed that step counts from that group were among the highest in the developed world. That is one issue.

The second issue is whether our frame of reference is changing and how that might affect data quality. I show the picture of the car trying to squeeze into the parking lot there. Has the distance that we allow ourselves to walk, that we allow our children to walk--to the corner store, to the park, and so on--drifted downwards over time? Has the distance that we would walk to the corner store as a child changed? I believe it has.

In the next slide the child never seems to find time to exercise. Beside that slide I show data from 350 kids. We have minute-by-minute accelerometry-measured movement counts on these kids. It shows that all these kids have six hours or more per day of non-movement, of sedentary time. They do have time to exercise. Their frame of reference about what exercise is, what physical activity is, and how much of it is appropriate has, I think, drifted down over time.

We look at trends in households with entertainment equipment that promotes sedentary behaviour. You see a bunch of lines in this slide. You can see that in the last generation we have almost saturated every home in the country with two or more TVs, DVDs and VCRs, computers in the home, high speed Internet in the home, cable or satellite TV in the home. Only one of those lines goes down, and that is the proportion of homes in the country that have only one television.

This is a big change in a very short period of time, and this screen invasion makes it very difficult to collect data. When we were children, we had one television in the home. It was in the family room. It was pretty easy for mom and dad to know when you watched too much TV; that was the only location you could do it. It was also easier, I think, at that time for mom and dad to fill out a questionnaire from the Canadian Fitness and Lifestyle Research Institute that said how much screen time their kids were having, because there was one.

It is not that way any more. I have four children, and we have a lot of screens in our home. I can tell you that our kids don't watch more than one hour of TV in the family room, where I can see them, but we also have a TV in the basement. We have two computers in the home. We don't have Game Boys and so on, but most families do. If it's only one hour on each of them, now you have six hours a day, yet mom or dad might be reporting one hour a day on the questionnaire. This is the big problem for data quality.

It is similar with the our size and our body composition. Most Canadian adults are overweight now. That is our frame of reference. The average, normal person, the one you don't get very concerned about, is overweight. The reality is that the pathophysiology, the medical complications, and the health issues don't give a darn about what normal was; they give a darn about what the overload to the body is, what the challenges to the body are, and how that body adapts. This is a problem, I think, as we go on.

The last slide on page 3 brings some data to this. Around the same time that we did one of the waves of the national longitudinal survey of children and youth, Ipsos Reid did a poll, a random sample of parents in the country. The poll asked the parents if they had an overweight or obese child. When StatsCan does a survey, you should end up with numbers fairly similar. What I show there is what comes out from the Ipsos Reid poll asking the parents: 12% say they have an overweight child; 0% say have an obese child. By chance, those numbers should be 27% and 12%--an enormous difference.

We are all wearing rose-coloured glasses, and again, the health outcomes come from the realities there--not what we perceive, not what we want of our kids, but what's actually there.

Further to the data quality issue, we don't have--except for what Cora presented on that pedometer stuff--nationally representative, directly measured physical activity data in the country. Statistics Canada is working on that, and we will have it in a few years; the U.S. now has it and just released the information in June. In the slide, I show that when you compare self-report physical activity, the proportion of Americans who meet the guidelines identified in the Surgeon General's report is around 32%. When you put a monitor on people and actually measure what they do, that 32% goes to 3%--a tenfold error in there.

That may help to explain some of the studies that don't show as strong a relationship between physical activity and health as we might expect to find, because we don't have data that actually reflects the movement of people.

The next two slides I won't get into in detail. They show accelerometer information from my lab as well. They show the way we can manipulate the numbers, depending on how we analyze. These next two graphs show the same data analyzed in different ways; they are all valid ways of analyzing things, but they basically show that anywhere from 100% to 0% of kids meet physical activity guidelines, depending on how you look at the data.

And this is my plea: We have very transparent data analyses and data presentations because it's not the statistics we present to Parliament, or that you can claim credit for, that make a difference in the lives of kids. It's changing their behaviour. So let's pick a standard, a robust analysis method, and go with it over time.

I'm here as chair of Active Healthy Kids Canada, which has a vision of a nation of active, healthy kids, and a mission to inspire the nation to engage all children and youth in physical activity. The strategic goals of the organization are to make physical activity a significant priority in the everyday lives of Canadian families, and to provide expertise and direction to policy-makers and the public on increasing and effectively allocating resources and attention toward physical activity for children and youth. This is exactly what we're all about.

Active Healthy Kids Canada is the trusted source for powering the movement to get kids moving. One of our main activities is to produce an annual report card on how we're doing, holding us all accountable for where the rubber hits the road. Are we actually making a difference in the lives of children?

The report card is a research-based communication and advocacy piece, designed to provide insight into Canada's state of the nation each year, on how as a country we're responsible for providing physical activity opportunities for children and youth. You see last year's report card, dropping the ball with an overall grade of D. That's available on the web. I didn't provide it to you. And this year's report card, released in May, again a D grade. I'm not going to go through all the grades here; you've got them in detail.

But we assess a number of parameters we believe are important in influencing the likelihood of children and youth being physically active. Different indicators of physical activity--and you can see there for screen time and organized sport and unorganized sport participation--Cora spoke to this as well. Family indicators: all in the D range. Very disturbing things: only 36% of parents regularly engage in physical activity with their children, and a third of them never do, or at least report they never engage in physical activity with their kids. Not good enough.

School and community indicators are there. You see some “incompletes” as well. Again, there is tremendous data need. As the problem gets worse and worse, we need to understand in finer and finer detail what the source of the problem is. And in the built environment and physical activity at school, we have very poor data in Canada, no really good surveillance and ongoing mechanisms to collect those data.

Perhaps relevant to this group, we gave a C-minus grade in the policy area. We released the report card not too long after the election, so we hedged our bets a little bit. But the party in power now had committed 1% of the federal health budget toward physical activity. We're still waiting to see exactly how that will unfold. The tax credit is starting to come in, and we, among others, have been contacted by the group, investigating how those tax incentives should work. So there's some activity there, relative to the importance and the prevalence of the public health issue--insufficient. And there are some health indicators there as well.

The media impressions for our report card exceeded 40 million last year. This is a big issue for people. We are overwhelmed with requests to get this information because it consolidates it into a tight package and doesn't force people to go to the literature. It far exceeds our capability as an organization to respond, but does give an idea of what parents and advocates are concerned about.

Active Healthy Kids Canada was established about 12 years ago. We're a national organization with a passionate voice for the development of active, healthy kids in Canada. I've given you the website.

I want to close by putting in a plug for ParticipAction. This second-last slide was in the newspaper in Saint John earlier this week. There's chatter in different hallways about a potential resurrection. This would speak to Cora's recommendation that we bring a consolidated, strong voice, a communication strategy, a social marketing strategy for Canada.

My recommendations:

We need better surveillance and audits of what we do because far too many programs are claiming wonderful credit when they're not actually changing the lives of kids. This is very frustrating when you start to monitor health outcomes and you don't see the changes you think you should. A good example, in Ontario and Alberta, is the daily physical activity program. For those of you who have kids in Ontario now, if they're in elementary school, ask them every day if they had 20 minutes of physical activity above and beyond their physical education. That's what's mandated in this province right now. I have four kids that fall into that category. Most days they don't get it.

I have a high degree of confidence that the provincial government is going to claim that this was a tremendous success, when it didn't happen and it didn't change the lives of kids. There won't be lower levels of obesity, because we didn't audit it. We didn't check to see that it's actually making a difference.

We need enhanced physical and health education programs.

We need comprehensive social marketing and a communications strategy, which we don't have in the country at the moment.

We need better possibilities and support for the NGOs. Cora's budget usually comes in, if it comes in at all, halfway through the next year. Active Healthy Kids Canada has never received a dollar, despite asking every year in its 13-year history, from the federal government. There is no mechanism to support us, and we can't respond to the constituents in an adequate way.

We need funding for a healthy living strategy, which was signed off and finalized in 2003. It was the previous government, but it's all there. The work was done. We don't have that in place.

We need improved and changed infrastructure, and we need to commonly have health impact assessments when we're changing our built environment.

We need additional research, and we need the federal government not to fund everything but certainly to show leadership.

Thank you.

[The Chair, Conservative, Rob Merrifield]

Thank you very much.

Now we're going to Dr. Ian Janssen, from Queen's University.

[Dr. Ian Janssen, Assistant Professor, School of Kinesiology and Health Studies, and Department of Community Health and Epidemiology, Queen's University]

Thanks again for the invitation as extended by Mark and Cora.

I've been in obesity research for ten years, and I actually went to graduate school when I saw this problem starting, with the intention of trying to solve the problem. It is nice to see that we're finally starting to get the attention this problem warrants.

I am an epidemiologist. What that means is that I look at the surveillance of obesity. I look at the risk factors for what's going to predict who develops or has obesity, and I look at what the outcomes are of obesity if you have it. I work a lot with children as well as with adults.

Today I'm primarily going to be sharing results with you based on a very large international survey I'm involved with. This survey is called “Health Behaviours in School Age Children Survey”. It's an international survey conducted in 35 countries every four years. The team of investigators that I work with at Queens are responsible for conducting this survey in Canada. We collect data every four years on about 10,000 kids from grade six to grade 10 all across Canada. The nice thing about this survey is that we can compare ourselves with other countries to see how we're doing. The other countries in this survey are primarily European countries, as well as the United States, so we're comparing ourselves to industrialized countries.

I'm going to draw your attention to the first figure. This figure shows the prevalence of inactive youth in the different countries. So in this case you want to have a low bar. It means you have fewer youths who are physically inactive. And as you can see there, Canada falls about fourth to the right. So compared to these other countries we're actually doing quite well, which is surprising. I see a lot of puzzled faces out there. I was also surprised when this result came up.

But I think we also need to look at the axis that shows that the prevalence is above 50% inactive within Canada. So even though we may say we're doing well compared to the Europeans, we're not doing well within our own country. More than half of our youth are inactive, and this is using European guidelines for physical inactivity, which are very conservative. As Cora mentioned before, if we use more stringent guidelines, as we tend to do in Canada, fewer than one in five of our adolescents meets our own physical activity guidelines.

If you now turn your attention to the second figure, it shows something similar but looks at the prevalence of being overweight instead of being physically inactive. So again you want to have a low bar. In Canada, unfortunately, we do very, very poorly. This shows the results for overweight. You would see the same patterns for obesity. We're right up there with the champions in Europe, which are the Mediterranean countries, and the United States. We're right up there. We're the fattest among the fattest of the fat. No questions about it.

So now you say, how can we be among the most active and at the same time among the most obese? It's a very puzzling observation, and I always get asked that question when I present this. And as Mark implied, we think there are some issues there with the data quality, since our frame of reference has really changed in Canada with regard to what counts as physical activity compared to what counts as physical activity in European countries.

The much more important thing is that when we look within our Canadian children, as shown in figure 3, we see clear gradient relationships between the amount of physical activity that youth have and their likelihood of being obese. So the bar on the far left represents the most inactive children, and the bar on the far right represents the most active youth. And we can see that as children get more active, the likelihood of obesity goes down. I can tell you as an epidemiologist, when I see risk gradients that are this strong, I'm doing cartwheels in my hallway. These are very, very strong risk estimates. When we look at the nutrition variables, they don't come out as being strong predictors of obesity in this particular group of individuals. So what that's suggesting to us is that we really need to be focusing on the physical activity side of the obesity problem a little bit more than the nutrition side.

I'm going to skip my next slide--because Cora has already spoken about many of these factors--and move into the question of how sedentary we are. We have some really good data in the HBSC, based on our asking the children how many hours they spend in front of the TV and in front of the computer in their free time. This does not include homework time. The Canadian Pediatric Society is recommending that our youth spend less than two hours in front of the screen. Less than one in five children in Canada meet those guidelines.

The average adolescent in Canada spends almost 35 hours a week in front of the computer or TV in their free time. That's almost a full-time job. If you calculate that out for the year, they spend more time in front of the screen than they do in the classroom over the course of the year.

Clearly, there is time to be active. There's lots of time. That is further supported by the observation that if you actually look at the relationship between how much time children spend in front of the screen and how much activity they do, they're not related very strongly at all. So there's lots of time, even for the active children, to sit in front of the screen.

That leads me into another point where, when we are talking about decreasing screen time, it's easy to tell your kids to turn the TV off, to get away from the TV, to get away from the computer. But what will happen if parents do that is most likely the child's going to move to another sedentary behaviour. The randomized control trial data clearly show that you actually need to not only reduce the TV watching, you need to be emphasizing that it be replaced with active behaviours.

I am now going to switch over to figure 4. The reason I want to show this figure is to bring to light the issue that not all sedentary behaviours are the same. In terms of obesity, television viewing seems to be the biggest predictor of obesity in the sedentary behaviours. This is showing that, as you go from those who watch the least amount of television to those who watch the greatest amount of television, the likelihood of being obese goes up twofold.

The additional point I want to raise here is that these effects are independent of how much physical activity the children are doing. In other words, if you took two children or youth and matched them in terms of how much physical activity they're doing and they're doing the same amount, the child who is watching the most television is more likely to be obese than the child who is watching lesser amounts of television. So there seems to be independent effects of physical activity and television viewing on obesity.

The last research point that I want to bring to your attention is shown in figure 5. The reason I want to bring this to your attention is that when we are talking about obesity, quite often we get really focused in on weight, and that's our outcome. We're worried about the weight, not actually worried as much about the behaviours as we are about the outcome. For obesity that's a very bad thing.

The reason I say that is because when we look within obese individuals, there are clear differences in health, depending on how physically active they are. You can be fit and fat. It is possible. So if you look at figure 5, that is an example of obese girls. Again, these are all obese individuals, graded according to physical activity participation, and as you go from low to high, the number of psychological health problems that these girls had went down in a clear pattern.

Again, we need to get the message across that it's not only body weight; it is the behaviours themselves that contribute to body-weight issues. They have impacts independent of any effects on body weight.

I am going to finish off. Really, this is a plea for help. We've really learned a lot in recent years in the obesity community. When I go to the United States and I talk to my American colleagues, they are amazed at what we have done in Canada, given the size of our country and the size of our research community. But there are more unanswered questions than there are answered questions at the moment, and the quality of data that we have in our surveys in Canada compared to that of the Americans is embarrassing. Plain and simple, it's embarrassing.

There are many more questions. I've only given three examples on that sheet, but there are many more questions and we do need more research money and support.

Thanks for your attention.

[The Chair, Conservative, Rob Merrifield]

Thank you very much. We certainly appreciate that. It is very interesting data and I'm sure we have equally piercing questions on this matter. We will start with that right now.

Dr. Carolyn Bennett, you have ten minutes.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Thanks very much.

In terms of the evidence and the data, it's obviously your preoccupation and concern that we still don't have the kind of data we need in order to be able, as Cora said, to prove what works and what doesn't work in terms of motivating and whether, again, we're sort of cutting down trees and producing tons of pamphlets that don't actually change behaviour. How would you suggest we would work, in terms of a strategy?

The second part of my question would be that in bringing back ParticipAction, is there evidence in the groups we're really worried about, particularly those children in poverty, that programs like ParticipAction work for those kids?

[Cora Craig]

Perhaps I could try to address that.

ParticipAction is internationally recognized as one of the most successful campaigns ever in the world. One of the reasons for that is even though they haven't run a campaign in the media, through television buys, for example, since the mid-1990s, the recognition of the ParticipAction name exceeds about 80% still. It's in the 85% range. That alone is unheard of, except in tobacco campaigns around the world. Other countries are frankly very jealous and would love to get that kind of recognition, but we haven't really had a strong campaign in a long time.

Social marketing campaigns require a long time to go through building awareness--and I think there is awareness of the obesity issue--but awareness of things that can be changed, both at the societal level and what individual parents and children can do. We need that as a backdrop to our activities.

The VERB campaign in the U.S. was successful in raising awareness. It had just started, in fact, to produce some behavioural outcomes related to that. It was a ParticipAction-like campaign, coupled with community support, and that's the key ingredient. You can't have just one thing work. You have to couple it with community support.

[Dr. Mark Tremblay]

I would echo that. The brand recognition for ParticipAction accelerates the whole process enormously. It has not only brand recognition but positive associations with that brand recognition, so it's legitimate. Whether it should be or not, it is, in the minds of Canadians.

As I said at the start of my presentation, I think there are some non-traditional messages--education--we need to get to parents that it's very subtle things throughout the day, in addition to swimming lessons and quality physical education, that need to be done in order to get us back to the amount of movement that we did throughout most of our existence. That's really important.

I think it's also really important not to isolate on one thing. ParticipAction alone, in the absence of better surveillance, better quality research, enhanced physical education in the schools, increased investment in community infrastructure to promote physical activity, friendly communities, and so forth, won't do it. It didn't do it with any of the other major public health issues and this is a very complex one.

We need to come at it from several angles and bombard it. It's going to take a massive effort. Resurrecting ParticipAction, giving them a budget for three years, and saying it showed some activity and should solve the problem clearly won't do it. A combination with a number of other things that have the potential to increase the health of kids and also deal with a number of other social issues as well is what's required in my view.

[Cora Craig]

Perhaps I could add to my earlier comment about not having an obesity campaign, particularly in social marketing. That was so we don't create a “blaming the victim” situation, because I really see this as a societal issue. As Mark was saying, many things have to work together to create change. It should be diet or physical activity, but particularly from the evidence, I'm in agreement with my colleagues here that it should be a physical activity campaign.

[Dr. Ian Janssen]

You mentioned the words “behaviour change” in your question as well, and that's part of the reason why it's going to require so much work and effort. If you look at individuals and behaviour change models, you can fall on a spectrum of behaviour change, in which you have people at one end who aren't even thinking about it and people at the other end who are doing it and have been doing it for years. The strategies and the marketing campaigns you would use are completely different, depending on where the individuals fall on that spectrum, so it makes it a very complex issue. For something like ParticipAction, where you're just trying to get people active, the strategies are different from those you'd use on people who are active.

[Carolyn Bennett, Liberal, St. Paul's, ON]

On the evidence base of changing behaviour, I understand the spectrum being from you're not even aware that this is an important thing to actually doing things that work. With respect to things like Saskatoon in Motion and the places where the community has mobilized around things, in terms of the bottom-up and top-down approach, do we have data that Saskatoon is now way better than other parts of Canada?

How do you find best practices across the country and get other communities to model themselves in terms of what actually works, as opposed to what makes politicians feel good about having done something?

[Dr. Mark Tremblay]

I was the dean of kinesiology in Saskatoon when Saskatoon in Motion--now Saskatchewan in Motion and Manitoba in Motion--came to be.

There are certainly best practices in terms of mobilizing community and making things happen, building capacity within the community. Childhood obesity in Saskatchewan is significantly greater than in Canada as an average right now, after Saskatchewan and Saskatoon in motion have been in place for several years. Activity levels are lower in Saskatchewan than the Canadian average.

It certainly hasn't solved the problem. How much worse it would be in the absence of that is the difficulty. This is the same as the assessment of ParticipAction: ParticipAction was here for 30 years, and obesity rates climbed through those 30 years; therefore ParticipAction was no good at all.

Well, yes, but you know computers entered our lives during that time, and screens invaded our homes, and buses replaced bicycles, and so on. Was ParticipAction supposed to stop all of that from happening? So how much worse it would be is difficult to know.

It's also worth mentioning that Saskatoon in Motion started with an investment from the Saskatoon Health District, which stepped to the table after groups, year after year--we've been part of them, and I'm sure my colleagues have been--came together saying we need to do something--health, education, community, usually the groups together--then they all ran away, saying “It's not us who should lead it.” No one's going to come to the table with a cheque.

What was unique there in Saskatoon is that Saskatoon District Health came with a cheque and said, “We need to do something and we're going to start paying for it.” And then everyone came in and said, “Well, actually we can contribute to it, too”, instead of the typical scattering of everyone as soon as resources are required.

They were fairly modest resources that snowballed, just like with ParticipAction. The amount of air time they could leverage from the media, the number of things they could leverage from industry and so on was huge, and continues to be. It's certainly a best practice that's out there, and we need to build on things like that. It's happening naturally, actually.

Saskatoon in Motion became Saskatchewan in Motion. It's now migrated to Manitoba. I know other provinces are in discussions with them as well.

It also doesn't happen instantly. This is relationship development that occurs at a much more intimate level than they are typically working at. It takes some time to do that. We're starting to see the benefits of that in Saskatchewan now.

[Cora Craig]

Also, when you look at Saskatoon in Motion, you'll see it followed the principles of what has been shown to work. There is evidence that community-wide activities and campaigns work for adults.

We have less for children, but they followed the same principles. It involved multiple sectors. It was multiple levels. They involved community change processes, including policies and environmental change strategies. So it has the right mix, if you like, and it's very important, therefore, that we are evaluating and monitoring them in a way that we can show whether or not they work.

In the same vein, we do have a monitoring system that can show change in communication campaigns and detect difference through our agency.

I think we're at a point in Canada where the monitoring systems are being piloted and are ready to go. There's the Canadian health measures survey that will be up. It will be able to detect changes in levels of activity of children and obesity levels over time.

There are other means for objective measures, including our own.

[The Chair, Conservative, Rob Merrifield]

Thank you very much.

Madame Demers, you have five minutes.

[Nicole Demers, Bloc, Laval, QC]

Thank you, Mr. Chairman.

Thank you for being with us today. I'm fascinated by what you've told us. I am aware there is a problem. I myself am obese. I realize that this is a much more complex issue and that it has much deeper roots than we are aware of. I am a mother and grandmother. Eating habits and recreational activity have changed enormously over the last 30 years, but at the same time, I think we're mistaken if we don't acknowledge that we're dealing with an obesity problem. If we don't do that, we will not go to the root of the problem. We tend to think we shouldn't victimize people who are affected by this or use the word “obesity”, but if we don't tell the truth, we will never solve the real problem.

We began to resolve the problem posed by smoking when we dared to actually say that it was dangerous, that it was harmful to a person's health and that it could cause cancer. But that didn't happen immediately; it took years. We began to resolve the problem once we were prepared to face it head on. But we refuse to face up to the problem of obesity by constantly going around it, thinking that with campaigns like ParticipACTION and others, we will ensure that young people don't experience this problem that we ourselves caused. Rather than giving them love and attention, we gave them food, or money to go and eat at McDonald's or buy a big bag of popcorn at the movies.

If we're not honest, and if we're not frank with our own children and with the parents, the problem will never go away. I think the first awareness campaign should be aimed at parents, to inform them of the repercussions and negative effects of obesity on their children. Our children will die younger than us if we don't put a stop to the problem immediately.

Personally, I've always been very active. I am a large woman in good physical condition, but I still have problems. If I'm not careful, my children will have serious health issues that could be very costly for our health care system.

That is my own view, and I would be interested in hearing what you think.

[Cora Craig]

I'm not saying that obesity isn't a problem. It is a huge problem, and I think we tell parents and educate parents about it. But my comments were solely around mass communications--ParticipAction-like campaigns that are 30 seconds long--that I'm concerned stigmatize children who are overweight.

We need to do all those other public education things and maybe have an awareness campaign targeted at parents as well, but have campaigns that use children's images and are targeted differently for children. It's a very complex messaging issue and there are multiple messages that need to go out, but in the ones targeted to children I just want to be careful that we don't stigmatize them.

Clearly we need to have physicians involved, for example, to talk with parents, and there's a very strong role there for education. We have to use our school system to educate children about diet, physical activity, and obesity. It's the popular images that I am concerned about.

[Dr. Ian Janssen]

Thank you for your comments. They are well taken. I'm all for calling a spade a spade. It's clearly a problem.

I'll echo Cora's comments that we need to be careful with the children, more so than with the adults. I have done some research, and children who are obese are more likely to be bullied than children who are not obese. That's one of the problems with obesity.

There have been some studies done where they have shown pictures of children with different physical disabilities--obesity, maybe they're missing a limb, they have scars on their faces, or they're in wheelchairs. They ask children, “Which one of these individuals do you not want to play with?” They always pick the obese child. That's what I'm afraid of.

I want to call it what it is, but I'm afraid that the person who is obese is going to get caught in that cycle. They're not going to have friends, they're going to be stigmatized, and they're not going to be able to join in the physical activity that the other children are doing.

[Dr. Mark Tremblay]

I think you raise a good point. Much research, and recently by the Canadian Medical Association, shows this disconnect between perception and reality: the problem is down the street, but it's not in my house; it's not with my kids. That's a problem to get, because parents are a key player here, and if parents don't think there's a problem; if parents think, “Well, my kid's chubby but he'll grow out of it”, or “My kids are active all the time”; if their frame of reference is incorrect and they don't think it's a problem, they're not likely to intervene with any parental change that's likely to correct a problem. It's very delicate, but I think it's very important.

[The Chair, Conservative, Rob Merrifield]

Thank you very much.

Mr. Fletcher, you have five minutes.

[Steven Fletcher, Conservative, Charleswood—St. James—Assiniboia, MB]

Thank you, Mr. Chair.

First of all, I'd like to thank the panellists for their presentation. I can say that this government and the health minister and the Prime Minister are committed to taking a leadership role in public health. You've alluded to some of our initiatives, with the tax credit and the portion of money that's been spent on physical sporting activities out of the health budget.

I want to just ask two questions. The first one is pretty fundamental, but I think important. It is this: is all obesity preventable?

[Dr. Mark Tremblay]

Most is. There are some disorders that are rare that have strange clinical implications and so on. But the dramatic secular change we've seen is not related to fundamental genetic mutations or increases in Prader-Willi syndrome or some of these problems.

[Steven Fletcher, Conservative, Charleswood—St. James—Assiniboia, MB]

The other thing that was in our platform, and something this government is very concerned about, is mental health. I think you've talked about it sort of tangentially, but I want to give you an opportunity to talk about it directly. If not all obesity is preventable, and if we're too aggressive with this campaign.... You talked about causing stigma, but there may be only so far some kids can go as far as obesity or being overweight is concerned. I wonder how we can ensure that we prevent as much of being overweight or obese among children as possible, but without creating a mental health kind of public health problem.

I wonder whether you could address that and maybe give this committee some suggestions on what you would like us to have in our final report to help deal with that challenge.

[Dr. Ian Janssen]

There are some clinicians in the United States who do surveys with their obese patients and ask: “What do you want to be called? Do you want to be called 'obese'; do you want to be called 'fat'; do you want to be called 'overweight'; do you want to say that you 'have a weight problem'?”

Never do they pick “obesity”; never do they pick the word “fat.” It's always “weight issues”; “weight problems”—things that address the issue but are not as derogatory. I think that's the way we can maybe tackle it in the media campaigns and with our promotions as well.