Health — Issue No. 4 — Tuesday, May 2, 2006 (HTML)

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

1. The Chair called the Committee to order at 8:03 a.m.

2. The following witness appeared before the Committee and answered questions:

3. The Committee recessed between 8:44 a.m. and 8:49 a.m.

4. The following witnesses appeared before the Committee and answered questions:

5. The Committee recessed between 9:32 a.m. and 9:36 a.m.

6. The following witness appeared before the Committee and answered questions:

7. The Deputy Chair provided the Committee with an update on the work of the Sub-Committee to Select a Media Consultant.

8. The Committee adjourned to the call of the Chair at 10 a.m.

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH



CONTENTS

		Page

Presentations		27
	M. Hayes
	J. Millar
	B. Schmidt
	B. Armstrong
	D. Hunter

Subcommittee Update		43

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:	Dr. Bob Armstrong (Provincial Health Services Authority) Dr. Michael Hayes (Simon Fraser University) Dr. Don Hunter Dr. John Millar (Provincial Health Services Authority) Brian Schmidt (Provincial Health Services Authority)

R. Sultan (Chair): Good morning. My name is Ralph Sultan, and I'm the Chair of the Select Standing Committee on Health of the British Columbia Legislature. We welcome you for a resumption of our hearings into the important public health issue of childhood obesity.

I would remind us all, again, that these are public meetings. The proceedings are being recorded and transcribed by Hansard Services of the Legislature. A copy of the transcript, along with the minutes of this meeting, will be printed and will be made available on the committee's website at www.leg.bc.ca/cmt.

In addition to the meeting transcript, a live audio webcast of this meeting is also produced and available on the committee's website to enable interested listeners to hear the proceedings as they occur. An archived copy of the audio broadcast will also be retained on the committee's website. I'm informed by our very efficient Clerk that this live audio webcast is being broadcast to the world over the services of the Internet, so there we are.

R. Sultan (Chair): I believe it's getting out even to your relatives in that part of the world, Dan.

Now, before we begin with our first witness, Clerk Ryan-Lloyd has a bit of a report to give.

K. Ryan-Lloyd (Clerk Assistant and Committee Clerk): Thank you. Good morning, everyone.

I just wanted to outline, for the benefit of committee members, the documents that we've distributed this morning. In addition to the meeting agenda, you will find on your desks two PowerPoint slides from the second and third presentations today: the first one by the Provincial Health Services Authority and the second one by Dr. Don Hunter.

In addition, our researcher Jonathan Fershau has prepared a document which you will find as the last item in your package, which is a summary of the preceding meeting, the testimony that was received from the BCMA and the safer cities delegates. It's Jonathan's intention to prepare those for you for every meeting — of the previous meeting. I hope that's helpful. If you would like any more information, please don't hesitate to ask Jonathan or me at any time.

R. Sultan (Chair): Our first expert witness this morning is Dr. Michael Hayes, who is the associate dean of the faculty of health sciences at Simon Fraser University in Burnaby, British Columbia. I would ask Dr. Michael Hayes to give us a brief biographical sketch of his background before he proceeds with his presentation, which we've scheduled for approximately 20 to 25 minutes, and then allow some time for questions and answers by the committee.

M. Hayes: Well, thank you very much. Good morning, everyone. It's certainly my pleasure and honour to be able to speak to you today. I would also like to apologize in advance for not sending slides of my presentation but will leave them with the Clerk so that you might have a copy.

My name is Michael Hayes. I have a PhD in geography and a background in geography and epidemiology. I've been at Simon Fraser University for approximately 18 years. Over the last five years I've been developing the new faculty of health sciences along with Dr. David MacLean, who is the dean of that program.

We're really interested in prevention of chronic illness and looking at the broader so-called determinants of health. The faculty itself, as you probably are aware, is at a university that does not have a medical school. We see this as a great opportunity for us to think about health in a broader social context, and perhaps that might be a fitting backdrop for the comments that I'll make this morning.

My understanding is that you would like me to speak about childhood obesity and issues related to public policy. I've chosen to do so starting with a global look at issues related to childhood obesity to situate this phenomenon in a broader context. I will finish my presentation with a look at some of the research that I'm doing, along with one of my PhD students, Lisa Oliver, and then some comments on how we might address questions about obesity and nutrition and activity by rethinking what policy levers might be available.

Obviously, you'll be listening to many witnesses. I've not tried to cover everything. I've only focused on a couple of specific citings to try to think about how we might do things slightly differently.

Just by way of very brief introduction, the issue of childhood obesity and the prevalence of childhood obesity, this incredible increase that we're seeing in childhood obesity, is a phenomenon that is global. Before you, you see data from developed countries — in North America, Australia and Europe — and developing countries, as well as underdeveloped countries. I note, for example, that Haiti has the same phenomenon, as do places like Egypt, Ghana and Morocco. It truly is a worldwide phenomenon. Every country in the world is experiencing increases in the prevalence of childhood obesity and the incidence of overweight.

Now, those measures themselves, as I'm sure you are aware, are based on a calculation of body mass index. I won't go into the details of that now. Suffice it to say, it is a global standard, so these increases are real increases measured against the universal standard.

One of the things that people often think about when they think about the causes of childhood obesity is that it's kind of a phenomenon not unlike a bathtub

with water running in, determining the level of flow, and water exiting. The balance between those things gives you how much water will be in your tub. That's really what this represents here.

Unfortunately, this is really not a very good picture of it, and I'm indebted to Dr. Kaminska for this particular slide. As she points out, to really understand this phenomenon, one has to understand these phenomena. That is to say, the complexity of different kinds of settings that obtain, going from an international perspective on the globalization of markets, questions about international development and media programs and advertising, right through to national factors, local factors and, finally, to specific setting factors in local communities….

It's really this that is the genesis of this phenomenon. It is not a phenomenon caused by lazy people sitting around eating too many potato chips, although that, too, may happen. It's a phenomenon that's bred of a lot of different things: how we construct our cities, the ways in which technology has impacted our lives, and the incredible change that has taken place in daily activity. It simply is a consequence of computers and computing and mass communications. We can all sit at home now and talk to the world, as I am doing this moment.

It's a phenomenon that's bred of other factors as well. When I was a kid, I had about 45 kids in my neighbourhood, and I could go outside and play until the street lights came on. I would have no end of play friends in my local vicinity. Changes in demographics have left few kids in our neighbourhoods to play with. When we combine that with fear and other issues of safety that I think permeate our contemporary society, we have a recipe for people having less activity, more availability of food and, consequently, increasing body mass.

How can we think about dealing with this phenomenon? Of course, there is no single answer to this. A multi-pronged strategy has to be adopted.

I present to you now just one conceptualization of how this might work, adapted from the work of McKinley. Really, the reason for showing you this slide is not because I necessarily endorse these specific interventions but, rather, to show you the spread of opportunities that exist to do things about this phenomenon.

One the one hand, at the extreme upstream factors, we've got the issues of changing food supply and policies related to food supply. At the extreme downstream end, we've got counselling patients about diet, and I suppose that at the extreme end of that, we would have things like stapling stomachs and so forth, to try to reduce body weight. Clearly, a highly medicalized set of interventions would be very, very expensive and would not really do very well in terms of preventing the occurrence. Prudence would suggest that we focus upstream.

I show you here a slide from the pan-Canadian healthy living strategy. I'm not sure if members of the committee would be familiar with this particular strategy, but it is a strategy that developed through the Federal-Provincial-Territorial Advisory Committee on Population Health, of which, of course, British Columbia is a member. This was a strategy that was endorsed by the ministers of health as a way of thinking about this particular phenomenon.

Now, it's a complex slide, so perhaps I could just walk you through it. First of all, we start with a vision of healthy living — that is to say, a healthy nation in which all Canadians experience conditions that support the attainment of good health. Within that, we have two specific goals — goals that sometimes can be at odds with one another. On the one hand, there's the goal of reducing health disparities. On the other hand, there's a goal of improving overall health outcomes. Realize that those programs, which are taken up by people who are, I suppose in general terms, better off and in better health differentially from the general population, would, in the short term, increase disparities in health status.

What we really need to do is to focus not just on the tails of an extreme but on really trying to shift the whole median. In so doing, we would attain the twin goals of reducing health disparities and improving health outcomes. That is to say, we need to adopt a population-health approach. To my mind, a population-health approach is something that considers the entire life course perspective. We don't start cross-sectionally, and we don't start by asking: why does this particular person have this particular disease? We ask the question: what would happen to a child today, what would the life trajectory of that child be, under different kinds of settings and circumstances?

One thing that we have observed repeatedly for 150 years has been a social gradient in health outcomes. The gradient is not immutable. We see different slopes to the gradient in different kinds of countries. Those countries with the most gentle social gradient also have the best health status. They have the widest participation in society and, overall, the best health outcomes. I am happy to say that British Columbia is near the top of that list. It's just a great honour to live in an environment in which that is the case.

One of the ways that we can, sort of, bring together the symphony, really, of strategies is to realize that this doesn't belong to the Minister of Health. This is the business of the corporate agenda of a government. We need to think about integrating policies, both vertically and horizontally. We need to think about partnerships and shared responsibilities, not only between government ministries but across all sectors of society. We need to strive to reflect on what the best practices are, related to any particular health outcome, in order to reach those twin goals of reducing disparities and improving health outcomes.

In terms of strategic directions, really, we see four different options here: leadership and policy development, knowledge development and transfer, community development and community infrastructure, and public information. Now, realize that this overarching and abstract kind of approach can be used to tackle

questions related to eating, activity and obesity, but we could also bring this very same strategy to bear on mental health or injury prevention or, indeed, any other kind of chronic condition.

What I'm really presenting to you here is a broad strategy for understanding how we might deal with the question of obesity, but it's a generic framework that could be used for other things. It's actually part of the public record, something that all the governments of Canada have signed on to.

The vision within this healthy living strategy is a healthy nation for all Canadians, accomplished through collaboration and cooperation between partners in society. That is to say: drawing on the various spheres of influence and resources; action on specific determinants of health through health promotion and disease prevention; and planning, both for long- and short-term kinds of issues.

Now, I just want to turn very briefly to some data that come from our own research. These data come from the National Longitudinal Survey of Children and Youth, so this is a longitudinal data set that allows us to follow children through time. What you have there is the relationship between neighbourhood socioeconomic status and the prevalence of children who are designated either overweight, on the left, or obese, on the right. I think what is so remarkable about this slide is that it shows our friend the social gradient.

These data are taken from all Canadian municipalities and organized by what are called dissemination areas aggregated into, then, these spatial units called neighbourhoods. If we now look not at obesity but at non-participation in physical activity — that is to say, the percentage of children in each of those neighbourhoods who do not participate, on the left-hand side, in organized physical activity and, on the right-hand side, in unorganized physical activity — we see quite an interesting difference.

Organized activities would be those things that require registration, some fee, some routine that requires perhaps a car or a caregiver or even the basic knowledge about the program in order to participate. One can see that non-participation is directly related to family resources.

Contrast that with the three bars that you see on the right of the slide. That's unorganized physical activity. This is just kids going out and playing — riding bikes, skateboarding, playing pickup hockey or doing whatever. You see that there is no class relationship in that kind of activity, suggesting that the cost factor, whatever that would be, and/or the knowledge factor — awareness of the program, organizing a schedule to get there and so forth — has a blunting effect across social groups on participating in organized activity.

If we think about what happened in the 1980s, when there was a very severe focus on deficit and debt reduction, there was, I think, a shifting onto municipalities of various activities. As cities ran out of money, they, too, started to charge more for leisure activities and things of that nature. I'm trying to just suggest to you that there's a buildup effect here in this kind of ability to participate at the local level, because municipal budgets, of course, are generated not exclusively through the provincial coffers.

One of the things I also wanted to point out to the committee was that in our research, when we look not only at the participation or non-participation in activities, but when we look at parents' responses to the question that this neighbourhood has safe parks and play spaces for children, you can see the percentages there who either disagree or strongly disagree, and that tracks exactly the distribution of obesity and the distribution of non-participation in organized activities. So embedded in this story is a question or concern about public safety, which again is related to the overall resources available at the neighbourhood level.

Where does this take us? Again, you can appreciate this is a very quick overview. These are a few ideas that I think really are reflective of a positive kind of policy approach to address this issue. Recreation and leisure activity investment is huge. I put up there Leisure Involvement for Everyone. That's the LIFE program that is in this community. It allows people to participate in recreational facilities like Crystal Pool, regardless of income.

Municipal subsidies for recreation targeted to those things. Bike paths, walking trails, streetscape enhancement would all be activities that could be undertaken to actually address the concerns of obesity and inactivity. If we think about the streetscape as a pleasant place to explore, it doesn't require a lot of money; it doesn't require a lot of equipment. People can go out and enjoy at any time of day if they have the right clothing. It's about trying to nurture people back into the streets. Give them something to look at, give them something to enjoy, and address the fear factor.

School-based activities as a core part of a curriculum. I'm thinking of things like walking tours to do urban geography, understanding the development of the city for history or geography. We can do outdoor activity for biology or for environmental sciences. Trying to integrate the classroom with the outdoors is something that would be a very inexpensive and, I think, a learning enhancement opportunity for young people — in fact, for all of us.

As part of the school culture, as well, there is in New Zealand a very successful program of a walking school bus. I don't know if the committee has ever heard of this, but essentially what happens is that groups of children walk to school together. They just start a parade that adds kids to it, and by the time they get to the school, they've got 15 or 20 kids walking together with an adult. Instead of driving the kids to school, it's a way of organizing children so that people are doing less driving, more walking and more socializing. Adults can then take turns getting the children to school.

Safety and activity programming in the schools relating to bicycles, skateboards, in-line skates or anything else. In other words, it's using the school to promote the safe use of these activities and also promote the activities themselves.

Participation in walks and runs for various causes, whether we're talking about the Sun Run, famine relief or anything else. Again, it's a very low-cost way of engaging people in activity when they're not even aware that it's the activity that's the issue. You can focus on something else as what people are trying to achieve.

I think school-based nutrition programs are huge in this. There's lots of evidence to show that they work, and they're universal, so it doesn't matter who has what kind of income or background. We're talking about parents who are often two-parent-income families. They, too, have enormous demands on their time budgets, so the easy route is to throw together something — a snack that can be done quickly, like Chinese noodles or something like that, not the most nutritious of food groups.

The other thing is that integrated into this are life skill program opportunities — discussions about food preparation and food procurement, helping people to learn how to actually prepare food when they're in their early teens so that when they become adults, they have a sense of it.

I think this may seem a little bit off the wall, but social and civic engagement…. If we think about the public city, we think about festivals and public programs — things that get people out and moving — as a way of both engaging activity and also taking back their environments, being a part of the community, seeing people that they know or that they don't know — just building what people like to call "social capital." I prefer "civil society."

Guided walks to talk about history, to talk about the environment, to talk about architecture, gardening or whatever. These are all inexpensive ways that we can build connections and allow people to be engaged. I've now shifted gears here, as you can tell, from children to people in general, because I don't think any strategy can simply target children. We actually have to think about all of us and the quality of the environments that we live in, in order for them to work for children.

Finally, neighbourhood social events. I'm thinking about your basic block party here, and so forth. It may not seem like there's a lot of activity that might go on there, apart from imbibing, but in fact what you do is allow people the opportunity to socialize and plan as a way of stimulating different kinds of activity.

Those are very low-tech, broad-based kinds of strategies that would, I think, not only address issues of obesity, activity and nutrition but actually, more generally and more importantly, the basic quality of life that we enjoy. Thank you.

R. Sultan (Chair): Thank you, Dr. Hayes. A very interesting and broad-based presentation.

Going back almost to your very first slide, when you talked about this being a global problem, I'm really curious. I liked your analogy of the bathtub, but in a global context there are huge variations. I mean, we assume, for example, that kids in Haiti probably walk a lot, and so on. Is there any research that shows…? Is there a common thread internationally that we can identify?

M. Hayes: There is. I'd have to say that the answer to your question really has two significantly different parts to it. One is the extreme long wave. We have to imagine our biology. You know, as Weird Al Yankovic says: "Every pair of genes is a hand-me-down." I think the idea is that….

If we think of it in evolutionary terms, we inherit metabolic systems that were really adapted to people who were foraging, who were used to feast and famine and needed to put on weight because that was a protection against not having food for short periods, and so forth. In a very, very short period, in evolutionary terms, we've gone from no change at all to something that's gone like this, with the rise of modern populations. Yet our biology is not capable of really adapting as quickly.

Part of the global phenomena is this phenomenon of a failure of our own success, in a sense, as a species. We no longer have these great…. At least, a great many people no longer have feast-or-famine kinds of things. Obviously, there are still people who live in the world for whom things haven't changed at all relative to our forebears.

The short-term issue is that a lot of that food that's available is what's called "energy-dense." That is to say, it has a lot of energy calories in it and yet not necessarily a lot of nutritional value. So it helps to build fat, essentially, without necessarily covering off the whole spectrum of nutritional need. There one can think of fast foods as an obvious example — the McDonald's phenomenon, or any other purveyor of fast food — and those kinds of food options being available globally, really.

I don't want to put it all just on fast food, but I think that's kind of an indicator of something that's happening more generally — that is, getting to market food substances that are widely available that allow people to really live in nutrigenic kinds of environments where there is just too much calorie content available relative to their needs. Yet it's not of high nutritious value, so you're building fat, not muscle or other important parts of our biology.

On the socioeconomic aspect of it, there's no question that unorganized activity is no longer there anymore and, itself, was probably the main benefit for people in my generation keeping their figures slim until they reached this modern generation — a good example of lack of activity.

Anyway, this walking school bus is of interest to me. I'm wondering if that actually has been put into

In my area alone — I'm quite close to a middle school and an elementary school; in fact, I'm too close, because in the mornings you just can't get out of your driveway — I've had some stats come to me based on the fact that 71 percent of both spouses work. I think that's part of the problem. Not only is there the fear factor of someone grabbing or molesting their child, or those aspects, but they're rush, rush, rush and trying to get…. Because they're busy, and all the rest of it.

D. Jarvis: I don't really have a question, other than to say that the walking school bus, I thought, would be a good idea. Has it ever been put into effect in places and been successful? How do you get the parents to get into it?

M. Hayes: I think that's a very good question. Again, it's uncannily low-technology, isn't it? Really, it requires organizing committees and people to buy into it. It has been studied in New Zealand, in particular, where two things have come of it. One is that, of course, the kids participate, and they do the walking. Secondly, it brings adults more engaged into the school setting, because it's kind of a gateway for them into involvement with broader issues in the school. Given that there's a rotation that goes on among adults…. It's not just one person being the pack leader; it's several people delivering kids to school. Consequently, they get to know the neighbourhood children. They get to know some of the teachers. They are just more generally interested in the school activities.

I'm not aware of this being enacted in Canada, but that's not to say that it doesn't exist.

M. Hayes: It does. It is a phenomenon that could be, I suppose, encouraged widely as a way of helping people to cope with….

I live in exactly one of the families you described: two working parents, and nobody has any time. I showed up here about a minute before the proceedings, which is indicative of my own time budgets.

M. Sather: Thank you, Dr. Hayes. I also thought that was a very interesting presentation. I like the whole idea of the integration of our total lives, if you will, and the social aspect of our lives with physical activity, with the subject at hand for us being obesity. To me, it sounds a lot like community-building. It's almost a factor of taking back the streets, if you will, because we've become so isolated, in many respects, within our own homes and within our automobiles and workplaces. For children, that's part of the picture as well.

I think that a couple of things you mentioned resonate with me in particular. You were talking about classrooms and getting the kids out more to have outdoor experiences. I know that my wife, who's an ex-teacher, was able to do that with her elementary children. They were fortunate to have a nice greenspace behind the school. She took them out and started teaching them a lot about the natural history of the area just behind the school.

I think that has a lot of benefits, not just in getting to know about nature, which I think is important, but also it's like suddenly now this becomes a place, a greenspace, an area where the kids have some expertise and a lot of interest and therefore more motivation to go. It's another reason to get a person out for a walk in your neighbourhood park or whatever, because you're now experiencing it in a fuller manner. I think that's great as part of the way towards getting kids more active — and all of us, actually.

Also, the thing about food preparation. I think that's really good. So many kids growing up and adults — especially male adults, perhaps — don't have food preparation skills. You're divorced, in many respects, from what you eat if you don't prepare it yourself. So I think that's just great. Getting kids to know about how to prepare food is going to mean that they're more likely to make their own food and therefore, hopefully, along with some education, better food.

J. Nuraney: I think some of the slides that you put out there raise some new thoughts in my mind. You showed that England has the least increase in obesity.

Just going back to during my student days, I don't remember driving a car, just walking back and forth for everything that we did. Either going to school, university or businesses or whatever, people were used to continually walking back and forth. That gives me the thought that maybe it is a public transportation strategy. If we had good, efficient public transportation, it would encourage people to walk, rather than drive. That is another element that you may, perhaps, want to put in your….

M. Hayes: I really appreciate that comment. I should have mentioned that community design is absolutely huge, if you think about the way — the factors, the influences and incentives that are available for building now. They send us up the valley and — I'm thinking now of the lower mainland — put us in cars for an hour and a half each way.

If you have not contacted him, a person you may be interested in speaking to is Dr. Larry Frank from the school of community and regional planning at UBC, who's shown that community design has a direct influence on obesity in adults. I don't think his work has really focused so much on children, but you can imagine the relationship there. If it's happening to adults, it's likely happening to children too.

When you think about design issues, it's not only the distances but also the configuration. You know, the design that was popular in the 1970s of cul-de-sacs and so forth seemed to work well for children playing in the street, but as those people age in place, it doesn't work well for people going out for a walk. There's no target or focal point for the walk. There's no shop to get to. It's kind of an endless morass — a maze, almost — of residential properties, and not really conducive to walking.

He's found that more direct routes, like the old grid patterns and so forth, have a much higher influence on people walking, especially when they're combined with a destination. I think about Cook Street village as a really good example of that: a small-scale place where people go for coffee, to pick up a movie, to get their clothes cleaned, to get a greengrocer or whatever, that brings all kinds of people into it. People are walking there all the time. We've got to reinvent those sorts of activities.

You know, we actually had that kind of streetscape, that kind of community design, and we let it go, because we were interested in this idea of big lots and drive-to and all that sort of stuff. That kind of mentality sold a lot of SUVs, but it doesn't do very well for us in terms not only of our body mass but also of our connections to other people.

J. Nuraney: That was my second question, about the architecture and the designs of projects. Maybe we should encourage the developers, because what you also showed was that unorganized sports have a better outcome than organized sports.

J. Nuraney: In the building, in the architectural designs of complexes, maybe that is something that needs to be instituted to make sure that there is space for unorganized activities for people living in that area.

M. Hayes: I would agree with that. Again, this comes at a bit of a cost, potentially — and that is, of course, fear. Public spaces can also be scary spaces, with dark parks at night, kids hanging out, and so forth. It tends to unsettle a lot of people. We've had too many reports of people having violence done to them. Whether or not people are involved in these particular kinds of locations, those are the images that people conjure, if I think about the Reena Virks of the world or whatever.

One has to, I think, have these kinds of spaces but also confront this generalized fear. I think that this fear is huge. It's kind of a substrate of all the stuff that we're talking about now. Of course, the crazy thing is that if we look at the actual occurrence of crime, the rates are falling, but if we look at people's perceptions of crime, they've never been higher. We have to do something to get messaging out to say: "Look, because the six o'clock news can follow every dastardly deed that's happened in your community, it doesn't mean that your community is only populated by these kinds of terrible events. In fact, they're relatively rare."

R. Sultan (Chair): We are running out of time, unfortunately. We will have two more brief questions and, hopefully, brief responses from Dave Hayer and then Katherine Whittred to conclude.

K. Whittred: No, no. I was just waving my hand to say that yes, there is this walking school bus in a few places.

D. Hayer: Thank you very much, Dr. Hayes. You know, I appreciated your presentation, and I appreciate that you sent it to us in advance so that we were able to review, before coming to this committee, some of the parts of this presentation that we received.

I wanted to say one thing, when we talk about transportation. It's really good to see you talking about transportation, but one challenge that sometimes comes in is that British Columbia is larger than many countries in Europe. Each has its own challenges, because of geography, as to how people can get from one place to another part.

But I think there's another thing. Do you think we should be encouraging people, maybe, when they go to shopping centres, to try to find a parking spot far away rather than closest to the door? Or if you're going to work, just don't park nearest to your office, so you have a chance to walk. As well, maybe you're trying to put more parks closer to where the communities are. I know that in my residential area, a lot of people are walking around the parks they developed in each neighbourhood.

M. Hayes: I think the issue of automobiles, though, is a tricky one, because the more we encourage car use…. It's not a bad thing to suggest that people park and walk from where they are to where they need to go, but again, if we think about people being time-challenged, you need to get to work that extra ten minutes in advance to do the walk that you're talking about. It seems to me that if you could walk the ten minutes at the beginning of the journey to a public transit that would take you to your work, you would solve that problem at the front end rather than at the back end, if you understand what I mean.

Sometimes there's a lot of uncertainty associated with distance or time taken to get to work, especially for complex commutes like those in the lower main-land, and an accident on a bridge, inclement weather or some other event often ends up making everybody late. Therefore, that's the first one to go in terms of a model, if you understand what I mean.

I think that I certainly wouldn't disagree with the idea. I just think that as a concept, the more that we

could do at the front end to encourage people to be active to get to their mode of transit, we might be that much more successful. I mean, clearly, this is a multi-headed problem, and there is no single solution that's going to work. Really, it's about nurturing a culture of ideas that isn't focused on the activity or the nutrition. That's not the goal; the goal is to actually focus on the social enjoyment of being in each other's company. The by-products of this are the activity and the increased focus on nutrition that we seek.

R. Sultan (Chair): Thank you, Dr. Michael Hayes, for a most provocative presentation. I can see that the faculty of health sciences at Simon Fraser is indeed taking new directions, and we will look forward to the continued evolution of your department. I would hope that you would make available copies of all of the slides from your presentation.

R. Sultan (Chair): Thank you for coming over this morning and enlightening us.

R. Sultan (Chair): We will now take a two-minute break while we set up for the next presentations.

R. Sultan (Chair): Our next expert witnesses are Dr. John Millar, executive director of population health surveillance in the provincial health services area, accompanied by Brian Schmidt and Dr. Bob Armstrong. To get us rolling, witnesses, perhaps you could just give us a very brief bio of each of yourselves to explain who you are, both to us and to our worldwide listening audience.

J. Millar: I'm John Millar. I'm a public health physician. I was previously the provincial health officer here in British Columbia. I've had the honour and privilege of appearing before this committee before, and I'm delighted to be here again today.

B. Schmidt: I'm Brian Schmidt. I'm senior vice-president for provincial services as well as public and population health coordination with the Provincial Health Services Authority. I've been in this job for about four years and previously worked with Children's Hospital and the B.C. Cancer Agency. Both are organizations strongly related to chronic disease, which of course we're here to try to prevent.

B. Armstrong: I'm Bob Armstrong. I'm a pediatrician working at Children's Hospital and UBC. I see children with developmental problems, but most of my time is currently spent as chief of pediatrics at Children's Hospital and head of pediatrics at the University of British Columbia.

R. Sultan (Chair): Thank you very much. We would ask you to proceed with your presentation. We'll allow 20 to 25 minutes and then, hopefully, have some time for questions from the panel.

J. Millar: Just to put a bit of context. PHSA has been in existence now for four years or so. It's been put in place to promote and deliver accessible health services for all British Columbians through an integrated health system and the establishment of provincewide standards.

I'm sure most of you are familiar with it, but just in case you are not, what comes under PHSA as an umbrella organization is the B.C. Cancer Agency; the Children's Hospital; the Women's Hospital; the B.C. Centre for Disease Control; Cardiac Services; the Renal Agency, providing dialysis and so forth; the transplantation agency; and mental health services — as well as myriad other services such as surgical wait-list management and a number of other services that are part of the organization.

Very early in the life of the organization, the board recognized that the provision of these high-level tertiary services in the province would not be sustainable, because of the upward pressures through aging, obesity and a number of other things, unless direct measures were taken to put some effort into prevention.

One of the four strategic directions in this organization is around prevention, promotion and protection. The board directed the executive of PHSA to find some budgetary assistance for this. In addition to the money already spent on prevention that goes on at Children's and Women's hospitals, B.C. Centre for Disease Control and the Cancer Agency, there's now an extra $2 million a year that goes specifically into this area. Where much of this money is spent is around data collection — the gathering, synthesis, and translation of evidence into policy.

That's what really brings us here today, because the executive of PHSA, following extensive consultations, directed us to focus particularly on two areas: one on tobacco and one on obesity. It's my pleasure today to bring to you the results of the knowledge synthesis that we've done. We've looked at the evidence about what works and what doesn't work to actually reduce obesity. We've noticed your particular interest and around incentives in society to address this problem.

What I'm going to go over for you is what we've been able to survey in terms of the evidence. The messages that I think you can take away from this today are, first of all, that we are in the midst of an epidemic, and we do desperately need to address this in an organized and coherent way. It's a complex problem, and it's going to require complex and coordinated approaches. We do know that progress is possible, and I'll show you the evidence around that.

This is very clearly what we are terming an environmental disease. This is a disease that is occurring because of the environment in which people are being immersed, particularly children. We can make changes in this environment. It's an important concept.

The last important message here is that we have very poor tracking of this problem in British Columbia. We can present you with some data here today about what's going on, but we're not doing it adequately. I hope to enlist your support in trying to get better monitoring of this problem and in looking at what we can do with evidence-based interventions in the home, in the schools, in neighbourhoods and through policy interventions.

I know that you're probably getting saturated with data about the nature of the problem, but let me just show you the latest data we've been able to glean for you. In this graph you see that blue bar there. That's the total combination of overweight and obesity in Canadian children, going from just over 10 percent to almost 30 percent over this period of about 25 years. This is measured obesity, not reported obesity, and this is in children.

This line here makes a very important point. This is what parents report their children's height and weight to be. This is what is measured — this upper one. So you can appreciate that there's a lot of either inaccurate reporting or deliberate underreporting of this problem.

On this next slide the dotted line shows you the best data I could find for B.C., but at best, it's rather sketchy and a rather small sample. The most recent data are from '03 or '04. We're now into '06. Our data come from StatsCan. The next time they're going to be in the field is in '07. It takes them two years to report it, so the next time we'd get any data like this will be in '09 or something, maybe 2010, the point being here that we really…. It's the old management dictum: what doesn't get measured doesn't get done.

What I'm pitching here is that we need to work together to find a way to actually measure heightened weight or waist circumference in kids. It's a tricky area. It's not done easily. There are lots of sensitivities around it, and there are lots of gender issues and all sorts of other things like body image. We don't want to precipitate eating disorders and so forth, but it can be done.

The U.K. is doing this. Every child now in the U.K., when he or she hits kindergarten, gets weighed and measured. They get it again in grade five. They've figured out sensitive ways of doing this. We need to replicate that in this province.

In B.C. the data show that it's gone from 5 percent to 20 percent over a 25-year period, so it's a quadrupling of the numbers of kids that are overweight and obese. You know all this, but let's just say it again. What results from obese kids is that they grow up to have high blood pressure, diabetes, heart disease or renal failure, requiring amputations…. They go blind. They get cancer. There are mental health issues. This is a devastating condition. It's not trivial.

I've made the point already that this is an environmental disease. It's a disease that is a consequence of the marketing that goes on — the deliberate social intervention of private sector companies to purvey fast foods, junk foods and so forth.

There are issues here around what we're terming "food security." I'm sure it comes as no surprise to you to know that there are significant numbers of British Columbians who, on a daily basis, go hungry, are worried about being hungry or cannot get access to nutritional foods. This is particularly true in more remote rural communities and in communities characterized by low incomes, because if you haven't got the money, you can't buy the right food and can't get access to exercise. Income issues are a problem here.

Another environmental issue is around screen time — the amount of time that kids are sitting in front of TVs, video screens and computers of various kinds. The average now in Canada is 20 to 30 hours a week — three or four hours a day in front of the screens. This is a major problem in terms of this environment.

Physical activity, correspondingly. We know that kids are sitting more, and they don't often have adequate access to facilities and programs. You've heard a lot about this, but I'm going to give you some of the evidence around what can be done in these areas.

Obesity as an environmental disease. In fact, there's a guy, Kelly Brownell, in the States who has said this: "In the absence of this toxic food and physical inactivity environment, there would virtually be no obesity." I believe this is true.

You've already heard from Michael Hayes, and you will hear from others around urban design, transport, cars, public transport, school policies. Location of schools is the key. One of the members here said that they lived so close to the school that it was interfering with them, but many kids live so far from schools that they can't even consider walking, so a walking school bus wouldn't work. The school is just too far away. They have to take a car or a bus. School location is a key point here.

Screen time and rural-urban issues I've touched on. Income security I've talked about. We'll say more about what can go on in the home and the family.

These are just a few of the things that I think you probably already know about. On the left here, for boys we have "Sedentary" and "Active." You can see that amongst the sedentary boys they've got almost double the obesity rate. The blue part there is the obesity. The same in girls — for the sedentary group here are almost 50-percent-higher obesity rates if they're sedentary. Simple facts.

This one is around screen time, going on the left from less than ten hours here to 30 hours here. Steady increase in obesity; steady increase in overweight. I'm just making the point that on the most recent Canadian community health survey data, we're seeing a gradient that unlike Michael Hayes's thing around socioeconomic, it's here around the amount of time sitting in front of screens.

R. Sultan (Chair): If I could just interrupt, Dr. Millar. You mean screen time television viewing?

J. Millar: No. Screen is the combination of TVs, computers and videos — so the combination thereof. MSN and all that sort of stuff. It's the combination.

J. Millar: This is an extremely important slide because of this one column here. I apologize for the small print, but you do have copies of this, I think, in front of you.

This is aboriginal, and that's 20 percent of aboriginal children who are obese — 20 percent. That's double any other group.

Immigrant groups. Southwest Asians here — they're doing better than your average non-immigrant, non-aboriginal Canadian. So this aboriginal group is at huge risk here. We know that they're already getting much higher rates of diabetes, heart disease, cancer, etc., etc. It's one area on which we need to focus.

It points out what I was saying earlier around the inequities that exist. There are inequities. We need to be thinking about how we address these inequities in the groups that are inequitably affected by this, at the same time as thinking about how we do it for the whole population.

Okay. So B.C. is in a very strong position to act here. We've terrific leadership from this government with the Premier's health goals. We are unique in Canada with this opportunity. When I was the provincial health officer, we were able to bring in some very broad health goals for the province. I'm very proud to have been part of that, but this goes farther.

The Premier has set these measurable targets, and this is hugely important. It's also very challenging for the government because the target for obesity is a 20-percent reduction by 2010. This will be very hard to reach. It's going to require close monitoring and a lot of work to get to this 20-percent target. It's going to require working hard on kids.

We've got the ActNow, Legacies Now, endeavours with healthy schools, and physical activity and nutrition in the schools — terrific programs. This getting fresh fruit and vegetables through cooperation with the private sector is a terrific initiative, and we need to build on these things. We are leading the pack.

You may have seen some data that we released quite recently at the call to action conference in Vancouver, showing that B.C. men now live longer than in any other country. But the bad news for the ladies is that women are not doing as well. Women are slipping relative to other countries. The reasons that they are slipping are several, but right at the top of this is the fact that their heart disease rates are higher, and diabetes is increasing. This is directly related to this problem of obesity. If we don't do it for both kids and adults, we will not meet that 20-percent target.

By 2010 we will not be the healthiest jurisdiction in Canada to hold the Olympics, at least from the point of view of women. Men — we're looking good. All the heart disease rates and things for men are coming down very nicely. That's why we've moved ahead of Japan. But for women, they're slipping behind other countries, and by 2010 it's looking, on current projections, that B.C. will be seventh in the world after Australia, New Zealand, England, France, Spain and Japan. It's directly attributable to the obesity problem.

We now have the B.C. Healthy Living Alliance, which I'm sure you're aware has recently benefited from a $25 million infusion of money from the government and which is in huge support of reaching these goals and back all of the goals of the government and are placed very well to assist in moving us along.

What can we do in terms of moving this agenda? I'm going to present you with some data around the home, around schools, around neighbourhoods and around the broad issues of social marketing and public policies.

In the home we know that kids who grow up in families where the parents set a good example, both on food and exercise, will follow those patterns. Role modelling by parents works. If the parents get more exercise, so will the kids. If the parents have a nutritious diet, so will the kids.

This takes us straight to what could be done. I'm not presenting this as evidence-based, but we know that parenting classes and so forth can influence this and that that in turn would increase better food consumption and exercise.

One area in which there now is very solid evidence is around soft drinks. The epidemic of obesity has been accompanied by a huge increase in sugar-sweetened beverage consumption. We now have solid evidence from the highest standard of experimental study, which is the randomized controlled trial, that children who are given a program to help them reduce their soft drink consumption do reduce their soft drink consumption, and if they are already overweight, they will lose weight.

There is just absolutely no question that sugar-based drinks are contributing to this epidemic, and there are measures that can come in to reduce that and reduce the weight problem.

Breast-feeding has been shown to be hugely protective for developing obesity in later life, so anything that we can do to further promote breast-feeding will help. That will have a direct effect in the home and family context.

In neighbourhoods…. Michael Hayes has given you some glimpses of this, as I'm sure others have. What I have to tell you about the evidence around this area is that there is no evidence at a neighbourhood or urban design level that can directly affect obesity — okay? We don't have that level of evidence yet. The evidence does tell us that we can make changes in urban design that will promote physical activity and promote consumption of a better, nutritious diet. We know that if we do those things, we can affect obesity, but it hasn't gone far enough in terms of interventions to gather that

kind of evidence yet, to translate it directly into effect on obesity, so I can't claim that for you.

We do know that by having more bike paths, more rec centres, more parks, appropriate zoning, the placement of food outlets, the placement of schools, having mixed-use in zoning…. In other words, as Michael was telling you, if somebody has a place to walk to, if they have a store to go to that's within easy walking distance, they will do that, and that will promote their activity.

Let's turn for a moment to the schools, because this is very, very important. The ActNow B.C. and healthy schools initiatives have tended to focus on two particular areas: more physical activity — obviously related to the Olympics — and more nutritious diets in the schools. I'm sure you've already been told about the Annapolis Valley project, but if you haven't, let me reinforce it for you. It's been a very important experiment in Canada, in Nova Scotia, showing that a comprehensive approach in the school…. All the things they've done are listed in the handout that I've given you. It's not just nutrition in food, but changing the whole culture of a school is what is really important, so the kids feel part of the place and there is a cultural change.

This is a very important concept, that we don't just try and pick off food or pick off physical activity, but we approach it as a more holistic problem, as we will have to as a society. We've talked about the walking school bus and locations and so forth. The main area in which we have evidence of reducing obesity is from that Annapolis Valley program, where the kids in that program…. There are half the rates of obesity that there are in the schools that did not have that. That's direct Canadian evidence.

I noticed in the minutes of some of your previous meetings that there has been a particular interest in price incentives. This has been recently reviewed in Canada, showing that sin taxes don't really work very well on the basis of the best available current evidence. Resist the temptation to start putting taxes on sugar-based drinks or chips or fast foods and so forth, because they don't seem to work. What does seem to work is lower prices for more nutritional food. It's more positive price incentives that seem to work best in this environment. I've put the references into the handout for you, for your researchers to follow up on that particular issue.

I want to make a point about inequities, because I've already shown you the evidence. For example, our aboriginal populations generally, families that are single-parent families and people with low incomes are the people who are most affected by obesity.

Lessons from tobacco in this area. What happened with tobacco, well-meaning as we were back 20 or 30 years ago with tobacco…. We went with health education. We just put out blanket messaging to people saying: "Don't smoke. It's bad for you." Who heard the message?

It was people like ourselves in this room who picked up that message and quit smoking. But who is continuing to smoke now? The people that are the smokers now are the people that are low income, people with chronic mental or physical disabilities, the aboriginal population, the marginalized. The disempowered in our society are the people who continue to smoke, and who are now bearing the burden of the diseases related to that.

What I'm suggesting to you is that we should avoid that mistake. That's not to say we don't put out these messages, but we also have to think about the people who are most susceptible, most vulnerable and least empowered to pick up our messages and think about what we can do to create environments that can help them and support them in making the right choices. We need to not only have general messaging and general attention to the whole population, but we need to particularly look at vulnerable groups, like the aboriginal population and low-income groups, so we don't make that mistake of making the inequities in our society even worse than they have been.

Finally, let me close by talking about the concept of social marketing. I'm sure it's not foreign to you, but I want to go back to my observation that by 2010, British Columbia women will not be the healthiest population ever to host the Olympics, on our current projections.

Since we're talking about the Olympics, I'm sure you know who the major sponsors of the Olympics are. They're Coca-Cola and McDonald's. McDonald's has a franchise to serve food to the athletes in the village. So there's a very interesting opportunity here, in terms of social marketing, for British Columbia to have a truly healthy Olympics, where we really think about having it smoke-free, having healthy food there. Here we could, I think, potentially work with the industries, work with Coca-Cola so that their non-sugar-based products are emphasized and work with McDonald's to get healthy food in there.

At PHSA we're already working with the Sauder school of business, who has a great interest in social marketing. We'd be very interested in working with you in this area to see what we could do to capitalize on corporate social responsibility — genuine corporate social responsibility, not just the marketing kind — where corporations really do want to do something positive for society so that we could capitalize on some of these opportunities.

In summary, my message to you is: let's work together to get better data about obesity in B.C. Let's solve this problem of how we can get some data on kids, so we can actually follow this program, so we don't wait until 2010 before we know whether we're reaching that 20 percent target that the Premier has set for us.

I've made the point that obesity is an environmental disease, and what we need to do is work together to make the right choices the easy choices. Let's create new environments where people can actually eat right and get good exercise. I've gone over the evidence of what can go on in the homes, in the neighbourhoods, schools and in price incentives. I've argued that

we don't want to make inequities worse than they are. I think we have some huge opportunities here around the Olympics and some social marketing opportunities.

Let me just close by saying that we at PHSA — with the Children's Hospital, the B.C. child health network, our resources that we have in terms of data collection, data analysis and knowledge reviews — stand ready to help you in any way that we can.

R. Sultan (Chair): Thank you, Dr. Millar, for a very dense, packed-with-ideas and informative presentation. My goodness, that was stellar. When you got onto the subject of social marketing, I see our Deputy Chair, who has aroused himself to come, finally, nodding his head, and I'm sure is bursting with questions. So we'll turn the floor over to David Cubberley.

D. Cubberley (Deputy Chair): Mr. Chair, I think I should defer to those who heard the entire presentation, and I can tack on questions at the end.

R. Sultan (Chair): Okay. Well, then we will start with your colleague Michael Sather.

M. Sather: On the issue of screen time and the positive correlation between screen time and physical inactivity, there are lots of ideas we've heard from your presentation, Dr. Millar, and from others about things that can be done in terms of encouraging children to become more active. Do you have any thoughts or is there anything that can be done to actually reduce the amount of screen time with any other sort of disincentive or directive or anything whatsoever?

J. Millar: Yeah. The good news on that, and I neglected to mention it just because of time and because I wanted to emphasize the comprehensive nature of a school program…. There are at least two randomized controlled trials of programs conducted in the school system that teach kids about the problems of screen time and encourage them to watch less various forms of screens, and they work. And they not only work, but they actually will result in weight reduction.

These are things that, I would argue, we should be looking at as bringing in as part of a comprehensive school program. That's a very good question, and certainly I can provide the references on that if your researchers want those.

D. Jarvis: Dr. Millar, you made me very happy because — and I'm being a little bit facetious when I say it — I can go home and tell my wife now that in four years I'll be healthier than she is.

J. Millar: Excuse me for interrupting, but don't bank on that, because women still live four or five years longer. They're just not improving as fast as we are, but we've got a long way to go to catch up.

D. Jarvis: I can appreciate that, and I know it as well. I find that kind of unusual, because when I wander around in my neighbourhood there are more women out walking, exercising, running, jogging, going to keep-fit classes, swimming and walking the seawalls, etc., etc., than men — by a multiple of ten, almost. Why is it that you're not going to meet those standards by 2010?

J. Millar: Well, we smoke at the same rates. The smoking rates are part of that, but that's historical.

In real time now, part of the issue is that, of course, the bulk of the hard manual labouring workforce is still men. So there are lots of men out there for eight hours a day getting lots of physical activity and getting paid for it. That's why we have kind of a reverse gradient in obesity, where it's the low-income folks — men — who have less obesity, and it tends to be high-income men that are obese. There's a bit of a complex story there.

D. Jarvis: Yes. Even in advertising you can see that it's mostly directed at women. I think so, anyway, in that sense.

J. Millar: Right. But despite all that good activity you're seeing out there, the data are showing a vast increase in obesity and overweight amongst women in B.C.

R. Sultan (Chair): We have a question from Dave Hayer, and I think the panel would be very interested if Brian Schmidt and Dr. Armstrong chimed in at some point as well.

My question is: is there some way you can suggest we can work with the McDonald's, the Wendy's and the A&Ws and say that maybe they can start adding some more healthy foods? The trend is already there. They are putting in some different sandwiches. They're already putting in more salads, some other parts to them. Get them involved more. Because, many times, regardless of how hard you work, that's all the kids are used to. They get some money and the first thing they do is run to buy McDonald's or Wendy's or A&W or other fast-food places. Have you tried to work with them or tried to come up with something that can work throughout North America?

J. Millar: We've taken some early tentative steps. I certainly wouldn't present myself as an expert in social marketing, but there are experts available to us in this province. At least some of them are at UBC at the Sauder school of business. We have opened some discussions with them to tap into their expertise. They are very interested in pursuing this, and we intend to follow up on that. I don't know if anybody else has thoughts on that.

B. Armstrong: I think the caloric intake side of it is really critical in the whole equation. Social marketing, trying to reduce the amount of caloric intake is critical

in the equation. It's definitely the area of focus. You have to do a lot of exercise to overcome the calories you get from McDonald's or Wendy's or from pop. Physical activity is clearly important, but the actual number of calories children take in is key to the equation.

I don't know if you've been to Wendy's lately, but I occasionally take my son there. And every time you go to the window, they're still asking you: do you want to super-size? Do you want to have the king-size pop; do you want to have the king-size fries? I think that's the important strategy that we have to get to.

B. Schmidt: What I did want to mention is I think that with the advent of all of the regional health authorities in the province, we have a marvellous opportunity to integrate health promotion and prevention into the mainstream of what the majority of the population would think is health care services. Not only, I think, is our board taking a leadership role and investing more in prevention and promotion…. In fact, about 6 percent of our budget is dedicated in some way to prevention and promotion, because we have a large number of screening programs such as the screening mammography program and cervical cytology screening program as well the investments we're making in prevention and promotion.

The investments in other regional health authorities, although starting, are still relatively small in comparison to the burden of the disease that could be prevented. I think it's just so important that we see the whole spectrum of health service delivery inside of our regional health authorities strengthened, right from prevention to early detection and of course, then, through the necessary and very important aspects of treatment when prevention isn't going to help. The more we can start to ingrain this as, if I can use this term, "a way of doing business" inside our health care system, the better we're going to be.

This is still a bit on the fringe, and of course the population still expects us to be providing very high-quality treatment services, and of course we're trying to do that. But at the same time, if we don't start to invest more and we don't start to move some of our investable money into prevention and promotion, we're going to be in a sorry state in 20 years.

R. Sultan (Chair): I think David Cubberley would like to pursue a point, and then back to Dave Hayer.

D. Cubberley (Deputy Chair): Just a quick question. I apologize for missing the presentation. I was unfortunately booked to go to another meeting late yesterday and couldn't not go.

Just in looking at the focus on schools — which I think is very, very important — and talking about a comprehensive program, I notice that there isn't any mention of travel to and from the school. I wanted to ask you: have you considered travel to and from school as a potential source of the 30 to 60 minutes a day of moderate physical activity that would be required in order to bring people to a better level of health?

J. Millar: Yeah. There are a couple of points that I made in the course of the presentation. One was also mentioned by the previous presenter on the notion of a walking school bus. That's a good one, but I also made the point that it has been identified in the literature from evidence recently that the placement of schools is very, very important. If it's ten miles away, a walking school bus isn't going to work. It comes back to the broader notion of urban design and how we actually plan our communities. Where schools are placed, where shops are placed, where parks are placed, where rec centres are placed — they all matter in trying to encourage people to walk to those. That's one of many endeavours that we could put in place.

D. Cubberley (Deputy Chair): If I could, just an observation on that: from where I'm standing, it also matters what infrastructure is supplied at the time a school is built. At the present time I see schools supplying infrastructure oriented towards the automobile in large quantities and no infrastructure oriented towards a pedestrian environment. I just want to raise everyone's awareness of that fact. We currently subsidize the automobile internal to the construction of schools. We don't subsidize or encourage any other mode of transportation, and then we get in a battle about who will pay for it afterwards when it comes to our attention that people aren't walking or cycling to schools.

R. Sultan (Chair): I'm remiss in not noting previously that we have an expert on fast foods on our committee, and I would like to turn the floor over to John Nuraney.

J. Nuraney: Thank you, Mr. Chair, for the introduction. Let me assure you that A&W has the best, healthiest menu among all the fast-food outlets.

My question to you was: when you mentioned about data and monitoring, what were some of the things that you would like to see instituted to gather that information?

J. Millar: I think the U.K. is proceeding in a way that we might be able to emulate. All children — and there is a provision for parents if they do not want their children to be involved to exclude them — when they hit kindergarten, go in and get weighed and measured and get a waist circumference done. Then they get that repeated at grade five.

If we were doing that on a regular basis right across the province. We would have a very accurate way of monitoring how we're doing in this thing. Now, it's not problem-free. Anybody who's been through this can tell you that there's great sensitivity around body image and eating problems and so forth. We would have

to pursue this, not just do it in a kind of a paramilitary way but do it in a very sensitive way.

What I'm told by the educators…. This is being done in B.C., I must tell you. In some school districts this is being done now. The way they approach this is they not only do the weighing and measuring piece, but they also have programs in the schools around self-esteem and body image and eating problems and all these things. So it goes hand in hand with some other interventions. I think that's one way in which we could move ahead.

R. Sultan (Chair): Thank you. If we keep our questions and our responses short, I think we have time for the three remaining people who've requested an opportunity to question our experts.

C. Wyse: Good morning. It's good to be here. My apologies to the delegation for arriving late — likewise, just one of these types of mornings.

I briefly looked at your comments around school environment in the written portion. I may have missed much more of what you had to say. Facilities and programs in schools, whether they be gymnasiums, activity rooms, things of that nature…. Any idea what the construction program in the education system has been around those items over the last number of years and, likewise, within the educational program as far as phys ed — that type of emphasis?

J. Millar: Around the construction side I can't comment, because I don't have any knowledge. Nor have I seen anything in the literature that relates the actual physical plant to the issue.

What we can tell you on the basis of the best available evidence in Canada is that leaving aside the physical construction thing, it's really the programmatic approach to this. I refer to the Annapolis Valley program, which is very comprehensive. It includes physical activity, and it includes nutrition — but many other components in this program. The kids that got that program have half the rates of obesity and overweight of the kids that did not have that program. So it's clear that in terms of making progress on this, we don't have to go and do a lot of capital reconstruction. This can be done just by changing the program in the school.

B. Schmidt: I think the Annapolis example, actually, is how you use the facilities of the schools as well. In one example the schools' gymnasiums remained open after school. Now, I know this requires supervision and that kind of thing, but what a wonderful opportunity for people. Instead of going to a fast-food shop to have a drink of a sugary beverage, they can stay at school and play around with a basketball and that kind of thing. I thought that was one of the best examples I saw of how we could use our built environment better.

D. Hayer: I think we've covered exercise, food and school location. The part I want to ask a question about is screen time. When I was going to school, mostly we watched TV and played outside. Nowadays the kids are not only watching TV but they're spending time on a computer doing some homework. Another big thing is the Internet. When their parents try to say to them…. They always say: "Well, Dad, we've got to do this and that."

Is there any other strategy, maybe through education or some other way, that you can suggest to encourage kids to spend less time on the computer, the screen time, which is watching all types of monitors?

J. Millar: Yeah, I referred briefly to it earlier, but let me just say that there is good evidence that programs delivered in the school setting will, in fact, have an impact at home. You can deliver a program in the schools to the kids, encouraging them to watch less TV and use less Internet and fewer video games, and when they get home, they actually reduce that. In fact, that has resulted in reduced overweight. There's good evidence that bringing that in, I would suggest, as part of a comprehensive school program could work.

D. Jarvis: Well, you're on my side of the water. I didn't know if you have any chance to…. Do you contact the school boards or the superintendents to discuss the fact that we don't have any catchment areas in our…? A child can go to any school he wants to in North Vancouver. We have very few French immersion, so they come from all over North Vancouver.

On top of that, all the parents — 71 percent — work, and everyone is in a rush. We have them all using cars, back and forth across the…. Have you ever talked to the school boards to see how they feel about it?

B. Armstrong: I personally haven't talked to the school boards, but certainly, the health care system is working with the school boards around healthy environments.

I just want to re-emphasize again that it's not just reducing screen time, but it's reducing the eating associated with screen time. It takes a relatively small snack to provide you with a huge number of calories. If you exercise hard for half an hour, you might burn up 400 or 500 calories. You can eat that in about 30 seconds or five minutes, so it's not just reducing the screen time. It's actually reducing consumption and obviously reducing opportunity for consumption by exercise.

It clearly is multifactorial. I think the schools are engaged. I think the province is in a position to really have a major impact. As Dr. Millar says, we have to be able to measure that impact in a real-time way, and that's where schools clearly…. They capture all of the children in the province, so we have to use those schools effectively, both to measure and to influence their behaviour.

R. Sultan (Chair): Thank you, Dr. Armstrong, Brian Schmidt and Dr. Millar, for a most informative and helpful presentation.

R. Sultan (Chair): Our final presentation this morning is by Dr. Don Hunter. He comes with an impressive resumé. Rather than try and summarize it, I would ask Don to give us a brief biography before he begins his presentation.

D. Hunter: Members of the committee, I've worked for most of working life in public parks and recreation. Most recently, when I retired, I was a general manager of parks, recreation and culture for the city of Surrey. Prior to that, I was the director of parks and recreation for Saanich. I've worked in other communities as well.

In addition to that, I've also had involvement at a national level. I was the first chair of active living Canada, which is a coalition of all physical activity organizations in the country. I was president of the Canadian Parks and Recreation Association. I've had a fair bit to do with the development of the active communities initiative in British Columbia. I'm currently involved with the World Health Organization, Europe region, in the development of their physical activity strategy. So I've had involvement nationally and internationally as well as, I think, primarily at a community level in numerous communities.

Surrey developed an active city initiative that I think has been a model. In fact, Surrey was named the outstanding community in North America for promoting physical activity and improving public spaces in 2002 by the Center for Disease Control and the Pan American Health Organization. I think what I bring is some solid experience in actually initiating and changing physical activity levels at a community level.

R. Sultan (Chair): Don, I should also interject that this room is scheduled for another committee meeting at ten o'clock, and the bells will ring. As we are rudely prone to do, we just get up and leave whether you're talking or not. So carry on, Dr. Hunter.

Again, a quick overview of the presentation. We want to take a very quick look at Canadian and B.C. physical activity levels for adults and take a look at the children and youth physical and activity levels and share some of the changes and the trends in that. I think it's worthwhile to share in the active communities initiative within ActNow B.C. and give you an update on where that initiative is currently in terms of trying to encourage physical activity levels among B.C. communities, and really then begin to focus on community design, the role of active transportation and then talk about some key areas in terms of how communities are designed.

Dave Hayer said to remind the group that some communities do, do it well in terms of schools. I think Surrey is an example of that. Surrey, in fact, works hard with the school district and the community to identify and develop school park sites and develop connectivity to and from that school in the beginning and cooperative development of additional facilities at the schools. That's an example, I think, of a community where there is joint planning and development to try to create things.

Here's the Canadian and the B.C. data. As you're aware, and you've probably heard this before, we're the most active population in the country at 58 percent. That 58 percent is identified as those who are active enough to achieve health benefits, even at a base level.

The number for Canada is 49 percent. Again, there are tremendous differences in different communities or areas in the country, with Atlantic Canada tending to be the least active, central Canada becoming more active and the Prairies less active, although the second most active province in Canada is Alberta, at 53 percent. Certainly, the coast and Alberta are the most active populations. Potentially, our geography has had something to do with that, as well as good programs.

We have become much more active. We're the only country to have tracked physical activity over the last 30 years, beginning with the Canada fitness survey in 1981. What that 58 percent really means is that it measures how active we are in terms of energy expenditure, and that's based on three kilocalories per kilogram of body weight per day, meaning people are very active. Moderately active are those from 1.5 to 2.9. That's what the Canadian community health survey actually measures. So if you put the two of those together — the 24 percent of people who are active and the 25 percent who are moderately active — that creates the 49 percent in Canada and creates the 58 percent in British Columbia. It's really those first two categories.

Activity is measured by those who are active for at least 30 minutes on a daily basis at a moderate level. The more active you are, obviously, the better it is for you. The real issue is not necessarily with adults, because we have become more active, even though we are weighing more than we ever have. Certainly, the issue is with children. I know Dr. Millar shared these concerns with you. Only one-third of our children are active enough to really achieve optimal growth and development. That gets worse for teenagers, where about 21 percent are active enough to achieve optimal growth and development.

The Ontario Medical Association, in terms of their data, says children, clearly, are 40 percent less active than they were 30 years ago. In other words, a great deal of what's happening is that children are now playing inside in front of a screen rather than playing outside. There are a variety of factors, including perceptions of safety, that relate to that.

The hard data we do have is that we know obesity has tripled over the last 15 years. It tripled from 1996 to 2001, and it's continuing to increase. We hope that

there are some signs that it will slow down, but we haven't seen those signs yet, although we are having good data, primarily through Mark Tremblay.

Children spend three to five hours in front of a television. Television use by children is actually decreasing, and it's decreasing because that screen isn't as exciting as other screens. So they're spending more screen time, but they're simply shifting to video games, other things and the Internet and a little bit away from television, because it's not as exciting as other forms of screen-time activity are.

Again, as Dr. Millar would have said, we're now seeing signs of chronic disease, particularly cardiovascular disease and type 2 diabetes in youth that weren't seen before. Again, there's a great deal of concern over whether this generation will have a longer age span than the one that we have now.

The last Canadian community health survey did see some positive signs. We don't know whether that's measurement or whether that in fact saw some increases in physical activity levels. I think that may be because we've actually had a good deal more effort and focus on this issue.

Here are the activity levels for youth. Those youth who are considered to be active from a health perspective are those that reach three kilocalories per day or are active for at least an hour per day. B.C. is just over the national average. B.C. hasn't grown in this period up until 2003, and we hope that the Action Schools initiative will show positive growth.

One of the key things this shows is the difference between boys and girls. There is virtually no difference for children between activity levels of boys and girls. The activity level spread begins to show up between the 12-to-14-year-olds. Between the 15-to-19-year-olds, it's at 19 percent in terms of those who are active on a regular basis.

In the Canadian population you see that same gap for individuals over 65 now. There's about a 15-percent gap between males and females over 65. For adults in the baby-boom generation, the difference is 3 percent. It's virtually disappeared, and I think older adults of the future will have that same gap. There will be very little gap as people age. The gender gap will disappear, because we have a new generation where women are just as active as men now in terms of adult activity.

This was the only objectively measured data we have. This was from Nova Scotia, not part of the Annapolis Valley but part of the whole broader initiative around active kids, healthy kids in Nova Scotia.

When they looked at grade threes, they found no gaps between boys and girls and that 90 percent of the children of that age were active enough to achieve health benefits. At grade seven that had gone down by about 50 percent, and in fact, the gap showed up.

In grade 11 is where their data disagrees with the national data. Again, the number of individuals that were tested…. They did this through an accelerometer that actually measured energy expenditure objectively. It had gone down to about 11 percent. The difference between the national data is that it doesn't show the gap between males and females. It just shows an extremely inactive population at that level.

Again, we have a key issue, not only for all age groups…. When you look at half of our population being inactive, you realize that that half of the population, or that 42 percent or 32 percent, is really the population that is generating the greatest health care costs. They're the ones who are the sedentary and are the challenge. We want to keep the active people who are active, but we, in fact, have to focus on that.

Physical activity has really come to the forefront in terms of provincial initiatives through ActNow B.C. I won't go through this. You're more than aware of ActNow B.C.

The two key initiatives have been developed…. Action Schools B.C., which now has over 850 elementary schools and will be adding middle schools and secondary schools in the next few years, has made a major impact. But the active communities initiative has had a profound effect, even in a very rapid time, in terms of getting communities mobilized around physical activity and reaching the inactive.

Here's the British Columbia target. You have targets in all areas within the ActNow initiatives, but the B.C. target is to increase the proportion of those who are active by 20 percent by 2010, which means going from 58 percent to 69.6 percent. It's taking that 58 percent and doubling that number by 20 percent.

The national goals are 10 percent, but that's a real 10 percent. If somebody says that we have twice as exciting a goal as the rest of Canada, it's not true. Ours is 11.6 percent, and theirs is 10 percent in terms of moving the number along. We're a little bit more ambitious but not twice as ambitious.

Here's what the active communities initiative is all about. I think it's worthwhile to mention it. It was launched in September 2005. To date there are 78 communities that have registered as an active community, which means they have committed to that goal, committed to do a plan and committed to deliver on a number of initiatives.

That 78 percent also includes some regions that are working together, such as the Comox Valley. That really is made up of nine or ten communities but in fact is one registered community because of their regional approach.

It includes six Indian bands, and those are being added. It also includes about 75 percent of our population, or about 3.2 million people in this province, who are already covered after only eight months in an initiative. It has initiatives all throughout the province, including every health service delivery area, and, again, excellent uptake throughout every region within British Columbia.

It's managed by the British Columbia Recreation and Parks Association, which is also a key partner in the B.C. Healthy Living Alliance. I think this is important in that it's a provincial initiative that is delivered by an agency that is connected to communities.

Rather than trying to deliver something directly as a province, the province said: "Let's in fact join and

support those who are connected, both through the Healthy Living Alliance and the British Columbia Recreation and Parks Association and, together, create change." I think that's been a good deal of its success — provincial support and guidance delivered by people who are connected to the community level, where change can occur.

These are the kinds of things that happen at that level. Building partnerships. Generally these committees are including health and education, so there's planning together in terms of a joint community action plan. There's a good deal around raising levels of awareness of the benefits of activity. There's a focus on the inactive — that this is different than simply providing the programs we did before. This is going out after those that are sedentary and trying to reach them.

There's a good deal around policy development but also a tremendous amount of work at the community level — creating more facilities, particularly more areas to cycle, to walk, to blade, to wheel — to create some solid opportunities and some infrastructure that supports active lifestyles.

Here's what Canadians do. For adults, walking is number one, and cycling is number five. For youth, walking is number one, and cycling is number two. You can see that, really, the key initiatives and the key focus, if you want to get people active, are really to look at opportunities to walk, to cycle, to use your feet, your legs, your arms, in the case of somebody wheeling. To create those opportunities for active transportation is the greatest impact point in terms of changing the physical activity patterns of British Columbia, and they're complemented by other areas.

Here are the levels of walking and cycling that Canadians do, but only 8 percent of Canadians actively commute. That is, they walk or cycle to work. Victoria is almost double that. In fact, if you had Canada move to the Victoria level, that would also not only increase and make people more active, it would save 33 million tonnes of greenhouse gases. Obviously, active transportation certainly has air quality issues and impacts as well.

These are some of the key elements within active transportation systems. The development of comprehensive greenway systems…. Greenways are major connector routes between major points in your community — between a college and major high schools, between major parks, between major shopping areas — that promote people using active transportation to walk or cycle to get to those destinations, rather than simply getting in a car and moving.

Bikeways are typically part of greenway systems, whether they be bicycle lanes or dedicated bicycle paths, because we know that individuals, when asked what prevents them from cycling, really talk about safe capacity routes as being the primary inhibitor of them utilizing these types of systems.

Developing trail systems in parks that create loops, particularly creating greater connectivity at a community and a neighbourhood level, is really a priority, and the creation and design of safe routes to school that promote things like the walking school bus. They also promote the knowledge parents have that their children can safely get to school, from a traffic safety perspective — and planning those things, as you begin to develop school plans.

You may have seen these before — and this is not data, quite honestly, that is causative data — but here are the obesity levels by countries. This is fairly current evidence from the Centers for Disease Control in the United States, showing the issue in the United States in terms of obesity levels, with women being in the red and men in the blue. With Canadians, obesity levels are at about 15 percent — and looking at the much lower obesity levels in other countries.

Match that with the percentage of urban trips by walking or cycling. These are not simply commuting to work; they're making urban trips, where people decide they're going to walk to the grocery store, walk to another destination, walk to school. Looking at B.C., it certainly is higher, but looking at the U.S., it's 7 percent. In Canada it's 12 percent. Looking at other European countries, almost half of those trips are made by that. There's a decision not to get in a car and become part of a car culture but to walk or cycle.

If you match those up…. Again, as I said, this is not causative information, but when you put those two pieces of data on the same line and look at obesity levels and the number of urban trips that are active trips, you can see a very, very strong correlation with what's happening in the U.S.A. and Canada and the other countries. There's almost a virtual match.

My colleagues in World Health Organization Europe are worried that that's changing for the worse in Europe — that the car is becoming more of a factor. They're seeing obesity levels rise, particularly in the U.K., and they're seeing some of those urban trips drop. It's becoming a major concern that they have as well. But they are far ahead of us in terms of the integration of physical activity into daily life, particularly from the standpoint of getting to and from destinations.

Really, some of the keys that we have are to ensure that when we design new communities and make those 50-to-100-year decisions, when we put infrastructure in the ground, we really design communities that are more sustainable and healthy. Dr. Millar was correct when he said that there isn't a definitive study that says that urban design, in fact, is matched with obesity and the impact. But we do have some excellent work by Dr. Larry Frank from UBC, who analyzed American communities and found, when he looked at the most walkable communities, whether they were suburban or not, that literally…. "The Suburbs Make You Fat" was a clear headline that came out of his initiative — that, in fact, the suburbs do make you fat.

Obesity levels in traditional American suburbs that create car culture, where you have no choice because of distances except to get in your car, or you develop the habit of getting in your car and never walking, but using it even for short trips or destination trips to shop, to

go to school or to go to work. That community design, in fact, is the most prohibitive of active transportation and of active lifestyles. The physical activity levels are lower in those environments; obesity levels are higher in those environments.

Now, through organizations like Smart Growth B.C. — I've got three minutes left, and I will wrap that up — let's try to identify some of these key areas. Smart Growth B.C. or Dr. Frank would be excellent people to talk to in terms of the creation of complete communities and the creation of compact communities. Ensure that there are people amenities that make people want to get out, but particularly, create connected communities that have great streets, that have public places and amenities and that have parks that are islands. Create those islands, create networks out of those by connecting them through greenways programs that have paths and bikeways, and have a connection between public transport and active communities. If you can connect the bike and walking to public transport, you again increase health and have an impact on health.

Again, key roles. I think we've identified those, and I think that as a province there are key things you can do. Empowering positive land use decisions by giving greater flexibility — the charter went a long way to doing that. Support of provincial programs — your support of the active communities initiative and of active schools is having an impact already, an objectively measured impact. Modelling workplace behaviours — you do that in the Ministry of Health but not in your other ministries, necessarily, yet. In particular, supporting infrastructure programs — whether they're federal-provincial infrastructure programs or ones unique to British Columbia. Some of the strongest infrastructure programs you can develop are active infrastructure programs.

R. Sultan (Chair): Now, I know members do appreciate the opportunity to ask questions. Maybe we could have one very dynamite question from a member before we all have to run off to the Legislature. Does someone want to address a question to Dr. Hunter?

D. Jarvis: Well, I'll ask you about the activity of men and women. You had this grid where the women— or girls, I should say, young ladies — were lower, considerably lower, but I see out there that there are more young ladies active in sports and activities than ever before. Or is that just B.C.?

D. Hunter: No, that's the Canadian data. Again, there is a gap between male and female at the teenage years. The good news is that females seem in the last data to have made a change or a switch, and I think we're going to see in the next data more and more of them. Certainly, with young women who are inactive, all of them make decisions in their early 20s and 30s to become active again, and you see that gap disappear. You're going to see an awful lot of young women who've made that decision, and you'll see an awful lot of adult women who've already made the decision, so the gap is gone.

R. Sultan (Chair): Well, I think we could explore many of these issues for at least another hour with Dr. Hunter, because he has raised so many provocative points. Unfortunately, duty — House duty, in this case — beckons.

I would like to thank Dr. Hunter on behalf of the Select Standing Committee on Health, and we shall carry on. Good day.

K. Ryan-Lloyd (Committee Clerk): I think it might be helpful, actually…. Just before we adjourn, can we get David to give us an update on the work of the subcommittee — just some generic information?

R. Sultan (Chair): Ah, yes. The Clerk reminds me that it would be very helpful to have a very brief synopsis of the work of the subcommittee from our Deputy Chair David Cubberley.

D. Cubberley (Deputy Chair): Just briefly, we did meet with the two short-listed candidates yesterday, and we did interviews. That process went successfully, and we would like to put a recommendation in front of you at our next meeting regarding a communications consultant.

R. Sultan (Chair): Thank you very much, Deputy Chair. This meeting is adjourned.

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REPORT OF PROCEEDINGS (Hansard)

SELECT STANDING COMMITTEE ON HEALTH

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH