Health — Issue No. 19 — Thursday, January 11, 2007 (HTML)

2006 Legislative Session: Second Session, 38th Parliament
SELECT STANDING COMMITTEE ON HEALTH
MINUTES AND HANSARD

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH



CONTENTS

		Page

Presentations		289
T. Bruce T. Warshawski C. Panagiotopoulos M. MacDiarmid R. Hulyk E. Young L. Woodland A. Hazelwood R. Duffell H. Hoult K. Romses

Chair:	* Ralph Sultan (West Vancouver–Capilano L)
Deputy Chair:	* David Cubberley (Saanich South NDP)
Members:	Dave S. Hayer (Surrey-Tynehead L) * Daniel Jarvis (North Vancouver–Seymour L) * John Nuraney (Burnaby-Willingdon L) * Valerie Roddick (Delta South L) * Katherine Whittred (North Vancouver–Lonsdale L) Katrine Conroy (West Kootenay–Boundary NDP) Michael Sather (Maple Ridge–Pitt Meadows NDP) * Charlie Wyse (Cariboo South NDP) * denotes member present

Witnesses:

Ted Bruce (Vancouver Coastal Health Authority)
Ron Duffell (Executive Director, ActNow B.C.)
Andy Hazelwood (Ministry of Health)
Heather Hoult (Ministry of Education)
Robert Hulyk (B.C. Medical Association)
Dr. Margaret MacDiarmid (President, B.C. Medical Association)
Christina Panagiotopoulos (Executive Director, Childhood Obesity Foundation)
Kathy Romses (Vancouver Coastal Health Authority)
Dr. Tom Warshawski (Chair, Childhood Obesity Foundation)
Laurie Woodland (Ministry of Health)
Dr. Eric Young (Deputy Provincial Health Officer)

R. Sultan (Chair): I will call this meeting to order. My name is Ralph Sultan, and I'm the Chair of what we call the Select Standing Committee on Health of the British Columbia Legislature. This is a committee consisting of both parties represented in the current B.C. Legislature, the NDP and the B.C. Liberal Party.

To my great satisfaction and, I think, to those members of the committee, this has been truly a non-partisan effort. There has been an absence of political intrigue, which I think has been helpful. Being politicians, sometimes we revert to our natural instincts, but all the committee members have shown great forbearance despite some juicy opportunities from time to time.

This is the Select Standing Committee on Health. We are having our final meeting today under the charge given to us by the Legislature, because it seemed highly appropriate that we do so prior to submitting our final report.

Before we really begin, I thought it might be helpful if we went around the table and introduced ourselves, perhaps starting with our witnesses today.

T. Bruce: I'm Ted Bruce, and I'm the executive director for population health with Vancouver Coastal Health. I'm here today representing our chief executive officer, Ida Goodreau.

M. MacDiarmid: I am Margaret MacDiarmid. I'm the president of the B.C. Medical Association, which represents about 8,000 practising physicians and medical students and residents in the province.

R. Hulyk: Rob Hulyk, senior public affairs specialist for the B.C. Medical Association. I've been doing a lot of the background work on the child obesity project at the BCMA.

E. Young: I'm Eric Young. I'm deputy provincial health officer for the province. I'm representing Dr. Perry Kendall, who is unable to attend today.

R. Sultan (Chair): It may well be that, if I'm not mistaken, Dr. Warshawski is participating on the speakerphone. Tom, are you there?

T. Warshawski: I'm Dr. Tom Warshawski. I'm the chair of the Childhood Obesity Foundation and past president of the B.C. Pediatric Society.

T. Warshawski: From the airport in Kelowna where my flight has been delayed due to 35-degrees-below-zero temperatures in Edmonton. Blame it on the Albertans once again.

R. Sultan (Chair): We have some officials present, civil servants who are in an observer capacity this morning, although I've explained that we welcome their full participation to the degree they feel they would like to.

L. Woodland: My name is Laurie Woodland. I'm the executive director of healthy living and chronic disease prevention for the Ministry of Health.

A. Hazelwood: Andy Hazelwood. I'm an assistant deputy minister with the Ministry of Health, responsible for population health and wellness.

R. Duffell: Good morning. I'm Ron Duffell, executive director of ActNow with the Ministry of Tourism, Sport and the Arts.

H. Hoult: Hi. My name is Heather Hoult, and I'm a director of healthy schools. I work for both the Ministry of Health and the Ministry of Education.

R. Sultan (Chair): Now we have several MLAs present physically and others on the speakerphone. Let's start with you, Dan.

D. Jarvis: I'm Daniel Jarvis. I'm the Liberal member for North Vancouver–Seymour.

R. Sultan (Chair): We hope that John Nuraney, whose name card you see in front of you, will be joining us soon. We're checking up on his whereabouts. I must say that the weather conditions here in Vancouver and in British Columbia generally have been a challenge for many of us.

I'm Ralph Sultan. I'm the Chair of the committee but also the Member of the Legislative Assembly for West Vancouver–Capilano.

K. Ryan-Lloyd (Clerk Assistant and Committee Clerk): My name is Kate Ryan-Lloyd. I serve as Clerk to this committee. I'm also a Clerk Assistant at the Legislative Assembly.

R. Sultan (Chair): I would also mention, on the speakerphone…. Val, do you want to introduce yourself?

V. Roddick: Good morning. Valerie Roddick, MLA for Delta South, which is the Ladner-Tsawwassen area.

R. Sultan (Chair): We have David Cubberley, the Deputy Chair of the committee. David, do you want to introduce yourself?

D. Cubberley (Deputy Chair): Good morning, everybody. David Cubberley here. I'm the MLA for Saanich South.

R. Sultan (Chair): Since this is my last opportunity to do so, I thought I would also acknowledge and introduce the three members of Hansard staff. Some of them are fairly recent additions to Hansard staff, but they and their colleagues accurately, diligently and — despite huge physical problems of moving complex equipment around the province — record every word that is said.

We have with us this morning from Hansard staff Wendy Collisson, Doug Baker and Michael Baer, who reminds me that he's not related to that former welterweight boxer.

I might also just mention our media consultant, in effect the communications director of the committee, Carla Shore. Stand up and take a bow, Carla. Carla has worked under contract to the committee since its formation and has done a very competent job of guiding this committee through the complex world of communications and media, which is very important to the success of the committee.

This is a public meeting like virtually all the meetings of this committee. We're delighted that some representatives of the media have been able to find their way here this morning. For that matter, perhaps some of you are just citizens, shall we say, who have come in for a free cup of coffee. If so, you're welcome, particularly on this cold morning.

As a committee of the Legislature we pursue Hansard protocol, which means that our staff is recording the testimony and comments that are made. It is also being broadcast live around the world, believe it or not. So you can be picked up in Nigeria — whatever you have to say this morning — in real time, through the services of the Internet.

The transcript of these proceedings will be available on the Internet within two or three days, I suppose. In fact, if anybody is quoted inaccurately, you have an opportunity to communicate with Hansard staff and say, "Well, you spelled my name wrong," or "I said something a little bit differently, and you didn't quite catch the meaning of my words."

I think the permanent record of Hansard of this committee's deliberations…. It would perhaps be an exaggeration to say that generations hundreds of years from now will study these golden words, but I think the fact is they do — in addition to the current public policy meaning and purposes of the committee process — also provide a superb historical record of health and social conditions in the province that future generations in fact will refer to, particularly a committee of this sort.

This is, as I mentioned, the final meeting of the committee, and I'll just read from our Clerk's e-mail to us describing what this meeting is all about.

As you have already learned, we have three very key ministries here represented by senior officials: the Ministry of Health, the Ministry of Education and the ActNow ministry. We're delighted that those three ministries are here to support us and to listen. I have suggested to them that we're not here to put them on the spot in any fashion by saying, "Well, what are you going to do about this?" or "What are you going to do about that?" because they are here in an observer capacity. However, knowing how in many ways you're already friends and colleagues in this professional area, I suspect that at least some of you would feel comfortable with mixing it up a bit and speaking quite clearly on the issues as you see them.

I would also like to, before we get into the gist of our meeting, extend to you the synopsis of a communication I received from Premier Gordon Campbell. He has written to me, thanking the committee members, in particular, for their work and for the diligence they've displayed. This has been a rather long and complex process, and he expressed the appreciation of the government for the work of this bipartisan committee.

I believe that the Deputy Chair, my counterpart on the NDP side of the House, who has played a key role in guiding the affairs of this committee, had something else to say on this subject. David, are you there?

D. Cubberley (Deputy Chair): I would like to offer, on behalf of Carole James, congratulations to the committee for its work. Carole James urges that we now focus our energies on following up the recommendations we have made, to try and ensure that they are implemented.

R. Sultan (Chair): Thank you, David, and thank you to the Leader of the Opposition for those sentiments. I am sure we will try hard to live up to her expectations.

I would like now to turn to the person who really is, shall we say, the master sergeant of this whole operation, making sure that the meetings start on time and that we know what we're supposed to be doing. That is Kate Ryan-Lloyd, and she is going to give us a little bit of a snapshot of where we actually stand on the report process.

K. Ryan-Lloyd (Committee Clerk): Good morning, everybody. The Chair has asked me to just briefly touch on a couple of steps that we've taken since the report was released on November 29. On that date the report became a public document, as the committee had deposited a copy formally with the Clerk of the House.

As the Legislature was not in session that day, it is anticipated that sometime in February — either the week of February 12 or 19 — the report will be formally presented to the Legislative Assembly by the Chair. At that time it is expected that both the Chair and the Deputy Chair would speak to the report in the House, and it will be, by way of a motion to adopt the report, that any other committee member could speak to any aspect of the report. In addition, any other member of the House can speak to the motion to adopt the report prior to the vote on the motion to adopt.

That would be, I guess, the final formality with respect to the work of this committee, who received a mandate just over a year ago to tackle this issue on behalf of the Legislative Assembly and provide them with the benefit of their advice.

In February we are also planning to have in the Legislative Assembly a revisit of our art display. As participants in the process know, we had over 400 artistic submissions by children across the province. In conjunction with the presentation of that report to the House, we anticipate having an art display again in the rotunda of the Legislature, where we will be congratulating the winner of the drawing contest — a young person by the name of Daniel Minney from Tsawwassen, who will be in attendance that day to observe in the chamber.

We have distributed the report fairly widely in the last few weeks. We have sent copies to all witnesses, such as yourselves, and experts who have appeared before the committee as well as all of the young students who participated during the committee's youth consultation process. We've tried to distribute it widely on the Internet. The committee's interactive website for youth, myhealthyspace.ca, continues to be active in seeking comments from young people, as well, on the contents of this report. We have also mailed copies of this report to all the health authorities in the province and all the schools in British Columbia as well as all the school superintendents.

That's just sort of a starting point of where we've gone with report distribution, but of course, if anyone has any suggestions this morning with respect to other agencies who they feel could be interested in sharing or engaging with us on this report, we would be very pleased to take those suggestions.

That essentially outlines the steps we've taken since November and where we look to be heading in the weeks ahead.

R. Sultan (Chair): Thank you, Kate. Are there any questions about where the report stands in the legislative process?

I'd like to introduce John Nuraney, who has fought his way through 12-foot snowdrifts to get here. We're delighted you made it, John. As we already have individually, could you just introduce yourself for the record.

J. Nuraney: I'm John Nuraney, a member of the Legislature from the riding of Burnaby-Willingdon.

R. Sultan (Chair): We have another person who has braved this severe weather to join us, from the Childhood Obesity Foundation of British Columbia. Christina, perhaps you could explain who you are.

C. Panagiotopoulos: My name is Christina Panagiotopoulos. I'm the executive director of the Childhood Obesity Foundation.

I thought it would be helpful…. We can kick this around amongst the committee members and our guests, who have the rather intimidating title of "Witnesses," but that's in fact your formal designation for the purposes of a parliamentary committee. If each of the witnesses would care to make an opening statement….

I think we're going to have a fairly relaxed give-and-take. There's no big protocol this morning. We're going to have a discussion, as the Premier has said, on obesity and inactivity, complementing his discussion on health. I would ask each of the MLAs to perhaps offer whatever words of wisdom they may wish to contribute, and then I would ask the officials if at this stage they wanted to add anything, which they may or may not wish to do. Maybe we could start, just going round the table, with you, Ted.

T. Bruce: Thank you very much, Mr. Chairman. Having gone to your website, I'm not sure whether I should address you as Mr. Chairman or "the big guy."

We appreciate the opportunity to be here today and address the contents of the report with you. As you know, our board, our CEO and our senior executive team are very interested in upstream work. By upstream work, we mean preventive activity that will help us address this huge problem.

Within Vancouver Coastal Health we have recently adopted a framework document called a population health approach framework, which sets out the role that we would like to play in leadership, partnership, policy development and advocacy. As we look at the report you've prepared, we see it as almost a model for the work we have to do. I'm sure you'll hear from many of the witnesses today that the report is very comprehensive. In fact, we certainly would agree with that.

In addition, the report really, I think, provides for us a blueprint for action. We've had discussions with a variety of staff since the report was released. I would like to acknowledge one of our staff here today, Kathy Romses. When they looked at the report, they were very, very impressed with it. One of the things they

said to me was: "This report actually provides us with an acknowledgment and validation of the work we're doing." As you know, much of the preventive work we do has very long-term outcomes, and they're often not credited with the type of work and benefits they provide for folks. So we're very pleased that the report acknowledged the upstream work we're doing.

I think the other thing the report provides for us is a tool for planning and discussion. Already internally we have, for example, in Vancouver our infant/child/youth program, which is going to take a look at the recommendations in the report. One of the things they've said is that it gives us an opportunity to look at all the work we're doing and actually take an obesity prevention lens and apply it to some of the work we're already doing. So that comprehensiveness is extremely valuable to us as a health authority.

I also want particularly to congratulate the committee on its community engagement work. Vancouver Coastal Health recently won an award for community engagement work. I look at the work you've done and the responsiveness you've had to the community at large, and congratulate you on that.

Another aspect of the report that I'd like to comment on in a general sense is the multifaceted approach to the recommendations. You have identified policy and program work across jurisdictions that has to be done. Very often we find that recommendations focus on simply a program approach, but you've also adopted a policy approach in your recommendations. The chain is often only as strong as its weakest link, so as we look at the recommendations, we certainly encourage that all of the action be taken. If we only focus on, for example, the program side of things, we won't be successful.

One of the examples I like to use is that very often our teams are out there motivating folks to make changes in risk factors and their lifestyle and giving them education and tools to make a difference in their lives. Yet if they're facing food insecurity barriers, for example, the work that we do is ineffective. They won't be able to act on that education. They won't be motivated. So the policy and program work has to be all taken together and acted on unilaterally across the board.

The report has made comparisons with what's gone on with tobacco, and I think that's a very apt comparison. Certainly there are lessons for us to learn from that.

The other general comment I would make is that from our point of view, we really are on the verge of a cultural shift regarding obesity. I recall years ago when we might have talked about the fat tax. I mean, people would have laughed you off the street about thinking anybody could talk about or in fact implement a fat tax. Now we're seeing that actually occurring. I think we really do have an opportunity here to capitalize on the cultural shift that's going on.

The shift in social attitudes to healthy living, however — I think the committee has recognized this — can clearly be undermined by the competing cultural and industry pressures. Certainly the culture of dieting can have a good impact on our community, but it could also have a negative impact on our community, as we've seen in things such as eating disorders. The entertainment industry promoting sedentary behaviour is another uphill battle that we have to fight — and also the fast-food industry.

As we look at the recommendations of the report, the committee has clearly taken a very balanced approach to policy and regulatory matters. In fact, I would say that the committee has really relied on very strong evidence and has reflected that evidence in its recommendations. We may have to see, over a period of time, perhaps a bolder regulatory approach to some of these issues. The reliance on and work with the industry as proposed through the council is, I think, the way to go. But as I've said, there are many competing interests within the cultural environment that we have to address, so over time we may have to look at bolder action.

One of the things I would suggest that the committee might want to consider — and certainly the council, if it's established, should consider — is setting some time lines and targets. You talk about the need for labelling and advertising guidelines, etc. Perhaps there need to be some time lines in place for that. If we go back to the experience with tobacco, we know that over time we've had to take a much bolder regulatory approach.

The implementation and execution of the report will be very important. The health authority sees its role clearly defined in many ways within the recommendations by the committee. We're already doing much of this work, but clearly, this can accelerate what we're doing. We appreciate the committee's recognition of the 6 percent of funding that you feel should be dedicated to some of the prevention and promotion work. I couldn't pass this opportunity to acknowledge that as important.

As you probably know, we are receiving infusions of new money right now in prevention and promotion, and have for the last two years. A lot of that funding is having to go to bolster and improve the 21 core public health programs that we operate, so we are quite limited in what we can do with the new money that we are receiving. We have made some wise investments that will help with the recommendations in this report. We've put about $1.2 million in diabetes programming, particularly focusing on screening, secondary prevention activity. We have done work in the early childhood area.

But in all of those activities that we're now trying to implement with that new funding, we do recognize the limits we have. For example, as you probably know, the B.C. Healthy Living Alliance was provided funding of about $25 million to support the ActNow initiative. We're very pleased to be working with the Healthy Living Alliance on that work. We recommended, for example, that we ramp up the implementation of vending policies in schools. The Healthy Living Alliance is taking that on, and they're going to allocate $1 million towards that work.

In their program plan they also call for the health authorities to allocate almost the same amount of money, yet through the funding we've received, we don't really have any dedicated funding to allow us to do that. So we have significant limits in what we can

Again, for that commentary from the committee — we appreciate it and look forward to continued infusions of new funding in the public health arena after '07-08, which is the last year that we understand those funds will be made available to us.

I'll draw to a close there, because I have, obviously, an opportunity to participate in the discussion today. I very much appreciate that. We have some comments on specific recommendations, which we'll get to in the discussion. The issue of a registry and the issue around food insecurity are two areas that we particularly would like to comment on.

In conclusion, Mr. Chair, we're very pleased to have this opportunity. We really appreciate the comprehensiveness of the recommendations in the report and the fact that it really does provide a blueprint for action. Thank you for the opportunity to be here today.

Before we proceed to our next witness, I might just interrupt again to say that my colleague Katherine Whittred has fought her way with snowshoes and skis to get here, I'm sure, from North Vancouver. Katherine, like the rest of us, could you introduce yourself to the panel.

K. Whittred: I am Katherine Whittred. I am the MLA for North Vancouver–Lonsdale.

R. Sultan (Chair): We were each making little statements, Katherine, so as we work our way around the table, maybe you could offer a few words when we get to you.

T. Warshawski: The Childhood Obesity Foundation congratulates the Select Standing Committee on Health for their exemplary work. These comprehensive recommendations in general are excellent and, when implemented, will be a significant step in improving the health of the province's children and youth. We wish to recap our view of the solutions to the epidemic of childhood obesity and how the strategy for combating childhood obesity in B.C. meshes with them.

In terms of key actions, we think there are five which are well supported by the evidence. Foremost is to decrease the intake of sugar-sweetened beverages. We know that one of the major contributors to the childhood obesity epidemic is the overconsumption of these beverages. One can of soda per day increases a risk of obesity by 60 percent. The studies show that between 30 and 50 percent of Canadian teenagers drink at least one can of soda pop per day.

Parents and children need to become educated on this important issue. It's a critical piece of social marketing which needs to be pervasive and sustained in order to counter the powerful marketing campaigns funded by the soft drink manufacturers. So recommendation 36, the social marketing campaign, will be crucial.

In addition, we thought it was quite elegant, in recommendations 16 and 17, with regard to the social services tax exemption in order to have these products pay their way. Recommendations 12 through 15, on sales, and 19, 21 and in particular 34 through 35, on preschools, would also be invaluable along these lines.

Our second major view or goal from the COF is to see a reduction in the time children and youth spend with electronic media — that is, monitor time. The latest Canadian community health survey data indicate that children who spend more than two hours per day in front of a monitor have double the risk of overweight and obesity — 36 percent — compared to children who watch less than one hour per day. We know this is a critical piece of intervention, and we would hope that this message will be a component of any social marketing campaign.

The third major focus should be on instituting comprehensive school health programs and the policies that support them. We know that school programs reach across all socioeconomic status sectors and therefore are efficient at targeting vulnerable populations.

The research evidence suggests that school-based interventions that adopt a comprehensive approach have the highest likelihood of achieving changes in health behaviours in childhood. Many of the recommendations in the strategy support this approach. In particular, 22 and 23, with regard to increasing physical activities in school, are essential.

A fourth major policy initiative should be to create treatment centres for childhood obesity. The recent CIHR report entitled Addressing Childhood Obesity: The Evidence for Action has stated that any treatment intervention is associated with a significantly increased chance of improvement and is favoured over no treatment.

However, despite this endorsement, there was only one obesity treatment centre in B.C. We feel that this is a key element which is still missing from the committee's strategy, and we hope there will be an opportunity to amend our recommendations to include what we think is a very vital piece.

We know that children who are obese when they enter into adulthood will likely die seven years earlier than their normal-weight peers. The younger the intervention begins, the better the chance the BMI will drop. We think this is an essential public health measure which is not fully covered by either the acute care component or the preventative component but needs to be addressed. The strength of a recommendation from the strategy could be essential in seeing this implemented.

There is probably a fifth policy plank which the Childhood Obesity Foundation would like to see incorporated into the provincial program, and this is increased support for research and evaluation of childhood obesity prevention and treatment initiatives. Our province has a number of excellent programs, but our ability to take advantage of the natural experiments that are underway is limited by lack of funding. For example, as more

obesity treatment centres will, hopefully, be created, they will need a well-funded research and evaluation arm.

In keeping with this point, as well, we just want to make one comment on recommendation 1 with regard to monitoring. We know the magnitude of the childhood obesity problem in British Columbia. We don't feel, really, that more random monitoring is needed. What is crucial, however, is focused measurement of particular child and youth populations, both pre- and post-intervention. For example, with school-based programs such as Action Schools or with treatment programs or with groups exposed to social marketing, we want to know what the effects of these interventions are both before and after so that we can compare those populations.

Lastly, although not directly related to the specifics of our views on childhood intervention initiatives, we soundly support the recommendation to increase the percentage of public health funding from 3 percent to 6 percent.

In summary, we applaud the great work of the committee and urge the speedy adoption of its recommendations. I want to thank you all for your great work on this.

C. Panagiotopoulos: No, I won't add anything. I think that was great. Thank you, Tom.

T. Warshawski: Thank you, Ralph. I'm going to stick on the line until…. My flight is set to leave in about 45 minutes.

R. Sultan (Chair): Wonderful. We hope you can participate in the discussion.

M. MacDiarmid: Mr. Chair, I'd also like to extend my compliments to the creators of this report. It's great and encouraging to hear that it was a non-partisan approach. I think this is something that everybody can get together on. It's such a worthwhile project. My first exposure to the report was in black and white, and when I actually received my colour copy and was able to appreciate the artwork…. It's a wonderful addition.

I think the consultation and the actual comments from the young people are invaluable — for example, with respect to things like physical activity, that sitting in a gym and watching other people play volleyball after you were knocked out is not what we're looking for at all. So I thought it was a great addition. My compliments to whoever the genius was that thought of including the artwork.

I'm a family doctor in Trail and actually live in Rossland, so I'm used to several feet of snow. But I must say, the challenges we all faced today here in Vancouver to get here were interesting. I'm really delighted that we were invited to the discussion today, and we'll want to be part of further discussions as well.

When we think about what has been happening in the field of childhood obesity over the last number of years, there has been some good work done. There's no question. But it seems that it's not making a dent. We're looking at the numbers and seeing that, as far as we know, the numbers are probably increasing rather than flattening out and decreasing, which is what we want to see.

It seems there's a big barrier of inertia that we have to overcome. I think the recommendations in your report will be extraordinarily helpful from that point of view.

There are also a lot of difficulties around language and feelings around obesity. Parents whose children are obese and overweight often feel like they're a failure. The children themselves may be targeted and exposed to unkindness and what I would call "fat bigotry."

We also have to be keenly aware of the prevalence of eating disorders — the undernourished, the child who is dieting at age five or six. We've got to be really sensitive in the language that we use. I think everyone has an appreciation of that, but tackling it head-on may be something people kind of dance around because they want to be careful to be politically correct, not hurt anyone's feelings, not use language that's hurtful and those sorts of things. I think there are barriers. They clearly have to be overcome, and the sooner the better.

We think about costs. The costs are important. The health costs are just going to be phenomenal to this province. Also, the cost that's not a dollar cost — the lost productivity, the premature death and disability. We need to think about those things.

When we sat before, when we made our recommendations to the committee in April 2006, there were three recommendations. The first one was to do with data collection. The data collection we're talking about is certainly not piecemeal or random. Our recommendation is that it be done provincewide. We really don't know the extent of the problem. We think we do, but we may find that when we actually get to measuring, it's worse than we thought it was, or maybe better. But self-reported data has been shown in the past to underreport.

We think it should be a fulsome process in all the schools. We were delighted to see that recommendation embraced by the committee and that it's your first recommendation in your report.

We think that if we're not also measuring in a really thorough way, we're not going to know what succeeds and what doesn't. We're not going to know whether we're doing better in this province and whether we're going to achieve the great goal that the Premier has set for all of us, for the province.

The second thing we recommended was the promotion of obesity prevention and treatment in primary care with a focus on healthy weights and lifestyles and, thirdly, the implementation of nutrition and activity standards for children in our schools. Those are straightforward and things that I think everybody probably has agreement on. We just need to go forward and do things.

Thinking about why we do these things, why you were successful in having a non-partisan approach and why people from various ministries are here and probably delighted to take the time to be here. A population health approach is important. I've already referred to the cost, both dollar and non-dollar, but I think there's a real human face to this.

I have a brand-new nephew — two months old, just learning to smile and laugh. You think about that little person. Rob Hulyk, to my left — his wife has just had their first baby, a beautiful baby girl born just before Christmas. Everyone here has nephews and nieces, children and grandchildren. Tom Warshawski and myself have our patients.

Those are the faces we're thinking about. That's why we really need to sit down, hunker down, get going, and why we're all hopeful that the recommendations in this report will be embraced, taken up and appropriately funded so we can go forward in a really positive way.

It is a very positive report, as well, in terms of constructive ideas — very thoughtful, very in-depth — and has some recommendations that I think will accomplish great things for B.C. Thank you again for including us.

R. Sultan (Chair): Thank you, Margaret. Robert, do you have anything to add?

E. Young: On behalf of Dr. Perry Kendall, who's our provincial health officer, and our office, I'd certainly like to reiterate what everyone else has said in terms of congratulating the committee, the committee Chair, the Deputy Chair, the researchers who pulled all of this information together and the staff, as well, for an excellent job.

We also really appreciate the opportunity to come back and give you some direct feedback on this. I think it's a wonderful opportunity.

This is an excellent overview of the issue. The scope of the recommendations is quite comprehensive — the ideas around food security, aboriginal health, cultural sensitivity; the support for ActNow, for enhancing public health funding, for Action Schools B.C. and for enhanced physical activity in schools, better nutrition programs, dealing with junk foods in vending machines, all of those issues. Infrastructure to access recreational facilities, the necessity for personal safety, for urban design…. I think you've really covered the waterfront with this.

The approach you've taken here with respect to social marketing and looking at social marketing from a positive perspective in terms of good nutrition and physical activity as opposed to targeting the obese, I think, is the way that we really have to go. Going the other way would actually be detrimental. We have enough trouble with eating disorders, as Dr. MacDiarmid mentioned.

Thank you very much for this. It's a great start. I think that a lot of the recommendations actually overlap the recommendations in the provincial health officer's recent report on food, health and well-being, which we put out in the fall, and the report that the PHO put out in 2003 on schools as a setting for health promotion, as well as the Forum on Childhood Obesity in 2005. This additional report will go a long way to creating the supportive environments that we need, rather than the current obesigenic environment that we're living in.

What I wanted to also address, though, are the issues around what else government and its partners will need to do as well as following many of the recommendations that you've made, if I may. Actually, I'm going to be saying a lot of what's been said already, but I'd like the indulgence of the committee to repeat it for emphasis.

The school program concept with respect to nutrition and physical activity as part of a comprehensive school health program, as Tom has mentioned, is really the way to go — dealing with mental health, emotional health, etc. We do know that obesity is a societal problem, but from the child's perspective, that may not be the child's most immediate problem.

If we look at the previous report of the MHO on school health, 2003, the McCreary group pointed out that mental health issues like depression occur in…. Twenty-one percent of females in grade 12 had contemplated suicide and 12 percent of males. That's an indication of depression, self-loathing. For those people, those would really be their critical issues.

Sexual abuse of girls by the age of 17. The McCreary report, and it's commented on in our report…. One out of four girls in British Columbia schools reports being sexually abused. So there are other major issues. I think it's really important, then, that when the government takes this forward, they do look at this as a part of comprehensive school health.

Secondly, with respect to health promotion. The focus has been on health promotion, but to reiterate what Dr. Warshawski and Dr. MacDiarmid said with respect to treatment, once we're doing promotion, we also have to have effective screening and effective treatment. The system has to be able to provide those services. As we start to enhance societal awareness, we'll have more people coming forward, we hope, for early diagnosis and treatment of these things. A lot of children have a number of cardiovascular risk factors by the age of ten. That's going to require support in the system.

The involvement of parents and families is a really critical piece in all of this. Children in preschool and elementary school basically eat what their parents give them and what their parents model to them. These children also are taken to places to exercise by their parents or encouraged to exercise or run out and play, etc. So the partnerships that we have to have with parents are really critical, and I think that's where part of the social marketing piece will come into play. That can also be interwoven into follow-up and implementation of many of the recommendations that you suggest.

The research piece, I think, is critical. You do mention that this should be all evidence-based. You do mention that we need program evaluation. I would support what Tom said about primary research on identifying issues that have led to this obesity epidemic rather than only just focusing — and I'm sure you didn't mean to — on what programs are working to fix it — so actually doing more in-depth research on the analysis of what are the psychological, economic, environmental, social factors that have led to this.

To reiterate what Tom said with respect to inactivity elements or couch-potato time or however you want to call that…. He calls it monitor time, I think. Maybe that's the current buzzword. That's a really big problem and needs to be addressed. That's got to be a part of this comprehensive approach to dealing with this.

There are a few areas where I think we have a different perspective from the recommendations in the report. There are three that I just wanted to make quick comments on, and we can discuss them further later. One is the recommendation to enhance corporate self-regulation of food and beverage advertising and marketing. The PHO report on food, health and well-being actually identifies government as being responsible for that kind of monitoring. So we have a different perspective there.

I think we also have a different perspective with respect to…. Although we fully agree with developing ways and means to scientifically measure the rates of overweight and obesity in children in consultation with the Privacy Commissioner, which you clearly outline and which I think is spot-on, we question the utility and the cost-effectiveness of a child health registry. I think we need a lot more discussion around that.

We need to know what it will do with data it would collect, by whom, for what purpose and at what cost. Then, also, what are the opportunity costs of doing that? For example, is it more cost-effective to look at the current research studies that are going on and add a piece to those?

We have the EDI, early childhood development index, that's being developed by Clyde Hertzman at UBC. A lot of work has been collected on kindergarten, about where children are in their physical health, emotional health, readiness to learn, etc. Adding on height and weight measures might be a very inexpensive way of doing that.

The McCreary Foundation has studies that are ongoing, but we need to not only look at what the numbers are. We need to know what is causing those numbers and what the risk factors associated with those numbers are so that, as Tom mentioned, we can actually go in there and say that this intervention will work, or that could be tried, etc. Then we'll evaluate that, as you recommend in your report.

My last comment is on recommendation 11, which is with respect to the development of an action plan for population health, interventions to address type 2 diabetes. From our perspective, to target a specific disease with health promotion is no longer the way to go. The approach now is to take the approach we're trying to take across government, and that is the action now approach.

The same risk factors — like obesity, inactivity, etc. — that lead to childhood obesity, adult obesity, hypertension, cardiovascular disease, cancer, etc., go across all of these areas. So a better approach than targeting promotion for prevention of a specific disease is targeting promotion of the risk factors that lead to those diseases. Certainly, you do need strategies to enhance things like diabetes. Screening — make that better. Make sure treatment is better, etc. — the management piece.

We need strategies for pieces, but I think, actually, that the broad strategies of ActNow B.C., Action Schools B.C., etc., are the way to go.

R. Sultan (Chair): Thank you, Eric, for some provocative ideas and some constructive disagreement. That's very helpful.

I don't know if the officials have any comments they would like to make at this time. Anyway, there will be lots of opportunity as the morning proceeds to participate in discussion or ask questions. This is pretty unstructured. Laurie, do you have any…?

A. Hazelwood: Just maybe a comment, without restating and recongratulating the committee, because I think you've done a wonderful job. These reports are terribly helpful to ministries and to a variety of parts of ministries to give us a road map. It does, as others have said, kind of validate to a certain extent what we're doing, but it also helps us move those agendas forward.

It was interesting to note that you also gave a bit of a report card on the previous select standing committee's report. That in itself is very helpful to keep us focused on: what have you done, and what are we going to do with this?

The other thing that I think has been mentioned by the witnesses is that it's becoming more and more evident that if we're going to be successful in population health, we really need to take a whole-government approach in order to implement the type of recommendations that both this report and the previous report provide us. This isn't a health issue. This is a whole-government and, really, a societal issue.

Unless we start engaging the rest of government — and I'm speaking from a Ministry of Health perspective…. We really need to engage, and it's nice to see colleagues from other ministries here at the table. But you also need to engage the Ministry of Finance. Certainly, food policy in the Ministry of Agriculture is a very important player. You can go ministry by ministry in government, and you pretty well….

These decisions — well, they don't have to be acted on by all of government at the same time. It's that cooperative approach where you get the Ministry of Health, Ministry of Education, Ministry of Agriculture, Ministry of Tourism all working together towards a

common goal so that we're actually going to see significant changes in population health over time.

I think this report certainly validates the ActNow approach, which is really a whole-government approach to health and public policy. I think it also validates the need to engage civil society. Unless we engage those non-governmental sectors to assist government and their volunteers in order to take the message into the community, I don't think we can be successful as government by ourselves.

It's really changing a societal norm. One of the witnesses mentioned that we've got a lot to learn from tobacco. If you think back 20 years ago to what was kind of normal in this province around tobacco and tobacco control, it's a very different world now. We've actually changed a societal norm within about a 20-year period; 20 years ago 50 percent of the adult population were smokers. There probably would have been ashtrays on this table. There certainly would have been ashtrays in most homes, because it was the polite thing to do.

It wasn't just Ministries of Health or health authorities or education telling people that they shouldn't smoke. It was a combination of public policy, of a societal norm being changed through civil society, the Canadian Cancer Society and the heart and lung association.

How do we do that and change a societal norm in healthy eating and physical inactivity? These are some real challenges. I think we need to kind of rethink the paradigm. There's a lot to learn in tobacco, but you don't have a big, bad tobacco industry when you're dealing with physical inactivity and healthy eating.

It's a different approach. I think there's lots to learn. These kinds of reports really give government and the bureaucracy a bit of a road map. I just wanted to kind of set that as a stage and congratulate the committee for doing that.

Just, again, to extend congratulations on the report. The ActNow is really, I believe, well suited to look at this report as a whole-of-government linkage, as the recommendations highlight. I'd like to think we have a stage set to look at issues in a broader sense now.

It was mentioned by Ted earlier to look not just at the programs but at the policies that influence daily lives and the programs, the legislation and all of the aspects that contribute to the health of the population, more so than the disease of the population.

I'd just echo that the position we look at is seeing this as broader than health. Some of the greater influences on our health are outside the health industry, and that's where we see some of the recommendations mobilizing that. It provides a blueprint and guide and is a very useful report. Congratulations.

H. Hoult: Thank you very much for offering the opportunity to be here today. I think it's great.

I, too, echo what's already been said in this room, but the one thing I would add is that I see that the formalized relationship and partnership between the Ministries of Education and Health clearly has really helped to move health promotion in general forward in the education setting. I think that we've been working across the system with regard to health promotion in the school setting for two years now, and I see a substantive change in the outcomes of that. So I see this as very positive in supporting that cross-system or whole-government approach, which I, too, agree is critical for this kind of change.

What I would like to propose now is that I give each of the MLAs an opportunity to either make a comment or perhaps ask a question or two, without getting into too much depth, starting with our Deputy Chair. Then we would have a brief coffee break, and then we would come back and have a general discussion.

On a delayed basis I'm giving the Deputy Chair the opportunity to make the lead-off comment or possibly ask questions on the part of our witnesses and others here.

D. Cubberley (Deputy Chair): Thanks to all the presenters for their insightful comments and, also, for the praise for the committee, which is enjoyable to hear, I'm sure, for all the members.

I'd just like to say a couple of things. One of the things that impresses itself on me is that the message being received by kids and parents about food choices and what's acceptable in food choice has to change if we're going to change anything at all. Similarly, the environment in which choice is occurring needs to be consciously modified in order to actually make the healthy and the active choice the easy one. There's obviously no quick fix for that. It's going to require concerted action on a number of fronts.

In the report that we have put together we have tried to create a strategy which I think will help to move those things forward. It doesn't represent a quick fix. It does require concerted action on multiple fronts, and what I think would be a tragedy would be if it were treated as a menu from which you can pluck a few items rather than being seen as an integrated strategy. I was very encouraged by the comments from all of the presenters in support of the general approach for the number of individual approaches embedded in the report.

One of the things that was balm to my ears was to hear the support from a number of presenters for the need for a comprehensive social marketing campaign to begin to change awareness, especially on the part of parents but also awareness around the messages being aimed at children. I think that is going to be, if we can achieve it, a very important vehicle in helping all of the other things that we're trying to promote to move forward.

It will be a challenge because…. It's not unprecedented, as we heard, and I was pleased to hear the reminder of how far we have moved with tobacco as a

society. In 20 years it has really been flipped right over, to the point now where it is borderline not socially acceptable behaviour, where once it was entirely endorsed and people were not conscious of the fact that there was a problem. And that's really happened in a couple of decades, perhaps 30 years at most.

Central to that changing of how we view tobacco has been intensive and sustained social marketing. I think we're going to have to encourage government to take the long view in this regard, and I'm just very pleased to hear the support around the room for the idea that we need to alter perception about food choices and activities and how essential activity is to a healthy life.

There are lots of individual things that I'd like to take up, but I don't want to occupy all of the field right now. Maybe we can hear from others and then have a broad discussion.

R. Sultan (Chair): Thank you, Deputy Chair. Val, do you have any comments or questions?

V. Roddick: Yes, I would like to make a couple of comments to follow up from David's and Andy Hazelwood's comments.

It does seem to me that this is going to require terrific work with the education system, as Heather was saying. We need to work with the schools. That tobacco…. Yes, it was great with the posters and the TV ads, but really, I think what made it was that whole generation of children coming home to their parents and saying: "Don't smoke."

I hate to say: "Put one more thing on schools." That's why I say very, very strongly that we have to work with the schools and the Education Ministry and the teachers, because we can't just keep piling more responsibility on them without giving them the support they require to carry this out.

A comment, I think from Tom in the Kelowna Airport, about treatment centres…. I think he was the one who was talking about that. Really, there's only one in B.C., but could we not, again, work with the schools here and the phys ed teachers and that sort of thing to possibly look at the ability of working that into the school system? Again, we need to give the proper support to be able to do that.

I like the word "agriculture." I heard it there a couple of times. Definitely, the food is the big deal. How do we make sure that they know about where their food comes from and that it's good food? But I feel very strongly that a positive change is starting. I get two flyers at my house. I now read them. I hate flyers, but I now get those food flyers, and I look at them.

Choices sent out a four- or six-page flyer with all sorts of courses and sessions that they were offering, not just in exercise but in choices on what foods, etc. And Save-On this week had a green insert in their food flyer about good choices. This is what we really need to push, and work with them, as well, to enhance the general public awareness. I think these newsletters are great.

The other thing I'd like to ask Kate: did we send a copy of this report to all the general produce managers of all the major grocery stores?

K. Ryan-Lloyd (Committee Clerk): No, we haven't, Val, but I'd be pleased to take that suggestion. Thank you.

V. Roddick: I don't know what the Chair or vice-Chair might think about that, but when I say the produce managers…. You know, there's a produce manager for every store. That would be provincewide, so it might be a huge undertaking. I don't know. It would be helpful if these stores could have this kind of material. This is a fun read when you flip through it. It's brilliantly produced.

R. Sultan (Chair): On that score, Val, we've pretty well depleted our first run of about 5,000 copies, and Kate is talking about going to a second edition. Is that the right terminology?

I'd like to ask each of the other MLAs here in person if they had any comments or questions, but we do want to take advantage of this unique assembly of experts and expertise, so I would ask you to keep your comments to our typical brevity.

D. Jarvis: When I was appointed to the Health Committee and the subject of childhood and adolescent obesity came up, I was a little apprehensive as to what it is. Like all of us — or me especially, who has fought weight all my life — you tend to continually look in the mirror, and you don't see any difference or any change, and there's no necessity to be worried about it.

There's no question that since sitting on this committee…. Childhood obesity is in a crisis situation, it looks like, throughout not only this province but the world. It's one of the toughest subjects to really make the public and children aware of, and it will not be a problem that can be cured overnight. It's going to take a long time to correct the obesity situation that's such a serious situation out there — and specifically to our health care system that we have.

Pages 93 and 94 lead to some of the medical things that could be caused by obesity, from heart disease and cancer and diabetes — and diabetes being one of the major things that is occurring right now to a lot of people of my own era.

Perhaps the other alarming aspect is the cost of what is occurring as a result of adolescent obesity. We all know that our health care system is badly stressed right at the moment, and when you read this report, you'll see that if you project it out into the year 2015, we're going to see possibly another billion dollars added on to our health care costs. Ostensibly, 70 or 80

cents out of every dollar that we produce in this province will be going into health care. That is something that really has to be corrected or changed to some degree. How we're going to do it — really, we do not know.

I think the focus of this report will be to…. It's a vehicle to be put forward to…. You know, some people have pooh-poohed the Premier's discussion on health project and the ActNow, but those two programs will certainly help us with our obesity problem — help make people aware of it.

Let's hope that we will be able to correct the situation like we have with, for example, cigarettes. It took me 20 years. I've been off smoking for 20 years, although I smoked for about 45. It's a hard habit to break. Eating junk food is a very easy habit — just like smoking — once you get started into it. So let's hope this report will be of benefit. I thank you for your time.

J. Nuraney: I also want to mention that the report has hit the right buttons in terms of the people and the stakeholders who are involved and interested in this area.

There are a couple of things on which I would like to pick the brains of our experts who are here in the room today. We talk about social marketing. I would like to hear some specifics as to what and how we could effectively implement this social marketing to encourage — and not only just to encourage, to make — the shift to take place.

The social marketing is targeted, I think, towards making that shift from not eating properly to eating properly. That is one thing that I would like to hear from our experts in terms of specifics: if they have any ideas as to what could be a good, integrated approach — perhaps lessons of what we learned from the tobacco history in British Columbia and Canada as to that shift that took place and what it was that made that happen. Some of those specifics and facts, if we could have them in front of us, would help us in moving forward.

The second thing that I would like to put in front of the group is the word "obesity." As the Chair of the Education Committee on literacy, I have just finished a report of our committee. One of the things we found out was that there is a stigma attached to the word "illiterate." When you want people to come forward to say that they cannot read and write, there is a stigma attached to that — socially and sociologically.

The word obesity may perhaps assume that connotation. When you talk about obesity centres, maybe people may not want to go there, thinking, "Well, if I go there, I'm fat," or some such connotation as that. I would like you to put some thought behind that, as well, as to what would be a more friendly term to use when we do launch a campaign of this sort to try to encourage people to be more active and to eat healthily. It is all relevant — not relevant, really — but we are directing it directly to the word obese. So maybe there are some suggestions in terms of how best we can make this happen in a much friendlier way.

R. Sultan (Chair): Could I ask our experts to take John Nuraney's questions to ponder during the coffee break? I would like to move along, and I want to have John's issues addressed, but perhaps just try and hit a coffee break here at 10:30, to make everybody aware of our schedule. We could ask Charlie and Katherine to make their comments, have coffee and then come back, and maybe we could begin by addressing John's important questions. Would that be acceptable?

J. Nuraney: Mr. Chair, just one more small point before I forget. In terms of technology, we have now also realized that obesity is caused by watching television and being on computers rather than riding a bicycle or going out into the park to play. Is there any way we can hook into the terms of technological advances to discourage obesity?

R. Sultan (Chair): Okay, good questions. Charlie and Katherine, we'll let you have your say, and then we'll break for coffee.

C. Wyse: I would firstly like to acknowledge the validation that we've heard around the table. As a committee, our overall goal was to try and come up with a vehicle to address an issue that has taken literally years to develop. The vehicle isn't perfect. That we do know. But it is good to hear from this group of experts that there is perceived to be validity and that there is some usefulness, then, contained in the report.

Now, something that I have learned, and I simply want to state it here. As the issue is prevalent right across the entire province, we're not anticipating that one solution is going to fit all situations. There is this rural-versus-urban component. There is an ethnic sensitivity that is required in our solutions as well as an affordability to all segments of society for the achievement of this overall goal.

Where I am going is that as our job wraps up and we present our report, one of the key aspects that we saw as a committee was the need for a long-term commitment to achieve this goal. As the issue developed over a long period of time, we likewise are not anticipating that the solution is going to be found immediately, nor is it likely going to be found in one area.

Similar to the point that John was making, what I am looking to hear from this group is: how do we move from government accepting its role and responsibility to enlarging all of society in general in accepting their contributing aspect to the problem as well as to the solution? Using the example that you have brought forward to us, this issue of tobacco versus food, though there are some similarities contained in that analogy, one of the things that we face in dealing with the issue of obesity is that tobacco can and has been set up as a boogeyman. Food is a requirement in order to live, and therefore we likewise are not in a position to set that up as a punching bag in order to achieve the overall goal.

The point that I would like to leave with our panel is that broad question of how we move from here with

We have suggested a nutrition council to help provide a vehicle to get started in that area, but we also recognized that there were some inherent weaknesses also contained in it. That would be the broad question that I would like to take advantage of this group of experts.

K. Whittred: One of the things about speaking last is that it's virtually all been said. I'm simply going to give a very personal comment, and that is that of all the committees I've ever been engaged in, since my time in government began in 1996, this has certainly been the most rewarding.

Several of our guests today spoke about the success that we had in making this a non-partisan committee and a non-partisan report. That's something I am extremely pleased about. I think, number 1, it's a tribute to those of us who sit on the committee — every one of us, and our Chair and our vice-Chair in particular. But I think it also, to some extent, reflects the nature of the subject that we were dealing with. When you're dealing, as someone pointed out, with children or, in fact, any population, it's a pretty non-partisan kind of subject.

I am particularly pleased with the feedback that we've received today and the manner in which people have pointed out that we seem to touch all the bases. I think that the committee — and I commend the Chair for this once again — in terms of the guests that we had and the witnesses we heard from, certainly gave us a very broad perspective.

The non-partisan nature was something that I did want to reinforce. The other was the point that Andy made about this being a whole-government problem. I won't dwell on that. I think that is also extremely true and, I suppose, to some extent self-evident.

I think that whole-government approach or concept is going to be the greatest challenge, perhaps on two levels. One is on the government level itself. As some of you may know, I am Chair of the social development committee, and that is actually my job. My job is to deal with these cross-government or cross-ministry initiatives. It is frequently quite challenging.

The second part of that I think is going to be to take those down to the community level. At some point we have to engage not just the people at this table or the people in ministries. We can make wonderful solutions at this level, but we have to engage, as I think Dr. Young pointed out, the parents and the children themselves. There's no one more rebellious than a 13-year-old who says: "It's my bound duty to eat as much junk food as I like."

Teachers. It's been pointed out by Val most eloquently that we're asking the schools to take on a big job here. People in rec centres, people who organize programs at the community level and so on — all of those. Getting it down to that community level is, I think, going to be another huge challenge. I'm sure we're going to be up to it.

R. Sultan (Chair): Before we break, I've been passed a note to make sure to ask Dr. Warshawski for his views on social marketing in response to the questions that some of the MLAs have had.

We will put you on notice, Tom, if you're still there. Are you still there, Tom?

T. Warshawski: I'm still here. I welcome the opportunity to discuss this further.

What I'll do is I'll hang up for the duration of the break and then call back in. What time do you expect to resume, Ralph?

R. Sultan (Chair): The meeting has been reconvened, and David and Tom have been having a spirited exchange of views on the phone.

Before we do that, I don't know if any of the media are still present. The Clerk suggested that I clarify one point that has received considerable media attention — namely, the issue of the junk food tax and have we, in fact, recommended a junk food tax. As those of you who have spent some time looking at the report probably realize, what we did strongly recommend was that the tax exemption on soft drinks and chocolate bars — which curiously is written into law as a separate line item from goodness knows what era — be removed.

That has, in fact, already been discussed with Minister Rick Thorpe as a possibility. Of course, it would be up to the Finance Minister and Revenue Ministry and the government to decide what to do about that particular provision.

Insofar as a junk food tax — a special new tax — I sensed that the committee was warmly disposed to that approach but didn't feel it had quite enough evidence to make a strong recommendation in that regard and suggested that a committee involving industry representatives, in particular, be struck to consider that possibility.

We have three issues that might be interesting to pursue in our open debate and discussion portion of our meeting this morning. We will, I think, terminate the meeting promptly at 12 o'clock.

The first is the issue of social marketing campaigns and specific components and strategies — explaining just what that might look like on the part of government. A second issue that I think has already been raised as one where there is not unanimous sentiment is the child health registry. I think we could well have further

discussion on that important recommendation. Thirdly, because of its pervasiveness, I think we could indeed spend more time just discussing school health programs.

Could we begin by responding to John Nuraney and, I think, Charlie. Indeed, I know this is a pet topic of our Deputy Chairman Cubberley: social marketing campaigns.

T. Warshawski: Well, yes and no. I want us to recognize that the viewpoint I bring to this is one of a clinician and sort of a scientific one.

Based upon the science, what do we actually know? We know that obesity is increasing dramatically. We know that obesity cuts years off people's life expectancy. We know it's going to cost the public health care system and all of us hundreds of millions of dollars into the future.

We also then have to look at the evidence to see what the major contributing factors are, which a review of the evidence would say are areas that need to be addressed. In childhood, one of the biggest issues which is shining out and needs to be addressed is the ingestion of sugar-sweetened beverages.

As I've said, the data is totally clear that there is a strong association between drinking sugar-sweetened beverages…. There is the dose response in that the more you drink, the earlier you become obese and the more obese you become. There is also an intervention response. If you can get people — and kids, in particular — to decrease their intake of sugar-sweetened beverages, they begin to lose weight or lose their BMI. This is very clear, evidence-based.

In terms of how you actually do that from a marketing strategy, that's one for the marketers to give us some advice on. But one of the caveats I really want to throw on the table is that this committee and government cannot shirk confrontation with industry if and when it's necessary.

Frankly, the sugar-sweetened beverages are being misrepresented as beverages when in fact they are really just liquid candy. These are desserts. This is not something that should be consumed with your meal. It should be in lieu of a dessert. The type of messaging that needs to get out there is going to be diametrically opposed to the interests of industry.

I know that people often will want to spin this to a positive thing and say: "Well, there's no such thing as a bad food. What we need to do is just exercise off all these calories." But that is very, very difficult to do.

I've given this example when I went before the committee, but I think it bears repeating. The normal serving now, which has become the norm for a soft drink, of 500 millilitres or 491 millilitres is 260 calories. It would take a 13-year-old boy 50 minutes of jogging merely to burn that off. That's going to be a lot to ask, and in fact most kids will not do that.

We know there is good evidence that there are school-based modules to get kids to decrease soft drink intake, that there are treatment modules to do it and that kids will lose weight. So in terms of social marketing, that's a big one — sugar-sweetened beverages. It's kind of a negative message. We've got to decrease the intake, but I'm very sure it could be done with the skilled advertisers and marketers we have.

The other one is on monitor time. We know for a fact that kids with over two hours of monitor time per day have a doubling of the risk of obesity. Kids with television sets in their bedrooms have a doubling of these rates.

There is a huge piece here that I think only government can fill. The citizens of the province collect money to give it to the representative taxes. They elect people such as you to oversee their well-being on particular policy issues. Health care is one of the most important issues to the citizens of this province. The expectation is that groups such as yours and groups such as the government caucus will look at this information and make the necessary and sometimes hard responsible decisions to turn this epidemic around.

We have here three of the leadership institutions that British Columbians rely upon to educate us about healthy living — namely, the BCMA, the provincial health officer and our own Vancouver Coastal Health Authority. How do you respond, if I could ask you directly the question that John Nuraney and others are raising?

We are convinced, I think we can take for granted, of the problem, as Dr. Warshawski has just reiterated. The question now is: what are the specifics of this social marketing campaign we keep talking about? What is it exactly? Anybody care to tackle that one?

R. Hulyk: I think I'll start, and in doing so, I'm actually going to tip into the registry issue as well. The first point that everybody knows is that we are competing against a multitude of marketing going on out there. They have more opportunities to do it, and they have more money.

In terms of addressing this from a marketing standpoint, when you do these things that we're talking about, you have to make them as effective as possible, which is one of the reasons that the BCMA made the recommendation around the registry. One of the reasons for doing that….

When you look at Arkansas, in terms of their experience, they have measured 450,000 children each year for the past three years. I just want to read very quickly the opening line of their report, which just came out a couple of months ago. "Analysis of the year 3 BMI assessments of public school students reveals that the progression of the childhood obesity epidemic has been halted in Arkansas. Despite these results, almost 38 percent of children and adolescents in the state continue to face obesity problems and associated health risks."

The point is that they're able, every year, to have guaranteed access to each child. The registry that we've

been proposing is one piece, but it's a central hub around which a number of other programs are established.

Not only do they do this measurement; they use it as a basis to provide additional resources, information and access to health professionals as a starting point. They're able to provide this information as a basis for evaluation. They're able to look at the map of their state and say which regions are the worst. They're able to then use it as a measure of evaluation of programs that they've actually implemented.

If I was to hold up a map of British Columbia right now, you couldn't tell me where the problem is the greatest, and you also couldn't tell me what programs have had the greatest significance.

On that point, in relation to things that Eric and Ted had raised, we absolutely agree that we need to do more analysis of the contributing factors towards obesity. But we believe that this is a key starting point. The reason that this sort of raises the hackles a little bit is because it will make a difference. It is what gets us past the poster stage, if you will. It's an actual intervention that we can start on, and we'll actually start to see a difference within the next couple of years.

R. Sultan (Chair): Let me understand the Arkansas result that you just reported, Robert. They have actually turned it around, and it's going down instead of going up?

R. Hulyk: Why, it's flattened. I'll be the first one to admit that three data points do not a trend necessarily make. But the result is that they actually have proof on an individual school-by-school basis about what's been done there.

In some respects they go a little bit further than maybe British Columbians would be comfortable with, so it's only used as an illustration. On that point, when the BCMA made its proposal, it did so as a discussion point. We know that there are issues associated with how this could be done. We know there are issues around the need to be very sensitive when we're talking about measuring in terms of eating disorders and all kinds of things. But it's that first point of intervention that we can actually make changes. I understand some of the hesitations and limitations around it, but it's something that we can actually make some progress on in the short term.

The last — and I'll then let some other folks ask some questions — is that if we don't do something, both the BCMA and the provincial health officer have made cost projections which we're all aware of. This is coming, whether we do something or not.

R. Sultan (Chair): Robert, it's impressive what they've done in Arkansas. How did they do it?

R. Hulyk: Basically, the Governor made a decision. I'm not sure if you know about Arkansas, but the Governor was about 70 pounds overweight about four years ago and had a health event which made him sort of make the decision in July of 2002, I believe it was. They started this, and he said: "By September this will be up and running."

R. Sultan (Chair): But what did they do, Robert, exactly? Did they run an advertising campaign? What was it all about?

R. Hulyk: Basically, they issued an edict to the school boards that this was going to be done. They provided information to parents through the media — those types of things — and provided letters of consent and information, too, that went out to all parents. Then they coordinated with various agencies to provide that backup information so that parents got the letter that said: "Your child's BMI is 28. This is where you can go for further information and further resources."

R. Sultan (Chair): They actually reported to each parent their child's BMI every year?

R. Hulyk: Yes. So not only did they measure the child's information to provide that database; they then provided a letter to each parent that said: "This is where your child fits. Here's where you can go to find additional information, and here are resources you can use to take the next step." That has been in place for three years now.

R. Hulyk: Across the schools. Basically, there are only a couple of schools that aren't participating.

E. Young: Just to comment on the questions that were asked. Before getting to them, because I'd like to talk about this one later…. But just to answer John's questions or give some thoughts about that, I think that clearly, the committee has realized that social marketing is not the be-all and end-all. It can be a piece of the big plan, and only a piece of the big plan. When we had social marketing for behaviour change for physical activity nationally at one time — Participaction — it didn't really make much difference, because all the rest of the pieces weren't in place.

You could have advertising campaigns or social marketing up the yingyang about tobacco, and unless you had all of the other pieces in place, it really wouldn't have made any difference, because you're dealing with an addictive substance. You're dealing with behaviour change. Those are extremely complex things.

I think that what you need to do in an approach to social marketing is look at what change or impact social marketing can have the best effect on within the big plan. But the big plan actually has to look at what theory or behaviour change we are going to use, because we have to change behaviours.

You might look at all the different theories, and you might look at Bandura's theory of social learning where

they actually look at the modelling that comes from society, the parents, the education, the information, the personal supports, the environmental supports, the social norms, etc. All of that has to be dealt with. It can all be dealt with in a number of ways, as you point out — with legislation, personal interventions, community interventions, and on and on. But all of that has to be in place.

Social marketing can help you change social norms, get people to start talking about, "Let's do some exercise; let's eat healthier foods," move people from precontemplation to the contemplation phase or the contemplation phase to the "I'm starting to plan for action" phase in Prochaska's model of stages of change. But I think you need to think about the theoretical frameworks that this comes under and then talk about how each piece can be best used. We do the same for social marketing — a full analysis of where this piece can be best used in the most cost-effective way. Clearly, it can make a difference.

T. Bruce: One of the things I would say is that our experience with trying to do marketing suggests that you need to target your audience and really figure out who it is that you're trying to communicate with. One of our great successes has been around, for example, the tobacco video program that we've used, where we've actually gone out and worked with young people to develop the marketing strategy. They've developed the video.

We've had the same thing in regard to suicide prevention, where we've actually worked with kids to develop a comic book. I think social marketers are very skilled at identifying their target audiences and working with them.

I think the committee, in its wisdom, in developing its own interactive work with kids, has put its finger on it. I mean, by working with your target population, trying to understand them, understanding what is meaningful to them and what their value base is, and working with them around that and then getting the messaging from them…. What are the messages that will impact them, which will bring about behaviour change with them? I think it's very important to work with the community, to work with that target audience.

The second thing I would come back to — I think Dr. Warshawski referred to this, and the committee recognizes it in its report — is that there is a huge counterweight that we have to deal with. The evidence around tobacco is that at some point there had to be much firmer regulatory action taken about advertising. I think the issue of banning advertising to children is important to discuss.

I know that the committee — and I really respect the committee — has taken the evidence around social marketing and policy initiatives and has not wanted to go beyond what the evidence says, but again I come back to my point. It may be necessary for the committee to really put in place some targets or time lines. If the industry is going to come forward and make some self-regulatory behaviour around their marketing and social marketing strategies, that's one thing. But if they're not going to do it, and they're not going to do it very soon, then I think we do have to look at the experience in Quebec and elsewhere, where there is much more restraint put on the industry marketing. My main point would be that you really do need to look at the target audience and work with them.

The messaging that we've been using in Vancouver Coastal Health tries to focus on the integrated approach of healthy living, like the ActNow program. I think that's important because when we look at our data — and we do have data that tells us where there are more problems than in other areas — we can see areas of Vancouver, for example, where the B.C. rates may be fairly low. I'm talking about adults at the moment — the data that we have. The obesity rates may be very low, but physical activity and eating behaviours are very poor. So you have to look at the full package of risk factors.

I think the messaging that needs to go out first of all needs to be targeted. We need to work with that audience to develop those messages and the best strategies for getting at that audience, but then also to really reflect the integrated approach to healthy living.

E. Young: If I could just comment on this question with respect to technology. The couple of suggestions I would have are…. There are new developments in technology for computer games, for example. Currently kids are couch potatoes. They're sitting there. They're either using their fingers or their thumbs with little controllers. But the new technologies coming — for example, the Wii technology, where the child actually moves like this and like this and the sword moves on the screen and all of that kind of thing…. The more that develops, the better, because then you're actually getting physical movement. These kids can play these for hours at a time, like we used to play outside as kids. That would actually make a really big difference. So I think that in terms of changes in technology, that's coming down the pipe.

There are marketing changes with respect to technology. I just learned about viral marketing today, where you put something up on YouTube that is really neat and is kind of like a video that kids help develop, etc. Some child looks at it, thinks it's great and sends it off to a bunch of friends: "Oh, isn't this a cool video." But in the video you're actually giving a message that would be really useful. I know that various industries are looking at marketing in that way. It could be a wave of the future as well. I'm sure there are many others that the techies in this group would know about, but those are the two that come to my mind.

R. Sultan (Chair): I've got a question on social marketing. Saqa, age seven, from the metropolis of D'Arcy — I'm sure you've all been through D'Arcy — submitted this poster on page 33 of the report, and it has been on my mind ever since I saw it.

It's a wanted poster. Obviously, Saqa has been watching Wild West cowboy movies or something, if they still have such a thing. It says, "Wanted," and I presume those brown things are chocolates and lollipops. The punchline is at the bottom of the poster: "For making kids sick." Age seven — "Wanted, for making kids sick." I thought: wow.

In social marketing, if we printed 1,000 copies of that poster and sent it out to the schools, is that legal? Is it effective? What do you think?

M. MacDiarmid: I loved that one, among many of the other posters, and I'm thinking that I have to head to the rotunda to see the art show.

Thinking of ways of reaching people, I would certainly share Dr. Warshawski's message, which is: if we want a really great marketing program, call a marketer. Doctors think they know how to do everything, but I would submit that I actually don't know how to develop a marketing program.

What I do know is — putting in a pitch, of course, for primary care physicians, both family doctors and pediatricians — that we see almost all the kids in the province. As with smoking cessation, we're potentially a place where we can get really powerful messages to people, depending on how you present the information.

I know for a fact with my grown-up patients that when I write them a handwritten exercise prescription, it's way more likely that they're going to — "My doctor gave me an exercise prescription" — go with that personalized prescription and do something rather than my just verbally telling them. I think there are a whole lot of individual interventions that we could do.

Rob has brought one of our little pamphlets, Eating Well on a Budget. We can develop these kinds of materials, and a doctor's office is one place where people can access that kind of information.

Everybody learns differently. For some people the verbal information is the most effective. Some people are going to go on line — YouTube. My mother wouldn't know what that is, but the kids definitely know what it is, so there's a whole bunch of ways. The family doctor's office and the public health nurse's office and all those places are places where we can continually sow the seeds and send the positive messages about physical activity and putting good food in your body.

I don't know if your committee ever looked at LazyTown, where you…. Did you ever…? No. LazyTown — you have to go to their website. I think it's in Iceland or Finland. It's this crazy-looking guy, this TV show. A huge culture has grown up out of it now. It's a kids' show, a kids' program. This country — I'm sorry; I can't remember, but I think it's Iceland or Finland — was having a serious obesity problem, even worse than Canada, and they've actually made some advances there with kids now becoming way more active. They talk about fruits and vegetables as "sport candy."

I suppose in a way it's manipulative, but it is social marketing, in a way, that has been effective to get kids to change their behaviour and change their families' behaviour. I think there are a lot of really creative things we could do.

I also would share the concept of not only what they do hear but what they don't hear. Maybe we do have to limit certain kinds of advertising and make it so that B.C. is a safer place for kids and families.

K. Whittred: I guess this is related to marketing, but it's one of my little pet peeves, and maybe it's more related to labelling. It's what I call deceitful labelling. I go in the supermarket now, and every second thing has a big label on it: "No trans fat." Well, it never had any trans fat to start with. What it doesn't tell you is that it's got 87 grams of regular fat, so it still is not a good choice.

I think that when we talk about marketing, we also have to include in that component some means to address that kind of issue. What are we going to consider to be a standard, if you like, in what we say about products, and how do we present these in a manner that the public can actually understand? I get the feeling that people are now throwing in their grocery basket anything that says: "No trans fat." That is not going to solve the problem.

R. Sultan (Chair): Could I suggest that we perhaps could profitably return to the issue that Robert again has raised on the childhood registry. This is a key recommendation of the committee, and it obviously has all sorts of sensitivities politically. But the BCMA convinced us that this was the way to go. So I'd like to hear some more conversation on this one. Perhaps the MLAs have some questions of our panel of experts.

K. Whittred: I have a question, and I guess it's just related to the doability of it. When I talk about doability, I'm including cost. This would be, I assume, a fairly pricey program. When is it going to be done, and who is going to do it? I'm not really commenting on the….

I think it's a valuable thing, but having spent my life in a school, I also know how difficult it is just to get parent permission forms back to inoculate kids. I mean, it takes weeks and weeks and weeks of chasing kids to try to do that. That is just one component of the doability of this.

R. Hulyk: When we looked at this issue, we developed a proposal. Within that proposal were cost estimates for what we believed to be the cost of actually conducting this.

R. Hulyk: I'm about to. We provided a low, middle and high estimate. Basically, we believe that this could be done for anywhere between $1 million and $2 million per year. On its own, that sounds like a lot. But when you consider that we've estimated that obesity and inactivity cost our province about a billion dollars a year, not so much.

In terms of how we think this could be done, we had proposed that this be measured once or twice per year in consultation with the schools. We've had discussions around possibly linking it to when they do immunizations. One of the things is that when you immunize a child, they need to sit around for 15 minutes to check for adverse reactions. That's a good opportunity to be able to do that measurement.

The other thing is that — again, learning it from our friends in Arkansas — they've achieved some cost-efficiencies. They dropped their cost 30 percent in year 3 by doing automatic entry with laptops and Palm Pilots, so they automatically have the data entered right at the site. Basically, all you need to do this measurement is a scale and a stadiometer. We're talking about 50 bucks.

In terms of how we thought this could best be done, we thought that using dedicated teams of folks…. It doesn't necessarily have to be a physician, but it should be a health professional of some kind who's been educated and trained on how to conduct this. These teams could then travel from school to school to school. Some of the conversations that we've had with school boards and other health professionals have also given us some insight into how that could be done. In terms of creating stations in the gyms, four stations, and doing it…. It basically only takes about 30 seconds to do. Generally speaking, the feedback we've received has been very positive.

R. Sultan (Chair): Margaret, as a practising physician dealing with families, could you predict reaction among your client group to something like this?

M. MacDiarmid: First, I just want to add to what Rob was saying. In addition, our suggestion was that this be anonymous, and we stressed that it would be private. So the child is not in any way targeted. This is a private moment. They wouldn't even need to know the data. Certainly in my own office I will sometimes weigh and measure adults, and they don't want to know. I don't tell them. We're just keeping track.

A lot of people feel very negatively about their weight, and I've addressed that previously. I think we would need to be doing some education around why we are doing this and the fact that it is meant to be anonymous and private. There's no shame message or anything like that. This is something we're doing to check on the health of British Columbians and help us to plan for their future health.

How it would go over. I think that in Arkansas…. It's a different place than British Columbia, but they had very few parents ask to have their children excluded from this. It was seen as: "We have to, by God, become more healthy here in Arkansas. Look at what's just happened to our Governor."

I think it was actually almost embraced down there as something that would lead to positive outcomes in that state. While all they've accomplished is a flattening of the curve, if you think about that, that in and of itself would be positive. We know we're on this….

We've seen absolutely astonishing statistics since 1978 in terms of what's happened to children and adults in Canada and in B.C. We're a little bit better off than the rest of the country, but it's not like we should be thinking we're doing terrifically well.

We're on a projectile now for ever-increasing costs, both actual dollar costs and really terrible health costs. So to not do something about…. No one in this room wants to not do anything about it, but there are really compelling reasons to act.

I think you'd have to frame it carefully. I think you'd have to make sure that people were understanding how we were doing this. The people who were doing the measuring would need to get instruction on how you handle it, how it's not perceived — like I remember phys ed class as a kid — as kind of like a punishment. You know, something that wasn't going to be any fun, and it was going to be gross, and I was probably going to hate it. It's part of…. You get your shot. That's not really a whole lot of fun. Then you pop on the scale, and your height is measured, and then you go off back to class again.

T. Bruce: I'll try to be brief. I mean, I think certainly we would agree with BCMA that information is a very powerful tool. It can help shape programs; it can help shape individual behaviour, etc. We certainly support the notion of trying to come up with better information and statistics.

There are obviously some very serious issues related to this, which have been addressed already. The committee may know that there is already a proof-of-concept project underway. The Provincial Health Services Authority and a number of the health authorities have a proposal in place now to do a proof of concept of measurement in schools. We're looking initially at about 20 schools and trying to sort things through.

There are huge issues of confidentiality, etc. There are also differences in terms of how this could work on the ground. It's easy to think that our nurses would be able to go out and do this, but it's not quite as simple as that. Even the urban-rural split, as the MLA referred to, makes big differences in some schools. The nurse is still on site in a small, rural school. The kids may actually go back to the classroom. So it's a whole other issue that has to be dealt with.

I think this notion of a proof of concept, trying to work this through and see how it could most effectively be done in a sensitive way, is very important. One of the things in terms of how people accept it…. Nurses and nutritionists from our staff have told me that one of their big issues is when they have an infant visit going on with our public health nurses. They used to bring out the weight and height charts with a new mom, for example, and say: "Oh well, your baby is not quite on the chart where they should be." There's an immediate change in the environment, and the focus then is all of a sudden on the weight and "Oh, my child is not healthy."

I think we do have to listen to our health professionals, and I'm so happy that you asked for that opinion, because they do see the actual impact of weighing and measuring on folks out there. This is a very real issue about the potential stigmatization — the impact it has on parents and how they view their children and what they do with it.

The other comment I would make is that there are ways, perhaps, of doing this that allow us to use representative sampling, perhaps even adding some cohort studies so we learn about the trajectory of growth and development in children in a better way.

Again, we certainly would support the need for better and more information. Whether the notion of a full-scale registry would make sense is more questionable, I think.

The final comment I would make about this is the challenge of registries from the health authority point of view. Often it seems that every issue, problem, disease entity wants a registry for their folks, and there is a proliferation of registries out there. You end up with…. The problem is that the health professional sees one piece of information without seeing other pieces of information relative to that person.

For us, having many, many different registries, which we already have, complicates the life of our staff. Being able to move to a more integrated picture of our patients, clients and residents is important. Using electronic medical records, etc., is one way of getting around that. I think a freestanding registry, with all of its inherent problems, really has to be questioned. It's looking at alternative ways of getting the type of information that will bring about the change we want to see.

C. Panagiotopoulos: I agree with that, actually. I'd like to add that both Margaret and Robert have quelled my fears that the sensitivity issue would be a problem. It's not a problem, obviously.

However, I would like to point out the bottom line that any screening tool used in public health is key. But what is also key is that if you do a screen, you should be able to offer some sort of treatment at the time, and I don't know if we are able to do that at this time.

E. Young: I'll put on my epidemiologist hat for a moment and talk about registries, sort of the universe of all persons in terms of collecting data versus doing adequate statistical samples in a variety of areas.

There is an advantage to a registry in that you don't have to rely on statistics; you know exactly how many people are overweight. The problems with the registries are…. One of the ones mentioned previously was the cost — $1 million to $2 million a year. That was kind of my off-the-cuff calculation last night, too, when I was looking at this. Half a million students, in terms of program planning, measurement data, entry data, analysis and system development, averages out to six to ten children per hour. Actually, the information comes out to us. That's 50,000 to 83,000 hours annually at $30 an hour. It's roughly $1.5 million to $2.5 million. Those are just back-of-the-envelope calculations.

My question is: from an epidemiological standpoint, can you collect the same information with statistical relevance for a much cheaper cost? The answer is clearly yes, you can. You can do adequate-sized statistical samples in a variety of areas, so you can compare health authority to health authority, HSDA to HSDA. If you put enough money into collecting statistical samples of adequate size to do good statistics, you can get the same number.

As Tom mentioned, we know the numbers. We're not so much interested in whether the number changing by 1 percent per year or 2 percent per year. We're interested in knowing the five-to-ten-year projection and to know that that is tapering off. But we need statistics that give us where the trend is. Is it going up? Is it going down? Are there big changes or not?

The other piece that you can't do with spending the money on a registry is…. I think what you need to do is look at what is…. You need to evaluate the variety of data collection instruments and strategies and determine which ones, or which combination, are the most effective.

For example, you might add collecting heights and weights to the EDI work that Clyde Hertzman is doing with all kindergarten teachers, going through 120 questions that they tick off on each child. That, basically, gives you a lot of general health information on the child, social factors, environmental factors — that kind of thing. Plus, in terms of the general health piece, you've got to add height and weight. For next to no cost, and I agree that the equipment is next to no cost…. You need to look at what mechanism is the most effective way to capture that information.

The other piece that a registry doesn't give us that's critically important is the piece that allows analysis. I've looked at the Georgia information, and the problem with just having numbers all across areas is that they haven't analyzed for each child what their risk factors and risk conditions are. What environments are these kids living in, in all of these different areas? What are the risk factors that each child has? All of that makes a difference to your outcome and to your weight. If you don't include that, you don't know, really, what's going on.

The other thing is that when you're applying programs, you may have seven different programs in one area. You may have a social marketing program. You may have school interventions. You may have something else. In another area you have a different set of programs. You need to be able to analyze what those particular programs are contributing to those particular outcomes. You can do that with research studies.

I guess what I'm suggesting is…. We all agree we need more data. The question is: what is the most cost-effective way of getting the data you need to answer the questions you need to answer? I guess my suggestion would be: what we do is follow this up with a full review of what the best data collection systems are that actually then give you the answers you're looking at.

Start with the objective in mind, and figure out what the most cost-effective way to do that is, as opposed to

You can get a bunch of epidemiologists together with a bunch of clinicians and a bunch of pediatricians — that kind of thing — to actually talk about what it is that we really need to know here. The people doing the programs…. What is it that we really need to know, and actually, how can you get the information that you really need in terms of the risk factors, your program's effectiveness, etc.? What's the best bang for your buck?

R. Sultan (Chair): Robert, we're going to let you have the final word on the childhood registry.

R. Hulyk: The first point I want to make about the registry is that we recognize that this is the starting point of data. This is an overview piece of data that allows you to get a generalized sense of where the province or various regions are. We understand that more detailed information needs to either be gleaned from other sources or whatever.

Now I'm going to put on my economist hat, because I was an economist before I was in public affairs. The one challenge with sampling is that it would limit your ability to do comparisons amongst schools, between regions and so forth. The smaller the data, the less opportunity you have for interregional comparisons. If there is a way that we could satisfactorily do sampling from all the various schools, I think that would be okay.

The second point of the registry is that it's not just a data analysis tool. It's an opportunity to guarantee interaction with every child in the province. If I was to say that not only for $2 million are you able to get this data, but you have guaranteed access to provide information to 600,000 children in the province…. Now, I work in public affairs, so I know how much buying TV and ad time costs. That's a pretty cheap bang for the buck. That's a lot of juice for the squeeze, as you say in communications.

You have to remember that when we made the proposal on the registry, it was not only to close the data gap, which is quite poor right now. I mean, we have select, good data, but we have a lot of self-reported data. It's also an opportunity to provide that information not only to hit the children, in terms of providing better information, but also ultimately the parents because not only are we trying to change the behaviour of the children, we're also trying to reach the parents.

When we talk about the registry, it's two things. It's the communications side and the data side. For $2 million, we think that's a pretty good investment for the province.

R. Sultan (Chair): Thank you, Robert. I'm tempted to give my little Harvard Business School lecture, since I taught sampling and market research. All I would say is it's not obvious that cluster sampling would be less expensive. You need a lot of smart people to figure out what is the appropriate cluster and the appropriate sampling technique, and the interpretation gets quite sophisticated. Then somebody will always say the sampling error was, you know, 95 times out of 100 some or other. You end up with a very confusing situation.

Anyways, I think we have had a thorough discussion of this very important proposal. It is a recommendation of the committee.

Tom, now that you've given up hope of getting on the airplane, did you have the final word, please?

T. Warshawski: If you don't mind, Ralph. I was interested when Robert alluded to the Arkansas data as showing a levelling-off of the trend of increase in obesity. I wasn't aware of that information.

The U.K. has a nationwide screening program where they screen all primary school children when they enter school and again when they are age ten to 11. I think the screening program that this registry has probably has perhaps three purposes to it, the last of which is an intervention in and of itself. We know from the study that most parents underestimate their children's BMI, their weight or their weight problem. This may be useful as an intervention just to get parents that information — and the children — which then they can look at themselves and try to do some behaviour modification.

As a source of general information, however, I don't think it's cost-effective. As Eric has pointed out, I think the opportunity cost is not a good trade-off.

Monitoring and getting BMI pre- and post-intervention is essential. What I think would be an interesting process for looking at this registry or this monitoring proposal is that you would have intervention in and of itself and to be studied like that…. So rather than implement a provincewide registry immediately, actually look to see what the effect of simply measuring is.

The Arkansas data, which Rob has alluded to and I'd like to have a closer look at, seems to show that simply measuring may do something to help — to be an intervention. That's new information.

R. Sultan (Chair): Thank you, Tom. Well, we have another 15 minutes–plus to consider…. At the coffee break there was a question by our reporter from the Vancouver Sun about treatment programs, inquiring about the only treatment program that Valerie said we have in the province. I think it's the Shapedown program at Children's Hospital, as I understand it.

I presume it does beg the question of what treatment for acute obesity is appropriate. Is this an opportunity that the committee overlooked? We really didn't say very much about it and, frankly, did not spend a great deal of time on it. That's a question I would ask our panel of experts.

That leads into the final topic that we'd identified: namely, school health programs. Do they even exist anymore? I mean, they don't have a course like I took on health, I don't think, anymore. We were taught to wash our hands and other important things. Does anybody have anything to say about treatment programs, and then about the broader issue of school health programs?

T. Warshawski: I always have a lot to say, and I would like to speak about treatment programs if I may. There is an urgent need to intervene for this population of children who are obese. If we just look at the statistics, there are 40,000 deliveries per year in British Columbia, which gives us a pool of approximately 200,000 teenagers at the highest risk for adult obesity — those who are obese in the teenage years. That gives us around 20,000 youth and adolescents who are currently obese. The statistics are that 85 to 90 percent of them will remain obese into adulthood and therefore have their lifespan shortened. This is a major health crisis in the works.

There is good evidence that intervention in this period of growth for children can be quite effective. The evidence right now still revolves around family-based treatment models like the Shapedown program in Vancouver, which is somewhat expensive, certainly at first glance. But it may be, in fact, cost-effective — thinking that there is a ripple or domino effect on the family as a whole — for the caregivers as well as for siblings.

The province, when it wisely went to sponsor the Shapedown model in Vancouver, was hoping that there would be pickup from other health authorities, that this would be a catalyst to have other health authorities set up treatment centres. This hasn't happened, primarily because all the health authorities are squeezed for financing. That is a problem in terms of the overall health care budget.

From the Childhood Obesity Foundation's perspective, prevention is key, but we simply cannot forget about these children who are obese and who usually will see their lives shortened. We know that there are effective, and probably cost-effective, treatment modalities available. We need to free up the resources, create the resources. Perhaps recommendations 16 and 17 with regard to the removal of the exemption for sugar-sweetened beverages and candies…. Those funds should be dedicated to things like social marketing and treatment centres.

This is a huge unmet need which I was hoping to see highlighted in the strategy for combating childhood obesity and for physical activity.

T. Bruce: I certainly appreciate Dr. Warshawski's comments, and I would think that everyone agrees that the treatment component does have to be in place for a number of children with obesity. I think everybody's sensitive to not overmedicalizing the problem, and that's obviously an issue.

The Shapedown program has proven to be quite effective. There is some fairly good research that's been carried out associated with the program. The program is reasonably expensive in terms of its form of delivery, so we do have to consider whether there aren't alternatives that can achieve the same success of treatment that may be less expensive.

One of the things about the program that's so important is the interdisciplinary nature of it. They have different professionals who actively participate in the program, and I think that reinforces the approach that's so important. That is, it looks across the spectrum at issues related to weight and tries to deal with it at multiple levels.

Certainly, we have had an interest in trying to expand the program in Vancouver. We've had proposals for it, and I think there probably is a business case to be able to expand that program. But as Dr. Warshawski said, there are clearly limits to our ability to do that, given the financial constraints that we're under.

R. Sultan (Chair): I know that the committee researcher, Jonathan Fershau, and I were very interested in hearing the presentation on Shapedown at the obesity conference held in this city in October. Jonathan pointed out to me that the number being treated, relative to the magnitude of those who perhaps could benefit from treatment, was minute. It was his impression — I guess you've confirmed this — that it's rather a labour-intensive and consultant-intensive, costly program.

C. Wyse: On this general area of treatment, my recollection is that there was mention from somebody across the table dealing with the mental health issues and youth, particularly in the areas of depression and sexual abuse. So there's another component that comes here into treatment.

I'm wondering if whoever mentioned that comment wouldn't mind refreshing me on how that fits in the general area of treatment, because I know, from where I'm from in the interior, that there are not enough available, trained personnel for dealing with youth in the area of mental health. I'm interested in expanding our discussion here into this general area of cause — if I could, Ralph, please.

E. Young: Sure. I mentioned that earlier, and that had been reported in the PHO report of 2003, which was the school health report, where we did mention that a large proportion — 20 or more percent of females in grade 12, and 12 percent of males — had contemplated suicide. That is huge. That is not something that we can ignore.

Clearly, the idea is that you really need a school health plan. A plan for just dealing with one issue is not going to cut it.

As I mentioned, for the society as a whole and for the health care system, yes, obesity is a really big problem. But for the individual, that may not be their biggest problem. Smoking may not be their biggest problem. You know what I mean. It may be other issues in their life that are much more important, and if they could deal with those issues, then the other ones could well be addressed.

For example, in the literature on sexual abuse there are studies that associate morbid obesity as an outcome in adulthood with sexual abuse in childhood. And there are psychological theories that people are building up

walls and all of this kind of thing. I'm not a psychologist, so I don't know, but they seem to make sense.

If you're going to talk to a person who has these deep psychological issues and you're saying, "Well, just diet," or "It's really important that you exercise," clearly, hand in glove with giving them that information is giving them the capacity to actually do that. For behaviour change you have to move through different stages, and you need to develop capacity to do that. If you don't have that, then you'll never make that behaviour change. For the individual, it's really important to have adequate treatment to deal with individual issues.

What we need to see from a population health perspective…. That's why we keep talking about the big picture. If you move those people at the very tail of the distribution, those who are extremely overweight, and if you focus all of your resources on that in terms of treatment, then you make a very small change in terms of the entire curve with respect to making people healthy and reducing lifetime risk of diabetes, etc.

If you can shift the whole curve down, or if you can narrow the far end of the tail — this part of the distribution — then you've actually made a huge difference in terms of the total population that you've affected with respect to moving down their weight, their blood pressure, and the risk of diabetes, cardiovascular disease, cancer, etc.

I think it's one of those things where you have to balance off where the acute care needs and the clinical needs are and what the societal needs are when you're talking big-picture health promotion — long-term, one-year-down-the-road issues. Like we did with tobacco, you can deal with each individual's lung cancer or the fact that they're smoking. Physician interventions have made a difference, but all of these other pieces had to be there to move that curve from 50 percent of males down to 20-odd percent.

R. Sultan (Chair): Perhaps this is an opportunity to pose the final question of the day in the few minutes remaining — which is, in fact, school health programs. I don't know whether we have any further thoughts or questions. I somewhat facetiously posed the question: do we have school health programs anymore, or did we ever? Is this an issue?

H. Hoult: I think that we're doing lots in the schools around the whole concept of comprehensive school health. I'm not sure how much the committee would be aware of what we're doing, but when you ask if there are school health programs, of course there is curriculum around health and career. There's physical education curriculum. You have your formalized teaching mechanisms around those two aspects.

Most of the school districts have psychologists. A lot of what I understand they are doing in relation to working with the students is more around career counselling and that type of work, but they do have psychologists that work on mental health issues, etc. But a lot of that is to connect with the resources in the community. It's not necessarily that type of service in the school setting.

We are doing a lot of things around trying to raise awareness about physical activity and healthy eating. Of course, everybody knows about Action Schools B.C., but we're also developing guides for families across the spectrum from K-to-12 targeted specifically around healthy eating and physical activities for families.

The biggest thing that we're doing, which I think is the most exciting project or program that we have on the go to build a sustainable system of comprehensive school health, is the development of the new healthy schools network. We have been working on this initiative to get it up and running for the past six to nine months.

H. Hoult: Well, I'm going to tell you — this is my opportunity — what the network is. There is an existing network in the education world that is the Network of Performance-Based Schools. They have performance standards around math and reading and writing and literacy. We are actually going to develop performance standards for…. We're calling it "Active living, healthy eating and school connectedness."

This is a long-term project. It's not something that will be produced in one year. It will probably take three years. But the network of healthy schools is schools that have decided to focus on health promotion in a comprehensive way. It's voluntary at this time, and they are joining the existing Network of Performance-Based Schools, which is a community of practice around performance standards in these specific areas.

When we announced that we were doing this, we had almost 100 schools call us within two weeks of the Deputy Ministers of Health and Education notifying that we were ready to launch. We couldn't accommodate that this year, so we have 34 schools that are in this network. We have schools from the independent schools; we have public schools. We have from elementary right through secondary that are interested in this and that are participating.

What they will be doing this year is assessing their schools with a comprehensive school health tool we have developed, looking at the whole spectrum of school health. There are three domains. They focus on how you look at comprehensive school health through teaching and learning, through the environment — which looks at school culture, at physical environment, at emotional environment. The third domain is partnerships.

One of the things all schools have to do to participate in this is that they must partner with some health promotion or health profession from the health community and build a school health team which has representatives from students, parents, administrators. To belong to the network, you must have an administrator from the school — a principal or vice-principal — and a teacher.

Anyway, it's a very exciting initiative, I think. It's an opportunity for us to actually build something that's sustainable on the ground, that will grow from the education community — not be imposed upon them from

any other sector, but a partnership between health and education. CFD should be connected. There are all kinds of sectors that can be involved.

There are lots of initiatives, as Eric said, a lot of one-offs, but this is really trying to take the whole-school approach, which looks at everything through a health lens and from the ground up. I think we have an opportunity to build something that is sustainable.

We are funding the schools $1,000 a year to belong to the network, and that goes towards their ability to plan. The performance standards will be developed with educators, and we are paying the schools that participate or help with the development of performance standards $1,000 a year as well.

We're just starting, but I think it's a really positive step in the direction that everybody talks about when you want to build a comprehensive system.

R. Sultan (Chair): The standards you're talking about would, for example, be standards of activity and diet.

H. Hoult: Yes, there will be those two. There is already an existing performance standard, which is social responsibility. We are consulting with educators right now around whether we would enhance the existing social responsibility standard, building into it physical activity and healthy eating and school connectedness, or would they be separate from that. That's not established yet at this point. But they would be standards that would be taught within the education system, within the different grades, as to what it looks like to meet a standard around physical activity.

I just would like to say one other thing. We are also going to be building criteria for a designation for healthy schools. Down the road, by the end of 2008, we would have these criteria in place, where schools that are part of the network would be designated as healthy schools based on these criteria.

J. Nuraney: Heather, in that program that you have, is the measurement that the BCMA is talking about included in that program? Can it be?

H. Hoult: It's not. I know when Ted was talking about the proof of concept…. We have been in discussions with the people who are involved in that and have offered that if we have schools in the network that are wanting and willing to participate in this initial look at how we might do this if it's feasible…. We're approaching the members of the network and asking them if they'd like to be a part of that. That's the role we've been playing thus far.

J. Nuraney: Yeah, but if that element can be included, then we are already beginning to collect data, which is so very…. I would think that it shouldn't take very much to just put those extra questions.

H. Hoult: In the assessment tool. But you actually have to have the people that would come in and do all the measurement, etc. Our assessment tool is to look at the school environment, and it looks at policy and at what they're doing around certain elements that are considered important — school connectedness and partnerships. We're not measuring kids in any aspect at all.

J. Nuraney: I don't intend to enter into a dialogue here, but if that element can be included voluntarily, I think it would be a great start.

T. Bruce: I think I've jumped in before BCMA a couple of times, so I apologize for that.

Just very quickly, there is a program called Healthy Buddies in British Columbia where there are measurements being done. That's in pilot-project phase up the Sunshine Coast area. They have not had huge difficulties in terms of the measurement protocol and dealing with the parents, etc. So we do have some small example of measurement going on in schools now.

I think this proof-of-concept project that's underway will help really inform what is most viable for us to do.

M. MacDiarmid: Several different people have mentioned in different ways the stigma that's attached to being measured, from the newborn baby where the mother actually feels negative because her baby is losing weight when it's born, when it's breastfed…. That's normal. So a normal human function is making the mom already feel, sometimes, not adequate — don't have enough milk; not feeding my kid well. I mean, it starts out early on, maybe even when a woman is pregnant.

You asked the question about the stigma of calling it an obesity treatment centre. I agree with you. These things are stigmatized in language, and the weighing and the measuring can be negative. To me, this doesn't say: "Don't do it." To me, this says that we need profound education as a society about…. No, the message isn't that you're only of value if you're young, thin and beautiful. The message is about health. The message is about using your body, being physically active and giving it good fuel.

It will take some considerable time and effort even to educate the educator. So when the public health nurse is measuring the baby, and you look at the growth chart — I do this in my own office — some kids are on the 40th percentile and some are on the 80th percentile.

We look around this room. There are tall people. There are short people. It's all a part of the norms of statistics. So you can neutralize it if you take a bit of time, but it doesn't mean we shouldn't do it. It means we need to take the steps to take the stigma away to the best of our ability — and the messaging.

The last thing I would want to do, not particularly to make a feminist statement…. But to reinforce the message that in particular females only have value if they are thin and beautiful — it's ridiculous. We all have value, and it's not how much we weigh on a scale or how tall we are. So it's not being negative and judgmental about how much people do or don't weigh, but rather, it's a health issue. It's a wellness issue, if you prefer to use that kind of language.

I mean, I think there is a huge amount of work to do, but there is also a great will to do it. I would hate to see us…. I read something in the National Post yesterday about fat people and the stigma attached to it and that the whole obesity is a mythology, it's not really a problem, and we don't have to worry about it. That just isn't true. I just think we need to try to normalize it and use neutral language, be positive, educate ourselves, educate British Columbians, and we'll be off to a successful, healthier future.

Departing from our regular norms, we have a member of our audience who would like to come and speak into the microphone and make a statement. Would you introduce yourself, please?

K. Romses: Sure. My name is Kathy Romses, and I'm a community dietitian who works for Vancouver Coastal Health. I think the registry…. As a surveillance tool, I'm somewhat comfortable. I'm actually more comfortable with some of the other issues that have been brought up, but I'm really concerned if it's used as a screening tool, because you cannot identify a child's healthy weight by one measure.

There was a study by the U.S. Department of Agriculture that said: "Okay. We've actually misclassified 17 percent of the population as at risk from overweight from this one measure." You cannot assess a child's obesity from one measurement.

By sending that piece of information home to the parents…. There's another study that says what the parents do with that information: 20 percent put their child on a diet. That's not helpful; 95 percent of diets don't work.

I'm really concerned about it being used as a "here's something for the parents" when there is no support and when it can misclassify them.

R. Hulyk: The best answer that I can give is no. It wasn't intended for that. Obviously, this is sort of the 30,000-feet initial assessment tool from which additional resources, information and interaction with professionals needs to happen. It is simply the very first step of the process — if that helps or not. No. It's not intended to be the be-all and the only thing that's ever measured.

Well, we have run out of time. I'm sure we could share data and consult for many, many more hours, but I think our experts here have a health system to run, and our officials have a government to run. The MLAs have to worry about making sure that their votes are secure.

I would like to ask the Deputy Chair, David Cubberley…. If you've been patiently still on the line, David…

D. Cubberley (Deputy Chair): The only thing I would like to say is that this has been a very, very useful discussion this morning. I'm impressed with the quality of the comments and the insight. I'm emboldened, as Deputy Chair of the committee, about the work that we have to do to bring this report home and to get government committed to implementing it.

I just want to thank everybody for their participation. I learned from it, and I enjoyed it.

I would also like to thank the witnesses who appeared before us today, as in fact many witnesses from many walks of life have appeared before this committee over the past, I guess, 12 to 14 months. In particular, the Vancouver Coastal Health Authority, the Childhood Obesity Foundation, the British Columbia Medical Association and the provincial health office and officer have been very helpful. I also would like to express the appreciation of the committee to the Ministry of Health, the Ministry of Education, the ministry of ActNow for participating in a useful wrap-up session and critique, which I think has added value to our final report and put it into some better perspective.

In conclusion, I want just to reiterate my personal appreciation of the support that Deputy Chair Cubberley has given to me and the active participation and commitment of Katrine Conroy, the MLA for West Kootenay–Boundary; Dave Hayer, the MLA for Surrey-Tynehead; Daniel Jarvis, the MLA for North Vancouver–Seymour; John Nuraney, the MLA for Burnaby-Willingdon; Val Roddick, MLA, Delta South; Michael Sather, Maple Ridge–Pitt Meadows; Katherine Whittred, North Vancouver–Lonsdale; and Charlie Wyse, from that wonderful community of Williams Lake in Cariboo South; not to mention the excellent and, I think, successfully cohesive efforts of our Clerk Assistant, Kate Ryan-Lloyd, who made this whole thing work; Jonathan Fershau; Carla Shore; and the members of Hansard staff, who I've already mentioned this morning.

The committee is, with some sense of regret on my part, expiring. Our mandate will shortly be over, and we will have to think of something else to do with our lives. Thank you all for doing, I think, a helpful and constructive job in the small step forward on a long journey to try and resolve a huge public health issue facing our children.

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	1)	Ted Bruce, Executive Director, Population Health, Vancouver Coastal Health Authority
	2)	Dr. Margaret MacDiarmid, President, British Columbia Medical Association Robert Hulyk, Senior Public Affairs Specialist, British Columbia Medical Association
	3)	Dr. Eric Young, Deputy Provincial Health Officer, Office of the Provincial Health Officer
	4)	Dr. Tom Warshawski, Head, Pediatrics, Kelowna General Hospital, Childhood Obesity Foundation Christina Panagiotopoulos, Executive Director, Childhood Obesity Foundation
	5)	Laurie Woodland, A/Executive Director, Ministry of Health Andy Hazelwood, ADM for Population Health & Wellness, Ministry of Health
	6)	Ron Duffell, Executive Director, ActNow BC, Ministry of Tourism, Sport and the Arts
	7)	Heather Hoult, Director, Health Promoting Schools, Ministry of Education
	8)	Kathy Romses, Vancouver Coastal Health Authority

Committee Staff:	Jonathan Fershau (Committee Research Analyst) Carla Shore (Committee Consultant)

REPORT OF PROCEEDINGS (Hansard)

SELECT STANDING COMMITTEE ON HEALTH

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH