Health Committee on Feb. 26th, 2007

[The Acting Chair, Liberal, Carolyn Bennett]

Thank you very much.

We'll go to Dr. Oliver, please.

[Dr. Sandy Oliver]

Thank you for inviting me to speak today.

I'm going to present research findings drawn from systematic reviews of the international literature about the effects of interventions that aim to promote children's and young people's physical activity and healthy eating, and from complementary systematic reviews of children's and young people's views about these topics.

The age ranges we studied were children 4 to 10 and young people from 11 to 16. These were all studies addressing children and young people generally, rather than children or young people who were obese.

The studies of children's and young people's views were all conducted in the United Kingdom, so I can't tell you how accurately they might reflect the views of Canadian children and young people. However, when I describe the findings, you will be able to judge for yourselves to what extent they ring true, considering what you know about the children and young people in your own country.

I shall describe each of the reviews in turn, starting with young people and physical activity. This review was published in 2001, with the latest included study published in 2000. The findings are based on 12 evaluations of the effects of interventions and on 16 studies of young people's views addressing aspects of the community or wider society that help or hinder young people's physical activity.

We found that multi-component school-based interventions had a little success in some circumstances. There was some improvement in knowledge, and young British women said the interventions influenced their behaviour.

Most young people saw physical activity as beneficial for both health and social reasons. Young women particularly valued the role of physical activity in maintaining weight and a toned figure, but unlike young men, they found that physical activity did not fit in well with their leisure time.

Ideas for promoting physical activity included increasing or modifying practical and material resources, such as creating more cycle lanes; making activities more affordable; increasing access to clubs for dancing and combining sports with leisure facilities; and more innovative choices in school physical education, such as dancing, cycling, and aerobics. This means that interventions are needed that increase the range of free activities, improve school facilities, provide more choice of activities in school, and emphasize the fun and social aspects of sport.

There are major gaps for research and development, particularly in the areas of parental constraints and the interaction with mental health.

At the same time as searching for these studies, we also sought studies about young people and healthy eating. The findings are based on seven evaluations from around the world that studied aspects of the community or wider society that help or hinder healthy eating and eight studies of young people's views in the U.K. We found a small number of well-designed evaluations that showed mixed evidence on effectiveness. All studies detected at least some positive effects on healthy eating. Interventions were multi-component, complementing classroom activities with school-wide initiatives and changes to the young people's environment, such as facilities for physical activity. The interventions also involved parents. There was stronger evidence for effectiveness among young women compared to young men.

Young people had clear views on healthy eating. Barriers to healthy eating included the cost and poor availability of healthy foods and the association of these foods with adults and parents. In contrast, fast foods were widely available, tastier, and were associated with pleasure, friendship, and being able to exercise choice. Ideas for promoting nutrition included the provision of information on the nutritional content of school meals--for young women particularly--and better food labelling.

Evaluated interventions often neglected the views of young people, especially in terms of their concerns about the taste, cost, and availability of healthy foods. This means that promising interventions are those that address concerns such as the high cost of healthy foods, a taste preference for fast foods or lack of will power to avoid fast foods, and food labelling.

Interventions, and their evaluations, also need to consider issues of gender, inequalities in health, and the interrelationships between healthy eating, physical activity, and mental health.

We followed these reviews, but there are few on children and physical activity outside of school published in 2003, with the latest included study published in 2002. It's based on five evaluations of the effects of interventions, all undertaken in the U.S.A., and five studies of children's and parents' views. We found that there are few evaluated health promotion interventions that address physical activity beyond school-based physical education, and even fewer have been rigorously evaluated.

Interventions shown to be effective include education and provision of equipment for monitoring TV or video game use, engaging parents in supporting and encouraging their children's physical activity, and multi-component, multi-site interventions using a combination of school-based physical education and home-based activities.

Approaches that appear to take into account the views of children in the U.K. but that require further evaluation and development include those that provide children with a diverse range of physical activities to choose from, emphasize the aspects of participating in physical activity that children value, such as opportunities to spend time with friends, provide free or low-cost transport and reduce costs, and aim to provide a safer local environment in which children can actively travel and play.

The findings mean it's not yet clear whether these types of interventions will always result in positive behavioural changes, which components are essential for success, or the extent to which they are appropriate for children in a particular context.

At the same time as searching for studies of children and physical activity, we sought studies about children and healthy eating, in particular, eating fruit and vegetables. The findings are based on 19 evaluations of the effects of health promotion interventions and eight studies of children's and parents' views. We found that interventions were largely school-based and often combined learning about the health benefits of fruit and vegetables with hands-on experience in the form of food preparation and taste testing. The majority also involved parents alongside teachers and health promotion practitioners. Some included changes to the foods provided at school and some targeted more physical activity as well as healthy eating.

The results of our analysis reveal that these kinds of interventions have a small but statistically significant positive effect. Bigger effects are associated with targeted interventions for parents with risk factors for cardiovascular disease. There was no evidence of the effectiveness of single component interventions such as classroom lessons alone or providing fruit-only tuck shops.

Six main issues emerged from the studies of children's views: one, children don't see it as their role to be interested in health; two, children don't see messages about future health as personally relevant or credible; three, fruit, vegetables, and confectionery have very different meanings for children; four, children actively seek ways to exercise their own choices with regard to food; five, children value eating as a social occasion; six, children see the contradiction between what is promoted in theory and what adults provide in practice.

The studies of children's views suggest that the interventions should treat fruit and vegetables in different ways and should not focus on health warnings. Interventions that were in line with these suggestions tended to be more effective than those that were not. This means that promoting healthy eating can be an integral and acceptable component of the school curriculum; effective intervention in schools requires skills, time, and support from a wide range of people; it's easier to increase children's consumption of fruit than vegetables; simple strategies may be branding fruit and vegetables as tasty rather than healthy or may be promoting fruit and vegetables in different ways; and more challenging strategies may be making health messages relevant and credible to children and creating situations for children to have ownership over their food choices.

For all four of these reviews, conclusions about effectiveness remain tentative because of the small numbers of rigorous evaluations found. Most of the research did not look at socially excluded young people or those who seldom go to school.

All four reviews found that although children and young people often have clear views on what helps or hinders their healthy behaviour, their views are rarely taken into account in the development of interventions. We recommend developing and rigorously evaluating interventions that take the views of children or young people as a starting point.

Thank you.

[The Acting Chair, Liberal, Carolyn Bennett]

Thanks very much.

As a committee, we are a little concerned that we haven't yet listened to kids. Maybe later on, in the question period you wouldn't mind letting us know a little bit about how you listen to kids on this, or whether you think that listening to kids just means in terms of academic studies or whether policy-makers should be able to interact with kids, in terms of what affects their choices.

Do you want to have a go at that now? Should we have had a hearing with kids?

[Prof. Roger Mackett]

I certainly think you should. Our experience with talking to children is they've got fairly clear views and are able to give you fairly clear answers to well-defined questions. I think it would have been very sensible to talk to them.

[The Acting Chair, Liberal, Carolyn Bennett]

Certainly what we found, when we were dealing with the Divorce Act, was that the kids had pretty strong views that ended up improving the report a great deal. So thank you for that.

We've got 40 minutes, so what would the committee like to do? Should we just go around to the people who haven't yet asked a question, and then we'll just keep going? Maybe we'll keep it to about four minutes, so we can keep going around. We'll reward the people who showed up this morning, rather than the usual toing and froing.

Let's start with Luc.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Thank you, Madam Chair.

Thank you for appearing before us today, ladies and gentlemen,

Last week, we had before us the Secretary of State for Sports from the UK, Mr. Caborn. He told us that there is a cultural change underway in the UK such that, slowly but surely, you are moving towards a society that is less sedentary, more active and also more inclusive.

Professor Mackett and Ms. Oliver, do you see such a significant cultural change at work in Great Britain today?

[Prof. Roger Mackett]

I would like to think there was, but I don't think there actually is. I'd be very interested in Caborn's evidence to support those statements. I'm afraid I'd be rather cynical on those sorts of things.

[Dr. Sandy Oliver]

I agree. I think there's a lot of policy interest. A few small projects get a high profile, but I don't know of any figures to show that, collectively, we're being more active or more inclusive.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

We know that income is one of the determinants of inactivity. What direct interventions could we apply to low income families in order to increase their ability to be active and to eat well?

[Prof. Roger Mackett]

I only wish we knew the answer to that question. I think it's very important. It's much easier to get messages across to high-income people. Most of our experience is working with them. Those parents understand these issues, whereas we don't get the message across to those people with lower incomes. I just wish we knew how to do it. Perhaps my colleagues know better than I do.

[Dr. Sandy Oliver]

In our systematic reviews we focused largely not on individual barriers to behavioural change, but on social and community barriers to behavioural change, and quite often it's the people with the lower incomes who are facing the greatest barriers. For instance, young people are often not allowed out in the evening because of basic environmental things like poor street lighting. There's a great concern about safety when going out in the evening, and parents are quite often not allowing their children to go out. So if they're not in a position to drive them in a car, they'd rather their children stayed home.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Thank you.

Seen from the outside, there seems to be some contradiction between the model proposed by Tesco, on the one hand, and the government traffic light scheme on the other hand, in terms of the findings of the various studies for the development of those two schemes.

Could you explain to the committee in what way these schemes are not contradictory but rather complementary? I mean, if they are.

[Dr. Jane Holdsworth]

There are many elements that are complementary in the two schemes. They're both on the front of the pack, and I would say that in the U.K. the front of the pack has traditionally been a place for brand values. It has not tended to carry nutritional information for consumers.

So, first of all, I would say having the two schemes on the front of the pack, and using that brand space to communicate simply to consumers about ingredients within the product is a major move forward for manufacturers. They both focus on four core nutrients: fat, salt, sugar, and saturated fat. But the GDA one also has calories, which, as I stated and Professor Sanders also mentioned, is an essential component with regard to the importance of calories in any obesity debate.

They both aim to give consumers a perspective on the food they're eating. The GDA does that by showing consumers how individual nutrients or calories fit into a total diet. The traffic light one does so by showing consumers whether or not the nutrient is high, medium, or low, based on a 100-gram amount. I think the differences are around the fact that GDA is based on portion and traffic lights are based on 100-gram amounts, but there are many similarities between the two.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Professor Sanders, would you like to comment?

[Prof. Tom Sanders]

I think one of the problems with the GDA model for the front of the pack is numerical. We did, at one stage, propose to the Food Standards Agency that they might consider using certain bandings of GDA, to use a colour coding rather than the amounts per 100 grams. So it would be a hybrid sort of methodology.

The other major problem I think with the traffic light system is that it does not discriminate between small and large portions of foods. For example, potato crisps are a food very popular with children, and I recall when I was in Canada last that the packet sizes are a lot larger in Canada--about 60 grams--than they are in the U.K., where they're about 30 grams. Under the traffic light system, they would be labelled identically, but they would be labelled differently if you used a GDA basis.

I stressed in my presentation that you need to separate the mode of display--whether it is numerical or colour coding--from the basis on which calculations are worked out. Nutritional value is the product of nutritional composition times the amount that is consumed. That is a fundamental basis of nutrition science--to look at the contribution it makes to the total diet, rather than at the amount in 100 grams.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Thank you very much.

[The Acting Chair, Liberal, Carolyn Bennett]

Thank you very much.

Mr. Dykstra.

[Rick Dykstra, Conservative, St. Catharines, ON]

Thank you, Chair.

I refer back, Tom, to your points. You started to iterate the issues around the fact that a food may ostensibly be healthy for you, but that too much of anything isn't necessarily a good thing, and that's what you're suggesting.

I wonder if you could comment briefly on how you address the issue with the food industry, from a government perspective, speaking about the need to quantify how much an individual should or shouldn't eat and then also trying to work in partnership with the food industry to be able to come to some sort of a conclusion that makes sense for both.

[Prof. Tom Sanders]

I think it's a point well made. I think when we're considering advice about food for children, the foremost thing we are concerned about is that they have an adequate diet. To look at the implications of labelling, if it demonizes certain foods.... The foods we're particularly concerned with are dairy products. Where in the U.K. 60% of girls have low intakes of calcium, we want to be very cautious not to put girls off consuming dairy foods if they're labelled inappropriately.

We also are aware of processed foods that come out quite badly on the traffic light system. Things like breakfast cereals, because they are dry foods, end up being labelled as high in sugar or high in salt. But the amounts consumed are relatively small, about 30 grams, and the important thing is they're consumed with milk. So you need to look at them in the context in which they're consumed. You have to work out what contribution the food makes to nutrient intake in the diet versus the potential negative effects of the food.

In the case of something like cheese, it's very clear. Once you go above about 1 ounce--30 grams--a day, you're moving to an area where you're probably consuming too much. So it is about proportion.

[Rick Dykstra, Conservative, St. Catharines, ON]

Thank you. I appreciate the overview.

I still want to dig down a little deeper and get an understanding of how, in a government–business relationship, you have been able to work with the food industry in terms of their understanding of the issue at hand with respect to proportions of what children are eating.

[Prof. Tom Sanders]

With the food industry, one of my roles has been as an advisor to a charity called Heart UK, which is concerned mainly about inherited forms of cardiac disease. It has been persuading the food industry to make cuts in salt in their foods, and particularly in the saturated fat content of their foods. Some parts of the food industry are being quite receptive to bringing about these changes.

One of the problems is when you change the labelling on a food to low fat, it doesn't necessarily mean it will translate into people eating less of that food. It's sometimes used as permission to eat. I think we do have some problems with the way food is sometimes marketed, that it may seem at first like a good change, a reduced-fat product, but then people think you can eat twice as much of it.

[Rick Dykstra, Conservative, St. Catharines, ON]

Thank you.

Sandy, you mentioned interventions. I wondered if you could just comment on that. I put a question mark down when you said that word, and I wondered what you meant by it.

[Dr. Sandy Oliver]

Intervention is the term we use to describe any effort made to intervene in people's lives purposefully. That might be something very simple like a leaflet or a classroom curriculum, or it may be something much more complex, like training for kitchen staff in a school accompanied by changes in labelling in the canteen for the children.

So you can have very simple interventions or you can have very complex interventions. But it's trying to put a boundary around any program or any initiative that is being evaluated.

[Rick Dykstra, Conservative, St. Catharines, ON]

You mentioned these quickly, and I wrote them down as fast as I could, the six main factors with respect to what children's reactions were or how you interpreted them. Just as an overview response, how did you get to the point of being able to acknowledge that there actually were six factors, and how did you determine them?

[Dr. Sandy Oliver]

I think you're talking about the main issues I mentioned towards the end, about children's views about healthy eating.