Health Committee on Oct. 26th, 2006

[The Chair, Conservative, Rob Merrifield]

I want to thank you for coming. I think this is our ninth meeting on childhood obesity, so I appreciate you coming to the committee to present.

We have with us today Lisa Oliver from Simon Fraser University. From the University of Toronto we have Valerie Tarasuk; and from KMH Cardiology and Diagnostic Centres we have Arvi Grover.

We'll go in that order. We want to thank you for coming, and we're eagerly awaiting your presentations to the committee.

We'll start with Lisa.

[Lisa Oliver, Ph.D. Candidate, Department of Geography, Simon Fraser University]

I have passed out a PowerPoint presentation as well as an article.

[The Chair, Conservative, Rob Merrifield]

I think we all have that.

[Lisa Oliver]

I would like to thank you for inviting me here to speak to you about this important topic. I'd also like to thank the committee for choosing to address the issue of childhood obesity this fall.

I'm a health geographer, which means I investigate how the local places where individuals live shape their health status. My research focuses in particular on how the neighbourhood environment influences childhood obesity by structuring opportunities to engage in activities that promote or inhibit weight gain.

I've been invited to come here today to present findings of my research on neighbourhood socio-economic influences on childhood obesity published in the Canadian Journal of Public Health. I would also like to acknowledge the contribution of Dr. Michael Hayes, who was co-author of this work. This research uses data from the Statistics Canada national longitudinal survey of children and youth.

Neighbourhood socio-economic status is measured from unemployment rates, median family income, and percent without post-secondary education. It is divided into four equal categories or quartiles, from low SES to high SES. Measures of overweight and obesity are based on children's heights and weights and use of body mass index cut-points from the International Obesity Task Force. Heights and weights are based on parent and self-reports.

The graph on page 4 shows the prevalence of overweight and obesity by neighbourhood SES among children and youth. First, a social gradient in overweight is apparent, in which the prevalence decreases from 41% in low SES neighbourhoods to 27% in high SES neighbourhoods. Similarly, the prevalence of childhood obesity systematically decreases from 19% in low SES neighbourhoods to 10% in high SES neighbourhoods. This pattern is also evident for obesity among youth.

I want to emphasize that the low category represents the bottom 25% of neighbourhoods in Canada. It does not represent only extreme poverty. Neighbourhood effects are real and persist after controlling for parental education, family income, and the child's age and gender.

The graph on page 6 indicates the likelihood of a child being overweight, adjusted and unadjusted for family factors. The solid bars show the likelihood of being overweight, adjusted for family factors. They show that relative to living in a high SES neighbourhood, a child is almost 1.3 times more likely to be overweight if they live in a low SES neighbourhood. This shows that neighbourhood effects are real, and a child is more likely to be overweight if they live in a low SES neighbourhood, independent of their family circumstances. Thus neighbourhood effects are not solely due to the clustering of low socio-economic status families in disadvantaged neighbourhoods.

What can be attributed to neighbourhood factors? The next few graphs provide some evidence to explain this pattern. The graph on page 7 shows the percent of parents reporting a lack of safe parks and playgrounds in the neighbourhoods. Again we see a similar pattern where a lack of safe parks and playgrounds is highest at 27% in low SES neighbourhoods and systematically decreases to 9% in high SES neighbourhoods. This is a three-fold difference in safe parks and playgrounds between the highest and lowest quarters of neighbourhoods in Canada.

The graph on page 8 shows the percentage of children and youth not participating in organized and unorganized sports. Organized sports include activities such as hockey or gymnastics. They have coaches or instructors and typically involve fees. Unorganized sports do not have coaches or instructors and include activities such as street hockey or simply playing in parks and playgrounds. I want to point out two things about this graph.

First, among children aged five to eleven, there was a clear graded relationship between participation in organized sports and neighbourhood SES, in which the percentage of children not participating is highest, at 52%, in low SES neighbourhoods and decreases to 30% in the high category. This is a substantial difference in non-participation rates between the highest and lowest quarters of neighbourhoods in Canada. It could be due to factors such as lack of programs in these neighbourhoods or to parental barriers, such as the ability to pay or to provide transportation for children to attend such programs.

Second, while non-participation rates are similar across all neighbourhoods for unorganized activities, the previous graph suggests that children in low SES neighbourhoods may undertake such activities in less safe environments.

Over the last few months, I have expanded upon this research by examining the emergence of neighbourhood disparities in obesity and overweight as children age. This research is important because if we can identify when these neighbourhood disparities emerge, then we can develop policies to address them.

Using the same data, from the national longitudinal survey of children and youth, but following children over time, the graph on page 9 shows the development of overweight and obesity by neighbourhood income among a cohort of children aged two and three.

First, among children aged two and three in 1994 there was no clear relationship between overweight and neighbourhood income. Second, when these children are assessed four years later, aged six and seven, a strongly graded relationship is apparent between neighbourhood SES and overweight and obesity, and this persists when children are aged ten and eleven.

The key findings of this research are that neighbourhoods with lower SES have higher levels of obesity, less participation in organized sports, and a lack of safe parks and playgrounds. Neighbourhood disparities in overweight and obesity seem to emerge between the ages of two and ten.

I have been asked to discuss what the federal government might do to address neighbourhood inequality and childhood obesity. Effective policy, I think, will require the federal government to take an active leadership role, involving both provinces and municipalities and other stakeholders as well.

Federal government support for the establishment of universal programs for physical activity through targeted support to municipalities may be needed. Universal programs run through community centres may begin to address the graded relationship between neighbourhood SES and non-participation in sports programs, and additional targeted programs may be required to improve participation rates in low SES neighbourhoods, which are very low right now.

I encourage the federal government to take an active role in reducing barriers to participation in physical activity for children. Targeted support could be directed towards municipalities or provinces to reduce such barriers. For example, providing transportation for children to and from home to recreational programs may increase participation, especially among children living in low SES neighbourhoods or families, and the elimination of user fees for programs, especially among low SES children or low SES neighbourhoods, may improve participation.

Increasing children's participation in unstructured activity is considered important to reduce childhood obesity, and improving the safety of parks and playgrounds would likely improve participation rates in unorganized physical activity. Targeted support for municipalities to address safety concerns relevant to their neighbourhood is needed.

For example, supervision of parks and playgrounds during after-school hours may improve safety and encourage use. Implementation of traffic calming in neighbourhoods, and especially around parks and playgrounds, may increase safety.

Without such initiatives, efforts to increase unorganized physical activity may meet with little success or could even have unintended consequences, such as exposing children to hazards.

Also, policies to address neighbourhood inequalities in overweight and obesity should focus on young children.

In conclusion, all Canadian children should be able to grow up in neighbourhoods with safe parks and playgrounds and opportunities for physical activity. Addressing childhood obesity will require policies that focus on the neighbourhoods in which Canadian children live. The federal government should take an active role in such initiatives.

When formulating anti-obesity policy, I'd encourage the federal government to ask what this policy will do for children living in low-income neighbourhoods. Effective anti-obesity policy must be relevant to children living in low-income neighbourhoods.

Again, thank you for inviting me here to speak to you about this important issue.

I would also like to thank the Statistics Canada research data centre program, which provided access to the micro-data files of the Statistics Canada NLSCY, which this analysis was based on.

[The Chair, Conservative, Rob Merrifield]

Thank you very much for your presentation to the committee. It was well received.

We'll now move to Dr. Tarasuk. The floor is yours.

[Dr. Valerie Tarasuk, Professor, Department of Nutritional Sciences, Faculty of Medicine, University of Toronto]

Thank you.

I was under the misperception that I was going to be making a PowerPoint presentation today, so what you have in front of you is a handout. It focuses on the relationship between low income and healthy eating. If you would draw your attention to it, I'll use it as I walk through some of the data I want you to be attentive to.

First of all, I would like you to take a look at page 2 of the handout, which is our understanding of the relationship between income and food purchasing. If you take a look at this graph, there are a couple of things I want you to notice.

First of all, as income rises, the purchasing of fruits and vegetables steadily increases. This is data based on household food expenditures from the food expenditures survey conducted by Statistics Canada. As income falls--as we get to the low end of that graph--what you can see are perilous drops in food purchasing, in particular for fruits and vegetables, and also for milk products.

The lines on this graph come from simply dividing food purchases according to the four food groups in Canada's food guide. When we break open those food groups and do a more careful examination of what's being purchased within those categories, what we see are more patterns that raise concern about healthy eating habits and how they are apparently privileged habits for Canadians.

When we break open those categories, what we see amongst the meat and meat alternatives group, for example, is that low-income Canadians are more likely to be purchasing higher-fat meats. As income rises we see the increased purchasing of lean meats. Similarly with milk products, as income rises households are more likely to be purchasing low-fat milk. Breakfast cereals are also more likely to be purchased by people with higher incomes.

So there are very clear income patterns in the nature of food purchasing among Canadian households.

As we translate those food purchasing behaviours into nutrients, we also see clear evidence of a social disadvantage amongst low-income Canadians. As income rises, the amount of nutrients in the food that is being purchased also rises. Amongst low-income households, if we look at what they're purchasing in stores, we see foods that are higher in energy density and lower in nutrient density. I can talk more about those two terms later if you want me to.

So our picture is one of a very clear income pattern in relationship to the kinds of foods that households are able to purchase.

Another window through which we are able to take a look at issues of income and their impact on healthy eating behaviours is through the food security measurements that have been included in recent national surveys. In your handout you have three questions that appeared on the 2000-01 Canadian community health survey, questions asking people how often in the last 12 months they worried about not being able to get enough food because they didn't have money for food; how often did they not eat the quality or variety of foods that they thought they needed because they lacked for money; and worst of all, how often did they not have enough to eat because they lacked for money. When those three questions were put on a national survey a few years ago, 3.7 million Canadians said “yes” to at least one of them.

The pattern of who is responding affirmatively to these questions is very clear. As we look at the adequacy of household incomes, it's very apparent that as income adequacy deteriorates, the likelihood of families reporting food insecurity rises dramatically, so much so that by the time we get to the bottom end of the economic spectrum, almost half of Canadian families are reporting food insecurity problems such as identified in those three very simple questions.

When we go a bit deeper in terms of asking the question of who it is who's saying they were having problems getting enough to eat or lacking the quality of foods that they think they need because they lack money for food, the pattern is even more disturbing. As we look at their sources of income, we can see, as you can see on page 11 of your handout, that the likelihood of somebody reporting problems of food insecurity on these surveys is triple if they are on social assistance. They are almost four times as likely to report often not having enough to eat if their main source of income is social assistance.

Another population group that is at particularly high risk for food insecurity is the one supported by federally run programs like employment insurance.

You'll note also on page 11 that those who appear to be protected from problems of food insecurity in our population are seniors. On that I would applaud you all as a positive statement on social policy, but that's the only positive statement I'll make today.

Before I move on, let's talk more about social assistance. Why is it that people on welfare are so likely to report problems of food inadequacy and food insecurity? It is because welfare rates, while managed at the provincial level, are all substantially lower than our notions of poverty. Across this country repeatedly, when people compare welfare incomes to any measures of expenditures required for meeting basic needs, we find that welfare rates are woefully inadequate. It would appear that the provinces are in a race to the bottom.

Other federal or provincial policies of particular relevance to the problem of food insecurity amongst low-income Canadians are the gutting of funding for social housing; the restructuring of employment insurance; and the national child benefit supplement program, which was a promising program when it was announced as a way to offset the ravages of child poverty in this country, but one that has been clawed back from welfare recipients in most provinces so that it has absolutely no impact on their health or well-being.

Why does this matter in terms of childhood obesity or health? It is because we know that people who are reporting food insecurity have substantially poorer dietary intakes. From examinations of dietary intake data, we also know that in households that are food insecure, there's evidence that mothers will sacrifice their own intakes for the sake of children. In fact, children—and particularly young children—are among the most advantaged in these households, but even there, there are indications of compromises in intake. The definitive analysis on this relationship has yet to come to you, because we are still in the process of examining the most recent Canadian community health survey, where we have nationally representative intake data.

The relationships between food insecurity and health are also cause for concern. Cross-sectional analyses repeatedly demonstrate associations between household food insecurity and poorer mental, physical, and social health and well-being amongst both children and adults. There is some evidence of problems related to body weight, although again we'd caution you that in terms of childhood obesity, those results need to wait until there's more analysis of this current CCHS data set.

I'll leave you with just a couple of comments from some research that we have in the field now in Toronto. We're currently doing a study funded by CIHR, looking at 500 low-income households in twelve high-poverty neighbourhoods in Toronto. We are simply going into low-income neighbourhoods, going up to the doors of market rental and subsidized housing units, and knocking on the door. If someone has a child under the age of 18 and if they have a low income—and we are using a very generous threshold there—we invite them to participate in an interview. We get 66% of them agreeing to that interview, and they provide some insight into the prevalence and the experience of food insecurity amongst low-income families in at least one major urban area.

There are three things I want to highlight from that study. The first is that with our methodology, we find that 65% of families that we are encountering are reporting problems of food insecurity. When we look at the issue of food retail access—which I know is an issue this committee has dabbled in—we can see that the access to food at major discount supermarkets differs between these twelve high-poverty neighbourhoods. There absolutely are differences in the urban core in terms of access to food retail opportunities.

However, when we look at food retail access in relationship to food insecurity, we find no relationship. When we look at it in relation to the purchasing of fruits and vegetables, again there is no association. So while I know food retail access is a major concern in some areas, I would caution you against making too much of that as you think about problems of accessing food for low-income Canadians. From our research, we would argue that this is more of a problem of purchasing power than it is one of food retail access.

We've also taken a look at the impact of community food initiatives, such as food banks, community gardens, community kitchens, and school feeding programs. While we find some participation in those programs by the families we've interviewed, in no case do we see any evidence that participation in those programs is protective. In fact, it looks like it's absolutely irrelevant in some cases.

Lastly, because of the way we've sampled our families, we've looked at the issues of subsidized housing and housing affordability. What is it that seems to determine which families are most likely to report problems of food insecurity in this sample of 500 low-income families in Toronto? Two things: income and housing affordability.

To summarize, then, I have tried to make the case to you as quickly as I can that the inadequacy of household incomes for low-income Canadians is a serious barrier to healthy eating. I believe that barrier in many ways reflects a failure of social policy. The fact that we can find such extraordinarily high rates of food insecurity amongst particular subgroups of our low-income population, defined by simple markers like welfare, speaks strongly to the failure of any semblance of a social safety net to protect those at the bottom end of the economic spectrum from very serious food problems.

The levels of food deprivation that we're documenting, the levels of nutritional compromise that we're documenting, are a real concern. They speak strongly to the need for federal leadership around income support programs, to ensure that people actually have enough money to buy the food they need to feed themselves and their children.

Thank you.

[The Chair, Conservative, Rob Merrifield]

Thank you very much. I appreciate that, and I'm sure the committee will have some questions for you.

Now we move on to Dr. Arvi Grover, a cardiologist and director of the International Heart Institute.

[Dr. Arvi Grover, Cardiologist and Director, International Heart Institute, KMH Cardiology and Diagnostic Centres]

Thank you. Last but not least.

I've been a cardiologist for some time, and I've been speaking about obesity to my colleagues, also for some time. I have submitted to the committee a brief that outlines the issues dealing with childhood obesity, particularly pertaining to the South Asian population, as I've been asked to speak on today.

[The Chair, Conservative, Rob Merrifield]

Just for the committee's information, the brief has come to us but it's only in English. We'll get it translated and get it passed around.

[Dr. Arvi Grover]

Okay, so you do have it, or at least some of it. The important members have it.

[Dave Batters, Conservative, Palliser, SK]

Mr. Chair, I'd just like to ask people in the room whose mother tongue is French if it's acceptable that the documents are only in English. If the documents were only in French, I wouldn't find it acceptable and we wouldn't be able to continue. I'd like to pose that question to Madame Gagnon and Madame Demers, with respect, to see if they find that acceptable.

[The Chair, Conservative, Rob Merrifield]

Just to make it clear, they are not distributed. I have a copy here. The clerk gave it to me, but it's only in English. We'll get it translated for the committee.

[Dr. Arvi Grover]

It's actually my fault. It was a late submission. I apologize.

[Dave Batters, Conservative, Palliser, SK]

Not a problem, sir.

But do we have copies of his comments in English right now?

[The Chair, Conservative, Rob Merrifield]

No, we can't distribute it until it's in both languages.

Madame Gagnon.

[Christiane Gagnon, Bloc, Québec, QC]

Could you be more precise about what you mean. You said that the important members of the committee have it. What do you mean by an important member?

[Dr. Arvi Grover]

I believe it's important, but—

[Voices]

Oh, oh!

[Christiane Gagnon, Bloc, Québec, QC]

Did you mean the chairman?

[Some voices]

Oh, oh!

[The Chair, Conservative, Rob Merrifield]

I'm going to call that comment out of order.

It'll be fine. Just continue with your presentation. We'll follow along without a script.

[Dr. Arvi Grover]

So I'll put the boxing gloves away.

I will outline for the next few minutes some important issues that everyone should be getting....

Some interesting statistics have come out. Foremost, we already know that South Asians are at an increased risk of cardiovascular disease. Further research has also determined that South Asian children not only have an increased prevalence of childhood obesity, they also have precursors for diabetes known as insulin resistance. I'm going to touch upon some of these issues.

Another interesting statistic that comes to mind is that the earliest age at which atherosclerosis, which is a form of plaque that forms in the blood vessels of the heart, has been shown to manifest is actually between the ages of three to ten. Having said that, put this together with the pandemic we have of obesity starting in children, and we have to try to come up with ideas to address this.

Other interesting statistics have come from the International Obesity Task Force, and they have suggested that by 2010, over half of North American kids will be overweight or obese. Now, when we hear this statistic we always look to our neighbours down below and say, well, it's really a problem of the Americans, their eating habits. In fact, the same group has looked at the prevalence of obesity that is rising in our children in the U.S. and in Canada, and it is rising by 0.5% in the U.S. and by 1% per year in Canada. In fact, between 1981 and 1996, American childhood obesity has doubled, but it tripled in Canada.

We know that overweight and obese kids have nearly an eightfold increased risk of developing high blood pressure and high cholesterol, not to mention diabetes, which goes hand in hand with childhood obesity. Once you develop diabetes, you are considered at a very high risk, increasing your risk of strokes, heart attacks. In fact, children who are obese, adolescents particularly who are obese, over the next twenty years, have a doubling of mortality. They're at a twofold increased risk of dying.

Speaking of the South Asians particularly, there is interesting research that has come out, some through England, some through Canada. I will mention a couple of interesting studies to you. One comes out of Birmingham. They noticed in Birmingham that 12% of Caucasian teenaged girls aged 14 to 16 and 23% of the boys were found to be overweight or obese; however, these proportions increased to 42% and 41% in the South Asian population in the same age group.

I've already mentioned to you that the same age group in children in the South Asian population, for some reason, already have precursors for diabetes, whether or not they're obese. Taken together with the obesity, that raises their mortality and morbidity figures quite significantly.

Other recent studies have suggested that there are not just genetic factors, but there are environmental factors that go hand in hand with children becoming obese. One such factor they have determined--and this was published recently--was that watching more than eight hours of television per week led to the development of obesity in young children. Also, when they looked at the age bracket between two and four years of age, they found other parameters, including parental obesity, that is, kids are now looking at their parents, finding them to be obese. They are accepting that body habitus much more so than if their parents were of standard body habitus.

Another parameter they found was short sleep duration. Less than 10.5 hours per night at age three was linked to the development of obesity later on in the children's lives. Early development of body fatness in preschool years was also related to development of childhood obesity and later consequences.

Certainly, there are genetic factors that play a role. However, the main message that we must maintain should be that it is the environment. It's not enough to say it's a genetic tendency that explains the recent rise in the prevalence of obesity in our population.

You've heard of some nutritional and other socio-economic parameters as to why this could be occurring. But what we need to do, of course, is to adopt a nutritional and healthy lifestyle. If we take Singapore as an example, they developed what's called a trim and fit scheme. It was a comprehensive ten-year program that actually began in 1992 and continues today. It featured teacher education, training, assessment of students, a program that involved reducing sugar in beverages that children consume, and more physical activity during school hours. They re-evaluated the program recently. They found that not only were these kids becoming more fit, but the prevalence of obesity was much less.

Some key points are outlined in the brief you will have. I will end with some tips we have for parents, especially South Asian parents.

One is to respect the child's appetite. Children do not need to finish every bottle or every meal. I don't know if many of you have had the opportunity to eat with a South Asian family, and looking around there's only one South Asian amongst us--shame on you guys--but what you'll find is that due to the cultural tendencies, the parents will make the kids finish their meals. Moreover, they will actually encourage them to take seconds and thirds. It is considered rude to not finish your meal, to leave any scrap on your plate. However, this is not the case in the non-southern areas. Some other Southeast Asians also have similar cultural tendencies.

We also need to tell the parents to avoid pre-prepared and sugared foods. What are these? We're living in an era where everything is at a fast pace. We're all busy professionals, and as a single, busy professional, sometimes I find myself going to the grocery store to purchase these pre-prepared foods, where all I have to do is microwave it or take it out of the can and heat it up. These types of foods are very high in calories, and high in preservatives, which leads to other problems.

Another piece of advice is to limit the amount of high-calorie foods kept in homes. If you ever visit a South Asian home, all you need to do is open up a few of the kitchen cabinets. There is always what's called a junk food cupboard. These junk foods aren't necessarily what we see in the non-South Asian population. They are not necessarily only pretzels. They are deep fried, full of preservatives, packaged foods that actually come from the South Asian countries and are bought locally in our grocery stores, even places like Loblaws.

We need to provide ample fibre in the child's diet. We need to be aware that we cannot reward action by food, by sweets. This is done quite a bit in the South Asian population. To encourage their children to finish their homework, or to encourage them to do something else, they'll give them a piece of something sweet. We also shouldn't offer sweets in exchange for finishing meals.

We should limit the amount of television viewing--and I've already outlined a study that dealt with this--encourage active play, and establish regular family activities, and this particularly applies to the South Asian population.

A recent study suggested that unless we get the parents involved with the education required to help their kids lose weight, to help them participate in the activities required for the kids to lose weight, it isn't going to be as successful.

There are a couple of other behavioural modifications that I want to mention. Recent studies have also suggested--and this was published two weeks ago, I think--self-monitoring, checking weight every day. Before, we used to say there was no need to check our weight every day, that we were becoming too obsessed. But in fact that auto feedback is an excellent tool to help not only the children but their parents realize what impact the interventions they are making are having on their kids.

For the sake of time, I'll end there and leave the rest for the question and answer period.

[The Chair, Conservative, Rob Merrifield]

Thank you to all the panellists.

I will now turn it over to the question and answer period, starting with Ms. Dhalla. You have ten minutes.

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

Thank you very much to all of our panellists. I have a couple of questions, the first to Lisa.

You mentioned in your presentation some interesting statistics from some of the research you have done in terms of the correlation between socio-economic status and the prevalence of kids being overweight and being obese. From the research you did, what types of indicators did you find actually contribute to it? You talked about having a low socio-economic status, and then you went on to also mention mothers who were single.

What barriers do you find in those types of low socio-economic households, with those types of parents, in terms of the dietary factors or advice they are providing to their children?

[Lisa Oliver]

They don't have dietary intake data in this study from the national longitudinal survey of children and youth, so unfortunately we can't look at the dietary advice, at those types of things, using this data set.