The Legislative Assembly of British Columbia

Select Standing Committee on Health

A Strategy for Combatting Childhood Obesity and Physical Inactivity in British Columbia Report

2nd Session, 38th Parliament – November 29, 2006

< Obesity and Inactivity in Selected Cultural Communities – Table of Contents – The Role of Schools >

Emily, Age 11, Richmond

THE NEED FOR IMMEDIATE INTERVENTIONS

The Committee is of the opinion that there are several areas in which the government can take immediate and comprehensive action to re-enforce the enormity of the overweight and obesity crisis.  Simple exhortations and small-scale interventions have done little in changing the behavior of parents and kids alike.  As discussed below, the Committee proposes: an enhanced role for ActNow BC; a renewed request for additional funding for public health and prevention programs; strict limitations on access to nutritionally-poor “Not Recommended” foods in public facilities; and a removal of the Social Services Tax exemption provided to “candy and confections,” “soft drinks” and other unhealthy foods currently exempt from the PST.  Furthermore, the Committee believes that it is imperative that government and industry work together to introduce enhanced labelling requirements and reductions in the amount of sugar, salt, and fats contained in prepared foods and beverages.

The Role of ActNow BC

In the Health Committee’s 2004 Report, the Committee recommended that the government should work across all ministries and, in collaboration with outside partners, develop a strategy to promote physical activity and healthy diets and combat obesity.  In March 2005, the government of British Columbia created the  ActNow BC initiative to promote cross-government and community-based approaches to address common chronic disease risk factors through programs and initiatives that support healthier eating, physical activity, ending tobacco use, and promoting healthy choices during pregnancy.  Initially operated under the Ministry of Health, the ActNow BC programs were given increased prominence within government, with the program being elevated to portfolio status on August 15, 2006 — complete with a Minister of State, the Hon. Gordon Hogg.  The ActNow BC portfolio currently resides within the Ministry of Tourism, Sport and the Arts.

During this Committee’s hearing with the former deputy health minister, we learned that the ActNow program consists of:

• A budget of $40 million over three years, and
• $15 million for the creation of an ActNow BC Incentive Fund to cultivate partnerships in communities and within ministries to develop programs and services to support all of the goals of ActNow BC.³²

The Committee is duly impressed by the speed with which ActNow BC has coordinated information resources targeting healthy eating, healthy weight, the cessation of tobacco use, healthy pregnancies, and reducing physical inactivity.  Similarly, the Committee appreciates efforts taken by both the Ministry of Health and ActNow BC to develop partnerships promoting healthy living.  We were also pleased to learn that the government continues to coordinate activities that promote healthy lifestyles through a committee of assistant deputy ministers.

However, in light of the significant resources that obesity — in particular, child overweight and obesity — drains from the health care system in British Columbia, only $13 million a year in funding may be an inadequate investment to prevent childhood obesity.

In reviewing the information presented by witnesses and by ActNow BC, the Committee concludes that current resources devoted to combatting childhood obesity are insufficient.

We also perceive a problem in the efficiency with which funds are allocated. For example, ActNow BC’s current roster promoting “Active Living and Healthy Diets for Children” encompasses more than 40 different programs.  We question whether these programs are all delivering measurable results.  We look to ActNow BC to measure their effectiveness in improving nutrition and reducing physical inactivity?

Perhaps some consolidation of programs is in order.  It is clear that much more work needs to be done to coordinate and synthesize currently available information pertaining to childhood obesity and physical activity. Although overweight and obesity rates have grown dramatically over the last 25 years, large uncertainties remain concerning the linkage between our science-based knowledge of childhood obesity, and the resulting public policy. Clearly, research into childhood obesity is still in its infancy.  ActNow BC has an important role to play in understanding   the extent of the problem, and what constitutes effective intervention strategies.

Front-line service providers — nutritionists, community recreation leaders, and public health officials — recognize the problem and are  implementing a myriad of community-based programs to address it, using their own unique specialties. For example, we heard great things about the Health and Recreation Alliance Committee of Greater Victoria’s convincing Eat Well, Get Moving and Leisure Involvement for Everyone programs. These programs are funded by such organizations as Canadian Tire and Coast Capital Savings, user fees, and municipal taxes. Likewise, when meeting with representatives of the Vancouver Coastal Health Authority, we were impressed by the diversity of programs offered within the different municipalities served by the health authority.

These front-line practitioners are to be commended for the work they have done to date. In many cases, they have developed programs for children and youth from scratch, seeking “buy-in” from the health authorities, municipal councils, and the private sector, and have delivered these programs on a shoestring budget. However, as outside observers, we look at these programs across the different municipalities and regions and see further opportunities to promote these programs which have the same objectives and similar delivery models.

At the provincial level, the BC Healthy Living Alliance has been successful in incorporating inputs from a wide variety of health and physical activity associations to set targets and intervention strategies for improving physical activity levels, improving eating habits, and reducing tobacco consumption.³³ The work done by the BC Healthy Living Alliance is to be highly praised and provides a great starting point for changing the behaviour of B.C.’s kids and parents. In fact, many of the recommendations contained in our report have originated from the work of the BC Healthy Living Alliance and the Childhood Obesity Foundation, along with the Provincial Health Officer and the British Columbia Medical Association.

The Committee believes ActNow BC is an important portfolio within government. With expanded funding and a broader coordinating mandate as outlined in this report, the Committee believes ActNow BC will be in a better position to assess the effectiveness of the quite confusing array of community-based programs currently trying to deal with the obesity issue, and help determine which ones work best and which ones merit expansion to the provincial level,  in a cost-effective  manner.

The Committee recommends that:

7. the government continue to designate ActNow BC as its coordinating fitness, diet and wellness agency.
8. all ministries should review their service plans to ensure that the objectives of ActNowBC are considered fully.
9. ActNow BC conduct a comprehensive review of programs directly funded by government and non-government agencies pertaining to physical activity, healthy eating, healthy schools, healthy workplaces, and healthy communities, and ensure that such programs are effective in targeting obesity and physical inactivity in both children and adults.

Expenditures on Public Health

In 2004, the Health Committee recommended that the government gradually invest in the “full ounce of prevention,” and increase the budget for public health activities from three percent to six percent of the total health budget. In 2004 dollars, this would translate into a budget increase of approximately $375 million annually.³⁴

Population health falls into five basic categories:

• Population health assessment: Monitoring the ongoing health of the population, the status of various groups, and understanding the underlying factors contributing to health status.
• Health surveillance: Tracking and reporting rates and trends in illness, disease and injury, such as early recognition of communicable disease outbreaks, cancer risks, food-borne disease outbreaks, and infectious diseases.
• Health protection: Environmental control of illness such as water treatment monitoring, restaurant and food inspections, air quality monitoring, and emergency preparedness and disaster response.
• Disease and injury prevention: Activities include immunization programs, investigation and control of disease outbreaks, encouraging healthy behaviors, and the fortification of water with fluoride.
• Health promotion: Education programs to encourage healthier and safer lifestyles.

However, information received by the Committee from the Ministry of Health indicates that while “the provincial government supports the idea of increasing funding for public health activities,” its additional investments to build public health capacity of $8 million, $16 million, and $24 million are limited investments compared to the total health budget.  The Committee reiterates its recommendation from 2004 that additional resources must be provided to public health to ensure it plays a greater role in the prevention of disease and illness.

The Committee recommends that:

10. the government implement the recommendation of the Select Standing Committee on Health 2004 report, to gradually raise the proportion of the Ministry of Health budget devoted to public health promotion and disease prevention from approximately three percent to six percent of total health spending.

Diabetes Action Plan

In December of 2005, the Provincial Health Officer released a report outlining the health impacts and costs associated with Type 1, Type 2 and gestational diabetes in British Columbia.³⁵  The findings of this report are shocking: in 2004, approximately 222,000 individuals were living with diabetes.  Of these, over 90 percent of the diagnosed cases were Type 2 diabetes, which typically occurs in adults who are also overweight or obese due to unhealthy eating and physical inactivity.  People with diabetes and its complications accounted for 19 percent of all hospital costs, 14 percent of Medical Service Plan costs, and 27 percent of PharmaCare costs — for a total of $1.04 billion in 2003/04.³⁶ 

Figure 4: Prevalence of Diabetes in British Columbia

Source: Provincial Health Officers Annual Report 2004,
The Impact of Diabetes on the Health and Well-being of People in British Columbia, 6.

In British Columbia, the Ministry of Health funds 80 diabetes education centres, staffed by health care professionals who provide support and information on healthy eating, the safe use of medications and how to prevent complications from the disease.  The Ministry also works with the Canadian Diabetes Association in providing information to people living with diabetes and promoting prevention campaigns.

Diabetes generally affects older segments of the population; however, the primary contributing factors of unhealthy diets and physical inactivity affect all British Columbians.  The Committee requests that the Ministry of Health, in conjunction with gradual increases in budget allotments to public health promotion and disease prevention, develop, in consultation with stakeholders, a comprehensive action plan for population health interventions to address the rapid growth of diabetes in British Columbia.

The Committee recommends that:

11. the Ministry of Health continue to develop an action plan for population-health interventions to address Type 2 diabetes, largely attributable to weight gain and physical activity.  The action plan should include a specific component for addressing diabetes in children and youth.

Vending Machine and Food Sales

One area in which the Committee believes ActNow BC should be taking a lead role is in the development, promotion, and implementation of made-in-B.C. policies concerning food vending machines — not just in schools, but in all provincial buildings.  The Committee encourages a broad stroke intervention that will serve to harmonize the linkage between government goals and effective action.

Vending Machines and Food Sales in Schools

The work undertaken by the Ministries of Education and Health provides an excellent starting point for a comprehensive public vending machine and food sales policy for all public buildings in British Columbia. Under the Guidelines for Food and Beverage Sales in B.C. Schools, the government has committed that foods classified with the “Not Recommended” designation will be prohibited from being sold in vending machines in B.C. schools.³⁷  Furthermore, by 2009 all schools and districts will be required to ensure that all foods and beverages sold in schools — including foods sold from vending machines, cafeterias, canteens, and fundraising events — meet the following composition:

• at least 50 percent of foods must come from the “Choose Most” category;
• 40 to 50 percent must come from the “Choose Sometimes” category; and
• no more than 10 percent will be from the “Choose Least” category.
  

Table 2: Overview of food classifications, based on the Guidelines for Food and Beverage Sales in B.C. Schools

Source: Ministries of Health and Education (2005).

The Committee endorses the work conducted by the Ministries of Education and Health to provide healthier food options to B.C.’s children and encourages all schools in the province to adopt the guidelines well in advance of the 2009 target date.

The Committee recommends that:

12. the government redouble its efforts to remove junk food from schools and modify food offered in schools to be consistent with nutritional guidelines for fat, sugar and salt content.

Saqa, Age 7, D'Arcy

Vending Machine and Food Sales in Public Facilities

I can tell you today that we’re going to extend that initiative to take junk food out of vending machines in all provincially owned public buildings, including hospitals.  We’ll act next spring to ensure all vending machine contracts for those facilities are full of healthy food, not junk food. (Premier Gordon Campbell, November 4, 2006)

On November 4, 2006, the government announced its intention to remove junk food from all vending machines in all facilities operated and funded by the provincial government.  Presumably, this directive would extend not only to schools and hospitals, but also to universities, colleges, and break rooms in provincial government and Crown Corporation buildings.  The Committee believes that this announced policy is an important step in providing harmonization in provincial government policy.  After all, if we as parents and grandparents expect our children and grandchildren to eat healthier, we too must be willing to change our behaviour.

In looking to define the “junk foods” referenced by the Premier, we would encourage the government to apply the same standards used in B.C. schools to a broader vending machine and food sales policy.  It is the Committee’s opinion that foods that are “Not Recommended” as defined by the Guidelines for Food and Beverage Sales in B.C. Schools are indeed junk foods and should not be available for sale in any vending machine located on provincial government property.  Furthermore, the Committee endorses regulations that would require the “50-40-10” guidelines (as outlined above) for the contents of vending machine to be followed in all public buildings.

Janahan Pathamanathan and Isabelle Tupas,
students of General Brock Elementary School, speak to the Committee in Vancouver.
The two students are the youngest witnesses ever to appear before a parliamentary committee in British Columbia.

However, vending machines are not the only food purchasing options available on government properties. For example, a typical university campus will have a convenience store stocked with candy and instant meals loaded with salts and fats, cafeterias offering everything from deep-fried chicken to bacon cheeseburgers, coffee shops offering high fat mochas and coffee- and cream-based beverages, plus banks upon banks of food and beverage vending machines.  Clearly, simply removing just “Not Recommended” foods from vending machines will do little to affect behavioural change.

What is needed is a comprehensive policy regulating the sale of all foods in B.C.’s public buildings.  Using the Guidelines for Food and Beverage Sales in B.C. Schools as a baseline, the government should prohibit the sale of “Not Recommended” food products by all companies selling food in facilities owned or managed by the province by 2009.  There needs to be an ultimatum issued to food manufacturers, distributors, and retailers: provide healthier food options or be prepared to lose your prime retailing space.

Furthermore, we would encourage all municipalities to follow the Committee’s recommendations and remove all “Not Recommended” foods from municipal recreation facilities, community centres, and municipal government buildings.  British Columbia needs a harmonized approach on the sale of foods in public facilities if we are going to make healthy food options the easy choice for both children and adults.

The Committee recommends that:

13. the government order the mandatory removal of all products classified as “Not Recommended” under the Guidelines for Food and Beverage Sales in B.C. Schools from vending machines and other food outlets on property owned or managed by the provincial government by 2009, including, but not limited to, schools, hospitals, universities, and cafeterias in government buildings, and follow the 50-40-10 food contents outlined within the Guidelines.
14. the government require all kiosks, restaurants, snack shops and other food outlets operating within properties owned or operated by the provincial government to adopt the Guidelines for Food and Beverage Sales in B.C. Schools, and prohibit the sale of “Not Recommended” products.
15. municipal governments be encouraged to consider adopting measures similar to the Committee’s proposed vending and food sales guidelines.

Lauren, Age 12, Chilliwack

Ending the (tax) Free Ride for Junk Foods

One debate the Committee heard during our public hearings was over whether British Columbia should implement a junk food tax on foods and beverages high in fat, sugar, and sodium. The argument in favour of adding taxes on junk or snack foods are twofold.  First, introducing such taxes may positively reinforce in an individual’s mind that the products being purchased are not the best options for healthy nutrition. Second, advocates of additional taxation on foods of poor nutritional quality argue that the revenue generated from such taxes should be targeted to support social marketing programs that reinforce healthy eating and physical activity messages.

At this point in time, this Committee does not endorse recommendations for a specific “junk food tax.”  Indeed, we learned that applying small taxes on energy-dense and salty foods would be unlikely to cause significant positive changes in consumption patterns and may actually push lower income consumers towards purchasing lower quality food items with higher fat and sugar loads.³⁸ 

However, the Committee believes that it is important for consumers to be made aware that those products with high levels of sugar, fat, and salt are undesirable choices.  Indeed, many jurisdictions in both Canada and the United States have instead opted to remove exemptions covering candy, confections and soft drinks from their provincial or state sales tax (see Table 3).  For example, seven Canadian provinces (including Ontario, Manitoba, and provinces with harmonized provincial and federal sales taxes) include candy, chocolate bars, and beverages as foods not worthy of tax exemption status.  British Columbia, to date, has not followed suit in removing the exemptions allotted to these products.

In reviewing British Columbia’s current policies concerning the application of taxes vis-à-vis candy, confections, and soft drinks, the Committee learned that such foods are notably exempted under section 70 of the Social Services Tax Act [RSBC 1996, Chapter 431].  We believe that this is an oversight that requires immediate attention.   

In addition, to ensure these products are not simply reclassified as “food products” under the Act, (that are also exempt from the Social Services Tax) the Committee recommends that the government amend Section 2.4 of the Social Services Tax Act Regulations (B.C. Reg. 84/58) to explicitly exclude candy, confections, and soft drinks as products not covered under the “food products” exemption.³⁹ Furthermore, the Committee suggests that the government consider classifying all products identified as “Not Recommended” under the Guidelines for Food and Beverage Sales in B.C. Schools as products that should not be exempt from the Social Services Tax.

Table 3: Food Excluded from State Sales Tax Exemptions for Food (2002)

Source: National Conference of State Legislatures, Federation of Tax Administrators

In conducting a cross-jurisdictional review of the revenue implications of this proposal, the Committee was unable to put a firm estimate on how much revenue it would generate within the Canadian context.  However, based on the work of Jacobson and Brownell in reviewing revenue projections from sales taxes on junk food in the United States — and using the state of Kentucky as baseline — the Committee estimates that removing the exemptions on candy, confections, and soda pop may generate additional revenues of approximately $40 to 45 million per year.⁴⁰  The inclusion of all “Not Recommended” food products would boost this revenue source.

The Committee recommends that:

16. the government introduce amendments to the Social Services Tax Act, (Section 70) removing the exemption provided to “candies and confections” and “soft drinks” under the Act.
17. the government, using the Guidelines for Food and Beverage Sales in B.C. as a template, remove the Social Services Tax exemption provided to all unhealthy foods and beverages meeting the definitions of “Not Recommended.”

Kramer, Age 10, Victoria

Nutrition and Exercise Council

In the Health Committee’s 2004 report, we recommended that the BC Progress Board be asked to measure health and wellness indicators.  We are pleased to report that the Progress Board’s Benchmarking Reports now include information on top-line health outcome measures such as cancer and cardiovascular disease mortality, life expectancy, and potential years of life lost.  The Committee fully endorses the continued collection of this useful data by the BC Progress Board.

However, if we are going to address the issue of overweight and obesity in British Columbia, the province requires an independent body to affect change and monitor specific outcomes relating to physical inactivity and unhealthy eating.  For this reason, a Nutrition and Exercise Council is needed.

To be comprised of senior representatives from all levels of government and the food and beverage industry, we envision the Nutrition and Exercise Council to advise government and take leadership on an array of issues:

• Work with the federal government and industry to develop new labelling requirements, including the introduction of mandatory “signpost” labels alerting consumers to high fat, sugar, and salt content in foods,
• Work with industry to reduce the levels of fats, salts, and sugars in foods,
• Actively encourage industry to adopt stronger self-regulation criteria of food and beverage advertising and marketing directed at children under twelve, and
• Publish an annual report measuring progress in improving diet and activity levels and reducing obesity.

Recently, the Food Standards Agency in the United Kingdom conducted research into mandatory “signpost” labelling requirements (Figure 5).  Placed on the front of every packaged food product, signpost labelling would require all food manufacturers to categorize the levels of fats, saturates, sugars, and salts as meeting pre-determined targets per serving size as “low” (green), “medium” (yellow) or “high” (red).⁴¹ The Committee is intrigued by this proposal and its applicability to British Columbia and Canada.

We envision the primary role of the Nutrition and Exercise Council to build upon the Guideline for Food and Beverage Sales in B.C. Schools and make recommendations on the classification all food products as meeting the criteria of “Choose Most” “Choose Sometimes” “Choose Least” or “Not Recommended.” Furthermore, we would like to see the Nutrition and Exercise Council to work closely with the federal government to require all packaged foods sold in Canada to have front-of-package labels with a modified version of the “Simple Traffic Light System” for ease of classification.  Using Guidelines for Food and Beverage Sales in B.C. Schools, foods with a “Choose Most” designation would be authorized to display a “Green Light;” “Choose Sometimes” a “Yellow Light;” “Choose Least” or “Not Recommended” a “Red Light.”

Such a system would provide both the consumer and retailers with clear and relevant information on the high risk factors associated with various foods, determine whether the social services tax is to be applied, and force consumers to make an easier choice on whether they truly wish to consume a product of low nutritive value.

We would like to remind the provincial and federal governments that opposition to similar a strategy was put forward by the tobacco industry when it faced mandatory labelling requirements.  The amount of fats, sugar, and salt in today’s prepared foods are also resulting in serious health problems.  In light of the serious health consequences raised by overweight and obesity, the Committee is of the view that consumers must be assisted in making informed choices when deciding on the foods that their children and families are to eat.

In addition, the Committee believes other tasks may be assigned to the Nutrition and Exercise Council such as:

• Conduct an investigation into the feasibility of new junk food taxes on non-nutritive foods and beverages.
• Develop ongoing public marketing campaigns to raise awareness of diet and exercise issues and assist in lifestyle change.

At this time, the Committee supports the idea of the immediate removal of the exemptions provided to “candy and confections” and “soft drinks” under the Social Services Tax Act. However, we also believe that the application of additional taxes to foods of little nutritional value will require additional consideration in the near future.  We believe that the Nutrition and Exercise Council would be an ideal agency for classifying products that are of little nutritive value and assessing an appropriate level of taxation, if deemed necessary.

In addition, we believe that the Nutrition and Exercise Council may also be the an appropriate body for conducting independent research into public marketing campaigns to change behaviours as they relate to physical inactivity and unhealthy eating in kids.  We believe that if we are serious about changing behaviours within our society, we must first know what messages will and will not work.  The Committee sees this council as providing strategic advice to government on the development of social marketing messages to fight obesity.

The Committee recommends that:

18. reporting to the minister responsible for ActNow BC, the government create a Nutrition and Exercise Council, composed of senior representatives of different levels of government, healthy living advocates and stakeholders, and food and beverage industry officials to examine and report out annually on progress made on the following issues:

• Negotiate with the food, confectionary, and beverage manufacturers and distributors to achieve voluntary reductions in the fat, sugar, and salt content marketed in British Columbia.
• Develop warning labels alerting consumers to high fat, sugar, and salt foods, such as a red-amber-green system, and/or a calorie-load-per-serving system.
• Investigate the feasibility of new junk food taxes on non-nutritive foods and beverages.
• Enhance corporate self-regulation of food and beverage advertising and marketing directed at children under twelve.
• Develop ongoing public marketing campaigns to raise awareness of diet and exercise issues and assist in lifestyle changes.
• Publish an annual report measuring progress in improving diet and activity levels and reducing obesity.

< Obesity and Inactivity in Selected Cultural Communities – Table of Contents – The Role of Schools >

© 2006 Legislative Assembly of British Columbia