Health Committee on Oct. 19th, 2006

[The Chair, Conservative, Rob Merrifield]

I call the meeting to order.

Could we have members take their seats and we'll get on with the presentations.

This is the seventh meeting of the childhood obesity study.

We want to thank the presenters for being here. We actually have two panels today and we are looking forward to each of your presentations as well as the questioning.

I will start by introducing the Canadian Medical Association. We have Dr. Colin McMillan. Thank you for coming. He's accompanied by the secretary general and chief executive officer, Mr. Bill Tholl. Thank you for being here as well.

From the Canadian Paediatric Society, we have Dr. Claire LeBlanc. It's good to have you here, as well as Marie Davis. Thank you for being here as well.

We'll start right with the presentations, and first up is the Canadian Medical Association. Dr. McMillan, the floor is yours.

[Dr. Colin McMillan, President, Canadian Medical Association]

Thank you, Mr. Chair.

Ladies and gentlemen, thank you for hearing us today. It's a pleasure to join our colleagues from the Canadian Paediatric Society to make this presentation on this vital area of public health concern.

I am a full-time practising physician from Atlantic Canada. I deal mainly in the area of adult cardiology, but I see a lot of pediatric patients who graduate to the adult population. I am also the proud father of five children, so I have a great concern over your issues about your policies, your constituents, and our patients.

I'm also joined by our chief executive officer and secretary general, Mr. William Tholl. Both he and I look forward, with our colleagues, to the dialogue today.

The general thrust of our message is going to be threefold. First of all, all of us feel we can do better for our Canadian children. Secondly, when it comes to the health of our children, we feel government must use every policy lever at its disposal. Thirdly, the area of your study—the combination of nutrition and exercise—really presents a public health challenge almost analogous to the challenge of tobacco use, and I think it has to be dealt with just as vigorously.

Since the facts of the situation are known to you, have probably been presented by others, and you'll be hearing more of them, I'm going to the area of trying to deal with perhaps some ideas and recommendations that you might consider in the context of the federal government role. We feel a joint strategy on healthy eating and physical activity must focus both on adults and children, since the factors that have created the epidemic are society-wide. We feel a comprehensive strategy is needed to combat the epidemic of obesity that threatens our nation. This requires actions at all levels of government and involvement and participation at all levels of stakeholder. We think the federal government has potentially three distinct policy levers it can use to address this problem: economic policy; communication policy; and regulatory policy, alone or in conjunction with other levels of government and society.

In relation to economic factors, we think we could follow the lead of other countries and some of the provinces that are looking at fiscal measures to promote the availability of and access to healthy food. Addressing childhood obesity requires that we take steps to encourage Canadian families to incorporate healthy eating and physical activity into their daily lives.

This does not always come cheaply. We all know that in some parts of our country, fresh food may not be available or may be priced out of people's reach. Yet you can be sure that high-calorie, nutrient-poor junk food is available everywhere for well below cost and is prominently displayed at fast food restaurants and convenience stores.

We could also follow the lead of other nations that use taxes to influence food consumption, or countries that use public funds and subsidies to promote access to recreational and sporting facilities in underserviced communities.

There is clearly no simple answer. There is not a simple drive-through option. In fact, we feel our country must examine all options.

Recently, we participated in a government forum on using selective tax credits to promote or provide an incentive for physical activity. We suggested three themes in that context. One was that tax credits for physical activity should be broad in scope and not limited to organized sports alone. Tax credits should target community-based programs that promote physical fitness in at least one of the three activity groups of Canada's physical activity guide, namely endurance, flexibility, and strength. And thirdly, the tax credits could be targeted and tailored to those most at risk. A tax credit for physical activity is but one example of an economic policy that, in the case of an incentive-based program, could address this problem.

We also think governments need to use tax incentives to remove barriers and to promote access to healthier foods. In targeting the use of incentives to remove barriers to healthy food and physical activity, tax disincentives—the flip side of the incentive coin—shouldn't be overlooked.

Using tax disincentives to encourage healthy eating is not a new or extreme concept. In fact, none other than the World Health Organization first proposed three years ago that nations tax junk food to encourage people to make healthier food choices. The American Medical Association is about to demand that the federal government levy health taxes on America's soft drink industry. The Clinton Foundation in the United States has convinced some of the junk food industry to examine their policy and distribution in school-related foods. At least eighteen of the United States have some form of snack food tax in place, and five have proposed policy and legislative recommendations.

Here at home, the governments of both British Columbia and Quebec have expressed recent interest in some form of junk food tax, and I am reliably informed that at least one additional province, possibly Manitoba, has that under consideration as well.

Yet even as these measures are proven effective by falling smoking rates, critics of these measures continue from the sidelines to call this social engineering. We do not consider this a valid argument. Canada has become, in part through government effort, a leader in tobacco control, and it is past time we show the same leadership in the future when it comes to controlling obesity, particularly childhood obesity.

In the area of communications, federal policy levers could be used to combat obesity through regulatory policies. The average North American child is inundated with food advertisements, and our colleagues appearing with us today have estimated that approximately 95% of these advertisements are in the area of junk food. Simply said, billions of dollars are expended each year on junk food advertising specifically directed at children.

Recently, researchers south of the border have concluded that fast food ads on television contribute significantly to this epidemic. They've also estimated that a total ban on fast food television advertising could cut the number of overweight children by at least 10% in the age range of three to eleven, and possibly higher in the age range of twelve to eighteen.

Countries such as Sweden have long banned fast food advertising aimed at children and have a much lower level of childhood obesity. The province of Quebec has similar prohibitions, with similar results. This is another area where we could simply do better.

We would also call upon the federal government to restore funding for public campaigns that encourage Canadians to be active and promote a healthy lifestyle. Public education can be a central element in any comprehensive strategy.

The third area I would like to touch on briefly is how the federal government can put in front of Canadians the information they need to fight obesity. I'm talking about the need for the federal government to consider use of its regulatory authority under the Food and Drugs Act to require appropriate labelling--and I gather that you will hear of this later. An educated consumer is simply one of our best defences against childhood obesity, yet Canadians don't always have the necessary information to make informed choices.

Health Canada has recently improved product labelling requirements, but so far, many Canadians are still exposed to potentially misleading nutritional information, particularly in advertisements and promotional material. Health claims made for food should be strictly regulated to ensure that they are based on the best scientific evidence and are actively communicated to consumers.

Food advertisements could be pre-cleared before airing in the media, and the provisions against deceptive advertising in the Food and Drugs Act could be strengthened. Brand-specific advertising is a less than optimal way of providing health information to consumers, and we owe it to Canadians who are seeking quality, objective scientific information about healthy eating to provide them with this valuable information.

Labelling is another area where we can do better. We need more programs where health professionals, industries, and government work together in the interest of informing and educating consumers.

In conclusion, in this area, I want to stress that when it comes to the health of our children, both in nutrition and exercise, the government should use every policy lever at its disposal with the same vigour that it has done in relation to the tobacco issue.

Governments have a critical role to play in helping their citizens make healthy choices. First, all levels of government, in cooperation with other stakeholders, must develop, implement, and maintain a broad, comprehensive approach. One-off policies don't work. Secondly, as I've outlined, governments have policy levers at their disposal, and they should be bold enough to show leadership and use them. And finally, the education of our population and denormalization of unhealthy behaviour is the key. The more our citizens know, the more they are empowered to make intelligent decisions.

I'd also conclude with some observations about health stakeholders and our need to do our part. We as an organization are working with our health partners, our colleagues with us, in preparing a health summit on the issue of childhood obesity and child health in the areas of risk. We have recommended changes to the medical school curriculum to address this important subject.

At the ground level, physicians continue to build networks with other health care providers, educators, and patients, so that they are referred to the services most appropriate to their needs.

Finally, I would be remiss if I didn't point out the unique challenges faced by our aboriginal populations. Over 60% of aboriginal children are considered overweight or obese. Any effort to combat childhood obesity, particularly by the federal government, must take this into consideration as an urgent need. We have been requested to meet with aboriginal leaders on this topic and plan to do so in the near future.

In closing, I would emphasize that this summer at our annual meeting we discussed the health of our children as a major priority. In the short time I have been president, more than 50% of the media requests, particularly but not exclusively in Quebec, have come to us in this area, much more than on the private-public question or some of the other areas we're addressing.

We congratulate the committee for undertaking this study and for looking at ways of doing better for our Canadian children.

Thank you.

[The Chair, Conservative, Rob Merrifield]

Thank you. You are to be applauded. Doctors right across this country are taking on this initiative. We thank you for the work you're doing.

We look forward to the day when you will prescribe food and activity, a grocery store and a gym, rather than medicine from a drug store. But we'll leave that for the questioning. Thank you for your presentation.

We will now move on to the Canadian Paediatric Society. Dr. Clare LeBlanc, the floor is yours.

[Dr. Claire LeBlanc, Committee Chair, Healthy Active Living Committee, Canadian Paediatric Society]

Thank you very much.

On behalf of the Canadian Paediatric Society, I really want to applaud all of you for being here today to take the opportunity to listen to me, a pediatrician; my society, which acts on behalf of children; and my colleagues at the Canadian Medical Association. Together we are really trying to do something to impact the health and well-being of children in Canada.

I don't have to tell you, because you already know, that we have an epidemic of childhood obesity in Canada. This is not unique to Canada and is occurring worldwide, but I believe that Canada is unique in that it has an opportunity to be a leader in this field, to really make a difference at a national level.

This can be accomplished here in Canada before it can ever be accomplished in other countries because we have very good leadership at all levels. So hear me out as I speak to you as a pediatrician on behalf of children and the pediatricians I represent all over Canada about why I think this is an issue and why we really need to do something together.

We know that children are more obese and overweight now than they used to be over 25 years ago. The statistics show that it used to be 15%; now it's 26% or so. We know that there are some children in Canada who are suffering more than others. They seem to be children who have lower socio-economic status, are in aboriginal or native-Canadian populations, and are landed immigrants who have been here for at least 10 years or so. As we strike to make a difference in the lives of our children in the future, we have to make sure all children are reached.

Why are kids overweight and obese? I wish we had one single answer for that. It appears that there is contribution from the intake of inappropriate high-caloric-dense foods--too much soda pop, too many sugar-containing juices, etc.--and not enough infant breastfeeding, but it's beyond that as well. Children have become used to being less active. There are tons and tons of opportunities in Canada and worldwide for children to make their thumbs very active, but not their physical selves. Children have opportunities to watch television and play video games, and they're not active.

I can tell you anecdotally that I had a parent come to me and say, “What do I do? Janey and Johnny are fighting over the Nintendo machine.” I was a little bit alarmed when they said they had found a resolution by buying two machines rather than limiting the amount of time on it and sharing. So we have to bear in mind that parents have an opportunity to be good educators and good role models for their children, not just in healthy nutrition but also in sedentary activities, because we know that kids are not as active as they used to be.

We know that children tend to be less active as they get older, and girls are less active than boys. Not only are they less active in terms of minutes, but they're less active in terms of intensity of activity, and they begin to be less active much earlier than boys. So whatever we decide on as a group to definitely attack this problem, we have to make sure we reach all genders and age groups in terms of activity, sedentary activity, and appropriate nutrition.

When I was in training I had never heard of type 2 diabetes, except as what you'd expect adults to get, but now I'm seeing this in my own office. I'm seeing it in kids in the tween age group, and I'm having to counsel parents with children who are three, four, and five years of age who are starting to show signs of developing the kinds of diseases we used to say only happened to adults. If you can imagine that our children are doing that now, what are they going to be like when they reach adulthood? Is it true that our own children will not live as long as us? Can we afford to let that happen?

We used to say that as physicians the most important thing was to make sure we taught parents and children to adopt healthy lifestyles, eat the right foods, be active, and not smoke. But that doesn't seem to be enough. This problem is far beyond what I can do as a physician. I'm trying. I'm trying really hard, and I can tell you that as a member of the Canadian Paediatric Society we have developed initiatives to help physicians in their offices counsel parents and families on how they can adopt healthy lifestyles.

We have also developed a network of champions across Canada, pediatricians and family physicians who are working with us to develop strategies in the office setting to help families out.

We are also working with hospitals to make hospitals healthier places to work, and healthier places for patients to be admitted, because right now we're part of the problem too.

So whatever strategy we create, whatever we do as a group, we need to be crossing all aspects of society. This is not something that is just something a physician can do. It's way beyond that. We need to attack it at the federal level with terrific leadership, which we know we have, at the provincial level, at the municipal level, and indeed well beyond that in the communities, to the families, to the physicians, to the community leaders, so that we're embracing this and changing our current obesigenic environment to one that is healthy, active, and promoting healthy lifestyles.

I think there are a number of areas that need to be addressed when we talk about changing an obesigenic environment. I wish to tell you today that I had a pill--I wish not to call it a pill--that would fix this problem, by golly it's gone and, wow, nobody has to worry about this any more. And sometimes parents come in asking for that.

Do you know what? There is no such pill. There is no quick solution. And the solution is not one answer; it's a myriad of answers. We really have to take this as a policy that's going to encompass many different strategies.

I absolutely applaud my colleagues at the CMA because they address the needs of all the Canadian population from cradle to grave. We, as pediatricians, obviously have a specific place in our heart for children, infants, and youth. I think it's extremely important that as we create strategies to make a difference for all Canadians, whatever strategies we come up with, whatever we decide to do, we make sure that children's issues are taken as a very important step. Many of the strategies to combat obesity in Canada are secondary obesity-related strategies. Once the adult becomes overweight and obese and is struck with type 2 diabetes, or hypertension and what have you, you are basically using health dollars to get those individuals well. What we have to do is attack the problem before it starts. Prevention is key.

From our perspective, we believe it's important for the federal government to ensure that children and youth have a special focus in the implementation of a national pan-Canadian health strategy. And I would encourage as well that information come from youth themselves. They have a lot to say, and it is in fact them who we are talking for. Should we be? Shouldn't they be at the table? I think so.

We need to make sure we provide funding for municipalities to promote healthy, active living through local programming, especially for children and youth. We should reinstate a federal physical activity contribution program to allow the voluntary sector to help Canadians integrate physical activity into their daily lives. And we should continue funding research that will allow us to identify the issues and treat this problem, and especially prevention strategies that begin in infancy and youth.

We do need to make sure that the national recommendations through the physical activity guide for children and youth in terms of physical activity itself and of course Canada's food guides are widely disseminated and made available to those who require them.

We need to improve accountability from advertisers who are targeting children. Remember that most of the commercials shown during children's programming are for fast foods, soft drinks, candy, etc., whereas only 4% are for healthy food choices.

And very importantly, we need to make sure that we identify and develop culturally based community-run programs, whether they be diabetes prevention or obesity prevention, for our first nations population, and bear in mind also our landed immigrants and what we have to do specifically to address that population.

We would like to encourage you to work with us to ensure our children and youth enjoy the benefits of healthy living. Our health care system will not sustain the burden of more than half a generation at risk for host diseases because of physical inactivity. It's time we looked at this as an ounce of prevention, because we really can't afford a pound of cure.

Thank you.

[The Chair, Conservative, Rob Merrifield]

Thank you very much for your presentations.

We'll now open it up for questioning, and we'll start with Dr. Carolyn Bennett.

You have five minutes.

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

Thanks very much.

Thank you very much for the great presentations.

I want to confess from the beginning that as a family doctor sometimes maybe I didn't comment on obesity because I was afraid of...an eating disorder. In young girls we went through that phase where we were afraid that we were going to tip somebody over into anorexia. I just want to know whether there has been any work on what our reaction as physicians has been to that.

The other piece I would love to know is whether there are countries where kids have been involved. I know we didn't do very well on tobacco until we let the kids write the ads themselves. Adults writing for kids doesn't seem to work. Kids for kids...and the idea of de-normalization and the target campaigns. The kids really did a spectacular job once they were given the tools to do it for themselves.

My third question is this. In the operating room it's not possible to confuse two different chemicals or IV solutions because they're in a different coloured bottle or they're a different shape, or whatever. I have always had trouble with the fact that the bottles for juices are the same, whether they're 100% sugar or 100% juice. Do you think you should be able to put things in the same jar when actually one is fruit juice and the other is just sugar? It's not really a medical question. It's just that the engineers took over in the O.R. so that we as physicians couldn't screw up by hooking up the wrong things together.

[Dr. Claire LeBlanc]

In terms of making an obese young girl or obese young boy turn into an anorexia nervosa...it's true that there certainly is a spectrum of research groups out there that are concerned about the possibility that obesity is part of a spectrum of eating disorders. I think that is a very small component of childhood obesity, probably somewhere along the lines of 1%.

I think what is extremely important to bring home is that when we promote healthy lifestyles, meaning appropriate nutrition and physical activity, this holds true for people who have anorexia or who are obese. In other words, the same message applies. As physicians, we are not asking children to go on diets. We know that's not successful anyway and it's not a healthy option. What we're looking at is having all children adopt healthy nutrition and physical activity.

In terms of youth involvement, I think you're right. We have seen it in different spectrums, where youth are very effective at communicating with their own group.

What I have seen anecdotally is physical activity opportunities in community-based settings, where actually the youth are leading the little ones and the youth are actually running programs for the little ones. The little ones are so impressed with the youth because they want to emulate them, and the youth have an opportunity to teach the little ones, who really have their attention.

I think it's a really wonderful opportunity to bring youth to the table, because I think they'll bring a whole different spectrum, and also a refreshing spectrum, to this particular issue.

[Marie Davis, Executive Director, Canadian Paediatric Society]

In terms of other countries that have involved youth, I don't know of any examples around physical activity, but I'd be happy to look for that and get back to the committee.

Certainly in the EU, those countries that have children's commissioners or child and youth commissioners have started to involve the youth and the children of those countries much more in the decision-making. I have just come from a meeting where Britain's children's commissioner presented. He spoke about the richness of the youth involvement and how they've been able to help Great Britain look at its national health goals and actually make them as appropriate as possible. But I will undertake to look more into that and get back to the committee.

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

Marie, just before the bottle question--

[The Chair, Conservative, Rob Merrifield]

Ms. Bennett, one more witness would like to comment. Then your time is pretty well gone.

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

Okay.

[William Tholl, Secretary General and Chief Executive Officer, Canadian Medical Association]

I'd like to comment with respect to labelling and how you tell juice from sugar.

This is not something the CMA has done, but it's from my old job at the Heart and Stroke Foundation of Canada. You'll note that when you go into a grocery store now, you see the health check symbol. One of the things the health check symbol does is it looks at claims like low fat when it doesn't necessarily equal low sugar. We did some market research indicating that when moms go down the grocery aisles, they want to see a health check on the food so that they can say no to the Froot Loops, no to the Cocoa Puffs, and say to their kids, “You can have anything with a check mark on it.”

My point is that you don't necessarily have to look to government regulation in all cases. You can also look to the not-for-profit sector to maybe help out in determining what's a sugar versus a pure juice alternative.

[The Chair, Conservative, Rob Merrifield]

Thank you.

Ms. Dhalla.

[Ruby Dhalla, Liberal, Brampton—Springdale, ON]

Thank you very much, Mr. Chair.

Thank you to all of our presenters as we study this important topic.

With regard to the pediatric association, I was just reading that there is also the International Journal of Pediatric Obesity, which outlines and perhaps points to the significance of obesity in children. By 2010, half of all the children and adolescents in North America will be overweight.

I don't know if you've had a chance to see it, but in the July issue of Maclean's magazine there was quite an interesting article, called “Fixing Generation XXL”. Among the innovations and entrepreneurial ideas, an individual has come up with a school out in California called the Academy of the Sierras. It charges $5,800 per child, per month, to encourage and promote good eating habits and also weight loss. In this article--perhaps the chair could distribute it--a number of children who have actually gone through the program are interviewed.

I don't know if you're familiar with the program, but if so, perhaps you would comment on it.

Touching on William's point, what do you think the role of government, the role of stakeholders, and the role of health care professionals should be in moving forward and addressing the issue of obesity? By the end of our study of this important topic, we're going to have to put together a series of recommendations. Perhaps you could provide some insight and your perspective on what that role should be, and also comment on this innovative idea of the school that's opened up at $5,800 a month.

[Dr. Claire LeBlanc]

First, we are aware of that program. I think you have to be cognizant that in any program that's tasked to deal with obesity in childhood--and probably the Sierras program is a little better than the most heavily touted research program, which has a success rate of about 45%--once the cat's out of the bag, it's very difficult to get the cat back in.

So I would still argue that primary prevention is the way to go, but you're right, since so many children and youth are affected, don't we need to do something about it? The particular Sierras situation is a very costly program, but they are very successful. One of the things we would like to see long term from that program is what happens when they go back into society. Is it a long-term solution or is this actually a quick fix? That's still not clear from a research perspective, in my estimation, from what I've been able to see.

I do think we're going to need to tackle both of these issues. It's just that, in my opinion and in the opinion of many other experts on this issue, primary prevention will go a lot further than trying to deal with it once it has happened.

[Dr. Colin McMillan]

I'd just complement that, Mr. Chair, by saying that our members tell us that families and children do listen to their family doctors and do listen to their pediatricians, and respect them. So our value added I think is really in the area of communication, not regulation and advertising.

[The Chair, Conservative, Rob Merrifield]

Thank you very much.

Madame Demers.

[Nicole Demers, Bloc, Laval, QC]

Thank you, Mr. Chairman.

Good afternoon. Thank you for coming and for giving us your views on childhood obesity. I also believe that it is a very important issue. I listened to your presentations very carefully.

Dr. McMillan, I would like to know if you are aware of the extended research work by Dr. Jean-Pierre Després. What do you think of his findings on obesity and childhood obesity? He believes that we must first diagnose the problem and then educate children and parents on how to count the calories taken in and the calories expended, what ithis represents, and so on?

Dr. LeBlanc, I have studied your documentation which is very well done.

If I eat a bran and carrot muffin and drink a glass of pure orange juice, I get 512 calories. Yet, it is supposed to be very healthy. However, I shall need one hour to spend those calories.

If we tell a child to eat healthy food and exercise, if he or she doesn't know what will be the final result, what's the point? The child must be informed and educated because otherwise he or she will tend to overestimate the number of calories spent through physical activity given that nowadays we do not move around much.

I would like to know your thoughts about this, Dr. McMillan and Dr. LeBlanc.

[Dr. Colin McMillan]

I'm not familiar with the specific research you mention. You do raise a broader issue, though, of the role of exercise in the broader public health.

I think there's a fair amount of literature on that, which indicates that rather than simply calorie expenditure, there are other mental and physical characteristics that are beneficial to people who exercise regularly. They tend to have fewer bad habits. They tend to have less osteoporosis. They tend to have fewer other things.

So it's only part of a comprehensive strategy, but we all know that the avoidance of obesity or a weight loss strategy that depends on exercise alone has certain limitations. With regard to the research, I think my colleague may know something that I don't.

[Nicole Demers, Bloc, Laval, QC]

Thank you.

[Dr. Claire LeBlanc]

When we talk about dealing with children with regard to the types of foods they eat and the activity they take part in, there's a lot of focus on wearing a pedometer and the number of steps a day and burning off a certain number of calories and not eating so many calories. I think I would be very concerned if we focused on specific calorie counts, or focused on specifically telling children how many steps to do a day.

I think the more important role we play as pediatricians is to encourage parents of infants and toddlers and young children to be eating healthy foods from the start, to be taking part in physical activity from the very beginning and to start doing things as a family. The family itself can go for walks. That doesn't cost any money at all. As the family starts to play together as a family, it's an opportunity for the child not only to be burning off calories but also to be bonding with the family.

So I would not want to focus so much on calorie counts and calorie burning, but rather on adopting healthy lifestyles.

[The Chair, Conservative, Rob Merrifield]

Thank you very much.

Mr. Fletcher, go ahead, please.

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

Thank you, Mr. Chair.

I really am keen to talk to you guys about trans fats, but it's dollars to doughnuts that my colleague Pat Martin will cover that topic in spades--trans-fat-free doughnuts, I hope.

I have a few questions. One is to Dr. McMillan. In the written presentation we have here, you said that products are available everywhere for little cost, but when you were speaking you said below cost. There is a slight difference in the wording but an important difference in the meaning, and I wonder if that was just a “speako” or if it was an actual point you were trying to make.

I have a question also for Dr. LeBlanc. I heard this morning that a school in Massachusetts has banned tag because they don't want students touching each other and they don't want them running around. It's all for liability issues. It just seems crazy. On the one hand, we have what you're saying and what we all think, but on the other hand, society is banning tag. They are allowing video games and creating alternatives in a competitive way that is beating out tag and other physical activities.

We're already there. We agree with you, I think; everyone on the committee agrees that prevention is the way to go. The problem is on the implementation and how to prevent obesity in the first place. I wonder if you could give us some examples of what this committee should have in its report that will lead directly to the prevention of obesity over time.

I throw those two questions out. Perhaps the CMA could answer, and then Dr. LeBlanc.

[Dr. Colin McMillan]

Are you talking about the top of page 4?

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

It's page 2, under “Economic Lever”. It says, “...you can be sure that high calorie, nutrient-poor 'junk food' is available everywhere for relatively little cost....” and you go on, but when you spoke you said “below cost”.