Health Committee on Feb. 9th, 2012

[The Chair, Conservative, Joy Smith]

I call the meeting to order.

Good morning, everybody, and welcome to the health committee. We're so pleased to have our guests here this morning.

As you know, we're studying health promotion and disease prevention.

We have with us Mary Collins, from the B.C. Healthy Living Alliance. Welcome, Mary; we're glad you're here. Mary is the director of the secretariat. With her is Cathy Adair, who is a representative. Welcome.

From the Canadian Association of Occupational Therapists, we have Claudia von Zweck, executive director--welcome, Claudia--and Mary Forhan, occupational therapist. You're actually the liaison with the Canadian Obesity Network; wonderful.

From the University of Western Ontario, we have Piotr Wilk, assistant professor--welcome, sir--and I believe that would be Dr. Wilk, then, would it not? Yes, it is, and Dr. Martin Cooke is with us as well. Welcome, Dr. Cooke.

Miss Rita Orji will speak as an individual. Did I pronounce your name correctly? Welcome.

We will begin with Mary Collins, please. You have a 10-minute presentation.

[Cathy Adair, Representative, Vice President, Cancer Control, Canadian Cancer Society, BC and Yukon Division, BC Healthy Living Alliance]

Good morning, Madam Chair and committee members. We welcome your interest in and commitment to health promotion and disease prevention and we thank you for the opportunity to present our experience and views on what can be done to promote health promotion and disease prevention.

BCHLA is an alliance of nine provincial organizations that have been working together since 2003 to address the alleviation of common risk factors and health inequities, which of course are a large contributing factor to chronic diseases.

British Columbia is a leader in health promotion and disease prevention. We're proud of the fact that we have the lowest smoking rates, the lowest obesity rates, and the highest levels of physical activity. However, if we look at the short-term and long-term projections, we know that B.C. and Canada will fall behind other world leaders if we don't begin taking action and doing some things differently as we move forward.

BCHLA's experience in overseeing $25 million in initiatives that were developed and delivered to address common risk factors and our involvement in policies to reduce health inequities in B.C. have provided us with a wealth of information that we hope you will find of interest and that we believe is applicable to Canada as a whole.

My colleague Mary is going to speak about those issues.

[Mary Collins, Director of the Secretariat, BC Healthy Living Alliance]

Thanks, Cathy.

It's a great pleasure to be here with you.

In the short time available, I'm going to highlight several areas we think are of importance. I won't read the brief.

I wanted to start by saying that Cathy and I have just come from the Chronic Disease Prevention Alliance of Canada conference at the Delta Ottawa City Centre, where we heard from an array of experts on these issues. There's a lot of new information coming out of that work, so I would certainly recommend it to you.

Yesterday Dr. David Butler-Jones, the chief public health officer of Canada, spoke at the opening. He talked about how prevention needs to drive the system. This message is increasingly capturing both the understanding and the imagination of policy-makers and of those across the country. Increasingly, finance ministers and health ministers are realizing that the costs of health care are potentially unsustainable if we don't do something to shift that curve over the longer term, and prevention has to be fundamental to those changes. It's not easy, but we are hoping that your committee and your colleagues will help us to achieve that goal.

There was a very interesting recent study in the United States about modelling the health care system. It's in Health Affairs. It looked at whether investments in care or investments in prevention really brought about cost changes over the long term. They showed, in their modelling, that within the next 25 years—and we realize that this is long term and that these changes will not take place overnight—investment and prevention are projected to save 140% more lives and reduce costs by 62%. Now, we know that our environment is somewhat different from that of the States, but we would suggest that you could look at similar objectives.

We recognize that we need to integrate the health care system and the health prevention system and that primary health care is fundamental to this objective. An integrated approach to primary care, which includes prevention and an array of health practitioners, is something that many jurisdictions are working on and something that we hope the federal government will continue to support.

We also recognize that the health sector isn't going to do this alone. We continue to preach, I guess you could say, that the issues about chronic disease, which are consuming over 40% of health care budgets, need what we call a “whole of society, whole of government, whole of person” approach. Perhaps you could just think about it in terms of those parameters.

“Whole of society” requires not only the involvement of government, but also of the private sector and of all the not-for-profit health care providers as well. We need better mechanisms by which we bring people together—we're not there yet—to come to good decisions and good conclusions. Again, we would encourage the federal government to help to facilitate those kinds of partnerships of bringing people together.

Also, when I say “whole of government”, I don't mean only the health ministry. If you look at infrastructure funding, for example, you need to understand what the impact of any particular infrastructure project may be on the health of citizens, and whether it in fact helps us to lower the curve around health equity. That's one of our biggest concerns: there's a huge gap in health and health outcomes among people of different socio-economic strata.

We would encourage all levels of government, including the federal government, to require that their ministries have performance plans to show what they are doing to contribute to better health among Canadians, and to require that these plans be assessed on a regular basis, in part to review whether there are, in fact, good health impacts stemming from major projects. These assessments must look not only at the environmental factors, which are important, but also at the health impacts of major projects.

When we talk about the determinants of health, which of course we've all known about for so many years, we know that these include where you work, where you play, and where you live. Your economic and social circumstances make a huge difference to your health. We need to think about initiatives that will understand the difference. We tend to be rather skeptical of the kinds of campaigns that use broad advertising; they may help those who are already healthier, but they don't necessarily address the needs of those who are in the poorest health or at the greatest risk of poor health. Sometimes we need to look at more segmented approaches to reach those people.

I know that you're particularly interested in the issues of healthy weights and childhood obesity. We've actually moved our language from saying “obesity” to saying “healthy weights” instead, because there is increasing evidence that saying “obesity” tends to stigmatize people, and we don't really think that's a good idea. There are already enough challenges involved in that area.

I won't go through all of our recommendations; we have quite an array. We have other reports available through our website.

There are a couple of things that are really important. One is to ensure that all Canadians can have nutritious foods, and this is particularly important for children as they're developing. There is a lot of opportunity through school programs to advance those interests.

One thing that's really of concern is that children are being bombarded by television and video messages about unhealthy foods, and there's evidence that this advertising tends to increase.... Children, of course, are not yet sophisticated enough to really know the difference.

Ideally this could be managed on a voluntary and cooperative basis. Unfortunately, the reality to date is that it hasn't really worked. While we would encourage that approach to continue, we really think it ultimately will require regulation. Quebec has done it, and we think what is needed in a more comprehensive way across Canada is restrictions on marketing to children, not only on television, but in commercials, cartoon characters, video games, and things like that. I know we don't necessarily want to regulate everything, but in this area evidence shows that it certainly can have an impact.

Another area has to do with designated taxes. As we know, nobody likes taxes, but there's increasing evidence, which we heard a lot about in the last two days at the conference, about designated taxes. We would suggest excise taxes on sugar-sweetened beverages--not just soda pop, but all sugar-sweetened beverages. Sometimes people think it's just soda pop, but we're not just going after that. Such a measure can make an impact by facilitating people in making wiser choices. In some cases provinces could do it, but there's also an opportunity for the federal government to try to help people make those better choices.

We can't forget the role tobacco and alcohol play; we would urge the federal government to renew the tobacco strategy, which we know is coming to an end fairly shortly. We've made great progress and we have lots of lessons, but we can't let up. We still have too many people smoking, particularly young women, who often associate it with low weight and think it's going to keep them slim. Of course, there's also alcohol; increasingly people are recognizing alcohol as a risk factor contributing to obesity, and also recognizing its connection with chronic diseases right across the board.

In conclusion, we recognize that over the years the federal government has played a leadership role in working with the provinces, the private sector, and the not-for-profit groups in a joined-up approach to promote and inspire the next generation of Canadians to live not only long lives but healthy ones as well.

We thank you and look forward to your questions.

[The Chair, Conservative, Joy Smith]

Thank you very much, Mary.

We'll now go to Dr. Claudia von Zweck, from the Canadian Association of Occupational Therapists .

[Dr. Mary Forhan, Occupational Therapist, Liaison with the Canadian Obesity Network, Canadian Association of Occupational Therapists]

Thank you--

[The Chair, Conservative, Joy Smith]

I'm sorry, Dr. Forhan; are you starting first? Are you sharing your time, then?

[Dr. Mary Forhan]

No, we're not, actually.

[The Chair, Conservative, Joy Smith]

You're going to do the major presentation.

[Dr. Mary Forhan]

Yes. Claudia will be able to answer some questions.

[The Chair, Conservative, Joy Smith]

Okay, thank you very much.

[Dr. Mary Forhan]

Good morning, Madam Chair and members of the committee. Thank you so much for the opportunity to present to the House of Commons Standing Committee on Health.

My name is Dr. Mary Forhan. I am an occupational therapist and a researcher in the area of obesity management, prevention, and treatment. I'm here today as a representative of the Canadian Association of Occupational Therapists, of which I've been an active member since 1990. CAOT is pleased to participate in this consultation on health promotion and disease prevention, with a focus on obesity.

The unique contribution to health promotion and disease prevention from an occupational therapy lens is the focus on occupation, which includes but is not limited to physical exercise. Occupational therapy is the art and science of facilitating participation in everyday living, and includes active engagement in meaningful activities or occupations. Occupations include everything people do in their day-to-day lives, such as paid employment, going to school, participating in hobbies and sports, looking after others, and taking care oneself. Occupation is the context in which people develop skills, express their feelings, construct relationships, create knowledge, and find meaning and purpose in their lives. CAOT believes that participation in meaningful everyday activities is important for Canadians through all stages of life, regardless of health or ability.

With the growing epidemic of obesity and the rising number of aging Canadians, the government understands the importance of promoting healthy lifestyles to foster health and prevent disease. Increasingly, research is demonstrating that participation in an active lifestyle fosters both physical health and mental well-being.

As such, CAOT recommends the adoption of a vision by the federal government for promoting health and preventing disease that would include individual and community engagement in active living, thus providing leadership for provinces and territories and broadening the focus from solely health care to include health promotion.

CAOT's health promotion and disease prevention strategy includes the development and dissemination of an active living guide. Together with researchers from Queen's University and McMaster University, CAOT has begun the development of this active living guide.

Active living is a collection of behaviours that promote health and wellness by reducing risk factors associated with chronic diseases such as obesity, depression, hypertension, diabetes, and substance abuse. CAOT defines active living as engagement or participation in meaningful activities that support a way of life in which physical, social, mental, emotional, and spiritual activities are valued. Active living goes beyond physical exercise.

The objectives of the active living guide are in line with this committee’s vision to promote the health and wellness of Canadians and prevent illness, as stated in the declaration on prevention and promotion from ministers of health, health promotion, and healthy living from across Canada, which I see was posted in September of 2010.

CAOT's perspective on active living and health promotion could also contribute to the Public Health Agency of Canada's national dialogue on healthy weights. This dialogue is currently under way, as I'm sure you're all aware. CAOT has the capacity to work with the Public Health Agency of Canada toward meeting its benchmarks related to health promotion and disease prevention. CAOT advocates that the federal government recommend the engagement of the Public Health Agency of Canada in the consensus-building, dissemination, and evaluation of the active living guide.

The intent of the guide is to identify the needs of different populations and promote not only physical health but other beneficial factors that contribute to individual health, such as connectedness, spirituality, and community engagement. The guide is intended to promote active healthy living for all Canadians, and pays particular attention to high-risk groups, including children and youth, first nations communities, adults transitioning from work to retirement and older adulthood, and persons with disabilities. The active living guide will provide strategies to address the physical, social, and environmental barriers to active healthy living identified by Canadians in high-risk populations.

Based on research to date, increasing active living is not simply a matter of just doing it. There are several dimensions of activity participation that are important to consider, and what follows are key elements of the active living guide.

Issues such as poverty, disability, and limited English literacy may restrict access or engagement in meaningful activity. Systemic barriers to participation need to be identified and addressed to provide individuals with the opportunity to participate in healthy activities. Having a choice is absolutely critical to whether an individual is motivated to initiate and maintain involvement. Rather than a prescribed schedule of activities, the emphasis in the guide would be on individual choice and preference.

There may be critical points in time, such as graduation from school, preparing for retirement, or the onset of a disability, when activity patterns are disrupted and need to be reconfigured. A framework for promoting participation in healthy activities needs to consider the life stages and transitions, which the activity guide will do.

The meaning of activities may vary depending on the individual's cultural, social, and political context. For example, young persons may be motivated to engage in a specific sport, but will not likely continue if it's not socially valued within their family or their peer group. Providing options for choice and healthy activities across a range of cultural contacts is required.

Balance is another important issue to consider in activity patterns. It is important to consider the points at which activity engagement has a positive impact on health and the point at which too much activity can have a negative effect. Research, for example, points to issues of balance with respect to the screen time of adolescents, the work-life balance of adults, and volunteer work for older adults. The participation in everyday meaningful activities and their impact on heath promotion and disease prevention is a core belief with the profession of occupational therapy. As such, the Canadian Association of Occupational Therapists also recommends that occupational therapists be included in the strategic planning and implementation of creating a new vision for Canadian health promotion and disease prevention.

To summarize, these are the key recommendations from CAOT: the adoption of a vision by the federal government for promoting health and preventing disease that includes individual and community engagement in healthy living activities, thus providing leadership for provinces and territories and shifting the focus of Canadian health care to include health promotion; federal government support to engage the Public Health Agency of Canada to participate in the consensus-building, dissemination, and evaluation of the active living guide; and the inclusion of occupational therapists in the strategic planning and implementation of a new vision for Canadian health promotion and disease prevention.

On behalf of CAOT, I would like to thank the committee for the opportunity to present. We certainly will be open to answering any questions.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much, Doctor.

We'll now go to Dr. Wilk, please, from the University of Western Ontario.

[Dr. Piotr Wilk, Assistant Professor, University of Western Ontario]

We'll be sharing our time, so maybe Dr. Cooke will start.

[The Chair, Conservative, Joy Smith]

You'll be sharing your time. That's wonderful.

Please go ahead, Dr. Cooke.

[Dr. Martin Cooke, Research Partner, Associate Professor, University of Waterloo, University of Western Ontario]

Good morning, Madam Chair, vice-chairs, and members of the committee. It's our pleasure to appear before you today to help you with this important work.

Rising rates of obesity, as this committee is very well aware, are among the most important public health problems we currently face. Childhood obesity is an especially important issue, as it brings with it a number of risks both in childhood and in later life.

Our current work is on the issue of obesity among aboriginal children. As the committee is also aware, aboriginal children face rates of obesity that are substantially higher than, perhaps more than twice as high as, those of other Canadian children. Unfortunately, we can't offer more precise estimates of those rates, because there is no national-level surveillance system in place to monitor health outcomes among aboriginal children. There is enough evidence to conclude that aboriginal children, regardless of their place of residence or ancestry, are more likely to be obese and are at much higher risk of experiencing the negative consequences of obesity.

Childhood obesity is a potentially major contributor to the health equity gap between aboriginal and non-aboriginal Canadians. This gap in health and health-related quality of life may widen as the current generations of aboriginal children grow into adolescence and adulthood. Moreover, 30% of the aboriginal population is under 15, so reducing the gap in inequality and improving the health of aboriginal populations therefore requires a focus on child health.

Of course, we understand that the committee is likely most interested in understanding what strategies have proven effective in addressing obesity among children, and among aboriginal children in particular. Unfortunately, the current research evidence is unclear on that point. Recently, our colleagues from the Northern Ontario School of Medicine systematically reviewed the literature and found little consensus about what works with regard to reducing obesity among aboriginal children. It seems as though what works depends very largely on the social context.

Currently we have funding from the Institute of Aboriginal Peoples' Health in the Canadian Institutes of Health Research to try to understand obesity among aboriginal children. We are working with the Métis Nation of Ontario and other partners. This research will investigate the effects of key determinants of child obesity at the child, family, and community levels. Our research program is focused on Métis and off-reserve first nations children. At present, more than half of aboriginal children live in urban areas, a population that is rapidly growing.

Although these projects are ongoing, we do have some preliminary results. Both qualitative focus groups with parents and analysis of Statistics Canada data indicate that family income is a key determinant of childhood obesity. However, there's also evidence that many of the social determinants that affect aboriginal children's health may be different from those that operate in the general Canadian population, reflecting cultural and historical differences. For example, controlling for family income and other factors, we found some evidence that children whose parents attended residential schools may be at higher risk for obesity than other aboriginal children.

It also appears that aboriginal children and families living in urban and other non-reserve areas may be more likely to live in neighbourhoods or communities that are underserved in terms of opportunities for physical activity or access to affordable healthy food. We're presently working on modelling the effects of neighbourhood characteristics, including the availability of fresh foods and proximity to recreation spaces.

[Dr. Piotr Wilk]

As we have heard repeatedly from our first nations and Métis colleagues, healthy weights among aboriginal children cannot easily be separated from other aspects of health or from well-being in a more general sense.

An important point is that the physical health of children is deeply connected to the emotional and spiritual health of the children themselves, of their families, or of their communities. Aboriginal children living in urban areas are affected by policies and programs of a variety of agencies and institutions, including aboriginal-specific agencies, public health units, clinicians, schools, and mainstream social service agencies.

Some children and their families are also connected to first nations or other communities and may spend part of their lives served by institutions in those communities. We are convinced that this health and wellness system can be improved. Currently we are conducting a project funded by the Public Health Agency of Canada that is attempting to improve the way aboriginal children and families living in urban areas are served by those institutions.

Through consultation with community partners and interviews with parents and caregivers, we have found that communities may have considerable resources to provide programming and services to aboriginal children. However, these resources may not always be used to the best effect because of a fragmentation in the system. For example, clinicians and other mainstream health agencies that serve aboriginal children may not always have access to the cultural knowledge required to provide effective programming and may therefore have difficulties retaining aboriginal children and families in treatment or health promotion programs. On the other hand, aboriginal-specific service providers may not have the same access to long-term funding or to the various financial and physical resources that may be present in the community.

We are convinced that by addressing this fragmentation and lack of collaboration, we can improve child obesity outcomes. Our proposed population health intervention is to build a collaborative structure among various community organizations and stakeholders whose work affects health and wellness of aboriginal children either directly or indirectly. By collaborating, local aboriginal and non-aboriginal organizations can use existing resources more effectively and leverage additional ones to improve how they serve aboriginal children and families.

We have started this intervention in London, Ontario, and hope to spread this model to other communities. At this moment, our project includes more than 40 institutions in London and nearby first nations. By actively connecting those partners around the issue of promoting healthy weights, we have been able to create new collaborative programs that would not have existed otherwise.

Perhaps more importantly, the collaborative model that we propose will improve relationships between aboriginal peoples and Canadian institutions that are a fundamental part of the disparities in health. We believe this process will help address some of the factors affecting the relative health of aboriginal people in Canada that are furthest upstream from them.

In closing, we would like to acknowledge and thank all the partnering organizations and the members of our project team. Without them, this important work would not be done.

Again, we would like to thank the committee for inviting us here today. We would happy to answer any questions.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Wilk.

We'll now go to Ms. Orji.

[Rita Orji, Ph. D. Student, University of Saskatchewan, As an Individual]

With all protocols observed, it is my honour and privilege to appear before you, the honourable chairman and members of the Canadian House of Commons Standing Committee on Health, to share some of my knowledge on health promotion and disease prevention, and more specifically on obesity prevention.

My name is Rita Orji. I am a Nigerian and a doctorate student in the department of computer science in the University of Saskatchewan. I am under the mentorship of Dr. Julita Vassileva and Dr. Regan Mandryk.

My primary research focus is on the influence of persuasive technology in the prevention of chronic metabolic diseases through lifestyle change, particularly the prevention of obesity. Recently I was awarded a Canadian government Vanier scholarship to conduct research on the design of persuasive technologies for healthy lifestyle change with a specific focus on obesity prevention.

I'm here to speak on health promotion and disease prevention, and more specifically on the topic of obesity. I'll be sharing the knowledge I've gained from studying relevant literatures and from some research experiences I've had in actively working in this area over the past two years.

Obesity is a major health concern worldwide, and specifically here in Canada. It has attracted attention from both governmental and non-governmental bodies. According to measured height and weight data from both the 2008 Canadian Community Health Survey and the 2007-2009 Canadian Health Measures Survey, approximately one in four Canadian adults is obese. Also, as of 2008 it was reported that approximately 61% of Canadian adults and 30% of Canadian teens are either overweight or obese.

Sedentary lifestyles and unhealthy eating habits are the two main contributors to the escalation of obesity in our society today. As a result, several worldwide attempts have been made by both governments and private sectors to counter the rising trend of obesity and associated chronic diseases.

The attempts are largely informed by the connections that have been made between obesity and poor health. Being overweight has been found to increase the risk of developing heart disease, diabetes, high blood pressure, mental illness, and in some cases cancer. As the prevalence of overweight and obese people increases, the implication in terms of premature death and burdening the Canadian health care system becomes acute as well.

Attempts at preventing obesity, especially in the last decade, have been targeted on such interventions as public awareness, counselling, and drug use. However, these approaches have not produced the desired long-term sustainable effect, for the following reasons: first, they are not based on the understanding of human behaviour--that is, how behaviours are formed and how they can be altered; second, they are not well integrated into people's daily lives and therefore face the problems of adoption and maintenance; third, they are not cost-effective and therefore face the problem of long-term sustainability; and fourth, they are based on the assumption that humans are rational beings and will always act to maximize benefit and reduce risk.

However, when it comes to lifestyle, we cannot assume that humans will necessarily behave rationally. Rational people would change their behaviours when exposed to convincing information about the negative effects on their health. Most lifestyle-related health challenges, including obesity, that we experience today should not be there, considering the widespread health education and health campaigns, yet this is not the case; it is very hard to make people stop smoking, eat healthfully, and exercise regularly.

A successful intervention for changing human behaviour should be based on the understanding of how behaviours are formed and how they can be altered.

A promising approach to health promotion and disease prevention that has emerged recently is persuasive technology. The goal is to design technology that would change human behaviours or attitudes in an intended manner without using coercion or deception.

Fogg, one of the authorities of persuasive technology, identified three major factors that are necessary for a successful change of behaviour.

These include motivation, ability, and trigger. For a person to successfully perform a behaviour, he or she must be motivated. The person must also have the ability to perform the behaviour and be triggered to perform it. These three factors must be present at the same time for a behaviour to occur.

Generally, persuasive technological solutions to disease prevention are effective for the following reasons: first, they can be integrated into people's daily lives, become part of their daily routine, and cause long-term behaviour change; second, they are based on health theories of behavioural change and motivate people in accordance with their strengths; third, they capitalize on some natural and individual human drives; fourth, they are more cost-effective than all other intervention approaches, such as traditional labour-intensive counselling; fifth, they make it easy to tailor interventions to individuals' needs, motivations, and goals; and sixth, they use the just-in-time approach to provide immediate feedback at the time and place it is needed to persuade.

The appeal of persuasive technology for behaviour change is amplified by the recent penetration of mobile technologies such as mobile phone and tablets. The mobile platform provides a unique opportunity for designing persuasive technology tailored to an individual user's needs and situations.

Mobile phones have become ubiquitous today and are now an important part of most Canadian homes. As of 2010, there were over five billion mobile phone connections worldwide. Specifically, the penetration rate of mobile devices in Canada was around 70% in 2010. Mobile computing holds great potential for motivating behaviour change, because successful intervention for all lifestyle changes will build on technologies that people already use and applications that integrate seamlessly into their daily lives. Mobile phones are part of our personal space; they are proactive and can alert us at exactly the right time.

For people who want to be healthy and have a healthier lifestyle, persuasive technology would make it easier to maintain such a lifestyle. It offers refined and personalized measurements by embedded sensors and delivers feedback accessible at the point of need. For people who are not convinced that they need to change their behaviour, persuasive technology can gradually persuade them through various strategies. Persuasive technology can be designed to expose both the long-term and short-term consequences of risky behaviour. It can also present the benefit of the desired behaviour and compare it in a captivating manner with the short-term gratification of unhealthy behaviour. What is most important is that these benefits and risks can be tailored to an individual's need, thereby amplifying their effects.

Persuasive technology application can be easily integrated into the user's daily life and can offer opportune moments to persuade the user accordingly.

A typical example of a persuasive application is a cellphone that measures an individual's physical activity level and provides feedback and encouragement through an interactive graphical interface.

In conclusion, we reiterate our belief that obesity is an epidemic that requires urgent attention. Although many interventions have been implemented to combat this epidemic, they have not been very successful so far. We believe that technology intervention is a promising approach to combatting this epidemic more effectively. We propose that for persuasive technology intervention to be effective, it must generally be based on sound theories of human behaviour change, tailored to the individual user and usage context, unobstructively integrated into the user's daily life, be easy to use, and be able to intrinsically motivate a user, using various strategies.

This direction for the future of persuasive technological intervention for healthy lifestyle change forms the core of my research. With specific reference to my research, our core interest and focus is on how to tailor various persuasive strategies and theories to users and user groups.

Specifically, it is not only how to intrinsically motivate healthy behaviour change but also how to integrate persuasive technological strategies into an individual's daily life using mobile and handheld devices.

On a final note, I wish to express my gratitude to my mentors, Dr. Julita Vasseliva and Dr. Regan Mandryk, who have been mentoring me thus far in my studies.

Last but not least, I wish to express my thanks and gratitude to you, the chairman and members of the Standing Committee on Health, for reposing such confidence in me and my work as to invite me to share it.

[The Chair, Conservative, Joy Smith]

Thank you so much for your presentation. We're very grateful for that as well.

We'll now go into our first seven-minute round of Q and A. We'll begin with Ms. Davies.

[Libby Davies, NDP, Vancouver East, BC]

Thank you very much, Chairperson.

Thank you to all the witnesses for coming here today. I feel we had a very good cross-representation ranging from B.C. to Saskatchewan that included a young student with emerging ideas and technology as well as national organizations. It was a very good representation.

Ms. Collins, I really liked that you started off by quoting Dr. Butler-Jones. I think you said that he said prevention needs to drive the system, which sounds absolutely right on. The multi-billion-dollar question is, how do we change the system, and who does it? Your organization has done some fabulous work in B.C.

I have two questions to all the witnesses. First, in terms of the various roles and jurisdictions, whether provincial or federal, even at the health accords we had in 2004 there was some emphasis on health promotion and disease prevention, and everybody seemed to buy into that idea. What specifically do you believe the federal government now needs to do to follow that up and to make sure those commitments are lived up to?

In the second question I want to zero in on a very specific issue, which is dietary sodium reduction. I don't know if you're aware, but a major letter calling for targeted reductions leading to regulation and signed by 17 major national organizations was sent out in December to the Prime Minister. It seems to me that the work that's been done there has been incredibly important, and we're now in danger of losing it. That one thing, sodium reduction, would be enormously significant in terms of labelling and moving towards clear reductions. I am very concerned that we're losing ground on that aspect. Have you done anything within your groups on that isue, or through the alliance in B.C.? Maybe something very positive is going on in B.C. that you could tell us about and that we could learn from.

Those are my two questions. One is a broad one about what the federal government should do to play its role in changing the system, and the other is specifically on sodium reduction. They are for anyone who wants to answer.

[Mary Collins]

I can start, and others will chime in.

In terms of the federal government's role, I think it has several. One is obviously a coordinating and convening role, in the sense that it has a lot of potential to be the leader in bringing parties together. The Public Health Agency and Health Canada do a lot of that, but I think it could be even further developed.

We had hoped that in a new health accord—and I'm not even sure you need to call it a health accord any longer—there would be some goals and some measurable targets everyone would agree to, things that the provinces and territories would agree to try to accomplish over the lifetime of the next accord. I think that is still possible, from what I've heard from various sectors, so if we could bring people together to establish those, we would all know that we're moving in the same direction.

Obviously the provinces, being responsible for health care, play a very big role in this too, but we feel there does need to be national oversight and some national standards that people can agree to. On aboriginal issues, we totally agree with our friends from western Ontario that aboriginal health is a huge issue that needs to be addressed.

In terms of sodium, I don't know if you're aware, but the B.C. government recently had one advertising tranche, and is having another, concerning sodium reduction. We've asked to see the evaluation of those initiatives. We’re a little skeptical in that you may be preaching more to the converted, and that's a bit of our concern about the mass advertising approach. I know Health Canada is looking at that. The day before yesterday I was at a session with them concerning some of their plans to continue their work on sodium reduction, working with the provinces, and we felt encouraged by that news. Obviously sodium is a big issue and a major contributor to heart disease and is the one that needs to continue.

To get the food producers to reduce salt, reduce trans fats, and reduce sugars in their foods is really tough. This is the big problem. There are some leading food companies that are committed, but they run into the problem that consumers, in many cases, don't like the stuff and won't buy it, so it's hard for the food companies to justify to their bottom line that they do that.

However, there is some movement. We would certainly like to see more. Again, I think the federal government could provide some leadership by supporting and helping those who want to make progress and want to do things differently. It could highlight those companies, and hopefully the laggards would come behind. When all else fails, regulate. It's not the first choice, but sometimes you have to do that.

[Libby Davies, NDP, Vancouver East, BC]

Would anybody else like to answer?

[The Chair, Conservative, Joy Smith]

Would anybody else like to comment?

Dr. Forhan, go ahead.

[Dr. Mary Forhan]

Thank you.

On what the federal government can do to help move health promotion and prevention into the forefront, a truly interprofessional and interjurisdictional approach is needed. We need to learn from models that are working in other sectors that can be applied to health promotion. I'm thinking of health economists, business models, and evaluation models in health services research right now that we can integrate to look at processes of care that are open to taking responsibility for health promotion in the primary health care sector.

As occupational therapists, we are very much into health promotion. We have models of practice that can be very flexible and allow for a move away from a focus on disease to a focus on health and wellness.

I would certainly agree with Mary Collins on outcomes; we need to have some consensus on sustainable outcomes we can measure across Canada and within different areas, regardless of what our focus is on. In this connection, I would really encourage the federal government—and it's a provocative comment, but I'm doing it quite intentionally—to move away from benchmarks of weight and more towards benchmarks focused on health and wellness beyond weight. There is a lot of evidence that focuses—

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Forhan; I've been trying to get your attention.

Witnesses, when you go over time, I try to give you some notice--