Health Committee on Oct. 3rd, 2006

[Christiane Gagnon, Bloc, Québec, QC]

Thank you for your presentations and for providing details on obesity among aboriginal peoples. It was very informative. We take note of the problem. I believe you have a very good grasp of what is happening in each of these communities.

We are not sure what needs to be done exactly in order to take care of each community. You have not really proposed a direction for the government to take nor suggested a particular type of leadership. You speak of a global plan but it is not clear to me how the government can play a proactive role to better support you.

The problems have been clearly identified. Some programs lack longitudinal studies but what do we need to do? Until now, you have not seemed concerned by existing program issues.

Do you want the government to play a proactive role in implementing certain programs to address the problem of obesity among Aboriginals? I wonder if someone can speak to this issue. Ms. Lafontaine seems to be saying that the government should have a global plan and that more numbers are required. I would like someone to clarify this a little. You need to provide clearer ideas on what the global plan should be along with your presentation of the report.

[Mark Buell, Manager, Policy and Communications, National Aboriginal Health Organization]

I'll bring it back to an earlier statement that was made, which was about the lack of data. The data exists; you're right, there is a lot of research out there. What there isn't is comparable indicators nationally on things like diabetes and obesity. The Inuit provide a very good example. The National Diabetes Surveillance System collects data on diabetes rates for Inuit in the Northwest Territories and in Nunavut. Santé Quebec collects the data in Nunavik. In Labrador Nunatsiavut nothing is collected, so we don't know. We don't know what's going on within Inuit communities from east to west to know whether or not certain interventions are working.

The other thing is, yes, there are programs that exist and have been going for years. However, we need to have those programs evaluated. We need to evaluate the existing public health interventions that are related to diet and physical activity to know whether or not those would be promising practices that can be replicated in other communities across the country.

The other thing we need to keep in mind, if you want a specific recommendation from me, is that a one-size-fits-all solution isn't going to work. There is a strong need to have community-driven solutions that address.... We're talking about a million aboriginal people in Canada. There are 600 first nations. There are 52 Inuit communities, and there are one million individuals. Each community is different, and what works in one community may not work in another. So any programs, policies, or services that are developed need to be flexible enough to allow for community variability so that communities know they can do what works. And we need stable funding to ensure that happens.

[Valerie Gideon, Senior Director, Health and Social Secretariat, Assembly of First Nations]

You have asked why we are not offering detailed definitions of the components in a holistic approach. Our document provides a framework that contains fundamental components. The framework is based on an evaluation of programs that have been the most successful in our communities.

It must be recognized that, at the community level, there are currently many administrative obstacles related to program management. There is a diabetes program, the Aboriginal Head Start Program, etc. There is little flexibility allowing for the transfer of resources, the identification of priorities or the determination of the need for recruiting additional skilled personnel. We don’t necessarily have the resources to accomplish these tasks. The bureaucratic system currently imposes many limits.

When provinces receive transfers to finance health programs, they do not face the same bureaucratic constraints we do. We must comply with a myriad of details and definitions, program by program, and produce reports for the government which take much time and restrict our ability to implement such a holistic approach. That is one of the recommendations we made when we met with the First Ministers. Governments want sufficient transfers, with a reasonable rate of growth, every year. We also want the required flexibility to identify our priorities and the strategies that will work in our communities. As Mark was saying, “one-size-fits-all” solutions don’t work.

In fact, we should be able to adopt a public health approach that is in better harmony with recommendations made by international organizations since the 1970s.

Our document shows that there are links with housing and education but our budgets are not flexible enough for all sectors to really work hand in hand. Communities are structured like the federal government and we know that doesn’t work. There is no communication between sectors. It would therefore be very important to recognize that fact and to facilitate a holistic approach. Of course, we must not be too rigid otherwise we will find ourselves in the same situation as we are now, i.e. being forced to dedicate our resources to one or two components of a program, in which case nothing would get done.

[The Chair, Conservative, Rob Merrifield]

I'm sorry, the time is gone. Thank you.

Mr. Fletcher.

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

Thank you, Mr. Chair,

Thank you, everyone, for your presentations.

I'm going to try to think outside the box, or outside our borders, for a moment and ask a question. What is done in other jurisdictions, such as Australia, New Zealand, and United States—and also in the case of the Inuit in Greenland and Alaska—to deal with this issue? I also understand that there are isolated, non-European populations in Siberia that may share some of the challenges we have in Canada. Also, there are populations in northern Scandinavia.

Can anyone on the panel comment on things they've done right or wrong in this area, or things we should include in our reports that would encompass what is known outside of Canada on this issue?

[Dr. Noreen Willows]

I can try to answer this and perhaps answer some of the questions that were raised by other members.

It's very difficult to give explicit examples to resolve this problem. As Dr. Cargo said, there have been reviews of studies of interventions in other populations in the United States that tried to reduce the prevalence of obesity in children. The majority of those have failed, if you look at modifying a child's body weight. They may have increased the knowledge, awareness, or self-efficacy that a child could make a change to improve diet or activity, but in general the results say that most interventions have not been effective, in terms of reducing the prevalence of obesity. It's an incredibly complex problem. We live in a society that makes it very easy to eat energy-dense foods and not move very much.

However, in Canada we have published examples of community-based diabetes prevention projects in first nations communities. Discussed here today was the Kahnawake school diabetes prevention project. In northern Ontario, there is also the Sandy Lake first nation school diabetes prevention program, and as Dr.Cargo mentioned, in the United States there was a National Institutes of Health study called “Pathways”.

What is clear from the publications on these interventions in first nations communities is that interventions cannot be focused solely on the individual. That's one of the major messages.

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

Do you have any comment on the international experience?

[Dr. Noreen Willows]

Well, there is the United States, if you consider that international. There are some projects in Australia with Australian Aborigines, but I'm not aware of the outcomes of those.

But what is clear is that interventions need to be participatory. That is, the communities have to be involved in the development of the form of the intervention. It may be frustrating, but nobody knows the solution to this problem yet.

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

Health Canada, have we been in contact with any of our international friends?

[Kathy Langlois, Director General, Community Programs Directorate, First Nations and Inuit Health Branch, Department of Health]

The information I have in front of me is mostly related to diabetes in international examples. But the link to obesity is clear, because when you're looking at preventing diabetes, as my colleagues across the way have indicated, you're looking at healthy eating and physical activity.

Looking at what I have in front of me, if I look at Australia, it would appear that there is a national diabetes strategy in Australia. However, there's no specific strategy for aboriginal people in Australia.

In New Zealand, the Maori have an 8% rate of diabetes, compared with 3% among the non-Maori, so it's an issue there as well. There is a New Zealand health strategy and a Maori health strategy that does focus on diabetes. So there's perhaps something to be learned by delving into that more specifically.

Pathways, in the United States, was mentioned. I would note that American Indians and Alaska natives have the highest prevalence of type 2 diabetes in the world.

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

Is 8% much lower than our prevalence?

[Kathy Langlois]

Our prevalence rate--I think we're saying three to five times--is about 15%. Yes, it's probably lower among the Maori. There are many different factors at play with the Maori. There is much more integration with New Zealand society. The culture is much more accepted.

There are a lot of different issues when you look at determinants of health.

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

Sure. Thank you very much.

[The Chair, Conservative, Rob Merrifield]

Thank you very much.

Now we'll move to the NDP. We have Ms. Priddy for five minutes.

[Penny Priddy, NDP, Surrey North, BC]

Thank you very much.

It's interesting. I think it was something Treena said, which keeps coming up at these sessions, which was about the ability to share information. You talked about how the community shared information, and you looked at what was happening in other places. It seems to be a recurrent theme in these sessions, our need to have a place where people can go for central information so that somebody can see what you are doing in another province or in another territory. It seems to be a recurring theme.

This is my first question. When body composition was looked at, it was acknowledged--I think by Dr. Cargo--that it changed behaviour, but it did not particularly change body composition. Is the body composition tool being used the regular BMI, or is it a BMI or body composition tool that has been adjusted for Inuit and first nations people? Because we have had some discussions about whether the regular BMI is suitable for first nations and Inuit people.

Second, I think Chief Whitecloud said earlier, at the very beginning, that there had been an increase in money, but it appeared to not always be getting to the community. I guess I'd like to know a little bit about what that means. I could perhaps guess, but I would not wish to do that.

I think that will probably take up the rest of the time, so I'll stop.

[Dr. Margaret Cargo]

To answer your first question, in our study the BMI was not adjusted for first nations and Inuit peoples, and I have not actually seen that available yet.

It might be something that Peter Katzmarzyk is working on.

[The Chair, Conservative, Rob Merrifield]

On behalf of the committee, just while you're on that, was that program designed by the first nations or the Inuit people, or did it come from somewhere else?

[Dr. Margaret Cargo]

The school curriculum was originally adapted from the “Know Your Body” curriculum in the United States and was culturally adapted by people in the community.

[The Chair, Conservative, Rob Merrifield]

Okay.

Ms. Whitecloud, did you have an answer?

[Katherine Whitecloud]

I'll do the best I can. Perhaps many of you already have the information close at hand, also.

I believe the question you're asking me is with regard to the Canada health and social transfer that I referenced. That's the reason Statistics Canada comes and knocks on all our doors and encourages us to fill out the forms: it provides the basis for providing the Canada health and social transfer dollars.

First nations people are included in the statistics for the Canada health and social transfer, but it goes to the provinces. The provinces' stand, as you realize, is that first nations people are the responsibility of the federal government--first nations people on first nations' land. Therefore, even though our peoples' statistics on reserve are included in Canada's stats for the transfer of the Canada health and social transfer, those funds do not come to our communities to benefit us.

[The Chair, Conservative, Rob Merrifield]

You have time for a little one, if you want.

[Penny Priddy, NDP, Surrey North, BC]

Thank you.

Several people spoke to evaluation. Other than changes in the body mass index, what else are people specifically looking at in evaluation or in efficacy of the programs? I mean, is it self-esteem? Help me. In evaluation, although I know it's not about counting numbers, you have to look at something.

[Dr. Margaret Cargo]

If I look back to the studies that are included in the Cochrane Review, the psychosocial measures that are typically assessed are perceived self-efficacy for dietary practices and for physical activities, so they're behaviour-specific.

Other measures include mastery of the general control people perceive in their lives--that work is only starting to come out. Generally, in quotation marks, the “gold standard” for determining whether or not these studies are effective look at some measure of body composition or prevalence of overweight and obesity.

[Penny Priddy, NDP, Surrey North, BC]

Thank you.

The other evaluations you gave would be pretty hard to get from a five-year-old.

[Dr. Margaret Cargo]

Well, you can't ask a certain--