Health — Issue No. 9 — Monday, June 12, 2006 (HTML)

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

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH



CONTENTS

		Page

Presentations		103
	M. Demers
	T. Warshawski
	J. Macdonald
	S. Strutt
	A. Wasserman
	A. Pitt
	C. Weinberg
	H. McKay

Discussion of Draft Report Issue		145

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:

Marie Demers
Janice Macdonald (B.C. Healthy Living Alliance)
Dr. Heather McKay (Action Schools B.C.)
Andeen Pitt (Wasserman and Partners Advertising Inc.)
Suzanne Strutt (Chair, B.C. Healthy Living Alliance Secretariat)
Dr. Tom Warshawski (Childhood Obesity Foundation of British Columbia)
Alvin Wasserman (President, Wasserman and Partners Advertising Inc.)
Dr. Charles Weinberg (Sauder School of Business, UBC)

R. Sultan (Chair): I would like to call this meeting to order. Good morning, and welcome to the meeting of the Select Standing Committee on Health, of the British Columbia Legislature. My name is Ralph Sultan, and we welcome one of our many expert witnesses this morning who will be addressing the topic of this committee, assigned by the Legislature, of examining many dimensions of the important public policy issue of childhood obesity.

Just to review the terms of reference of the committee, to remind us all: in February the Legislative Assembly asked this committee to be empowered to examine, inquire into and make recommendations with respect to finding effective strategies to change behaviour and encourage children and youth to adopt lifelong health habits that will improve their health and curb the growing rate of obesity and to achieve the great goal of leading the way in North America in healthy living and physical fitness. In order to do that, we're empowered to conduct consultations, to engage in special studies and, of course, to hear from expert witnesses, such as we will do today.

I would also like to remind us all, particularly the witnesses, that today's meeting is a public meeting, which will be recorded and transcribed by Hansard Services, who are very capably at work next to the window here. A copy of the transcript, along with the minutes of the meeting will be printed and made available on the committees website at www.leg.bc.ca/cmt.

In addition to the meeting transcript, a live audio webcast of this meeting is also produced and, in fact, is being broadcast as we speak. It's available on the committees website to enable interested listeners to hear the proceedings wherever they might be in the world, in real time as they occur.

The committee has already been at work this morning visiting one of our wonderful public schools in the public school system. I just mention in passing, for the record, the gratitude of the committee for the visit we had to Hollyburn School in my riding of West Vancouver–Capilano. It's the first of many such visits we intend to make at schools in the ridings of various committee members around the province.

I would like to thank Geoff Jopson, the superintendent of the West Vancouver school system, and Glenn Rose, the principal of Hollyburn School, for a wonderful morning of exercise — jumping, skipping and generally working up a sweat. It was invigorating, and now we breathlessly await our first expert witness.

I would like to now introduce Marie Demers, the author of Walk for Your Life! Restoring Neighborhood Walkways to Enhance Community Life, Improve Street Safety and Reduce Obesity. We will spend 20 minutes on a presentation, approximately, and then, hopefully, have some time for questions and answers with the committee.

Before I forget, we should also introduce the committee. Perhaps we can just go around, and I will also introduce two who will be here shortly.

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

K. Ryan-Lloyd (Clerk Assistant and Committee Clerk): Kate Ryan-Lloyd, Clerk to the committee.

R. Sultan (Chair): I'm Ralph Sultan, the MLA for West Vancouver–Capilano and the Chair. Joining us very shortly will be the Deputy Chair of the committee, David Cubberley, and absent just for a minute to go down the hall is John Nuraney, MLA from Burnaby. Those are the committee members here today. One other committee member will join us later.

With that somewhat interrupted introduction, Marie, we would turn the meeting over to you. Before you begin your formal presentation, maybe you could just give us two or three sentences about yourself. Who are you?

M. Demers: I'm an epidemiologist. I'm with the Quebec council on science and technology. I'm also a research associate with the University of Sherbrooke. During my free time, when there is some free time left, I write. I just published this book on the influence of the built environment on the decline in walking, last January.

R. Sultan (Chair): Thank you very much for coming. You've travelled a long way to be with us this morning. We thank you for taking time out of your busy schedule to do that.

M. Demers: It's a pleasure to be here. But I have to apologize for my strong French accent. I just hope everybody will understand.

I will talk about obesity but mostly about physical activity, because when we talk about obesity, the first thing that comes to mind is food intake. We know that we eat too much. We eat too often — large portions. But we do not put so much emphasis on our lifestyle, and our lifestyle has changed a lot during the last 50 years. It's what I'm going to show with these slides.

Opportunities for physical activity have decreased a lot because most people have sedentary work and leisure activities. Because we have labour-saving devices for almost everything, we don't even have to change the channel on the television. We don't have to open the garage door. We don't have to do anything anymore.

The way we are moving now.… Because most of our destinations are too far away from home, we have to take the car to get there. We abandoned active transportation for more passive transportation.

Our urban environment has changed a lot. It is now characterized by sprawl. Residential areas are far away from workplaces. Even schools are now allocated away from residential areas. James Hill, who is an expert on obesity and wrote the foreword of my book, said we have engineered physical activity out of our lives.

Where does this epidemic come from? Everybody knows that we eat a lot of energy-dense foods. We have soft drinks everywhere. We have an overconsumption of energy, but at the same time, we do not spend enough energy. We spend less and less.

For those who do not believe…. Some people think: "Oh, we exercise more than before. My kids are taking swimming lessons, soccer lessons." For those people, I can show some statistics on physical inactivity in Canada.

The walking habits of adult Canadians. A survey carried out in 2004 showed that the day before the survey, only half of Canadians walked more than one kilometre. A survey a little bit older, from Environics, showed that even if 82 percent of Canadian children live close to school, only 36 percent walk to school. In fact, parents think it's too dangerous to send them to school because there's too much traffic, so they drive them there. But then because they drive them, there is too much traffic.

Only 21 percent of Canadian adolescents have a level of physical activity meeting the optimal norms for their development; 56 percent are physically inactive. Two-thirds of Canadian school-age children are not active enough for optimal development, and 51 percent of Canadian children age five to 17 rely on inactive modes of transportation to go to school.

We realize that we are not performing any of the activities previously necessary for survival. We don't go hunting or fishing. We don't pick fruit. We don't grow vegetables. We almost do not move at all anymore. But at the same time, we eat more than ever.

This might be the only option left for physical activity. Some people are now taking the escalator to the fitness club.

What happened to our schools? They are now located far from residential areas, with large parking lots and just a little grass, so children cannot walk there. They cannot play there. As you can see, there are not too many windows either. Then we are surprised that so many children are hyperactive.

Houses went from architecture to car-chitecture. This expression was developed by Jane Holtz Kay, who wrote Asphalt Nation a few years ago. It's just to show the place of the car, because the garage is more predominant now than before.

With all the highways we have — not here in Vancouver, but in the rest of North America, I would say — crossing the street is a very risky enterprise. At first we can think that those things are there to protect us when we cross the street, but in fact, they are just showing how our pedestrian habitat is shrinking. The outside world is now for cars and not for people.

Children cannot go anywhere. They cannot even go to the movies by themselves. Parents have to drive them, so they are becoming more dependent. Sidewalks have disappeared. When we get them, they are useless or dangerous.

Jane Jacobs, who died last month, talked in her famous book The Death and Life of Great American Cities about the role of sidewalks for children. We think it's a dangerous place, but she said it provides a safe environment because when there are a lot of people outside, you have more eyes on the streets. So it provides supervision.

The concept of familiar strangers developed by Stanley Milgram, an American psychologist, is also very interesting. When you walk outside every day, you meet the same people all the time, so there is a kind of trust developing between the people you meet, even if you don't know them. The more you have pedestrians outside, the safer the area is. Sidewalks also provide good opportunities for contact with others, and they help socialize the children.

I use this slide to show how children have become dependent, because most of their trips are now done by car. They cannot decide to go anywhere by themselves.

As you can see, the percentage of trips done by walking — it's in the United States, but it's not so different here — was 15 percent in 2001. It's what's happening now, according to the economists.

We forgot that walking was a survival behaviour, and it is still a survival behaviour but for other purposes. Because of urban sprawl and car dependence, we now have a series of problems. We have less autonomy for children, for the elderly, for poor people who cannot afford to buy a car. So it's a higher burden for parents who have to drive their children or the elderly people everywhere.

We have reduced public realm and social cohesion; the destruction of walking distances — everything is too far; more physical inactivity and obesity; more traffic injuries and fatalities; more air pollution, global warming and asthma; more traffic congestion and time lost in traffic; destruction of the landscape and wildlife habitat; more crime; and a higher cost for infrastructure.

Everybody knows how we define obesity now, with the body mass index, which is the weight…. I cannot say it in English. It's so difficult for me. Sometimes I have some problems.

In Canada almost 60 percent of adults 18 and over are now overweight, and 26 percent of children from two to 17 are overweight or obese.

This map shows the distribution of obesity in Canada in 2003, according to the Canadian community health survey. Usually we see this map with provincial rates. This one is from research I have done with researchers from the University of Sherbrooke. It shows differences, even inside each province. As you can see, Vancouver is in the best position. There is less overweight and obesity here than in Toronto, for example, and Montreal scores the worst among the three cities. The dark areas are concentrated in the aboriginal part of the country, and also the Maritimes, where people are more obese.

The evolution of obesity. We realized that during the last 25 years the rate of increase was higher among adolescents compared to adults, but the increase is strong in all age groups. Among children age seven to 13, the rate of increase is very high among males and females.

At first we can think obesity is more a question of appearance, how we look, but in fact, it's related to health and health care costs. For example, type 2 diabetes, arthritis and hypertension are three consequences of obesity, and we can see that many millions of Canadians are suffering from these three problems.

Physical inactivity. The cost of physical inactivity was estimated at $5.3 billion in 2001, and the cost of obesity was estimated at $4.3 billion. Experts are now predicting a decrease in life expectancy among obese children and adolescents if nothing is done to change the situation. We can already see more problems — more respiratory problems like asthma, more orthopedic problems, more neurological problems, more type 2 diabetes, more hypertension and also some psychological problems — among obese children and adolescents.

We might think the situation is bad only in North America. In fact, it's worse here and in the other English-speaking countries, but Europe is following us, unfortunately. We can see that the rate, the prevalence, of overweight children in Italy is now very high. It's 36 percent, according to the International Obesity Task Force. Greece and Spain are following. I think their rates are around 25 percent — the rate of overweight, not of obesity.

There are a lot of social trends leading to obesity: increased use of motorized transport, less physical activity, increased sedentary recreation. People watch TV more than ever. The International Obesity Task Force….

I'm afraid I will take too much time. Maybe I should go faster. I'll skip this one.

R. Sultan (Chair): I think if you move to your conclusions on the slides, then we could ask you some questions. You have raised many, many important issues.

M. Demers: Okay. Since I am not talking very well in English, I realize, I want to show you the pictures.

D. Cubberley (Deputy Chair): That's not true. You're doing very well in English.

We are living now in an opportunistic environment because of our food policies. Sorry. I think I will have to switch to French soon. Just one minute. I'm really not used to presenting in English.

M. Demers: As you can see on this slide, the benefits of walking are very high, and the risks are very low compared to other forms of exercise. In fact, the health benefits of walking are numerous. There are many benefits other than only health.

If people walked more, we would have less traffic congestion, less money spent for gas, less traffic air pollution, fewer accidents, reduced global warming, a booster to local economy. We would have safer neighbourhoods, a greater public realm and a greater sense of community.

We can see that people from most European countries are walking and cycling much more than Canadians and Americans. Although the length of daily trips is not that big in the United States, half of daily trips are three miles or less, so they could be done walking or cycling, which would lead to a reduction in traffic.

What I am talking about in this book — it's better when I write, I tell you — is about the creation of a walkable environment. We should limit sprawl development — which is the worst problem for walking, because everything is much too far — and favour a compact and mixed-use environment; change zoning laws and policies; promote transportation alternatives to car driving; change the streets to have narrower streets, traffic counting devices, sidewalks, lower speed limits, bike lanes, walking paths, parallel parking. We should restore public squares and public parks, implement sidewalk cafés and restaurants and restrict parking areas.

It's also possible to improve the school environment by expanding opportunities for physical activity, restricting parking areas and increasing grass areas around the school; ensuring that all children participate in a minimum of 30 minutes of moderate to vigorous physical activity during the school day; facilitating active commuting to school — walking or bicycling; providing bike racks and bike sheds; limiting traffic levels around the school; giving access to school facilities after school and on weekends.

The Heart and Stroke Foundation just last Monday published a report with a lot of policy recommendations to increase the level of physical activity.

This is the easiest part. What do we need to change our environment? More pedestrian streets, mixed-use environments, more transit.

When you get more transit and more people outside, you increase the public realm and then the sense of community. Narrow streets and large sidewalks, like here — this photo was taken in Zurich, Switzerland. More compact housing, because when you have compact development, you can have a good transit system, an efficient transit system.

Priority for pedestrians. As you can see here, there are no street lights, but the cars just stop. More inner-city parks, where people can rest during the day. More sidewalks. More traffic-calming devices. More urban squares, small urban squares for special events. Parallel parking, which is a protection for the driver and also for cyclists, because if the driver opens the door, the cyclists don't get hit.

More open markets. Stair-climbing. These are the most famous stairs in Quebec City, and there are always a lot of people climbing these stairs. Trails for dog-walking, cycling, roller-skating, and keeping the riverfronts for active transportation. We should never forget that good habits are established very early in life, and the weather…. Because I come from Quebec City, where it gets very cold, the weather is no excuse.

R. Sultan (Chair): We should be the ones apologizing to you for not being as fluent in French as we would all like to be, but c'est fantastique.

D. Hayer: Actually, it was an excellent presentation, and I had no problem understanding you. I think you speak excellent English.

Most of what you talked about, I think, is common sense. Why do you think it is that people seem to be getting away from putting sidewalks on the streets in the housing complexes? I know that in the city I live in, in my neighbourhood, a lot of people are walking around, but there are no sidewalks there. Have you looked at an analysis on why the cities aren't…? Are they just cutting the costs?

M. Demers: I think it is because it is cheaper. The developers, when they develop a new neighbourhood, don't plan the sidewalks, because it is cheaper that way. During the last 50 years we put emphasis only on cars and transportation, so the outside world has become a world for cars and not a world for people.

D. Cubberley (Deputy Chair): This is very well done. I found it very good reading. One of the things I found quite useful and novel in what you're saying is the idea of focusing not simply on physical activity as a whole but on walking as an activity, almost as a primordial activity, and focusing on it as a mode of transportation, not simply as a recreational activity.

I wondered if you could expand on why you're suggesting that and what kinds of changes are required in order for it to flourish as a mode of transportation.

M. Demers: I put the focus on active transportation, because I think if we tell people to get more active and to do more exercise, there is always a part of the population who will not get involved. Usually they are those who need it the most. They need more exercise. If you can walk for transportation, if you have to walk for transportation, then you don't have to decide you're going to do some exercise today. You're just doing it because your environment is designed for it. It would have a bigger impact on the whole population and not only on those who already exercise.

What we can do…. I think one of the problems is that the way cities are designed, it is very difficult to change now, because the development is there. There is a problem, because municipal authorities are not responsible for public health in their area. Maybe there should be responsibility for public health in municipal authorities like there is, for example, in London, England.

D. Cubberley (Deputy Chair): Well, I'm interested in the linkage you're suggesting. In your mind, if they were responsible for health, that might lead them to look differently at the way the city is designed and to invest more in pedestrian….

M. Demers: I think so, because Livingstone, the mayor of London, when he decided to impose a tax for the cars entering the centre of the city, did it for traffic congestion but also because of the health problems resulting from respiratory problems and accidents resulting from too much traffic. I heard that he was responsible for public health in the London territory.

I think that if you are responsible, you have to do something to prevent disease.

K. Whittred: Thank you very much for your presentation. I could understand you just fine. It was very well done. There was one linkage that occurred to me as you were speaking that you didn't mention, and I just didn't know if it wasn't part of your research. That was the linkage between home and workplace.

I'm sort of thinking back. For example, my grandfather, in his day — and it is not always useful to compare generations — walked to and from his work, and he would do that in the morning, home at noon, back to work and then, of course, home again. So in the course of a day, he was making his walk four times. Very few people do that anymore.

I was at a meeting just recently, and I learned that in my own community in recent years there has actu-

ally been a reduction of jobs available in the community. It is becoming almost impossible for people to walk and, in many cases, to cycle to work. I wonder: was there any aspect of your research that dealt with the workplace and the relationship to home, where people lived?

M. Demers: I understand that it is not always easy to move close to our work, especially when we change work often, but I think the importance is not only walking to work but walking to transit to go to work. When you have a good transit system, you have more chances to walk — to include walking in your day, in your schedule, because a part of your trip will be done walking. So I believe we should put more emphasis on the development of a good transit system.

K. Whittred: So you're saying that the walking part of walking to the bus is part of the actual transportation — that is, walking as a mode.

As politicians, we are very interested in the obstacles or enthusiasm or lack of it that one would find in the government in Quebec City, or in Quebec itself. How much do they embrace your ideas, and what can be done about it? What can government do? You've listed many, many factors, but how do you mobilize public and government opinion? Have you got some lessons you could leave with us here in British Columbia?

M. Demers: I think maybe Quebec can learn more from British Columbia than the opposite, but right now what I can say is that in Montreal there are a lot of groups — advocacy groups, people from the public health department, researchers, doctors, the metropolitan agency for transportation and also the opposition party.

They are all involved in the promotion of a good transit system, tramways, and they want Montreal to be a walkable city. There are a lot of things going on in Montreal right now, because there are a lot of accidents and respiratory problems. There are many groups sharing the same view, and they are trying to change the situation. They even convinced the mayor of Montreal that yes, a tram would be something good for Montreal.

R. Sultan (Chair): You think, I would surmise, that public opinion in Quebec is moving to adopt your way of thinking.

M. Demers: Not because it is my way of thinking. It was also their way of thinking at the same time. I think there is a movement not only in Quebec, but also in the United States and in many countries going this way, because we want to reduce global warming. We want to reduce respiratory problems and traffic congestion. I think there is a general movement going in this direction right now.

I would not say "in Quebec." I would say that in the province of Quebec it is more in Montreal. In Quebec City it is slightly different. Quebec City is the city in Canada with the most kilometres of highways per person. We always think of Quebec City as a beautiful, walkable city, but it is only inside the walls, in the old part. The rest of the city, the suburbs, has the same problems as big American cities.

J. Nuraney: From your presentation it seems to me that there is a disconnect between the urban planners and the advocacy groups like yourselves while promoting healthier lifestyles. Is there any linkage that is established whereby groups like yourselves or the advocates for a better lifestyle have an opportunity to present this kind of stuff to the urban planners?

M. Demers: Do you mean the urban planners working, for example, for the Ministry of Municipalities?

M. Demers: I presented there two months ago in French, and they were very interested, but what they said was that they don't have enough power. They don't decide much what is going on.

M. Demers: No, because the developers — those who buy a piece of land — decide the way they will develop it.

J. Nuraney: But they have the authority in terms of how that planning needs to take place. If a developer applies to the municipality to rezone the property and they show the plans of what they want to do with that area, certainly the planners have an input in what they want to see. Is that not correct?

M. Demers: Yes, I think so. I think it should be that way, but I'm not sure if it happens that way. I think the developers have a lot of power. They have a lot of money. There is an American expert, for example, who wrote a book called Sprawl Kills and published it, I think, last year, showing the power of developers. I don't know this part exactly, because it is not my field. But I know there is a disconnection between the developers and urban planners — for sure.

R. Sultan (Chair): I think we have time for one more brief question from Mr. Charlie Wyse.

C. Wyse: Thanks, Marie, for your presentation. I found it very informative. It may be a little bit to the

aside, but in your presentation you showed that here in British Columbia the urban areas are actually doing better with regards to the obesity aspect than the more rural areas. Do you have any comments about this concept of walking for improvement into more rural communities?

M. Demers: We see the same thing in the Quebec province, for example. People from rural areas are more obese. They have no opportunity to walk somewhere, because everything is too far. The same in the suburbs — people are more obese over there than in cities.

C. Wyse: You have given me a little bit more insight to it. It is an aspect that we need to wrestle with, with the large geography here in British Columbia, to make sure that we get this point across to all of British Columbia.

There is a third level of government that comes into play here, and that would be the federal government, with regards to the first nations. You had made reference that that is a segment of our community where obesity is high, and yet that is now a third area that has another government involved in it besides the local government, as well as the provincial government. You've given me some new information and insight that I didn't have until you spoke to us. For that, I'd like to thank you.

M. Demers: But there is something, also, about — I would not say rural areas — smaller cities. In the study I have done with researchers from Sherbrooke University we realized that, curiously, people from the Okanagan area, where there is a lot of fruit production, eat fewer fruits and vegetables than people from the city. I guess it is not because they cannot afford them, but I guess they are not available, or maybe they are not available to them in their area because they go away, or it is not in their culture. I don't know what is going on. It is the same in the Niagara Valley in Ontario. People eat fewer fruits and vegetables than in cities.

R. Sultan (Chair): Thank you, Marie. I wish Val Roddick could have attended this morning, because she would give us one of her patented lectures on…

R. Sultan (Chair): …eating right and agriculture. She is busy with the Agriculture Committee, as a matter of fact, this morning and sends her apologies.

Well, Marie, you have given us a good insight not only into a dimension of the problem that we don't always hear, but also given us some perspective on how it is being dealt with in another important part of Canada.

We thank you for coming many thousands of miles to bring us your message. I'm going to recommend to the Clerk that we get a copy of your book here, Walk For Your Life by Marie Demers, PhD. It looks very helpful, so thank you.

M. Demers: I apologize for my bad English. I'm used to talking just more informally, but a formal talk is more difficult for me.

R. Sultan (Chair): We have a fairly tight deadline, and we are few minutes behind, but not irrevocably, so I would like to now move on.

We are fortunate to have as our next presenter Dr. Tom Warshawski, who is with the Childhood Obesity Foundation of British Columbia. I would ask Tom to lead off his presentation just by telling us something about himself and the foundation.

T. Warshawski: Sure. The Childhood Obesity Foundation was formed about two years ago. I was approached by Don Rosenbloom, who is a lawyer here in Vancouver. At the time I was the president of the Society of Specialist Physicians and Surgeons and also president of the B.C. Pediatric Society. Don was on the ground floor for the startup of the Suzuki Foundation and was concerned about the childhood obesity epidemic. He is friends with Nancy Greene, and they approached me and said: "We've got to do something about this obesity epidemic."

We gathered together a group of clinicians — pediatricians and also clinicians at B.C.'s Children's Hospital — clinician-researchers, scientists and people from non-governmental organizations to sit down together and think what we can possibly do to help move forward on this issue. We coalesced in 2004. Part of our group — at that time I was with the B.C. Pediatric Society — worked with the Provincial Health Services Authority to hold the childhood obesity forum, which was

in March 2005. The Premier opened that. That particular two-day forum had 110 individuals from all walks of life in British Columbia — we had business, media, schools, health, health authorities, parks and recreation — sit down in a room, hear about the scope of the problem, brainstorm and come up with some solutions.

In terms of the Childhood Obesity Foundation, just this year we received our charitable status. We're now a tax-deductible organization, so we're quite pleased with that. We want to get on with our work. In terms of our raison d'être, we want to identify, evaluate and promote best practices in the prevention and treatment of childhood obesity.

Stemming from that childhood obesity forum, there were six major points that were our end results and that came out in our press release. One was the need for a sustained social marketing of effective, practical messages that families could take, hold on to and then move forward. We also felt that we should create obesity treatment centres. There's a huge population of obese children in this province — I'll go on to that later — and there's a paucity of treatment opportunities for them.

It's important and vital to support and enhance comprehensive school health policies. There's very good evidence to that. I know from reading the transcripts of previous speakers — John Millar and others — that you've heard a little bit about that, and I'll just allude to it as well.

We want to be involved with promoting healthier communities, working with the UBCM. Also, we want to get involved with healthy active living promotion in preschoolers. This particular age group, say from infancy up to preschool, is a population at risk. There are not a lot of programs for them.

Under the childhood obesity forum, there was a recommendation that each health authority create service inventories, lists of opportunities for physical activity and also resources regarding nutrition, so that people in their health authority who are interested — parents, teenagers, health care providers, whoever — can access and go to a one-point source. Each health authority, each geographic area differs in its own resources. We wanted something that was relevant to each resource. Those were six points that came out of the obesity forum.

From the Select Standing Committee on Health…. I want to applaud the government actually for the myriad of initiatives that they have, including ActNow B.C. and the fruit and vegetables promotion, and the select standing committee's interest in this topic. You've asked us for our organization's practical recommendations for reducing childhood overweight and obesity rates in British Columbia's youth.

In my presentation I'm going to stress the practical. You've heard a lot of things over the last month or so, some of which are easier to obtain than others. Hopefully, I'm going to try to stress things which I think are more practical. If there's time at the end, I want to stir up a bit of a hornet's nest and talk about the use of incentives and disincentives to help influence behaviour.

The scope of the problem. I have to apologize. I think every speaker has to always trot out the same statistics too. It's sort of a mantra here. I've got to do it; I can't help myself.

Anyway, the scope of the problem. We all heard this. Twenty years ago we had 15 percent of the population that were overweight or obese. Now those numbers have easily doubled. The amount of obesity probably is close to triple, and the amount of overweight has easily doubled.

As an aside, I just assume that you've all been briefed on what BMI means, what we use to measure fat and the whole bell curve that we looked at — the 92 percent — on why it's not healthy.

When you actually go out and measure these children, I think the B.C. statistics are even more concerning than the overall statistics that we get from Health Canada. In Action Schools they went out and measured students in the lower mainland. This population was fairly representative of the lower mainland and certainly the Vancouver population; 50 percent were Indo-Canadian or Chinese Canadian. Of this group, fully 14 percent of these 11-to-13-year-olds were obese, and 17 percent were overweight. That cumulatively is 31 percent. That's almost a third of children in that age group who are overweight or obese, and that's a very startling statistic.

R. Sultan (Chair): This is above the tendency in the population as a whole, I presume.

T. Warshawski: Is this above? Maybe. It's always a matter of how accurately you're actually measuring. If it's self-reporting data, we know the parents always underestimate. We all underestimate our weights. When they actually go out there and measure, it's probably fairly close to what the measured statistic will give you — true anthropomorphic measurements.

Why obesity matters. Again, fat is not just unfashionable excess padding. It's an active hormone-secreting organ, and it's associated with numerous medical consequences, primarily in adulthood but also in children. The adult consequences of obesity…. Certainly, there's a correlation with impaired mental health, poor self-image, and obesity is one of the last few publicly accepted prejudices. TV and movies often ridicule obese people, and it's not something that would be accepted if it was any other sort of minority group.

It's associated with bone and joint disease, osteoarthritis. There's a link with cancer. It's not as strong a link as with other illnesses which I'll talk about. There's also a link with dementia and Alzheimer's, especially as it relates to the increase in hypertension.

More problems. Hypertension, strokes and heart disease you've all heard about. Fatty liver disease is something that the gastroenterologists are getting more and more concerned about. As we lay down fat, store fat, it sometimes gets preferentially stored in the liver. That storehouse in the liver creates an inflammatory

cascade, which is probably going to lead to an epidemic of cirrhosis. I want to step back a little bit and not get too hyperbolic with my words about epidemic, but they're probably going to see a lot more cirrhosis than we ever have before. Again, you all know that this is going to be tremendously expensive to the population in the long run.

Also type 2 diabetes. In terms of type 2 diabetes, I think this is what probably has most health care providers the most concerned. In America, due to the obesity epidemic, it's thought that of that birth cohort born in the year 2000, one in three will progress to develop type 2 diabetes. Type 2 diabetes is a very, very significant disease. It's very costly. It leads to nerve damage, heart disease. With the peripheral vascular disease, you get amputations. You get kidney failure. People go onto dialysis, and your lifespan once you go on dialysis is, on average, five years. This is not something that can be done indefinitely, and it is extremely expensive, not to mention the poor quality of life.

Once it was commonly known as adult-onset diabetes. Now for the first time in some places in the States, they're actually seeing more type 2 diabetes in children than they are seeing type 1 diabetes. In British Columbia we're also very concerned because type 2 diabetes with obesity tends to have a predilection amongst Asian-Pacific and aboriginals. We have a large Chinese and Indo-Canadian population here in British Columbia as well as a large aboriginal population. From previous speakers you've heard about the high incidence of obesity in that group. This is going to be very, very costly.

There are also significant health consequences to children with childhood obesity, but they're not quite as serious and not as early as they are in adults. On the left side here we talk about obesity emergencies. Those are relatively rare — not that common and not all that expensive. On the right side, probably the top four or five are the ones that are the most significant in terms of mental health, the effects with hypertension.

There's a study which looked at hypertension in children. Hypertensive children actually have poorer cognitive function than do children who have normal blood pressure. It probably relates to the way the body adjusts blood flow to the brain. If you correct the hypertension, you can actually improve their scores on testing.

I've talked about type 2 diabetes now for the first time beginning to appear in the adolescent population. Fatty liver disease, dyslipidemia, refers to the hypercholesterolnemia. Again, that's probably more long term, down the road. Polycystic ovarian syndrome, PCOS — that is a syndrome that affects obese adolescent girls, and in adulthood it can lead to infertility. Then we have asthma and Blount's disease, which are less common.

In terms of mental health, I think we all know about western society's obsession with thinness. We probably have a third of the childhood population who are outside of that possibility. They've gained weight, and it's very difficult for them to lose weight. The prejudice versus the obese children probably starts at around the age of three to five years. You can track this. There are lots of studies which look at teachers' reactions, adults' reactions, to obese five-year-olds.

I've seen it myself in the emergency department. An obese nine-year-old boy comes in with glomerulonephritis, a disease which has nothing to do…. It's nothing that he caused, not to mention that his obesity is nothing he could cause. The staff and the physicians, much to my shame, were somewhat dismissive of this boy. They blamed him for his obesity.

We know there's decreased quality of life associated with obesity in school-aged children. In a study that compared children with cancer versus obese children, the children with obesity rated their quality of life lower than did those children with cancer who were being treated.

The social ostracism pervades school, work and home. There is discrimination by peers, teachers and other adults, and rejection may add to weight gain to some extent. The data is not all that clear sometimes with depression, whether depression leads to weight gain or weight gain leads to depression. Probably they're mixed in, and they just sort of spiral out of control.

I hate to say it, but the future really is quite gloomy. Obesity tracks very well into adulthood. If you're an obese adolescent, the chances of you becoming an obese adult are above 70 percent to 80 percent. The modern lifestyle that we lead accentuates this tendency to gain weight with age.

StatsCan last summer came out with some, I thought, very chilling statistics in which they looked at the normal weight of 20-to-29-year-olds and studied them over ten years. Of that normal weight group, fully a third progressed to be overweight. Of the group that were overweight in that ten-year period, a third of those went into obesity states.

We have basically a one-way street where people are moving further and further, gaining more weight. If this statistic holds true and this type of momentum holds true, within 20 years, of that group that is 40 in 20 years from now, probably about 70 percent are going to be either overweight or obese.

We all know the cost of obesity — $422 million per year. Health care is 40 percent of the provincial budget. At the current rate of growth of health care — I'm certain Dr. Ballem has told you all of this a million times — by 2019 it will be 70 percent of the budget. Clearly, this is not sustainable. That's the dollar toll, but the human toll….

From a study that was done a few years back…. The previous speaker alluded to this, about how we're going to outlive our children. This looked at a group that was overweight at age 40. On average, their life span, as you follow them for the next 40 years, was cut by three years. If you're obese at age 40 — now we're looking at probably 30 percent of the population who in 20 years is going to be obese at age 40 — your life span on average is cut short by seven years. It could be

argued that with advances in medical care, these people probably won't die as rapidly, but they're going to have years of ill health, and it's going to be very costly to the health care system.

The bottom line is that we may be the first generation in centuries whose children can expect to die at a younger age than their parents, and it's all because of being overfed and underexercised. So we're launching our children into adulthood on a trajectory of ill health, chronic disease and early death.

We all know about this. It's the equation that is too much energy in and not enough energy being expended. I want to spend a couple minutes talking about the more salient aspects of what that equation is. I think the data is really accumulating in terms of excess calories in sugary drinks as being a major culprit, and I'll explain more about that in a few moments. By sugary drinks I don't just mean pop. Also, juices are part of the problem, sports drinks and everything with a relatively high sugar content to it.

Calorically dense food is also blamed as part of the problem. That's the typical junk food that we talk about. But junk food and sugary drinks are somewhat different in terms of…. Our mothers always told us not to eat this before supper because it would spoil our appetite. Well, sugary drinks don't actually seem to spoil our appetite. We'll eat the same amount as we would otherwise. Whereas with calorically dense food, although nutritionally they aren't so optimal, you tend to, to some extent, balance off and eat a bit less.

There are people that are chronic overeaters. There's often a psychological component to that. We are sort of deluged with large portions. It's actually human nature for us, if we have a large plate of food, to consume most of what's on our plate. Fast foods we eat so quickly now that we don't get a chance to get that normal satiety break in our system to tell us to stop eating.

For families — I know Janice Macdonald talked about this earlier — it's a big problem. People are eating separate meals. The kids eat over here. You whip them off to soccer. Dad eats later when he gets home. We're not sitting down and eating together. That really does change the tempo and the amount of food that's eaten. I think the calories in are probably the biggest part of the problem in this obesity epidemic.

Calories out. The best evidence that has accumulated to date is about excess monitor time. Again, from previous speakers you've heard about monitor time. It's been defined as all monitor time — not just television but computer games, hand-held toys, MSN messaging, all that sort of thing.

There's also a serious lack of unstructured time for children. There is a study out of Michigan that was done about five years ago comparing kids in the '80s to in the '90s. The biggest change in their lifestyles is a shrinking of their unstructured time for play. There's a lot of structured activities. Homework has not changed that much. Oddly enough, TV time didn't seem to change all that much. But the biggest shrink was in that unstructured time.

Of course, in general, there's a lack of physical activity in the schools and at home. So it's also multifactorial, although I pointed to and highlighted two major aspects of that whole list. Like any complex problem, there's a whole series of steps in this, and there's going to be no one solution.

There's also a group of people that are strictly efficient metabolizers. I should have taken a picture of this family I had in my office last week. Twins. Mom was really quite big; she probably weighed about 250 pounds. Dad was more slender. There were twins, a girl and a boy. The girl was just like mom. I was referred to see this girl, this little baby of one year, because of her obesity. She was way over the growth charts. The little twin, identical milieu, had taken after dad, so he was four kilos less in terms of his weight.

This was really genetic metabolizers. This little girl had inherited her mother's tendency to hold on to all the calories that she ingested. She had a very efficient way of moving, so she didn't burn off a lot of calories. The little boy was all over the office at one year of age, and he was slender.

There's evidence about breastfeeding versus bottle-feeding. We don't really know how this works. At one time people talked about the number of fat cells that were put on if you were a fat baby. That probably doesn't hold true. It may hold true, actually, with other aspects in terms of what the family milieu is like but also the tastes and textures that a baby gets used to if they're being breastfed, because breast milk varies from day to day, depending upon what the mother has ingested.

We're also battling physiology. The way that we are constructed, when we eat in calories, we store it as fat if it's in excess, and our body wants to hold onto that fat. If we exercise more, it will actually slow down our basal metabolic rate. If we begin to diet, it'll slow down our basal metabolic rate. It wants at all costs to hold onto that excess fat to help us through the lean times, which unfortunately nowadays never really come.

In terms of reducing obesity rates, there are going to be two things. One is prevention — prevention is the key, but I think it's also very hard to do — and also treatment. I think it's really unconscionable that we sort of abandon that 10 percent of children who are obese and say that there's nothing we can do to help them. It's a big problem, but I think we have to do something to address them.

In terms of prevention, the Canadian Institutes of Health Research in 2004 did a systematic review and published it, called Addressing Childhood Obesity: The Evidence for Action. At that time, they stated that there is no systematically reviewed evidence to support a specific approach to obesity prevention through childhood. What that meant was that all sorts of things had been tried for prevention, but nothing really shone out as being a strong one that we should try to pursue.

However, since that time, there have probably been four emerging routes, which I wanted to bring forward to this committee. These are ones that I think, politically, are something that the government can act upon.

Number one is the sugar-sweetened beverages — the SSBs. As I alluded to earlier, there's a biologic plausibility to this, because sugar-sweetened beverages do not induce satiety, for whatever reason. If I sit here, and you hand me a glass of Coke, and I drink that glass of Coke, and you put a sandwich platter in front of me, I will eat as many sandwiches as if I had had a glass of water. All those calories in that Coke are just additional to what you otherwise would have eaten, and it's very hard, as I'll talk to later, to actually burn off those additional calories.

Soft drinks and sugar-sweetened drinks are cheap, and they're widely available. They're heavily marketed to children, and children are particularly vulnerable. They're naive. They have very little life experience. More than that, they're not just simply inexperienced little adults. Mentally and psychologically, the way that they're structured, they have very poor foresight. They can't imagine that what they do now will actually cause side effects an hour later, never mind ten or 15 years later. Many of us still have that difficulty. But that is actually a biologic and physiologic thing that you can track, and it changes into adolescence.

They're also very trusting. When a child under the age of eight watches a TV ad, they cannot imagine that an adult would be promoting to them an obviously fun drink, beverage or food that is going to be deleterious to them. It's simply not in their mental framework. There is a strong correlation between intake of sugar-sweetened beverages and obesity. The intervention studies have been very strong in supporting that link between sugar-sweetened drinks.

In terms of the overall data, we know that one can of soda per day increases a child's risk of obesity by 60 percent. That's a conventional can, which is very difficult to find nowadays in the supermarket. It's just that 350. Now the portions get bigger and bigger. Soft drinks are the most popular Canadian drink. In the '70s the average consumption per person was around 55 litres per year. By the late '90s it had gone up to 110 litres per person per year. The population really cannot sustain that degree of sugary drink consumption, and it actually parallels nicely that rise in obesity.

The average 591-millilitre bottle of pop — and I don't want to point out Coca-Cola because as I'll show later, they're all the same — contains 16 teaspoons of sugar and 260 calories. So a 13-year-old who drinks that has to run — they have to jog — for 50 minutes to burn off that soft drink they just consumed. It's very difficult to exercise off all the excess calories consumed, and that's if you're running. If you're walking, the rate that you burn up calories is that much slower. This is a key issue about the amount of calories that we consume and how difficult it is to exercise it off.

In terms of the sugar load of beverages — I come here from Kelowna in the Okanagan where we have Sun-Rype, and it's always hard to say this — juices really are not that good. They probably have the exact same properties as pop in that they don't induce satiety, and they have a relatively high sugar load. Orange juice is on par with colas, and then apple juice has a higher sugar content. Pineapple juice and grape juice, which my kids absolutely love, have the highest sugar content of all, and they've got the same properties.

They don't have a whole lot of vitamins and additional things that we used to think they did. I remember at one time nutritionists would say that you could substitute a glass of juice for a fruit. You can't do that. They're radically different in terms of their health properties, so juice does not equal a fruit. You should eat your fruit, and you should drink your water.

In terms of prevention, there was a great study done in Britain in 2005 that was in the British Medical Journal. It was a school-based prevention, and it was around a song called Ditch the Fizz, which was a rap song that they played to these seven-to-11-year-old kids. They had four one-hour classes, so that was one hour each term where the kids learned about the deleterious effects of soft drinks — and juice, as a matter of fact. They compared the treatment group to the non-treatment group, and the intervention group lost weight versus the control group which went on to gain weight. This is, from a treatment point of view, a relatively easy intervention which was startlingly effective in terms of decreasing soft drink consumption.

A more recent study was in Pediatrics in March of 2006. This was in Boston. They took about 110 teenagers, and they divided them in half. I should say that these teenagers were pre-selected because they consumed at least one drink per day. They were randomized into two separate groups. The treatment group was given non-caloric beverages to drink, either water or the diet drink of their choice. The other group had their usual drinking program.

After six months the overweight and obese kids that were drinking diet drinks or water lost weight. In terms of intervention, it's very hard to match this with all the other things we've done, including very heavy exercise intervention. This was quite an amazing bit of information.

In summary, reducing the consumption of sugar-sweetened beverages is a very promising intervention. School-based interventions seem to be effective, as well as a treatment modality. This is something that from a policy point of view, the government has to look quite seriously at.

The second thing we'll talk about is reducing monitor time. What does monitor time do? Well, it displaces physical activity, so kids are watching TV. They're not active. There's some data that suggested that when watching TV, you actually have a lower metabolic rate than you do when you're sitting and talking. You're almost inert when you're watching TV. Also, kids tend to eat while they're watching TV, and TV promotes junk food. That's why they advertise on it, and it works. It sells it.

There was a recent study from the Archives of Pediatrics Adolescent Medicine from April 2006 entitled "When Children Eat What They Watch." It clearly demonstrated that increased TV viewing is associated with increased caloric intake by increasing consump-

tion of calorie-dense, low-nutrient foods frequently advertised on TV. This is common sense. Advertising to children works. They buy these foods; they consume them. Those kids that were heavy TV watchers consumed more calories per day. It wasn't just that they were eating more junk foods. They actually consumed more calories per day than did kids who watched less TV.

In terms of sedentary factors, that's an intervention study. But just in terms of observational studies, there's a strong link to childhood obesity. You have a markedly increased rate of childhood obesity if you watch more than three hours of TV or monitor time per day.

There's this horrible problem with children having TVs in their bedrooms. There's a very strong correlation between a child with a TV set in their bedroom and the development of obesity. The study from the States was appalling in terms of 40 percent of children having television sets in their bedrooms, which I think is really indefensible.

Video games. There's an inverse relationship between adolescent physical activity and video game use. It makes sense. If you're watching video games, you're not going to be out there exercising. And then, in terms of screen time, more data: you're twice as likely to be obese if you watch more than two hours per day of TV.

If you look at Canada, the prevalence of overweight and obesity in terms of screen time, you'll see that if you watch less than an hour per day, your rates are probably up there to what they were in 1980 or so — around 15 percent for overweight and obesity. For one or two hours, it needs to go up. If you get beyond two hours, you're up in the 35-percent range for overweight and obesity. It's a clear correlation between the amount of time that you just sit there and your weight gain.

Canada has the dubious distinction of almost leading the world in terms of youth computer use. I suppose, to some extent, that may be a good thing if it's used for homework, but a lot of it is not. This graph is more of the same, more information showing that at every measure — girls, boys and by age group — we use the computer more than Americans do and a bit more than other northern European countries.

Again, promising intervention was a school-based intervention. That was in the Journal of the American Medical Association in October of '99, entitled "Reducing Children's Television Viewing to Prevent Obesity." These were third- and fourth-graders. The intervention was a bit more intensive. There were 18 lessons over six months. That intervention group had a lower rate of rise of their BMI. Again, that didn't mean their BMI actually dropped. Though we expect kids' BMI to grow anyway as they grow older, if you remember those graphs, their BMIs begin to level off into a more healthy range. Again, it's a very promising intervention.

Comprehensive school health policies is another of the four I mentioned that are very important for prevention. I think John Millar has alluded to this in the past. They're very effective. Here in British Columbia we have Action Schools. There's the Annapolis Valley project that was in the American Journal of Public Health last year.

The good thing about these school policies is that they reach the at-risk population. I'll show a slide later to show you about the socioeconomic status of kids who become obese. For those kids it's very hard to reach them with exercise programs and tax incentives. But school is where they are, and you can reach those kids there. They can be difficult to implement, and the educators are feeling more and more of the burden. They're busy enough trying to teach our children the three Rs, not to mention health literacy and all the other sort of things that we're demanding of them. But they are very promising as an intervention.

Breastfeeding has been spoken about here. Breastfeeding is a very important thing to do for all sorts of reasons, but in terms of its capacity to prevent obesity, it may not be all we want it to be. In Pediatrics, which is the journal of the American Academy of Pediatrics — the summary of the presentations at the conference to prevent childhood obesity — it was stated as one of their main findings that breastfeeding as currently practised seems to be significantly, albeit weakly, protective against obesity.

I think we all have firsthand experience of knowing parents who have breastfed their children and everything's gone fine, but they've still gone ahead to become obese. Breastfeeding probably doesn't do a whole heck of a lot. There was a systematic review last year in the International Journal of Obesity which came to the same conclusions. Breastfeeding has a small but consistent effect against obesity in children.

So breastfeeding — again, not to denigrate it — is very important for all sorts of reasons. Breastfed kids have low rates of Crohn's disease. They have lower respiratory tract infections. There seems to be some evidence that their IQs are higher than for kids who are not breastfed. But for a potential to really impact on the obesity epidemic, I don't think that's going to do it.

In terms of treatment. Again, from the Canadian Institutes for Health Research document, Addressing Childhood Obesity: The Evidence for Action, the evidence for treatment actually is better. What they've stated again in their main finding was that any treatment intervention is associated with a significantly increased chance of improvement and is favoured over no treatment. Many treatment regimens work. They don't work great, but they are somewhat effective.

The rationale to start up these treatment centres in British Columbia is that fully 10 percent of adolescents are obese, and they don't outgrow it. It tracks very well to adulthood. These people are going to be at significant risk for illness — a high risk for diabetes, stroke, heart disease and hypertension as young adults.

The younger the obesity begins, the younger the disease has its onset. We know that in particular for type 2 diabetes, which is our big bogeyman, studying the aboriginal population, the obese child, teenager, begins to develop their kidney disease probably in

their early 30s, and the progress to renal failure takes about, say, ten or 15 years, regardless of when you develop your diabetes. Typically, what we've experienced in North America is that people don't have their type 2 diabetes until their 40s or 50s; then they've got 15, 20 years before they go into their serious complications. If you develop your type 2 diabetes at 20, you're going to have your serious complications at 35 or 40. So we're going to have a lot of years of life lost because of that.

Family-centred interventions are of proven efficacy. They're expensive; they're difficult to do, but they do work. The expert consensus opinion is that there should be active efforts to induce weight loss for children over the age of six years whose BMI is greater than the 95th percentile. Again, we're talking probably about 10 percent of the child population above six. That means you've got over 28,000 affected teens here in British Columbia and a slightly lower number of affected children between the ages of six and 12.

Currently we have one treatment centre in the province, and that's in Vancouver. These treatment centres are expensive to run. I, amongst others, have worked with the provincial child health network. The Ministry of Health is really strongly promoting this in the train-the-trainer program to try to get the health authorities to have an increased uptake with these treatment centres, but the health authorities have, quite frankly, other priorities. They find that, from their perspective, they have a deficiency of funding. If they were to start up a treatment centre for childhood obesity in their health authorities, it would mean something else would have to be cut. They look at me and say: "What can we cut?"

As a clinician, I spend most of my time in the hospital. I work with my other colleagues. There's not a lot of fat on the bone in the health care system, certainly on the acute care side. I can't look at anything in the hospital that I could walk around and say: "You're fired. We can stop doing this." This is very tough. On the other hand, this needs to change. It's indefensible that we don't offer treatment to that 10 percent of the children who are obese.

The other thing I want to mention — and John Millar alluded to this earlier on in his presentations — is a need for ongoing evaluation and research. B.C. has a myriad of excellent programs, strong support from the provincial government, but we need to study these programs. We also need baseline population data — good measurements. As Dr. Millar had mentioned, in Britain they're doing this. They're measuring kindergarteners, measuring their grade five, and they're looking to see if their interventions are working. We need to have a similar process in place in British Columbia. This isn't simply sort of navel-gazing. We need to do this to analyze whether or not what we're doing is effective.

Interventions, as they get put into place, also need evaluation/research components to them. We're part of a worldwide effort to combat childhood obesity. Really, we have an ethical obligation to share our experiences. The research components, as well, help us to fine-tune. If things are working, they should be propagated. If things aren't working, they need to be changed.

The analogy I'll make again as a clinician is the childhood cancer study group. This is a North America–wide initiative whereby all children in North America who have cancer are immediately entered into a study. There are treatment programs which are then implemented. Every three years the data are analyzed. Things that are working are amplified. Things that aren't working are changed or amended. This is what we need to do with the battle against obesity.

When I talked about these childhood treatment centres being effective, the efficacy is maybe 30 or 35 percent. That's not good. If this was a cure for heart disease, it wouldn't sell very well. We have to improve upon that. It doesn't mean we shouldn't be treating. We need to be treating this the best we can do for now. We have to evaluate it; we have to fine-tune and make things go better.

In terms of practical, evidence-based steps to reduce childhood obesity, which is what we were asked about, I think number one on my list is programs to decrease the consumption of sugar-sweetened beverages. Social marketing is important, and school-based is important. This is going to be difficult to do because, you know, we're up against an advertising juggernaut. These products are heavily marketed to children. They have big budgets, and it's going to be very difficult to do. But I think it needs to be done.

We need programs — and again, there's good evidence that they're effective, and there's a template to actually use — to help decrease monitor time. This would be through social marketing or school-based interventions.

We need to promote comprehensive school health policies. We talked about the Annapolis Valley project and also Action Schools. As Action Schools gets amplified, it goes out into different age groups. But we also need to have some program evaluation. Promoting breastfeeding is sort of a motherhood issue — no pun intended.

This is one of the pitches I'll put before this particular committee. We need to mandate provincewide obesity treatment centres, and this has to be part of the performance agreements for the health authorities. As a clinician involved in pervasive childhood pediatric care, the example I'll give is the neonatal programs. Until the Ministry of Health stipulated in the performance agreements that we had to create level two centres of treatment, these things were not done in the health authorities. They have too many other priorities, too many competing priorities to rob Peter to pay Paul. There needs to be a directive from the policy-makers, which are committees such as yourselves.

It's critical that all these programs have ongoing evaluation components. Again, it's not simply navel-gazing. We have to know if it's working or not working. If it's working, we continue. If it's not, we have to change things.

If I had time, I was going to quickly go to incentives and disincentives. What's our time like?

R. Sultan (Chair): Thank you, Dr. Warshawski, for one of — to borrow one of your phrases — the most energy-dense presentations and perhaps one of the most alarm-inducing presentations this committee has seen so far. If we could beg the tolerance of our next presenters for just a little bit, I think many of the committee would have some questions they'd like to ask of Dr. Warshawski.

Taxes and taxation. It's one of three bullets in the invitation that talked about incentives and disincentives for physical activity. One of the things that comes up, and I've talked to media about, is the issue of taxation.

This involves two things: incentives — so deductions for childhood physical activity costs — and also increased taxation for specific deleterious products.

Looking at the issue of inducements, youth participation rates in organized sports at least once a week is still pretty high. Kids are active. They're getting driven to soccer, but these activities are really not all that efficient. I think about taking my son and driving him to hockey. It's a 30- or 45-minute drive. He plays a third of the time, which is one hour, so he's playing for 20 minutes. I drive back for another hour. So in the three hours out of his day, he's been moving for 20 minutes. It's really not all that efficient.

If you look at physical activity, PE time…. I think Heather McKay will talk about physical activity, distinguishing it from physical education. We're not world leaders in weekly phys ed time. We're at the bottom in terms of the amount of physical activity kids get in the schools. Again, that really is something which should change.

From my presentation, a lot has stressed the role of too many calories. Physical activity, though, can't be underestimated. I don't think it's going to be the answer for the obesity epidemic. It's part of the solution, but it has so many health-giving effects in terms of mental health, hypertension reduction and prevention of diabetes. It's a very important component of life, which we really do a poor job of here in Canada.

Also very telling is if you look at the socioeconomic status and obesity — the correlation. If you look at the obesity rates in the lower SES groups, that group which is least likely to benefit from any tax incentives where you take away the 7-percent sales tax or give a rebate on taxation…. That's not their biggest worries. I have patients come into my office who can't afford to put their kids in hockey, and they don't say: "Doc, if I didn't have to pay 7-percent sales tax on shin pads, he'd play." It's way out of reach.

The higher socioeconomic group, which would benefit the most, probably needs it the least. Their obesity and overweight range isn't really all that different from what it was back in the '80s. They've been relatively insulated from the B.C. epidemic. It's something to think about.

In terms of tax incentives, the lower SES group is most at risk for obesity and would benefit the least. There's already high participation in organized sports, which are relatively efficient, and physical activity is sadly lacking in schools, where these at-risk children could probably benefit the most.

The flip side of this is: what about taxing deleterious products? Well, it's really quite controversial. I think society accepts the whole idea if a product is strongly linked to a sufficiently serious health threat, and the example is tobacco. I don't think many people would say we should take off the taxes on tobacco.

We use those taxes on tobacco. They've been proven to be strong disincentives if the tax rate is high enough, but they also generate funds to help pay for the unwanted effects — the externality of that product. Tobacco causes cost because of chronic obstructive pulmonary disease and other issues — emphysema. So it helps to offset that cost.

Price disincentives can work if the price goes high enough. It depends upon the price elasticity of that product. But also, more importantly, the money could be used to fund social marketing and treatment campaigns.

When I hear about the teachers who are threatening to strike because they're not getting paid enough for what they already do, and many of our treatment interventions talk about putting more things into the school, it's hard to imagine they're going to embrace this all that readily. We're going to need more resources.

Do sugar-sweetened beverages qualify? Well, hopefully, I've given you some evidence that they are major factors in childhood obesity. They're not the single-most factor. They are not the smoking gun, but they are a big component. Obesity is a major health problem. I wanted to alarm people, because I find it very, very alarming about obesity and the health effects this is going to have on us.

It's also been said in the public health literature that tobacco pays its way, but sugar-sweetened beverages do not. The taxes on tobacco offset those health costs, but sugar-sweetened beverages certainly do not.

There is a slide back there that didn't show up, actually. I'm going to try and find it. It looks at the consumer price index in the U.S., and the index goes up like this. Fruit and vegetables have actually increased by 50 percent. They've become relatively more expensive over the last 20 years. Sugar-sweetened beverages have become less expensive. I'm going to go back and try to find that slide.

Is there any evidence that these things work? Well, from the American Journal of Preventive Medicine, "Food Taxation and Pricing to 'Thin Out' the Obesity Epidemic…." This is data. I can't defend it all that strongly. States without a soft drink tax were more than four times as likely as states with a tax to undergo high rela-

tive risk of an increase in obesity. They found that states without taxes gained weight more rapidly.

Sugar-sweetened-beverage tax? I think it's questionable given the price elasticity. There's some evidence that there is really quite a high price elasticity, meaning that people will pay for it regardless of the price. It may require a very high tax rate for a disincentive. This has never been tried. So if anyone tells you there's evidence that it doesn't work, I'd actually take issue with that, because nobody has put 100-percent taxes on soft drinks. There's simply no appetite for that.

However, as a funding source, it has a lot of promise. But again, no jurisdiction has used these tax-generated funds specifically for obesity treatment and prevention. Even in the U.S., where over 20 states collect soft drink taxes, they go into general revenue. I think one of the biggest problems is that the population doesn't trust the government to actually take this money and then use it for its particular cause. The question is how to fund these B.C. programs without cuts.

R. Sultan (Chair): Tom, that was terrific — and a very provocative question, Katherine.

D. Hayer: That was a very good presentation, very informative. There was one slide that showed 50 percent of Indo-Canadians and 50 percent of the Chinese community having a problem with childhood obesity. Is there any specific study you have done on why that is? I know Dr. Gary Randhawa has worked on it, and he has been trying to help out with the health fairs at different Sikh temples for different community functions.

T. Warshawski: We have it here, actually. I know Gary quite well. He's a physician in Kelowna. When we had the Childhood Obesity Forum, we tried to reach out to the Indo-Canadian community as well as the Chinese Canadian community. We weren't all that successful. At the Childhood Obesity Foundation we have a website, and one of our goals is to have a section of that in the Chinese language as well as in Hindi or Punjabi so that we can at least make the information available to people.

Then there needs to be a concerted effort to look at particular cultural attributes which predispose a population towards obesity. Not enough has been done.

D. Hayer: That's one of the highest-growing populations right now in British Columbia — first nations or the Chinese Canadians or Indo-Canadians. That's going to have a major effect.

R. Sultan (Chair): We have a question from our Deputy Chairman, David Cubberley.

D. Cubberley (Deputy Chair): Thanks very much for the presentation. I hope that we could perhaps get a copy of your slides.

D. Cubberley (Deputy Chair): That would very useful for us. It certainly put a lot of edge on it, and I appreciated that.

You recommended a number of points — creating regional treatment centres — but you didn't pencil in too much content for how the treatment centres would work. I just wanted to engage you a bit around that and also a related idea. Our prior presenter, Marie Demers, had a suggestion in her book on…. She noted the very low incidence of physicians who ever give an exercise prescription. Most people visit a doctor and get a prescription for drugs. Very few visit a doctor and get a prescription for exercise, and nobody gets one for walking.

In your comment on how a treatment centre would work, maybe you could comment on the viability of engaging physicians, who have enormous stature, in prescribing exercise.

T. Warshawski: I'll do the second one first, in terms of a prescription for exercise. The Canadian Pediatric Society through their Healthy Active Living Committee, of which I'm a member, has these prescriptions for health which do just that. It's a little handout which talks about how much exercise you should be doing each day — a greater increase in walking. The problem with that is there's still not good uptake amongst general and primary care physicians. It's in the pediatric community. The BCMA has done some work with their Eat Well, Live Well, Play Well Committee. They're trying to move in that direction.

I think often physicians feel they can't do anything, that it just doesn't help, that they're just wasting their time with these recommendations. That's not altogether true. It helps a certain percent of the population. It doesn't help everybody. There's kind of a learned helplessness in the physician population around that, which we're trying to address.

In terms of the obesity treatment centres, I didn't go into it, but there's an existing shapedown program in Vancouver right now. It's family-based therapy. It's quite intensive. It spans over 12 weeks, with weekly sessions which are primarily group sessions. It's a team of physician, nutritionist and counsellor.

The genesis of this was out of the University of California, San Francisco, and it's quite an effective program as far as childhood obesity treatment centres go — probably around a 30-to-40-percent ten-year significant reduction in obesity rates. It's expensive. We're looking at probably $100,000 or $120,000 a year to run a program, and it doesn't treat a lot of children for that. We're looking at maybe treating 100 children, so the cost per child isn't very favourable.

T. Warshawski: It's a savings, but also you treat the family. This is family therapy. The parents lose weight. If they're changing their activities and eating better, it's not just that single child that's treated. It's three to one. So we're really quite keen on this, and we're trying to promote them.

J. Nuraney: Thank you, Tom. It was, like everybody else said, a very good presentation.

A couple of things I would like to ask you about. While it is good to have these activity programs in the school, which this government has initiated and launched, it is that time after the child leaves the school and goes back home. So unless there is a buy-in from the parents and the family into this kind of activity and watching less television at home, the program is not totally complete, in my opinion.

Some years ago, as you know, we had this huge campaign, Participaction. I thought that really did us a lot of good. Do you foresee any kind of public campaign on this issue?

T. Warshawski: I think there needs to be a public campaign on the issue. People need to have the information given to them. At the very least, if they had the information, we may or may not be able to act well on it.

The activities at school are vital, especially for the at-risk population. Again, children are naive. They've very vulnerable. They can't make their parents take them out someplace. There's going to be a certain group, for whatever reason, whose parents just don't have the initiative to engage that. School is where those at-risk kids can get out there and be physically active. As I showed earlier, though, it takes a lot of activity to burn off 590 ccs of a soft drink. Probably you wouldn't get that amount of physical activity in school, but it does have mental health effects. It does lower your risk of heart disease, of diabetes. I think a school is critical.

In terms of Action Schools, which is a great program, the other really at-risk group, though, is adolescents. If you look at a graph of physical activity by age, five-, six-, seven-year-olds are active and moving all the time. It drops dramatically just after puberty. There's a segregation which occurs in terms of organized sports. All of a sudden, good athletes become very, very good. Poor athletes aren't that good, and they just drop out. It's especially bad for girls, so that you're looking at maybe 11 percent of teenage girls, 15 or 16, that are sufficiently physically active.

How to reach them? It's hard to know. I mean, if it's physical activity in the school…. Schools are also important because it's peer group. I don't know how many of you have kids. You can tell your kid one thing, but if all the kids in school are doing it, that's what going to happen. Peer groups are vital, so school is an important part of the solution.

R. Sultan (Chair): Dr. Warshawski, I'd like to thank you for a compelling presentation. I wish we could, perhaps, just chat away for the rest of the afternoon, but we have some other equally promising presenters on deck, and we'd like to leave ample time to hear from them. Thank you, and thanks to Childhood Obesity Foundation of British Columbia for making you available.

If I may reshuffle our agenda a little bit on the fly, we were originally scheduled to have a presentation by Sonya Kupka and Suzanne Allard Strutt of the B.C. Healthy Living Alliance. They are with us now.

With their permission and with the consent of the committee, I would like to suggest that we maybe take a two-minute break and have them present next but also have our lunch on the fly, as it were.

In other words, if you would tolerate a certain amount of motion to the sandwich table and so on, on the part of committee members and staff, I think we could devote an hour, if appropriate, to your presentation and a question-and-answer. Would that work for you?

R. Sultan (Chair): The Clerk has pointed out that the B.C. Healthy Living Alliance team has been joined by Janice Macdonald. We welcome all three of you, and we will take a two-minute break.

R. Sultan (Chair): I will call the committee back to order, and once again we are pleased to hear from the B.C. Healthy Living Alliance — Sonya Kupka, Janice Macdonald and Suzanne Allard Strutt. Janice and Suzanne are going to be the presenters, I presume.

R. Sultan (Chair): Perhaps you could just tell us a little about yourselves and the B.C. Healthy Living Alliance and then proceed directly into your presentation.

S. Strutt: We've actually included that information in the presentation, but I will introduce myself. I'm Suzanne Strutt. I'm the chair of the B.C. Healthy Living Alliance. I'm also the chief executive officer of the B.C. Recreation and Parks Association, and I'm a founding director of the Childhood Obesity Foundation, so I'm a colleague of Tom Warshawski as well.

J. Macdonald: I'm Janice Macdonald, and I'm a founding member of the B.C. Healthy Living Alliance, which was established three years ago, and the re-

gional executive director for Dietitians of Canada for British Columbia. I had the pleasure of presenting to you in early May — May 11, to be exact — so I'm glad to be here again.

R. Sultan (Chair): Thank you. Can you give us a bit of a cameo on Sonya, here?

S. Strutt: Sonya Kupka is the director of the B.C. Healthy Living Alliance Secretariat.

S. Strutt: I haven't even begun our own presentation and I'm going to deviate from it, if I may, just to mention that before we conclude this afternoon, I can provide you some information, David and the other members of the committee, on a partnership our organization has with the BCMA for a physician-referral physical activities strategy.

Thank you very much for the opportunity to present to you today. It's the second opportunity you have afforded us to meet with you. We made a presentation as part of your original consultations in 2004, and we were very pleased with the recommendations that came out of that report. In fact, undeniably, your recommendations have influenced recent major health-promoting initiatives in B.C.

Through our presentation, Janice and I will share with you some background information on the B.C. Healthy Living Alliance, and we will ask you, as the Select Standing Committee on Health, to take some specific actions on childhood obesity. As Janice mentioned, the alliance was formed in February 2003. It's a very unique, unprecedented coalition of non-governmental organizations, government, health care and service providers, all committed to promoting wellness and preventing chronic disease.

The alliance includes non-traditional sectors, such as parks and recreation and elected municipal officials. It's a unique model where advocates, community representatives, health service provider organizations and policy-makers sit around the same table to achieve our collective goals. We influence each other's agendas by sharing information and perspectives, and we collaborate in ways that were unheard of just a few years ago.

BCHLA has a coordinating committee whose members together reach 50,000-plus volunteers, 184 local governments and over 4,300 health and recreation professionals. We work closely with the Ministry of Health, the provincial health officer, the provincial health authority and all five regional health authorities as well as the Public Health Agency of Canada.

In addition to the coordinating committee, we have a general membership, which is open to any non-profit organization that has a provincial scope or is a regional alliance with a mission that is aligned with the work of the B.C. Healthy Living Alliance and endorses its mission and goals. Most recently we brought together our general membership into an all-day call for action, where together we looked at priority areas for advocacy.

It's important to note that our mission refers to risk factors, not diseases. This is the common ground that brings all of the partners together. However, we've not lost the chronic-disease portion of our work, as our strategic direction specifies that while the alliance recognizes there's a wide range of chronic diseases, our primary focus is on common risk factors — physical inactivity, poor eating habits, tobacco use and obesity — and the underlying determinants that contribute significantly to cancer, cardiovascular disease, chronic respiratory disease and diabetes.

We're working together to reduce the burden of chronic disease by targeting activities in the following goals: advocating for health-promoting policies, environments, programs and services; enhancing collaboration among government, non-government and private sector organizations; and increasing the capacity of communities to create and sustain health-promoting policies, environments, programs and services.

I don't think we need to tell you that there's a problem. You've had many presentations outlining the extent and impact of the disturbing trend of childhood obesity, so we will be a bit light on facts. What we want to focus on are the cause and the solutions.

This slide outlines the focus of our presentation. We see obesity as an environmental disease. Solutions need to be, at the same time, comprehensive, collaborative, targeted and for the long term. Obesity is an environmental disease. Today's children are not inherently lazy. Nor are they indifferent or totally ignorant when it comes to their food choices. One researcher has noted that with the absence of a toxic-food and physical-inactivity environment, there would virtually be no obesity.

What are the environmental contaminants? There's the marketing of soft drinks — and I believe you've heard from Dr. Warshawski on that regard; fast foods that are energy-dense but low in nutrients; food insecurity; and income insecurity.

There's evidence to indicate that low income contributes to obesity. People with little financial resources try to stretch their food dollars as best they can and often will purchase food that will provide the greatest number of calories. This is very much a social determinant of this health problem.

There is, of course, excessive screen time — TV, video games, computers. On average, we know that British Columbia children spend at least 12 hours a week in front of the screen.

There's a need for greater access to facilities and programs that support recreation and physical activity, and of course, our modern urban design also has a play in this. It doesn't encourage physical activity, and we need to plan and design our neighbourhoods in ways that they would. The built environment has become a major issue in terms of an area for a solution.

Looking for solutions, we can apply lessons learned from the war against tobacco. But we note also that

there are three other major health and social movements which employ similar tactics — seatbelt promotion, helmet legislation and breastfeeding promotion.

What's important to note is that these interventions must address the fundamental behaviour and social causes of disease, illness and disability. Multiple approaches must be used simultaneously, such as legislation combined with public awareness and community interventions.

What we also know is that the financial levers — the incentives and disincentives — have consistently been shown to be the most crucial at the level of population health, but never used in isolation. There have to be multiple levels of influence: individuals, families, schools, workplaces, communities and government at all levels — municipal, provincial, federal.

Inequalities exist and need to be addressed, and interventions must recognize the special needs of specific groups such as teens at risk and communities. This will require nothing short of a paradigm shift. It will take a long time. Interventions must have long durations. Childhood obesity didn't become a problem overnight, and it will not be resolved overnight either.

Changes take time and need to be constantly reinforced in each subsequent generation if we want the new social norm to be "eat well, live well." Let's remember that tobacco reduction efforts began in the 1930s, and we're not there yet. Tenacity, I think, is what's required.

We also need new partners. We need to involve a variety of sectors that are not traditionally associated with health — businesses, engineering, law, parks and recreation, media.

While many have tried to apply the same strategies used to reduce smoking, eating and activity are quite different. But there are some learnings that we can apply based on the evidence.

Food and activity, unlike tobacco, are essential to life. Food and exercise don't kill half their users when used as intended. "Don't smoke" is an easy message. "Don't eat" won't work, although "don't exercise" might have some appeal. It's illegal to sell or market tobacco to minors; it's not illegal to sell or market food to them.

While stigmatization of smokers may have worked and continues to work, as we know, it has not worked for people with obesity. Quite the opposite. I read somewhere that children who are obese rate their quality of life as low as children living with cancer.

Now we're going to turn our focus on some solutions, and I, in turn, will turn it over to Janice to do that.

J. Macdonald: You've heard from Suzanne that childhood obesity is not a simple problem. It is a complex problem. In our Winning Legacy report — you have a copy of the executive summary in your package — we have outlined a number of strategies for improving the health of British Columbians, and we'll provide an overview of the strategies that we're recommending in the Winning Legacy report.

First of all, we recommend that we must take a comprehensive approach. The problem did not begin overnight. It will take many efforts, working together over a long period of time, to address the problem of childhood obesity.

We recommend that there be regulatory and economic incentives, community-based interventions and school- and workplace-based interventions. For example, in the regulatory and economic area. There is some evidence to indicate — and you had quite an overview on tax incentives from the previous speaker — that if we price healthy foods at a lower price than unhealthy foods, children, for example, are more likely to choose the healthy foods. There's also evidence to indicate that if we offer other incentives or disincentives when it comes to physical activity, this can make a difference in the choices that people make.

Rather than focusing entirely on the individual child in trying to address childhood obesity, we need to focus on schools, workplaces and our communities. In our communities it needs to be easier for our children and their families to exercise. There need to be bike paths, for example, where it's safe for people to ride their bicycles to school or to work.

We need to focus on neighbourhoods that are safe for physical activity. We need to ensure that it becomes normal for families to engage in healthy eating practices and being physically active together as families.

In schools there has been some evidence to indicate that comprehensive approaches do in fact work. We've had previous presenters talk about the Annapolis Valley work that focused on a comprehensive approach that had a positive impact on reducing obesity levels. In British Columbia we're fortunate enough to have the Action Schools initiative that's received support from our provincial government. We need programs and initiatives like this to continue to be supported so that they're available to all children in every school in British Columbia.

Our Winning Legacy report also focuses on collaboration, in addition to the comprehensive approaches to dealing with our health problems in British Columbia. We focus on there being leadership from the top. We have a good example here in British Columbia with our Premier taking leadership on ensuring that we're focused on healthy living targets and establishing the ActNow B.C. initiative, which focuses on us being the healthiest province ever to host the Olympics.

We need to focus on having new partners. Suzanne mentioned that unlike tobacco, we need to develop new relationships with the food industry, for example. They are not the enemy. We need to work closely with them. There are some examples within the school environment where vending machine companies have been very innovative in developing healthy food choices for vending machines in British Columbia, to help schools meet the new school food guidelines that were released by the provincial government just late last year.

We're excited about these new school nutrition guidelines, but we have one additional recommenda-

tion related to them. It is noted that they should be implemented in British Columbia by 2009. We believe that we need to be more aggressive in implementing these school food guidelines in our schools in British Columbia and that schools need more and better support to implement these guidelines more quickly.

Our report also notes that we need to look at new models of collaboration. We believe there's another example here in British Columbia, with the government focusing on the B.C. Healthy Living Alliance and allocating $25.2 million for us to work together to look for solutions to the various targets that we've established for our alliance, which include ones related to obesity as well.

There are groups within our population that are having a harder time with being healthy, that are experiencing more obesity — for example, low-income children, new immigrant children, aboriginal children. We support universal programs for the general population, but at the same time we believe there need to be special initiatives that focus particularly on those who are most at risk for being obese. These are some examples within our population.

Some of the efforts that we have focused on universally do not generally reach the low-income population or the aboriginal population, for example. We need to look at new ways and new focuses to ensure these groups that are impacted the most by obesity have an opportunity to succeed.

I'm going to briefly relate a story from a woman who e-mailed the B.C. Healthy Living Alliance a few months ago, outlining to us some of her problems with dealing with obesity. She said:

We know that obese children grow up to be obese adults more often that not, and we want to prevent these kinds of stories from impacting on the future generations in British Columbia.

You may be aware — I'm sure you are by now — of some of the statistics on childhood obesity in this province. More recently, within the past few months we've had data released on actual obesity rates, based on measured heights and weights of B.C. children. This is the first data we've had available to us for a long, long time.

We need to establish better surveillance and monitoring initiatives in British Columbia and across Canada. Otherwise, we're going to lose sight of where we've been and where we're going. Unless we continue to measure and monitor the problem, we will become less focused, determined and insistent on reaching our objectives of minimizing childhood obesity in this province. I encourage you as a committee to support better monitoring and surveillance in British Columbia.

I've outlined the main focus of the Winning Legacy report on comprehensive approaches, collaboration and working together. Our Winning Legacy report outlines 27 recommendations based on evidence. We've set targets for healthy living, and we've conducted a cost analysis to help us achieve the 27 outlined evidence-based interventions. The cost of that: $1.1 billion. That may seem like a lot of money, but based on the Cost of Obesity in British Columbia report in 2004, it costs $489 million a year to continue to deal with obesity in this province.

We encourage you to take a look at the full report, which you can find on our website, or at least review the overview that's available within your handouts. Our website is bchealthyliving.ca.

Just to provide you with a quick overview, I reiterate that obesity is an environmental disease, so our approaches need to be comprehensive. We need to collaborate. We need to continue to focus on the problem, working together across communities, across schools, across workplaces. Our initiatives must not just focus on the individual. We must not blame people for being obese.

We need to continue to focus our efforts on targeted populations, including low-income, immigrant populations and aboriginal groups. We need to ensure that we're persistent and insistent in dealing with the problem of childhood obesity in British Columbia.

Our alliance is a real advocate of working together, and our nine coordinating committee members have been doing that for three years. We believe that this cartoon from Nancy, which I hope you can read here, demonstrates the importance of working together to find solutions to problems in British Columbia.

I thank you for your time and attention. Both Suzanne and I would be very happy to address any questions that you might have.

R. Sultan (Chair): Thank you, Janice and Suzanne, once again, for a very comprehensive presentation. We will now entertain questions.

D. Hayer: Thank you very much. Very good presentation. We have heard many of the things from many of the presenters. I think it's good to see that the challenges, issues and solutions are similar, so that at least we're on the right path there.

One of the things I look at is the immigrant population, which is growing in British Columbia. When they were in the old countries, many times the mode of transportation was different, the weather was different, and there was a lot more exercise done so that they could burn up a lot more calories. When they come here, there are different types of issues, you know.

When we go to the shopping centre, most of us try to park the car right next to the store there so that we have to walk the least. Then we go home and park right next to the entrance to the house. Many people don't realize that the change in exercise is worse than diet. That's a huge issue, especially, I know, in the Indo-Canadian community, when I talk to them.

When you talked about doing some sort of media information — getting people to understand the issues — it's much easier if it's coming from an organization like yourselves or the doctors to find some of the solutions. When we the politicians say it, they take different action.

Even in the Sikh temple, when we go, they have food there. I always talk to some of the board members. I said that maybe we should start thinking about cutting out some of the sweets and putting more fruits and vegetables and some other stuff. I'm happy to see you looking at it.

Is there anything else you suggest that we should be doing to target some of the new immigrants so they can learn in a different environment how diets have changed, exercise has changed, to get them healthier and more fit, especially with the children?

J. Macdonald: Okay. We'll both comment on that, and thanks for your question.

One thing I think we need to focus on is…. Rather than just focusing on the individual and providing them only with information on making healthier choices, we need to look at the environment within which they live and work.

One thing we've found is: what food is available, and how readily is it available in their community? Is every corner store stocked with unhealthy food choices? Are there only sweet shops available? Are fruit and vegetables widely available in that community so that the community can look together for solutions, making fresh fruits and vegetables and healthy choices more available within walking distance from their homes?

I'll let Suzanne comment on the physical activity aspects. That's one area where we need to focus.

Back to your question from the presentation before. There is some evidence to indicate that, unfortunately, new-immigrant populations tend to adopt our western ways more aggressively than is likely in their best interests — for example, more likely to choose the unhealthy food choices that they associate with western society. We really do need to focus, when we're dealing with new-immigrant populations, for example, on ensuring that healthy food choices are promoted just as much, or more, as the unhealthy food choices that tend to be associated with the western style of eating.

S. Strutt: Just to deal with the physical activity part of your question and to comment, there is an initiative that's rolled out — provincially funded by ActNow B.C. and delivered by my organization, B.C. Recreation and Parks Association — called the active communities initiative. There are currently 89 registered active communities, and these are groups at the local level.

Community is loosely defined. We have some first nations groups that have registered as a community. We have groups of students who have registered as a community, as well as municipalities.

At the local level they bring together parks and recreation, elected officials, the health authorities, representatives from the education sector — the range of community organizations. Together they look at the communities and the people who make a part of it, and they develop an active communities plan that takes into account cultural differences as well. That's one way to approach it. It's a very comprehensive and collaborative effort.

The active communities initiative includes a workbook, some workshops and some tools and resources, including templates for walking programs. We're now working with multicultural communities to adapt the resources so that they're relevant to all British Columbians.

K. Whittred: I wanted to ask this question about what I call the clashing of values, if you like. I'll try to give you some examples. For example, I have a friend who is a primary teacher, and she doesn't believe in homework. She says these kids don't need homework, but there is this incredible pressure from parents: kids must have homework. So my friend says: "No, your kid should be out playing." "No, they must have homework." That's one thing that I mean.

We have certain schools that are — for example, I think in the whole Okanagan — now giving every grade nine child a laptop computer. I'm not suggesting for a moment that that is a bad thing. I'm just suggesting that it kind of puts an emphasis on what we're calling screen time. We have the promotion of all sorts of video games and PlayStations and all that stuff. We've talked about the promotion of bad drinks, but we haven't talked about the promotion on that other side, which to me is a huge factor in presenting to young people the idea that we should be spending and that it's very valuable to be actually doing all this high-tech stuff.

In your mind, with all the groups you work with, how do you reconcile those? I mean, I think there's kind of a clash of values there.

S. Strutt: The United Way of the Lower Mainland hosted last month, I believe, a middle childhood sum-

mit. Those issues came up. There is a survey currently being done of children in the lower mainland to look at how they spend their out-of-school time.

As I've said, I don't believe all the data has been gathered so far, but the researchers have been able to make some preliminary conclusions. It is that what children are asking for when out of school is more physical activity — physical activity, not sport. They didn't say sport. They want to be out moving. They're looking for opportunities to stay behind in school and play pickup games.

Those findings are going to be very interesting. They're going to be combined with some demonstration sites in four communities in the lower mainland and with some additional research that's being done around any piece of public policy that touches our children and children's lives.

I know it's not a direct answer, because this is an area where we're actually in the process of gathering information, but it's absolutely key. Children and society are receiving and giving conflicting messages.

K. Whittred: Sort of growing out of that, in your conversations, because you deal with so many organizations through your alliance, it is my observation that in my community we have an abundance of parks. We have no shortage of play space, bicycling space, walking space, parks. The unfortunate thing is that you don't see anybody in them. I was out, for example, yesterday walking my dog in this beautiful big park, and there's a sign, "Nobody allowed on the field without registration," or something. In other words, you had to register with Parks and Rec. You couldn't just go out there and throw a ball around or a Frisbee.

You're the ones that are communicating with these organizations. What has come up in terms of those kinds of conversations?

S. Strutt: Well, I'll tell you one thing that's come up. We hosted last week a summit. It was a provincial consultation on the future of recreation. It was very interesting because some of those folks who operate community centres and recreation departments said that we need to look at removing fees and charges. We need to be realistic because the revenue those fees generate doesn't go very far at all in supporting the operations of the facilities. That's pretty bold, but people are talking in those terms.

The access to recreation and physical activity. I mean recreation in its broadest definition. It's not just physical activity that makes people healthy. It's people being able to socialize and to be together with their peers for older adults to remain mentally active. All that comes into play for creating healthy individuals. I think the question of access to these opportunities is right at the top of the agenda.

J. Macdonald: Can I just make an additional comment related to the parental values that you were referring to. There is some evidence to indicate that although there haven't been a lot of changes related to structured playtime over the last ten years, for example, there have been changes to unstructured playtime.

Maybe, just maybe, part of our promotion with parents and communities is to make unstructured playtime an okay thing, rather than parents feeling that they have to constantly structure and plan all of the time for their children outside of the school environment — that it's great to go pick up a couple of friends on your street and go across to the park and play if that's a safe environment. I think some of the deterrents for children playing outside together are around safety issues, and we as communities need to work together to address some of those issues as well.

C. Wyse: Once more, it is very nice to see you and thanks for the presentation.

I'm going to come back to a group that's provided me an opportunity to at least look for a comment around this statement, because I don't really have it formulated in the area of a question. It's low income contributing to obesity.

When I look at your specific populations being targeted, there is an overlap, at least in my mind, when I look at some of the groups with a connection with income, as well as with your five groups that you've targeted for specific programs in health — whether it be first nations, the mentally ill or, of course, low-income population. No question, but would you mind elaborating upon that statement how low income contributes to obesity?

J. Macdonald: You're commenting on the fact that we mention low income in, say, aboriginal groups, and often aboriginal populations may also be low-income. There's definitely an overlap across the targeted groups that we're talking about: low income, aboriginal populations and new immigrants, for example.

J. Macdonald: People with mental illness. It's not that you can focus just on low income without considering some of the other aspects of why and who are low-income. Is that what you're getting at?

C. Wyse: In part, and then I'm also maybe trying to look for a solution in this general area. Or are the programs to be developed yet? When you say, "Support the programs for health for these targeted groups," do you have ideas around that general area at this moment?

S. Strutt: Well, the one I mentioned, which would be the removal of fees and charges to access places of physical activity. But in true recognition of our work in

public health, I think we need to look seriously at the social determinants of health. We need to look at the issue of poverty, and that's way beyond our mandate.

S. Strutt: Okay, so we're applying solution to a much bigger problem, but we're not getting at the root cause of the problem, and this is what we're urging you to do as government. It's well beyond our mandate as a health-promoting alliance, but it's a fundamental problem that we've identified, and it's probably the greatest barrier.

C. Wyse: Thanks very much for that statement. Sitting on this committee, it helps me very much.

D. Cubberley (Deputy Chair): I wanted to come back to something you began by framing your presentation around, which was the idea of learning from tobacco. This is something that physical activity promotion has been saying for 15 or 20 years — that we've got to learn from tobacco.

One of the big challenges, I think, in learning from tobacco is that tobacco presents you with an obvious demon and a smoking gun, so there is a basis for formulating very effective campaigns based on fear. Most anti-tobacco programs are based on exciting or initiating that sense of fear about: "If I continue with this behaviour, I'm going to die and it's going to be ugly." Some of the best stuff has been using very ugly images to dramatize threat, so the marketing is threat-based.

The question I have is: are you suggesting in this — and I'm not trying to imply that you are — that what we need to do with something like obesity is try the fear-based marketing with the smoking-gun approach and the imminent threat to health? Or are you looking at some other aspect of promotion that we could learn about from tobacco? Because you're either going to marshal fear or marshal hope. Those are really your only two tools.

S. Strutt: I think what we're suggesting is that much broader approach. I would suggest to you, in fact, that what's worked with tobacco control was not the fear factor. In fact, the fear factor did not motivate adolescents, for instance. What has worked is the combination of approaches: the legislation, the taxation, the social stigmatization of smoking.

I think the approaches that are based on fear — any social marketing based on fear — run a risk. We note that that's an approach that didn't work for AIDS education, for instance. Fear didn't work in the social marketing and raising public awareness of AIDS.

We know that it would not work around obesity and overweight. What we're suggesting to you is that individual behaviour will much more likely change if the environment itself changes in making healthy choices the easy choices — and easy in every sense of the word, including your pocketbook.

D. Cubberley (Deputy Chair): Just to carry that on one step, one of the things that did work with tobacco as a direction was the approach that involves denormalization — this moving it out of a category where it was an acceptable, individual choice supported by the availability of consumer items that enabled it on a daily basis, done out in the open, practised by all, not subject to public comment. A whole array of things, including the fear-based marketing, began moving it, deglamorizing it and denormalizing it as a choice.

Is that more what you're thinking about with the actual areas of concern — whether it's snacking on junk food, drinking too much pop, or too much screen time: that we start to shift that into identifying it openly as problem behaviour?

S. Strutt: Yes, and key to that is availability. That's where Janice was absolutely right in saying that the food industry is not the enemy. We need to work with them, because we're now seeing some healthy choices even for potato chips. The whole issue of trans fats is on the public agenda. We're going to see new food products, and we need to encourage that. Again, it's a question of availability.

D. Cubberley (Deputy Chair): I've got to tell you, though, that on the weekend I bought chips. I was at the store, and I started reading all the bags. Virtually every one of them now says "zero trans fats" on it. Same chips, same garbage — zero trans fats. You feel: oh well, this is a positive consumer choice.

I take your point, though, and I think that I wanted to draw that out a little bit. We do have to be specific around tobacco. There was an attempt with the AIDS campaign to apply the same logic, which was a smoking gun. It was less successful, and it was also a more restricted package of objectives that were put into the field.

D. Cubberley (Deputy Chair): I want to thank you all, on behalf of the committee. We've reached the end of the questions, so what we will do is take a 15-minute break at this point and then return for more. Thank you very much for an enlightening presentation.

This a continuation of the Select Standing Committee on Health of the British Columbia Legislature being broadcast around the world by the miracle of the World Wide Web. People in Kazakhstan are waiting for every word you will offer us today, Mr. Wasserman.

We are very fortunate to have today Alvin Wasserman, who is the president of Wasserman and Partners Advertising. The committee members felt that it was all very well to listen to the medical experts and the education experts and the community recreation experts talk about various aspects of childhood obesity, but many of us felt equally strongly that it was important to hear from the world of marketing and commerce as to what is going on out there and what advice a representative of that sector might offer the committee.

Before turning it over to Alvin Wasserman, I would ask him to perhaps just give a short description of himself and his firm and then to proceed directly into the presentation.

A. Wasserman: My background is advertising and marketing, which I've been doing for a long and studied — and maybe storied — career. The firm that I established, Wasserman and Partners, is in its 11th year. We have a long track record of doing social marketing, and we've done some social marketing programs that have been very, very effective over long periods of time.

We were involved in some of the early years of Drinking Driving CounterAttack which, as you know, has made a huge difference in the reduction of deaths by impairment on the road in British Columbia. We did an anti-racism campaign that started in British Columbia and was used across Canada and into the United States. We have done work promoting the value of education, of health — in terms of nurses, for registered nurses of British Columbia over the years — and now recycling. And you'll see some other examples of work for road safety.

I have had a lot of personal experience spearheading and using techniques that were normally reserved for mainstream advertising — using them for the promotion not of selling product but of social change.

What you'll see is a presentation that talks very quickly and succinctly about those tools and how they could be used effectively for the childhood obesity issue that we're facing in B.C. and also around the world. We've done some initial looking at what's available, and a lot of programs are just in their beginning stages on this issue. We'll have a quick recap of a couple of jurisdictions where I think there is something to be learned. That's pretty well the preamble.

R. Sultan (Chair): If I may interrupt, could I ask you to introduce your colleague.

A. Wasserman: That's just what I was going to do. Andeen Pitt, who is a colleague of mine, is a partner in the firm as well. She has a particular expertise in media and in effectively capturing your audience through the right selection of both traditional and non-traditional media. Andeen is also a very good strategist and has been involved in many social marketing campaigns at their inception with the agency, so that's why I thought I would have her along with me.

Our agency has about 55 people, so even though it says Wasserman and Partners, it's not like there are four people in a corner somewhere. It's the third- or fourth-largest agency in the market and the largest independently owned full-service agency in British Columbia.

A. Wasserman: Thanks for inviting us. What we'll try to do is go through some basic tenets that hit the wave tops in terms of social marketing precepts, and then into a little bit of an overview of some of the things that are going on with the issue you're now studying, which I think might be of help as you start to form your opinions as to what's necessary to move from the exploration and discovery stage into behaviour modification stages.

We always start with very simple precepts in terms of what we have to do. Like anyone else, you start at the beginning. Knowing that something has to change really is the beginning, because if you don't think that anything has to change, then social marketing is not for you.

Understanding what that change is and your part in it is obviously next. These are just really basic things. Then we find that some people forget that telling someone to change without giving them alternatives is not effective whatsoever — or consequences. It's the old "You must have consequences" — very, very important.

In terms of advertising and communication models, we find that the trigger has to be an emotional one. There have been quite a few studies in terms of how people process behavioral change in terms of their cortex development and the things that trigger it. No decision is possible at all without an emotional trigger is what's being generated. Even if you have some wonderful facts and they're wonderfully laid out and make all kinds of sense, without an emotional trigger there is nothing. We call that emotional trigger "the leap," and our whole positioning is in making the leap. That's the position we use in terms of our agency.

A. Pitt: There are many definitions of social marketing. We subscribe to the Social Marketing Institute, which is relatively new. It's an organization out of the U.S. where minds come together around this subject. There are now textbooks written on the subject. It's

now being taught in post-secondary institutions. Essentially, they say it's about using commercial or traditional marketing techniques to forward social causes, but we think of it as so much more than that. It's not just selling a social product. What we find is that it's balancing social benefits and individual needs, and balancing public policy with social responsibility. Those things sound easy on paper; they're not that easy to achieve.

A. Wasserman: Often in terms of traditional advertising, they talk about the four Ps — product, price, place, promotion. If anyone's been through normal marketing 101, they'll be familiar with all this. We find that if you twist it a little bit, you find that the product here is a package of benefits. It's a different kind of product. The price is what you actually have to exchange to get it. It's usually not monetary. Sometimes it's something you have to give up, whether it's a good behaviour or something that's reinforced — a habit or whatever. You actually have to give up something to change something. That's the price, and it's not always a monetary issue.

The place is: where does this transaction go on? If you're talking about the issue that you're looking at, there are zones that I know the action group has come up with — the school zone, home and so on. There are certain places where this goes on.

Finally, promotion. You actually have to promote change. It doesn't just happen spontaneously because we'd like it to and we're all thinking about this issue, and isn't it great.

A. Pitt: If we think about the issue of social marketing on a continuum, we have things that are fairly low awareness where people are more or less unengaged right up to high levels of awareness and mass engagement. Things move up and down depending on where we're at as a society and how things are promoted.

A. Wasserman: If you look at Drinking Driving CounterAttack, which is something that I think has been in the public consciousness since the late '70s, we're over on the right on that. A lot of people know about it, and tons of people are engaged. Bad behaviour in a bar — people will notice. If someone slips into a car, chances are that someone is going to say something. We've moved a long way. When we started that way back when, the idea of being a designated driver was unknown. Even the term "designated driver" was not known. The sort of heroizing of the designated driver — being a good guy, and he's the one who gets free soft drinks and is celebrated and all that stuff — happened over time. So we moved that to the right.

Other things you see here. Recycling — it's pretty high awareness. We've placed it fairly high on the chart. There's been a lot of work done on it in B.C. We have very high return rates. It's quite engaged.

There are other things, like racism, in the middle. Maybe there's a lot of awareness, especially with the recent front-page news and the Toronto-area arrests and those kinds of things, but it doesn't necessarily mean there's mass engagement yet. There's awareness but not engagement.

Things slide up and down on this scale. Of course, where you're starting and your issue is, is towards the bottom left.

A. Pitt: To the left are things that are just emerging — for instance, homeland security. You can see where that may be a big social marketing issue. It's being talked about a lot, but the individual is not aware of their role in it necessarily and is not actively engaged.

We put obesity just up a notch in that there's a lot happening, a lot of gathering of information around it, but we don't have mass engagement. SIDS is another one that we see there, and ECC, which is a campaign that we worked on with ActNow B.C. — early childhood caries. I heard someone say: "What's ECC?" It's really serious dental decay in very young children, which is an issue, and we're trying to change that. Organ donation may be one of them.

We argue from time to time as to where things are, but clearly we can agree usually on the extremes.

A. Wasserman: So the idea is to move from the left to the right — very simple.

We also talk about an arc of change. An arc of change is: change, even once triggered, doesn't actually happen all at once en masse in society. You have to increase awareness throughout society because people reinforce it at different levels. You have different stakeholders — teachers, educators, parents, whatever it is — on an issue. Then there has to be solution and actions, and those kinds of things have got to be understood.

Then there is framing. There are massive seminars on how to frame social issues, and that could be a study in itself. There's actually an institute called Frameworks, which talks about framing issues for social marketing. They have a wonderful website. If you want to find it, you can just google Frameworks.

D. Cubberley (Deputy Chair): Just on that, is your sense that the obesity issue has in any sense been framed for the discussion that needs to occur in society for change to happen?

A. Wasserman: I think there's inadvertent framing going on now. It's not purposeful. It's not conscious, which is the worst kind. What's happening is that it's becoming just a fast-food issue when, in fact, it's way more, from my knowledge. I'm not an expert, but it's way more than a fast-food issue. It's a much deeper and wider issue, and in order to change it, just changing fast-food habits is not going to do the change, not by any means. So yes, the framing is very important.

The proper framing creates the environment for change. That's the next thing you see there. Once it's framed, people can say: "Oh, I didn't see it like that. I

never thought about it that way." How many times have you heard that when somebody starts to shift positions? You need that before action starts — right? They say the lightbulb goes on. Then there is trial behaviour to get people to try something different, reinforcing that, and then measuring what the heck's happening and starting all over again. That's what we call the arc of change.

A. Pitt: We see some clear keys to success. We need a clearly focused, meaningful issue — no surprise — but consequences that matter close to home. We like to say that it's not really about changing the world; it's about changing you, yourself, your immediate environment.

A. Pitt: There also has to be real social benefits to that behaviour change. I need to be able to see them in my life and in my surroundings. It's not saving people on the other side of the world.

We need to look seriously at incentives and disincentives and tools to make them happen. So we need to arm people with things that make it easy for them to change effective communications, of course — but to all segments. These issues never relate to a specific group. It's a broad kind of societal change. They're the people who are dealing with the issue, the people who influence them — where they shop, where they go to school. They're doctors, lawyers and you name it.

We need a response mechanism. People need to feel they can respond in some kind of way — either to say they've achieved, or what can I do, or help me with this. We need a long-term commitment. There's no social marketing change without a long-term commitment to the program and, of course, good research that tells us where we are at any point in the program.

A. Wasserman: I just want to underscore the long-term commitment, because it's your mandate to look at this. I can only say that if it's a token thing — in and out for a few weeks — or if it's, in the end, the sense of…. Then forget it. You might as well send the money to a really good cause, because it's not changing anything.

I would underscore that from a committee point of view — a long-term commitment or none at all. Otherwise you're going to end up with things you cannot research. You won't have enough change to measure. You ensure failure. It's as simple as that. Societal change is a lot harder than selling a box of Kleenex tissue, just so that's reinforced in terms of your report.

The next thing I wanted to quickly talk about is making a connection. That is relevancy. It's somewhat to do with framing. How is this thing relevant to me and my values? I think that if people do not see an issue as relevant to them — their values, their life, the way they see the world — then you cannot connect. If you connect on that level, that's when an emotional trigger can come in and you actually effect change.

You're always looking for what current mainstream values exist that we can plug into. That's what you're looking for. You sort of start to mine the field. That will be very important in the initial briefing, whether it be to educators or communication people or whatever. Everyone is very hot and concerned about your issue, and that's fine. It's like the input jack. Where do we plug in our issue to a mainstream current that's already out there? That's very important to find. That's what we talk about in terms of empowerment and connection — very important.

The next little slide. There's all that to remember, and we thought that was too much. I know you've been taking notes, and that's good. We appreciate that. I have a little acronym here that's so easy to remember. It rolls right off the tongue. It's called CARE, which is very easy to remember for social marketing. If you remember these four things and measure your program against it, you're going to be going up the right alley.

The "C" is consequences. There have to be consequences. There's no change without consequences — period.

The "A" is alternative. There's got to be a better way. Well, then what is that better way? Show it to me; talk to me about it. What are the better ways?

Response. What can I do about it? What does it have to do with me? What can I do? That's just basically the "R."

The "E" is emotion — the emotional trigger. How, in some way, can we get this to be an emotional issue?

That is basically our little checklist. If you have that little checklist around, it'll really work wonders. We check all of our creative in this area against that list.

A. Pitt: Just quickly a couple of examples of some of the work we've done, and then we're going to talk specifically about obesity or increasing physical activity. Encorp Pacific. The issue there is that B.C. landfills are filling up with recyclable materials — very easy, clear issue. The leverage? Well, we're going to need more, and they might be in your back yard.

A. Pitt: It's as easy as that. The emotional trigger? Well, we can do something about the impact on the environment. We had a movement here. People are concerned about the environment. The action, which we coined: "Return it; it's worth it." This was surrounded by a whole suite of things that included deposits on beverage containers, depots, grocery store return programs. We had collateral materials, school programs, advertising, PSAs.

A. Wasserman: How to make it emotional. You'll see a little spot here that makes the returning of beverages emotional.

It's just a nice little emotional thing, and you start to feel for the bottles, for God's sake. So if you can make bottles an emotional kind of trigger, then you can imagine what you can do with some other, bigger is-

sues. We actually have the highest return rates of recyclable containers in North America.

D. Cubberley (Deputy Chair): We have a container deposit-refund system, which is part of the reason.

A. Wasserman: Well, there are a couple of other places that have jurisdictions, and we beat them as well. But as we said, it's a total system. We have the refund system, we have the education, and we have the beliefs. It all works.

D. Cubberley (Deputy Chair): Credit to you and others who've marketed this program, because if you think about the barriers to actually taking these things back — getting into a line and waiting miserably long periods of time to get $4 back….

A. Wasserman: Yes, the program has been terrific. We've been very fortunate to be associated with it, and it's very gratifying to see the rates work up.

Just a quick flip over to ICBC. A very tough audience, a youth audience. This is a fairly new program — this part that we've inherited. We're looking at what these people care about for road safety — the connection. How do you plug in?

A lot of them actually say they don't care much about themselves. "If I go down in a flaming blaze of glory, well, so be it." We've heard that in focus groups. It's quite scary. But they don't like to leave behind the emotional wreckage of their friends and those kinds of things. So it became very much a friends thing — protect your friends versus protecting yourself.

We did a little bit of probing. It's hard to break through. These people have seen a lot of car wrecks. They've seen CSI episodes up the yin-yang and those shoot-'em-up games. Blood and gore by themselves won't do it. You need an emotional thing that breaks through.

We came up with a very interesting little hook that we tested on them, and that seemed to get their attention — that is, it's no fun being dead. So this is the No Fun Being Dead campaign. I'll just give you a couple of examples. This is largely on the Web, which is where they spend a lot of time.

There's a whole bunch of things. It's no fun being dead, playing with your friends….

A. Pitt: You know what's interesting about this? How it did with young people. There was the laugh, and then there was the "Oh." That was exactly the response.

A. Wasserman: No. Some very young people in our agency wrote this one. It freaked me out a bit when I saw it, I have to tell you. I said: "We're going to do what?"

A. Wasserman: It's hugely popular. People are coming, making comments. The amount of hits is huge.

When I first saw it — but I'm not the audience — I went: "Are you sure? Dead people?" But it's been amazingly successful.

A. Pitt: This is a really recent campaign that we did with the B.C. Dental Association and ActNow B.C., which was around the issue of prevention of early childhood tooth decay. The leverage, of course, is the physical and psychological damage that's done to young children. The emotional trigger is that children are vulnerable. They need you to help them. They can't do it themselves. The action is very simple. The first time out: don't put young children to sleep with anything other than water.

A. Wasserman: Very simple messaging, and the mainstream value that people really understand is that you have to take care of babies because they can't do it themselves. It's a very simple plug-in. Let's keep it together.

A. Pitt: Although this was a very broad campaign, it tapped into some key communities, so we had multiple languages. We reached into native communities. We had telephone access, kidsmile.ca, collateral materials, tips on how to prevent it.

A. Wasserman: It's a very effective, simple…. That last shot of the baby sucker — hopefully not the sucker itself — became this sort of visual icon that translated into all the materials.

When I look at, again, a quick checklist of results of social marketing…. You have to get something like that — a visual image or a phrase like "it's no fun being dead" — which becomes a rallying point that people can always remember. It anchors all the material, and it comes back to one thing. It's too easy to dissipate; 150 good messages, and they're worth nothing because people don't remember them.

You need that one strong phrase or visual icon, like that, to really focus the attention. That's hard to get.

You have to work on that. Then that helps promote meaningful communications and helps you achieve breakthrough. You see a lot of the work here. There's always something that makes it a little bit different to break through, and you need that breakthrough in order to effect change in behaviour.

A. Pitt: Let's talk about obesity or lack of physical activity, which are two sides of that coin. We know that it is a worldwide issue, certainly for the have countries. There are a lot of people with no weight problems, thank you very much. The WHO has been involved in the issue — and public health agencies, governments, health care professionals. Certainly, here there is no shortage of organizations. Everybody is involved, but there is still more gathering of facts than taking of action.

We have even others who are involved in one way or another. Schools are involved. Pharmaceutical companies are involved, coming up with new drugs to deal with the issue. Even fast-food marketers are involved on the fringes. You see it in the shift to so-called healthier meals, more concern about trans fats and so on.

There is a lot happening, but we thought we would share with you some of the things people are saying maybe elsewhere that seem to be taking us away from just talking about cause and effect to real tangibles around the issue.

The Robert Wood Johnson Foundation, you may know, is a huge philanthropic organization in the U.S. just around health. They actually looked at initiatives that people would support. At the top of the list are things like requiring 30 minutes of daily activity in schools, teaching of nutrition, down to limiting fast-food outlets near schools. There was very little support for the things that limited where people would get the food. It seemed like education, require more physical activity…. But don't ban junk-food ads during kids' shows; don't limit fast-food outlets near schools; taxing soft drinks and so on.

A. Wasserman: It's interesting. You go right to 79 percent, which is basically giving….

A. Wasserman: Right from there is taking away — 79 percent to 61 percent and down from taking away. A very interesting break.

D. Cubberley (Deputy Chair): Do you think that would be as sharp a division in Canada?

A. Wasserman: We don't know. I would guess that depending on the province…. In, let's say, Quebec, I would say it would be pretty close to this. They are really, I would say, anti–government…

A. Wasserman: …intrusion. I think B.C. might be midway, and Alberta, I would bet, at the other end of the scale. They would be for a couple of these bans. This would be my guess.

K. Whittred: I find it interesting that on the 61 percent, they only say elementary school vending machines, not school vending machines.

D. Cubberley (Deputy Chair): Remember, the American Constitution is designed to render government inactive. It does not want activity.

A. Pitt: That was kind of interesting, because it certainly takes it out of just discussing the subject to starting to look at things.

This was even more interesting. The University of Auckland, New Zealand, did a segmentation of high school students. This is the kind of thing we have to look at doing.

A. Pitt: Yes. What they were trying to do was figure out how best to reach overweight high school students to get them to lose weight or be interested in losing weight.

A. Wasserman: I'm not sure who classified them as overweight. Did it say that in the research?

R. Sultan (Chair): So we've got overweight people describing how to reach overweight people?

A. Pitt: No. The university embarked on a study that looked at…. They were looking at the issue of how to create change, and their feeling was that we're not looking at it the right way. We're not looking at the types of messages that we send to certain groups of people, which is what we do here. It's interesting that they applied this to obesity.

A. Pitt: Yes. There are people who don't think about weight loss — not an issue — but subconsciously they want to lose weight. Blissfully unaware are people who think about weight. They say that they are happy with the way they look, and subconsciously they don't really want to lose weight. The ready-to-go are the people who are looking to lose weight — no holds barred. And beautifully big love their size and don't want to lose. What's interesting about it is that they've gone one step further, to actually look at the group and say they're not all the same. So where are people at?

R. Sultan (Chair): Excuse me. I've been cautioned by a Clerk to impose my disciplinary powers, and we will save the interventions until the question-and-answer period. I was the first person to break the rule.

A. Wasserman: Well, we're almost towards the end, because we tried to power-pack it toward here. What's our time? We're at 1:35, and we were scheduled till…?

R. Sultan (Chair): Well, I would just carry on as is. Our next presenter's not here.

A. Wasserman: Well, what they then did was look at different messaging, which is very interesting, and tested against these four segmentations. Guess what. One size didn't fit all. Quelle surprise.

The blissfully unaware students were actually much more likely to lose weight and effect change when they were shown both types of messages. Both types they have here are educational and motivational or a combination.

This is interesting, because when we do advertising, we would never think of an educational thing without an emotional trigger. They obviously had some that were strictly information, which we wouldn't do but which they did anyway. You needed both, which doesn't surprise me, to effect change for the unaware.

The beautifully big people were slightly more likely to respond to educational messages. I think that's because they didn't find an emotional trigger for them. They were already emotionally happy with their state.

The unaware-and-don't-care students showed a slight preference for motivation — something that gave them more of an emotional thing.

The ready-to-go? Well, they're ready to go, so no preference. Anything you told them triggered the behaviour, because they were on the edge.

I found that very useful. Of course, we don't actually make messaging like that. We would have combination messaging. But it does say, if you're going to make short notes in your mind, that one message doesn't suit all. You should have a campaign as opposed to a one-off ad. And a campaign meaning not just advertising but materials, Web support — the whole suite of communications and societal tools to get through. One thing doesn't do it.

A. Pitt: Just quickly on this as well, the American Heart Association and the Clinton Foundation have actually developed a four-pillar approach. They've stated that there are industry objectives, healthy schools, kids themselves and the health care system.

A. Wasserman: Basically, we're talking about our methodology, and you're doing your study. But you need an umbrella, something that the various organizations that are tangentially involved in this can get behind. You need some sort of umbrella and centralization in some way. Otherwise, the efforts get dissipated, which we've already seen.

There's been a little bit of effort here and there, but if you go out and talk to people, I would say the awareness is incredibly low. The answer isn't more of the same of whatever's been done. The problem is very simple. There's an activity level deficiency as well as, obviously, some eating temptations or habits that have to be broken.

Consequences aren't clear to people. I mean, even without research, we were realizing the consequences of this were not clear. Again, to go back to one of the original slides, no change without consequences. We have a problem here without a consequence that's visible for lots of people. That's a big issue.

Key audiences. There is very minimal involvement of all of these audiences right now. If you look at where

you are in the continuum, I'd say that you are on the low left-hand side — unengaged by masses and unaware and no activity throughout your stakeholders. The incentives and disincentives are somehow very abstract to people. They're not real, not tangible. People don't know what they are.

A. Pitt: I think we have a few areas where we can start pushing people towards trial behaviour. We know that through 2010 Legacies, there are some programs that they're talking about, and the B.C. government is supporting these. SportFit is one; Action Schools and of course, that 20-Percent Challenge.

Challenges are pretty controversial things. The One-Tonne Challenge comes to mind. Canada said 10 percent, and we upped it. We doubled it — 20 percent. But there are more. These things are getting out there.

Sustained behaviour. We know that Action Schools B.C. is at an opportunity to sustain…. We were looking at what was happening. Do these things have legs to help the program along?

Measures of success, of course, would be more engagement in healthy activities, and we can measure this in any number of ways as we try to move the program along. Levels of awareness of the issue as well as what can be done about it — that's a very first stage. Things like school gym participation. We know that in the senior grades you don't have to take it. Can we look at that over time as a gauge of how we're doing?

Consumption of water is very simple, so it's not about everything. You could look at consumption of water versus less consumption of soft drinks.

Increase in sports participation. That's signing up for groups and so on. Self-tracking, using a medium that youth use — are there on-line trackers and that sort of thing?

A. Wasserman: Ways that people can actually have individualized programs and then be reinforced individually. It's a move of mass awareness, I would say, combined with individual responsibility and individual reward. It's a nice combination, and luckily with technology the way it is, you're able to do that now.

R. Sultan (Chair): Thank you, Andeen and Alvin, for an excellent presentation. I'm sure the committee has many questions.

We'll start with the Deputy Chair, David Cubberley. And by the way, let me jump in — interrupt myself — and welcome Michael Sather to the committee table. He's the MLA for Maple Ridge–Pitt Meadows and one of our key and thoughtful members who I'm sure is looking forward to what our people have to say about the presentation.

D. Cubberley (Deputy Chair): A couple of things. It's nice to talk about it at this level rather than the kind of level that we have been talking about it at, because I think a lot of what we're hearing is completely detached from how you affect perceptions and how you trigger behavioral change in a meaningful sense.

It's not even engaged, really, at the level of: is it education, or is it emotional presentation? It's mapping the problem. We need to act and hear some things that we think might work, but no sense of a broader kind of program that would attempt to shift attitudes across schools as opposed to school by school.

When you were talking about consequences, did you think at all about the advisability of a link of some kind to disease in later life in tolerating overweight and obesity? If you did, did you come back very quickly to the fact that low self-esteem is one of the predisposing factors in some cases for overweight? There can be stigma attached to going to consequence and this whole troubling potential to reinforce that this is a problem and that you're a loser, or some undesired kind of chemistry.

A. Wasserman: I think we haven't worked it through in that you have to go through a number of steps, including some research, before you actually hit on a creative solution. I can only say that you can do consequences incrementally. You don't have to go to the biggest consequence to make your point. You could find the consequence that won't stigmatize or revictimize somebody…

A. Wasserman: …but still trigger. Finding that little zone is part of the creative exercise. We've done that before. When we were attacking racism and doing anti-racism commercials, we didn't want to reinforce different racial stereotypes or give people any language that is slang language and have it out there, because when it's out there, it just gets picked up and used.

We had to find a way of modelling bad behaviour. We just went through the language, very carefully scripted — we had people who were representing negative things — so that we didn't make them cool in any way and didn't give them a handle that could then be picked up and misused.

I can only say that it be part of a proper briefing. When you get the right research, you'd be able to give consequences without bad modelling.

D. Cubberley (Deputy Chair): Would the right research involve taking apart the differences between kids at a certain age and how they see themselves, and then how tweens see themselves?

A. Pitt: Sometimes different consequences work against different audiences — right? So to a young person, the consequence of having a serious disease 20 years from now is inconsequential.

C. Wyse: Thank you for the presentation. Do you have any idea of how long a program it is, let's say, to move the topic we're talking about up one segment to the right?

A. Wasserman: Yes, one segment? You mean the next segment would be some awareness…

A. Wasserman: …and some engagement? I think you could probably do that in two to three years. You can't do that in a 16-week media buy.

C. Wyse: All right, and then as you move further to the right this will require the corresponding increased length of time to move up to….

A. Wasserman: You're talking like Drinking Driving CounterAttack. We've been at it since the '70s, and there's enormous change.

A. Wasserman: It's cumulative. Exactly right. It's funny. We measure awareness. Let's say you do a year campaign, and then you're off for six months or eight months. Then you go back again. You don't drop to nothing, but you'd be amazed how fast you lose traction — hugely, quickly, distressingly, is all I can say from someone whose business it is to keep the numbers up.

A. Pitt: What impacts that sometimes are the incentives and/or disincentives, in terms of how quickly you move up.

M. Sather: In one of your slides you had that this may be the first generation to not outlive the one before. I assume you meant that in this generation, their longevity may be less.

A. Wasserman: We plucked one consequence out of a hat. We didn't put about 18 consequences there. We wanted to do the top of the waves here, as opposed to an in-depth analysis of all the possible things that could go wrong.

A. Wasserman: Yeah. It is actually quite an interesting thing to think about — that we may have already peaked in terms of our society. That's not just in that but also in terms of jobs and all kinds of things. It's sad, and I'm hoping it's not true.

K. Whittred: Thank you. I found your presentation to be very interesting. In terms of some of the examples you gave, there was reference to what I saw as several different themes. You have the theme of healthy eating. You have the theme of obesity and losing weight. You refer to that from the New Zealand studies. You talked about sport participation, about training for athletics and sort of Olympic-level athletics.

While I certainly see there is a common thread to all of those issues, I'm wondering from a marketing point of view if they are necessarily all one package. Are they mutually exclusive? I can see, for example, a campaign about healthy eating that may or may not touch upon obesity or, particularly, reducing weight in the very obese. Am I making my point clear?

A. Pitt: Yeah, but in the measurement of it, Alvin can talk to you. Sort of a campaign focus, but in the measuring of it you can still measure all of those things because in theory, if you were to change any one — right? — you're probably changing some of the others. If you're eating well and if the campaign is around healthy eating, you're probably going to see an increase in physical activity, lower weights and so on. If the campaign was around increasing physical activity, you could probably still measure eating, sports participation and so on.

A. Wasserman: Yeah, and I think from a campaign point of view — to go back to one of the other slides — you'll likely need a rallying point, something that it all goes around, and then you would segment the messaging. Certainly, elite athletes are not going to be needing this.

When we talked about the 2010, it was a legacy program to increase fitness. That's a fitness program that they're thinking about doing, and it's not: "Let's all become Olympic athletes." That's beside the point in this target. We're not concerned about them.

But a rallying point is a good idea — whether it be a positioning line, a key visual, a key way of thinking — so that when you have all these programs…. I see in B.C. that there's a real tendency to do this at grass roots, which is great, to start. But in order to get critical

mass, someone is going to have to grab it and say: "We are going to be putting all these programs together under an umbrella. It's going to be called X, and it's going to have this as a theme. We'll be able to run it for a number of years, and we'll report in and see the kind of progress we'll make and adjust the program as we go along."

If, as I said, you get more of the same in any of this, there's no end to the ways you can waste energy on this.

R. Sultan (Chair): My final question. We are moving forward under the label "childhood obesity." Is that a useful choice of words in the present context?

A. Wasserman: I don't think so. I think it's awkward, because there's something about "obese" which is a bad language thing, and language is power. I don't know what the language is — I think it might be something worth exploring — but I think you need something that is sensitive to the fact that you don't want to stigmatize people in whom you want to change behaviour. You want them to be actively involved in their own transformation, and that means reinforcing them from the beginning as opposed to stigmatizing them. So I wouldn't use that myself.

R. Sultan (Chair): The committee would like to thank Andeen Pitt and Alvin Wasserman for an excellent, thought-provoking and stimulating presentation — and, I must say, entertaining as well as serious.

Thank you for coming. We will look forward to trying to incorporate much of your advice in the final recommendations.

R. Sultan (Chair): We will take a two-minute break while we set up for the next presentation, which will be by Dr. Charles Weinberg.

We are very fortunate to have as our next presenter Dr. Charles Weinberg, who is a professor at the Sauder school of business at the University of British Columbia. We will ask Professor Weinberg to introduce himself in terms of his own background and then plunge directly into his presentation.

C. Weinberg: I'm pleased to say one thing. I never had Mr. Sultan as a professor, but I am a graduate of Harvard Business School, and I've admired his work for a number of years. I've been at UBC for 27 years now, and my area is marketing. I work in two main areas of marketing. One is building sort of computer mathematical models of marketing systems, and my secondary is marketing for public and non-profit organizations. That's the area that I'll speak in today. Picture, if you would, the papers and books I've written in that area.

R. Sultan (Chair): I think we would like to try and finish in about 35 minutes or so — is that possible? — or 40 minutes.

C. Weinberg: Sure. Anything's possible. Or I can speak for two hours; I'm a professor.

C. Weinberg: What I want to do today is distinguish marketing from other interventions to achieve social change, including advertisement, which presumably you've just heard about; at the same time define what marketing is so you can see how it stands out from other types of organizations; share with you some lessons learned from social marketing programs, both those which have worked and those which haven't worked. Hopefully, I'll have time for some conclusions as well.

C. Weinberg: I have to stay still? It's impossible for me to stay still. Marketing is too exciting to stay still. I'll see if I can sit down for everyone.

There are a lot of different approaches to behaviour change. One is the notion of communication and education where basically what you do is — and I'll define it more fully in a second — provide information and try to motivate people. Another is the area of regulation and law — about passing regulations, the enforcement of regulations, taxation and pricing, technology and marketing. I'll define each of these in a little more depth for you except for regulation and law, which you know well.

Basically, communication and education are messages that attempt to inform people, persuade people. There is a notion sometimes that if people would only be aware of what the problem is, they would then be able to change their behaviour. As you well know and others know, this turns out to be really difficult. Sheer communication tends only to work when people are really ready to make that behavioral change.

I'll give you two examples of campaigns. One is with regard to SIDS, or sudden infant death syndrome, and it has really been quite remarkable. In the United States in 1992, 30 percent of babies were put to sleep on their backs. Around that time accumulated scientific evidence found that in terms of sudden infant death syndrome, which is a very sad, tragic thing when it happens — you put the baby to sleep at night, and the baby doesn't wake in the morning — counter to what your intuition would be, to put the baby to sleep on the tummy, it's better to put your baby to sleep on the back. Six years later, by 1998, 83 percent of people were putting their babies to sleep on their backs. Now, this is incredible.

I mean, people were talking before about obesity and so forth. Why is it that with basically a straightforward education campaign, we're able to make this change?

C. Weinberg: That wouldn't explain speeding on driving, drunk driving and other things. So it's more than fear of death. You have to stop — and it's what we do in marketing all the time — and say: "Think about who the consumers are." Well, the consumers here are mainly young parents — right? When young parents are starting with their first baby, what sort of mode are they in? Well, they're very much in information-acquisition mode. "I want to know what I can do best for my baby."

If there are scientific studies which say, "It's best for your baby to put your baby to sleep on its back," you're willing to do that for your baby. You don't have an old behaviour to break, because it's your first or second baby. If your parents say, "Well, in our generation we always put the baby to sleep on the tummy," you just say: "Well, it's a new age, mom and dad. Get with it." You don't have to change your own patterns. You're looking for information, so that's very successful.

It's also very rare. Sheer information campaigns like this rarely work. Even here there's need for continued reinforcement. In the United States, if you're a young mom or dad and you buy Pampers for your baby, what do you find on the diaper? A little message that says: "Put your baby 'back to sleep.'" So it's a constant reinforcement of the message.

On the other hand, here's a food pyramid. There's a communication campaign. We're supposed to communicate to you that this is your diet and that you should eat from these five health groups. I want to caution you. This is the simplified version of the food pyramid.

If you think that this type of information campaign is going to change anyone's behaviour, you're really a terrific optimist. I should point out, by the way, that there…. I mean, they realize that it's not just eating well, but it's also physical fitness. So those people you see running up there on the side, that's supposed to represent physical fitness.

In fact, advertising campaigns are an important part of marketing. Providing information is an important part of marketing, but it's just one part of marketing.

Regulation, again, is another area. You know it well. I thought I'd comment briefly on a few regulatory activities that relate to marketing that might be of concern to this committee.

First of all, there's a lot of concern with warning labels. A recent study in the United States says that warning labels constructed in conformance with the Nutrition Labeling and Education Act basically have had very little or minimal impact, though there is some suggestion that simpler labels might be more effective. At the end, there is some discussion of changing food programs in schools and so forth, and we have yet to see what the impact of that would be, but that would seem to have the potential for impact.

One of the earliest laws — and one of the few, actually, directly addressing the issue of advertising to children — was the Quebec law which bans advertising to children. Even though this law was passed in 1980, surprisingly, there's been very little evidence to see how it has changed consumption patterns. I'm happy to say that two of my colleagues, Kathy Baylis and Tirtha Dhar, are just doing a study right now. What they're looking at, among other things, is fast-food expenditures over time among francophones in Quebec, anglophones in Quebec and then francophones and anglophones in Ontario.

What the law banned was advertising to children on programs or stations originating in Quebec. Well, that most affects, then, francophones in Quebec, because anglophones can get their U.S. stations over cable and so forth. What they tend to see — it's very preliminary — is that this ban seems to have some effect on francophones in Quebec as compared to others. I think that suggests that some of these regulations can have an effect, but one has to be careful about not being overly optimistic.

Now it has come to marketing. What is marketing? Marketing is a broader activity. It's concerned with creating, communicating and delivering value to consumers. This value to consumers can be in the form of physical goods. It could be programs. It can be services. But the key underlying notion in marketing is that what we see is voluntary exchanges, that people are giving up something — be it money, be it time, be it inconvenience — in exchange for some benefits.

What marketing is about is creating these exchange opportunities in a way that's relatively easy for people to adopt. Now, rather than sort of go on and try to define this in too much academic detail, I thought I'd give you an example of a program called Road Crew.

Road Crew was designed to deal with drunk driving in rural Wisconsin communities. What they have is a lot of Friday and Saturday night, very heavy drinking, primarily among young males. They said: "What can we do about this problem?"

The first question is: who are the "they"? Well, the "they" are people who are involved in highway safety

and so forth, and they said: "There's too much DUI — driving under the influence — and too many drinking-driving accidents. What can we do to control this?" They went out and surveyed and asked people what they wanted. What would make their drinking experience more pleasurable? What would bring them out of their cars?

What they came up with was a program where they would pick you up early in the evening in a late-model luxury car sort of like a limousine, and bring you to a bar. Then after you got tired of that bar, they'd pick you up and bring you to the next bar and the next bar after that, and they'd bring you home at night afterwards. While the price they charged varied from community to community, $10 would be the typical price that you'd pay in advance — probably for the obvious reason that by the end of the evening, you don't have any money left.

This was a marketing program — right? — as compared to a communications program, because you've really designed a service. They call it Road Crew. It's a drive service. And what's the benefit that they're providing? It's more fun to drink if you don't have to worry about a ride home. That's the benefit.

What happened? Well, we find that males see less drinking and driving; females, less driving with people who've been drinking. We see that's a great effect. But what don't we see? We see that the level of drinking is not changed.

One of the things that you need to think about in marketing is the notion of competition. If you're concerned with roadside safety, this is a great program, but if your program happens to be for binge drinking, a very serious problem, this program does nothing for you. One of the things you have to keep in mind is that even though we use the term "social marketing," we always have to ask: social for whom? These are designed by organizations to meet the organizations' objectives, and you have to think through that there may be other social causes at work here as well.

The other characteristic of social marketing is that while there are some private sector examples, it's typically carried out by government agencies, non-profit organizations, and the question is: what's the bottom line? The bottom line — at least, I believe, and I've written this a number of times — is that behaviour is the bottom line. Things like building awareness and favourable attitudes are necessary steps along the way, but if you want to measure success of a social marketing program, you have to measure success based on behaviour.

I should also keep in mind that the targets of your behaviour change can vary at different levels. The examples I'm mainly using are individuals, but you also can be concerned about organizations, community groups and so forth, broader provincial or federal government agencies.

To give you an example of an organizational program — I won't elaborate on it — there's something called the Center to Advance Palliative Care. Their target is to get more hospitals to have better and stronger palliative care, so their target market there is hospitals — right? They say: "If hospitals have better palliative care, then from there we'll move on to the individual level." But most of what I'll talk about today, because of time, is marketing to individuals.

What are the critical aspects of social marketing? First of all, behaviour is the objective. Awareness is only one step. I'm going to come back to behaviour in a second. I think that what you heard before is that you've got to be concerned about target market selection. That is, marketing chooses its targets carefully and works with different programs with different targets.

You have to understand, from the users' point of view, what are the costs and benefits involved in this situation, and design the product to appeal to them. Road Crew is an example of that, because you want to appeal to people who are doing heavy drinking on Friday and Saturday nights.

Your problem is that you want a program to reduce drinking-driving accidents, and that's what their product is designed to do. Different organizations might design different props.

Then, marketing programs involve more than just the advertising. They involve the product design. They involve the pricing strategy, delivery strategy and so forth. One of the advantages of working in the public sector is that these strategies can be done with the help of regulation — the law and policy and so forth. Enforcement is always one of the critical elements.

The other thing I'll point out is that as compared to private sector marketers, public sector non-profit organizations have an advantage in that they can collaborate, but they have to be aware of competition. For example, if the Vancouver Symphony Orchestra, Vancouver Opera and Ballet B.C. wanted to get together and arrange their schedules so that they don't overlap the same nights, most people would say that's really quite good, so it helps the general arts community. But if a few car manufacturers wanted to get together and schedule their price promotions, we'd say that's collusion. There are more opportunities for collaboration among the non-profit sector. Even though there are some dilemmas with the Road Crew program, there are opportunities for cooperation.

In terms of behaviour, and you may have heard this before, probably the biggest mistake people make is they think that changing your behaviour is a one-step process. There are a variety of different models. The one I happen to like is by Prochaska and DiClemente, which says that people go through a variety of stages — precontemplation, contemplation, preparation, action.

To give you an example in more concrete terms, think about using cell phones in your car. When we all first got cell phones, we said: "This is great. We can use them in our car and talk all the time." Then we realized that's not such a good behaviour — right? Well, maybe we're starting to think about it a little bit.

If I'm not going to use the cell phone, how am I going to prepare to do that? What steps do I have to think about? Maybe I can use a hands-free mode. Of course, even using a hands-free mode, you're still talking. You're still focusing on your conversation. So you try to say: "How do I do it? What steps do I have to take?"

I prepare. Maybe I start to say that I'm not going to use the cell phone in the car. Then I have to tell my colleagues: "Don't call me during certain hours, because I'm going to be driving in the car." I have to arrange my work schedule so that I don't use it.

You can see there are very many steps along the way. Now we finally say: "Well, we're not using the cell phone." Then what will often happen is there's recidivism. People go backwards. I'm not going to use the cell phone, but today is really an urgent day and very busy, so I go back.

You have to allow for the fact that going from not being aware of something, or even having a favourable attitude towards it, involves a number of different steps. It's not a linear progression, and people go backwards and forwards in terms of how they proceed.

What sorts of pitfalls do we typically see in social marketing programs? I'd say one of the biggest pitfalls is short-term focus. They just focus on the immediate campaign — I'll give you an example in a minute — and underestimate the competitive effects, including the competition of sheer inertia. I'm happy the way I am right now. Why should I change?

We proposed, and while we didn't actually do it, we were looking at driving…. People have this strategy when they drink and drive. They say: "What I'm going to do is go more slowly and go on the side streets." The problem with that strategy is that very few people actually have these drinking and driving accidents, so in fact, many people think not only is it a good behaviour, but it works, because they haven't been caught yet. It's a strong competitor to what they have. You have to recognize that people are engaged in behaviours. You have to change the behaviours they have — focus on behaviour change and not behaviour maintenance.

What are the emerging opportunities in marketing? One of the biggest things we're seeing now is the rise of branding. It happens because people are very busy, and brands are a way of quickly summarizing the information about a product, a company or an activity.

We all know private sector brands. There are a lot of public sector brands. We'll talk about that later on, but in Australia they have some very effective drinking-driving campaigns. What's their brand? "If you drink and drive, you're a bloody idiot." Their other brand, to deal with speeding, is: "Speed kills."

Branding provides a very important opportunity — a lot more opportunity for collaboration with businesses. We're beginning to see organizations with much larger budgets attached to social problems. That means we have a broader type of scope. But keep in mind, and properly, that all this goes on with increasing public scrutiny.

I want to give you an example of two case studies in social marketing. I think the case studies are a better way of communicating these ideas than just talking in general. One is a program I'll show you. The first 911 program in a major city was in New York City. Before 911 was introduced, New York City had 12,000 emergency calls a day. After they introduced 911 it went up to 18,000 calls a day.

Why did that happen? It happened because 911 is a terrific product. For any imagined emergency wherever you are, as long as there's a phone available, you can call 911, and you'll get a response. That's a great product — right? People adopted it, and they went from 12,000 calls to 18,000 calls a day, but it wasn't successful. It turns out that in New York only 40 percent of the calls are for true emergencies.

I haven't looked in the past year, but last time I looked, in Vancouver…. You don't think STD information is an emergency?

There are some things that people just don't know. You look outside, and there's a fire hydrant spewing out water. Should you call 911? You look outside, and you see a car being stolen. Should you call 911? Depends if it's your car, of course.

The question is: what would you do to reduce the number of non-emergency 911 calls? What a marketing person says is: "What I want to do is understand why people are using 911, understand what the reasons are."

When they do this research, they find a number of reasons. One is that people are confused. They're not sure when they should use 911. If you see a car being stolen, should you call 911 or not? People just don't know if that's what they should do. They're genuinely confused.

Other people feel it's just much easier to call 911 than figure out what the right response is. "It's a very convenient service, so I'll do that." They don't see the cost of using 911 inappropriately. And there are some people who are just abusers.

What did they do? Well, they designed a campaign that said: "Save 911 for the real thing. Call your precinct or city agency when it's not a dangerous emergency." So you call 911 for a dangerous emergency.

They further defined what is and is not a dangerous emergency. What they're doing is redefining the product: 911 is a product to use when you have a dangerous emergency. If you have a noisy party in an abandoned car, don't call 911. They also put — we now see this all over — on the front page of the phone book a list of numbers to call if you have some other problem, to make it easier for people to find it.

What happens? The first year they run this campaign: a 20-percent drop in total calls and no change in the number of real or dangerous emergency calls. What happens in year two? In year two city officials say: "We've solved that problem; it's time to move on to something else." Basically, marketing, in most cases, is

about continual behaviour, and the number of non-emergency, non-dangerous emergency calls goes right back up again.

Unless you're there marketing the product continuously, it's not going to be successful. That's why I say marketing involves behavioral maintenance, not just behavioral change.

To give you another example from a program in Australia: the road safety campaign is particularly interesting, I think, to a group like yours, because it involves a change in enforcement standards, a change in laws as well as a marketing campaign.

What they found is that there was an increase in drinking and driving. They had detailed focus groups asking people what they should do and what they shouldn't do. They said: "Don't tell us we can't drink. Don't threaten us with authority figures. You can be emotional about what you want to tell us. Leave the audience thinking that this type of thing could happen to me." So they developed this campaign — a series of very hard-hitting ads. If you remember a few years ago, they had semi-hard-hitting ads for Drinking Driving CounterAttack. These were way beyond that.

Each of these ads was targeted to different people. There were people targeted to young males, people targeted to new drivers, men and women, to people in the countryside. They had different sorts of ads. Each had a different type of program looking at what you would do. It's very much target marketing, because what would appeal to a young male is very different than what would appeal to a young woman. Some people drink and drive. Some people just do it because of speed, so each has its own marketing program.

The basic notion behind these social-behaviour-change and health types of things is that you have to convince people that the risk is real and it could happen to me. But then, something can be done about it, and I can do something about it. We see that.

One of the things you will see in a lot of successful campaigns is that sometimes we tend to be too cognitive. There is a high emotional element to this. Behaviour change often involves a fair amount of emotionality. They've run this campaign over a period of time — a very long-term drop in the traffic fatalities — and it's being continually marketed. There is always something new going on. Here is an example of a T-shirt.

The other thing that I didn't get a chance to talk about today is social norms. Basically, why do you get in cars with people who are drinking and driving? It's social pressure — right? You have to deal with those types of issues.

What do they find also? They have a system there where in the first year you get a provisional licence. A provisional licence is supervised driving. The next year you get a licence where you can drive by yourself, and then you get a regular licence. In that second year people are three times as likely to have accidents as older drivers. However, if you can get more driving in that very first year, up to 120 hours in varied conditions, then that accident rate drops by a third. They have created a website called Helping Young Drivers Stay Alive where you can log your experiences and get different rewards to motivate people to get this experience in their first year.

My point is to show you that the marketing campaign and program is diverse, with many different elements, and not just one element.

To sum up and leave time for questioning: what do I see in terms of social marketing? It requires a systematic, multifaceted approach. I think it can make a difference. It has made a difference in all sectors of the economy, so it's going to continue to grow. It complements other behaviour-change approaches, behaviour-change interventions.

I'm not going to tell you that marketing is the way to do it. Marketing is one approach that builds on others. Behaviour — not awareness, not attitude — is the bottom line. Keep in mind Prochaska and DiClemente. There are many steps along the way until you get to the behaviour change. I think there are a lot of both challenges and opportunities.

R. Sultan (Chair): Well, that was a great lecture. My hat is off to you. I hope I pass the exam.

D. Cubberley (Deputy Chair): Your distinction between campaigns or approaches based on providing people with information and campaigns that have to persuade and somehow trigger behavioral change….

Your sense would be that in tackling something like what we have in front of us, which is the tendency towards weight gain and physical inactivity in kids, you're going to have to be on the side of trying to trigger behavioral change. Putting information in front of people is not very likely to lead them to different choices.

C. Weinberg: I agree. I think behaviour change involves…. It's a world of voluntary exchange. People are free to make choices, and unless you provide them with products that make the benefit-cost ratio favourable to them, they're not going to adopt the behaviour.

Now, the benefits, in fact, can sometimes be not directly to me but to other people. There's a very successful Australian program that very much focuses, when they show their ads, on…. It's not that the driver can get hurt but that the person with them can get hurt. The idea is that a lot of young people think they're invulnerable. They are the focuses. What's going to happen to the person who's with you?

But in things like exercise…. "Exercise," they say, is not a good word to use, but I know you already want another word for "childhood obesity."

D. Cubberley (Deputy Chair): We want one for "physical activity and exercise" too.

C. Weinberg: "Physical activity, being fit" and things like that would be a much more positive way of looking at it, but then we have to make it easy for people to be fit. What's required? There are examples.

If you look at the Vancouver Sun Run…. Take the number of people who participate in that Sun Run and how it has increased over time. I think they said there were more than 50,000 people this year. Well, it's not just because they have a message that says: "Participate in the Vancouver Sun Run." They've made it very easy for you to participate in it. They give you T-shirts. They involve a lot of organizations in doing it. There's a group challenge or corporate challenge. It's a very elaborate type of campaign. It's the fun run. It's a lot of fun. It's much more than just telling people that they should be fit.

Of course, the problem with the fun run is: what do I do the rest of the year? How do you maintain that fitness level over the course of the year?

K. Whittred: I have two questions, actually. One is related to slide 11. I was very interested when you mentioned that social marketing is typically carried out by government agencies, the public sector and so on. Then you spoke about the bottom line.

I just wanted to ask you about, I guess, the subtleties of marketing. Do you consider it marketing for social change when, for example, Labatt's advertises, and everybody who drinks beer is young and active and so on, or when Coca-Cola markets its product? I mean, it never markets its product as an unhealthy product. I think I understand what you mean by "behaviour is the bottom line," but I'm just wondering. Do not, in fact, commercial organizations…? In fact, isn't the whole line of marketing to change behaviour basically for people to buy their product?

C. Weinberg: I think that's a very good point. There's a problem with the term "social marketing," because then whose social agenda are you advancing? As you saw on the example with Road Crew — I won't take away from what it has accomplished, because I think it's a terrific program — it has really accomplished the goals of people who want this one particular focus. In other areas, different jurisdictions in terms of what the regulations are with reduced — helmets and bike riders and motorcycles and so forth….

People have different types of social change activities. I agree that commercial marketers are, in fact, trying to change people's behaviour as well, and you always have to look at what the goals of the organization are.

K. Whittred: Thank you. My second question was around…. I loved your example of "simple" under your pyramid — the children's nutrition pyramid. I just wanted to ask you, from a marketing point of view, about simplicity. Again, I'm showing my age here, but I notice that several of us around the table are getting toward the same age. I recall being raised on Canada's Food Guide and how a third of your plate should be potato or rice, a third should be veggie and a third meat, which struck me as way simpler than this. It was very much ingrained into my head as a child. My question, I guess, is: why did marketers make it so complicated?

C. Weinberg: Well, I think what's going on is that there are a number of different interest groups that are concerned on this issue. The sponsoring agency is the U.S. Department of Agriculture, USDA, and they represent a number of different groups. I think one of the problems is that some of these programs involve a balancing of interests. Sometimes from a marketing standpoint, the focus is more on the organization and the sponsoring organizations than on the people who are going to use it.

I don't consider that particular symbol very user-friendly. I haven't seen direct market research. I'm only speaking from opinion. But I can tell by everyone's reaction that few people would say: "That's a simple approach to do it."

You look at it, and it just defies the imagination. How could it be that that's really going to convey what you should eat? That's just a screenshot from a webpage. You can play games involved and so forth. But meat and beans? How, in your mind, do you think about meat and beans as being the same thing? It just doesn't make any logical sense from a consumer standpoint. I think what they suffer from — and businesses suffer from this also — is a lack of focus on the consumer. It wouldn't pass my marketing class.

R. Sultan (Chair): I've got a question, Charles. I know we're not paying you a big fee to design our program, but we might squeeze some freebies out of you a little bit. Maybe you're a little less resistant than your predecessor to our blandishments.

If you were designing a marketing campaign for the childhood obesity initiative of this committee…. For example, we're going to recommend a campaign or a program to the government. Is it possible, in your view, to combine…? We have two situations here. We've got the diet aspect, the food, and then we've got the exercise. Do you think they could be, for example, combined under one umbrella in a campaign, or should they be separate campaigns?

C. Weinberg: Being a professor, of course, I won't answer the question directly. I certainly don't have data to form a judgment on, but my first instinct would be that, from a consumer viewpoint, they're two separate activities — eating and exercising, being fit and so forth. Obviously, we can see relationships, but they may well be two separate activities, so I'd be a little bit concerned that you're trying to force them together.

Obviously, there are some groups who would see them together. I'll confess my own weakness. When I'm on the exercise bicycle, as I do enough things and as I

watch it turn around, that's another beer for me. I have my own mental accounting.

I don't think they're necessarily joined together. While they're both serious health problems, I'm not sure if they're joined together in the minds of consumers or whether or not it would be a good strategy to do that. Again, that's with the caution that I haven't looked at actual market research data.

R. Sultan (Chair): To test your hunch in a similar area, if you're going to organize a campaign, is it obvious that you would be more inclined to target children or youth or adults or maybe some other entity entirely? Can you give us your hunch on that one?

C. Weinberg: My opinion is always to start young. You can't start too young, because you have to be sensitive to when it is too young to start with children. I think there's a lot of evidence that if people adopt behaviours when they're young, they'll continue them throughout their lives. If I were this committee making recommendations, I would move down the age cycle to the relatively young.

That's not saying that other groups don't have a problem. This is one of the big problems in public sector marketing as compared to business marketing. In business marketing, I can be involved in a company and I can say that the right segment is 15-to-19-year-olds. We're going to concentrate on them. It's true that 20-to-24-year-olds could be a market segment, but 15-to-19-year-olds is our profit segment.

As you know — I should be the last person lecturing people like you — that's much harder to do in the public sector, because people say: "Well, what about me? Don't I count?" Getting focus in the public sector is, in my view, much more difficult. But if it were my advice, I would go: "Yeah."

R. Sultan (Chair): Well, I also am tempted to ask you another question. I posed the issue to Charles's colleague on the MADD campaign that I guess they are continuing to run — and have perhaps for 30 years, I gather — here in B.C. I said: "What's the cost of the campaign?" She said: "It's roughly between half a million and one and a half million to two million a year." They've been doing this for 30 years.

I know it's hard for you to just flip these numbers and pluck them out of thin air, but if we were to do something on this obesity file, is it reasonable to conclude that we're probably talking the same order of magnitude to begin the move along that scale that Alvin talked about?

C. Weinberg: If you think about all the money that's spent on marketing other types of food. It's hard to make a dent with that budget expenditure.

R. Sultan (Chair): What would be some typical ad budgets in British Columbia on some popularly advertised products, just for comparison — just order of magnitude?

C. Weinberg: I don't know the answer to that question, but it would certainly exceed that level. I just don't have the numbers in front of me, so I can't….

C. Wyse: No, I was just tracking what Charles was saying here. Huge sums of money, because the advertising market comes cross-border, cross-province and through the Internet — just such a wide area — and the influence is huge, I suspect.

C. Weinberg: I think that's one reason. It's also because eating is a fairly deeply ingrained behaviour, and so it's hard to change. It's not like the SIDS campaign, which I think is remarkable. That's one of the reasons I wanted to let you think about it. Now, here's a situation where it's set up for change. Full credit to them for doing it. I'm not taking away from it, but it's set up for change.

You think of trying to change eating habits. Even aside from what comes in from the United States on television, there are so many things which push it. On the other hand, it's not only advertising. There are things going on about what should be done in schools, what restrictions we should have, providing kids with healthy choices.

Companies are responding, to some extent also. One of the things that fast-food restaurants have a problem with is that mainly people don't go to restaurants by themselves. They go as a group. So one person, potentially, has veto power. One of the reasons, I think, that you see healthy foods in restaurants is because not everyone who goes to this restaurant wants to eat healthy. But if you have a group of four people, and someone says, "There's nothing for me to eat there, but there's something for me to eat in that restaurant over there," what are you going to do? They're your friends, so you're going to go over to the other restaurant.

It's not only the money. There are other factors, but it is a deeply ingrained problem.

C. Wyse: Are we taking on a topic that doesn't have an answer to it in the reduction of obesity?

C. Weinberg: I don't have an answer off the top of my head, but do I think it's a behaviour that could be

changed? Yes, I think it's a behaviour that could be changed. Do I think it could be changed easily? No, I don't think it could be changed easily.

Are people willing to make a long-term commitment to it? One of the characteristics of Mothers Against Drunk Driving is that they've made a long-term commitment to it.

I urge you to go to the website for the Transport Accident Commission in Australia, because they're out there year after year changing what they're doing but keeping their focus on what the need is — adapting their product over a period of time.

One has to have a view that we're going to do this for an extended period of time and not just do it on a one-time or one-year basis. I think that's the approach you need. It's a terrific website. You know, because of time, I didn't play the commercials and so forth, but I think it's a very effective program.

R. Sultan (Chair): Charles, on behalf of the committee, I'd like to thank you and the Sauder school of business at UBC for very thoughtful and indeed scholarly observations on the not so easy challenge that this committee has. Thank you for putting that into perspective.

R. Sultan (Chair): We should take a two-minute break, and then we will have a presentation by Dr. Heather McKay of Action Schools.

R. Sultan (Chair): I will call the meeting to order. This is the resumption of the hearings of the Select Standing Committee on Health into the issue of childhood obesity. We are really privileged to have with us today Dr. Heather McKay, who is a professor at the faculty of medicine at the University of British Columbia and also director of the centre for hip health in Canada. That sounds interesting.

Before we ask Dr. McKay to give her presentation, I would report to the committee that Charlie Wyse has to catch an airplane. He has some observations and suggestions about the program of the committee through the summer months that I would like to hear and I'm sure that we would all like to hear before he leaves. I've asked Dr. McKay if she could target 3:30, and that would allow Charlie ten or 15 minutes to make his points and then be out of here in time to catch the airplane.

C. Wyse: That's great. I think ten or 15 minutes is long, but thank you for the offer.

R. Sultan (Chair): Let me turn the floor over to Dr. Heather McKay. I would ask her to first of all give us a little capsule biography and then to explain the various programs in which she's involved that are of relevance to this committee.

H. McKay: I'd like to first of all thank the committee for inviting me to present to you today. It's indeed a privilege. I've read through a number of the Hansard transcripts. I know that you have a lot of pretty interesting data and information to digest, and I thank you for letting me contribute to that.

My background. I'm a professor in medicine — not a clinician, though — in the faculty of medicine, the department of orthopedics, the division of orthopedic engineering research. My work is in fact on the skeleton, but my work has always been with children and physical activity. I've been in the schools for about 15 years doing physical activity interventions to see how we can enhance the growing skeleton so as to prevent osteoporosis in later life. In the course of doing this over the last 15 years, I've seen first hand the levels of obesity increase in the schools in British Columbia, because I've been doing this work here.

When you're doing research on the skeleton, part of what you need to know is what's happening with the other tissues. To us, fat is another tissue. I look at fat tissue and the accrual of fat tissue, muscle tissue and bone tissue sort of equally — so physical activity interventions to look at how these tissues are responding to those physical activity interventions.

I come to you from a convoluted pathway, but my work has always been in the schools. I've engaged schools at all levels over the last ten years. I do think that's our pathway to change. My focus has been on bone, but you will see that, as the PI for the Action Schools B.C. pilot evaluation, we had multiple health and chronic disease risk factor outcomes. That's why I'm here today.

The centre for hip health. I am the director of the centre for hip health. This was a Canada Foundation for Innovation grant that we were lucky enough to receive, worth about $27 million, to build the state-of-the-art musculoskeletal research facility at the Vancouver Hospital site here in British Columbia. That really fits in with the work I'm doing in orthopedics. There is a soft-tissue lab in that centre, so there is a connection here, if you will allow me that. I'll continue on from there.

I don't need to provide you with any background at all today, and that's a good thing. You know the healthy choices that children have to make are a lot more difficult than the unhealthy choices. You've heard from every single speaker regarding that. They are living in an environment whereby it's much easier to choose the wrong direction than the correct direction towards health — in this case, and of interest to this committee: healthy weight.

I'm going to target three main points. I'm going to hopefully leave you with the idea that it's going to take a global village to make the change I think you're going to be discussing after all of us have left you. I think it's

possible to make change, but it will involve key partnerships. Everybody has to be at the table and be ready to make change if we are to succeed.

I think my job is to introduce to you models that represent positive solutions to the problem. I will focus on Action Schools B.C. and tell you about the success that we've achieved so far. Then I will end with just three key recommendations that hopefully you will take away with you and consider in your deliberations later on.

Looking first at key partnerships. You would have seen a form of this diagram from Dr. Young, who presented to you a few weeks ago. He called this the ecological approach. I'm calling it the socioecological approach. I won't go through all the levels, but what it's really telling us is that in order to make change at the individual level — and in this case, at the level of the child — towards increased physical activity and healthy eating behaviours, we need to engage at every other level. That's at the level of family and peers, settings and organizations. In this case, it could be community centres or schools.

I'll focus on the school as the key environment that influences a child — the larger community environment. I will touch just briefly on the built environment and how our cities are built. I won't spend any time whatsoever. Also key in this are policies at the level of municipalities, provincial and federal governments that support the direction we've agreed to take in this.

Let's move right into some solutions. I haven't really paused on the level of the provincial government, but I think it's important that we acknowledge…. From my perspective as a researcher who's been dealing with child health from a number of perspectives for years, I think this government is engaged, and I think it's making a lot of really positive choices. That needs to be acknowledged. ActNow B.C. is really the framework they have put in place to achieve some of these goals. I don't have to introduce you to that, so I'm not going to do that.

You heard from Suzanne Strutt this morning about active communities and the B.C. Recreation and Parks Association. As I go through this, I'd like to just leave with you that none of these initiatives should really dwell in isolation. There needs to be some formal mechanism to link and integrate them. That doesn't happen by itself.

I know that for a while I spent a lot of time trying to link across these groups so that efficiencies can be recognized and formed. Although they're taking place, the idea is that they should take place in unison with really strong communication among or between them.

The other group that maybe Suzanne spoke with you about this morning was the Union of B.C. Municipalities. I also know that Dr. Millar told you that we don't have a lot of good data yet on changing how communities, municipalities or regional districts are formed and how it relates to obesity. I'm going to challenge that a little bit and say that evidence is mounting.

I'll show you some from a researcher who now has been recruited to UBC from Georgia. He's a Bombardier chair at UBC in regional and community development, and I'll just give you a little snapshot of the work he's doing.

I think this is key. We talk about what's called doorstep decision-making. If you're walking out the door of your house, and you've got a five-lane freeway that's greeting you, it's going to be a lot less attractive to put on your walking boots and head to the shopping centre than if you've got a nice community where you're walking by parks and interesting shops.

It just makes sense that if it's a neighbourhood conducive to moving, including around schools, we will choose to move more often. An example is taking a landscape that looks something like this and transforming it into a landscape — the very same picture — that looks something like this, making communities safe, attractive and really movable places to live and work.

The work that Larry's done and has published in a number of places…. This is Larry Frank. I don't know if he's presenting to this committee, but you may want to hear from him if you haven't. This is cross-sectional data. It's not the highest form of evidence. It wasn't an intervention study. That's hard to do. What he reported was that for every 30 minutes per day spent driving, your odds of being obese increased by 3 percent. For every additional kilometre walked, that decreased your odds of being obese by 5 percent. So less time in the car, more time with your tennies on, actually promotes decreases in obesity.

He also suggests that for each quartile increase in land use mix, there's a 12-percent reduction of being obese. By the land use mix I mean the things that I presented in a previous slide, where we want attractive neighbourhoods that are a mix of residential, retail and parks, with wide sidewalks, well-lit and conducive to walking or on your bikes. That evidence is mounting. I actually just returned from a conference where there was a lot of focus on that. These are difficult studies to perform, but I think we are learning that it is possible.

I'm going to group all these other levels together by focussing in on Action Schools B.C.. It can be considered at both the organizational level and the individual level, because that's where peers of children reside. Then I'll talk to you about how it can affect not the health behaviours of children but actually the health of children, because we measured that directly. I'll share that with you.

I don't think you've heard from any other Action Schools B.C. associates or colleagues of mine, but I do hear that you'd spent the morning jumping around at a school over in West Vancouver, and I'm hoping your joints survived that. That gave you a really nice glimpse of what we're talking about.

Inasmuch as I'm speaking to the science, there are many things around community and building a strong sense of community that cannot be measured. I'll tell you a little bit of that anecdotally.

The vision for Action Schools B.C. is really stated here. There are some key words in this definition, but that physical activity, and now healthy eating, would be integrated into the fabric of elementary schools and

maintained through partnerships — I've mentioned many of those to you already — with family and the larger community. The key word is integrated into the fabric. I'm talking about social change here. I'm talking about a cultural shift from what schools have been to what we're hoping schools will become: healthy places to be and learn.

That's a really big and probably a pretty optimistic vision, but I think it's possible. I was out in Richmond two weeks ago with one of the teachers who was a really, really early participant in a healthy bones study. She said to me when I came out there: "You want a culture shift? You've got a culture shift. We cannot go a day without the children reminding us that we have not had our action breaks today." They had to substitute one of their action breaks for a Roots of Empathy presentation, I think it was. They were reminded: "We haven't had our action breaks. It's time to do that."

When you walk into that school, it's been transformed in that skipping ropes are hung along the walls and boys and girls are picking up the skipping ropes as they go outside and begin skipping as they exit the building. It's just what they do. She said that it's a part of everything they do in the school. It's how they define themselves and how they understand who they are. So I do think it's possible. There are lots of success stories.

The question you should be asking me in May, when I'm finished, is: why this model? There have been lots of these that have been tried around the world. Many have failed, many have not achieved success, and many of them have not really gained any traction. Why is this one any different?

There are a number of unique aspects to Action Schools B.C., which I've outlined here. I don't want to spend a lot of time, because I'm aware of plane departures and such, but the idea with Action Schools, if you met the team today, is that they go into the schools and sit down with the self-identified action team. Together with that team, they customize a program of activity.

Action Schools is just a framework — I'll present that to you in a second — with six action zones. You can plug whatever you want into those zones as long as there's representation within those zones. If you live in the north and snowshoeing is what you do as a school, then you can plug snowshoeing into that. It's really adaptable across the cultural landscape that is British Columbia. It's very flexible, and that's one of the key parts about it.

The other part is that teachers and parents are engaged at the get-go. They're partners in creating what this looks like. It is not prescriptive. We're not going in and saying: "This is what you must do." We're going in and saying: "What are you doing now that works? Okay. Good for you. Let's build on that. Let's fill out those points that could use a bit of tweaking, and then off you go." So they're guided and facilitated towards better opportunities for children.

The goal of Action Schools B.C. is to target not those children who are already driving their parents crazy by being involved in five different sports. They don't need another sport. The goal is to really somehow reach that child that would not otherwise be physically active or be making healthy eating choices. The idea is, regardless of skill level, that there has to be something in this framework that is attractive to every child. That is the goal of this model, and that seems to be working.

Action Schools is delivered by the generalist teachers. We don't have physical education specialists in very many elementary schools in this province. From talking to these teachers, it seems to me that many of them are generalist teachers because they hated physical education as children, so now we're asking them to deliver these kinds of things to their children. They need to be trained. They need to be empowered. So workshops for teachers are a big part of this model. Workshops for the generalist teacher are a big part of this model so that they feel comfortable delivering and providing these kinds of activities within the school.

I'm going to talk a bit about this, but I think a huge success of the Action Schools B.C. model was evaluation of the pilot. We have evidence that shows it works. As I go around the world, in most continents now, presenting this model and the benefits of it, it is the fact I have evidence that people are listening to me. The reason we're being heard is because we have the evidence to support promoting something like this.

We're aiming to have long-term health benefits. I've heard from the previous speakers that this is not a short-term fix. It will not happen immediately, but the goal would be to sustain whatever initiative is chosen.

Finally, the partnerships that I've already introduced are key. These partnerships were formed as a part of the Action Schools B.C. model and as a part of the socioecological framework. They're listed here, and there are many, many more. They are key. There was a readiness. You heard from Dr. Ballem. I think she launched the presentations to this group, as I recall. There was a readiness within government at the provincial level. There's a readiness within government at the federal level, and there's really a readiness within schools. Teachers are ready to go. Parents are ready to listen to us. I presented to the superintendents conference. Everybody is really sort of perched.

They say that there's an alignment, and I really believe that's true. If we're going to make a difference, now is the time to do that.

I don't know if you've seen these stats. I'm not going to spend a lot of time. The date of October 15, 2004, is on your left. This is a volunteer program. It's not mandatory. Schools, teachers, districts self-select as to whether or not they want to be involved. There are 1,600 elementary schools in B.C. Our goal was to reach 40 percent of them after the second year. We're just in the second year of this now. You can see we have over 50 percent of schools who have already self-identified.

Some 800 schools have registered. That involves about 6,000 teachers. Our regional trainers — there are 50 of them. These are unpaid positions. I've delivered about 560 workshops. The reach of this model is about 153,000 children in this province so far. It's quite substantial.

Again, I know that you heard a bit about this, but I wanted to revisit it. Really, at the school level what can be done? Well, active transport to school can be done. You may have heard the statistic, but 50 percent of Canadian children rely on inactive modes of transport to get to and from school. I mean, I am told by teachers that parents drive their kids to school from homes where they can see the school from their home. This is not driving the five kilometres; this is driving the five blocks in some cases.

I think these walk-to-school programs and initiatives can be effective. I'm thinking of something novel, like a policy that cars are not allowed within a certain region of the school, where there's a parking space a kilometre away and parents meet and greet the kids and walk them the rest of the way to the school. That becomes the hub of the school, as opposed to out in front of the front door. Those kinds of things can be considered, and I think they can work.

Here's the Action Schools B.C. model, and these are the six action zones. The whole idea of it — I'm not going to spend a lot of time on it today because we don't have the time — is that schools would select something from each of these zones.

You can see that we recommend daily physical education as a part of this, but we otherwise recommend 150 minutes of physical activity throughout the week within the school either before, after or during school. Really, the landmark of this model and what's quite novel about it is the classroom action component.

This is called five-by-15 — five times a week, 15 minutes of physical activity in the classroom. That may have been what you were involved in today. The action bins are in the classroom. They throw the beanbags and they put in a tape and do a little hip-hop dance, because the benefits of physical activity are cumulative. I don't have to do 60 minutes of intense, continuous physical activity. I can do little bits of it throughout the day and receive all kinds of benefits.

I'm going to present now, as I sort of head towards the end of the presentation, the results of the evaluation. Again, I probably cannot impress on you enough the importance of this. The reasons for this are listed here. I think we have a responsibility to invest in programs where there's evidence that it works. I mean, this seems like a no-brainer, but very few of the programs across this country have ever been evaluated in any way. I know that sometimes within government, research is not considered a good word, and it's something that universities do.

I will urge you to consider evaluation being part of this investment, and the reason is that it provides an accountability to stakeholders. It allows us to assess the compliance of teachers and all other stakeholders in this model. The results that I will show you in a second are enhanced if the teachers were actually delivering the model. Go figure — right?

We can teach them how to do it, but in those schools where there's high-end compliance, where they're delivering the model 80 percent of the time, we're seeing much greater benefits than in those that are delivering it 30 percent of the time. Teachers need help with that, but we need evidence to know which schools that is or is not happening in.

We're now at the point where we've got some really nice early-adopter statistics. What about those late-adopters? What about those schools that are reluctant to become involved? With evidence of what other schools are doing, with models and stories from other teachers as to what worked, we can actually engage them much more readily when we show that what we're doing has been successful so far.

To my way of thinking, the idea isn't to collect data to say: "Yeah, good for us. This is the best program ever. Give us tons more money." That is not the goal.

I think that one of the other goals is to really take a hard look at what is working and keep that, to take a look at what is not working and get rid of that or create a more intense intervention but to modify it in a way, as we're going along, that continues to allow some success. There have to be these continuous course adjustments as you move these models out. It also gives us some chance to compare across programs.

Here's the Action Schools B.C. evaluation model. As I told you, I was the principal investigator for this. At the core was us trying to encourage increased physical activity delivered within schools to students by teachers. We also wanted to see physical activity by children enhanced or increased.

We measured, at the individual level, whether there were health benefits for the skeleton — that's the healthy bones piece — and whether they improved their consumption of fruit and vegetables. We did a very small component on healthy eating. Physical activity was our focus in this first phase.

We looked at academic performance to see if children's scholastic standing or their academic achievements were compromised in any way because their teachers were spending less classroom time on academic pursuits. We looked at their psychosocial health — self-esteem, body image, those kinds of things — cardiovascular health, and of interest to this committee, we looked at healthy weight and obesity as a primary outcome.

The overarching piece, the arrow at the top, was a process evaluation. That was the work of Dr. P.J. Naylor, who actually used to work for the Ministry of Health and now is a faculty member at the University of Victoria. What she did is conduct interviews with parents, students, administrators and teachers so that we could identify the barriers and the facilitators to a model like this, to a framework like this — what's working; what's not. Believe me, teachers have a lot to say about that, and we need to hear from them.

Looking first at physical activity, here are the results. In all of these slides except for one, as I recall, the control group is in pink. These were schools. We're looking at ten schools here. The control schools were asked to continue on their usual physical activity. We didn't intervene in any way except to measure them the same as we measured everybody else.

Okay, that's reversed. The intervention schools are in the pink; the control schools are in the green. The colours are right in the legend, but the labels are wrong at the bottom. So pink is the Action Schools B.C. schools.

After 16 months of the intervention teachers were delivering 50 minutes more of physical activity, mostly within their classroom, than the usual-practice schools. So that's a really good start.

We saw an increase in physical activity by both boys and girls. These are the results of our pedometer measurement. Boys in the Action Schools B.C. schools took approximately 1,200 more steps per day than boys in the usual-practice schools — so an increase in physical activity. We saw the same effect for girls, but measured by questionnaires. It really just demonstrates that boys and girls are undertaking different kinds of physical activity.

We saw huge benefits for cardiovascular health. Children in the Action Schools B.C. schools improved their fitness by 25 percent compared to the children in the usual-practice schools. This is after 16 months, so it's a big improvement in cardiovascular performance in those schools that were involved.

Academic performance. For those of us interested in human physiology, it seems like a small claim, but for the Ministry of Education, this is of huge interest. What we showed was that — and this is a little bit difficult to describe — at follow-up, children performed similarly. What it means is that despite Action Schools B.C. schools spending more time in physical activity and physically active pursuits, the academic performance of their children was not compromised, and we had healthier children at the end of the day. That's good news.

Here's the one. Here's the outcome that you're interested in. This is our healthy-weight measure. Now we measured body fat directly, using an instrument called the DEXA instruments. We measured it directly. We didn't use BMI, so I'm reporting percent body fat as measured directly and not as estimated by BMI or any other measures. This is after 29 months of the interventions. We intervened beginning in January to the end of the first school year, a complete second school year, and with funding that I've contributed, we've now followed these kids for an additional school year. These are the results of that.

Really, the take-home message from this slide is that all boys and girls were decreasing their percentage of body fat as they moved towards adolescence. But if you look at the blue bar right here, this is the Action Schools B.C. boys. We're starting to see a trend for a greater decrease in percent body fat in the boys who were greater than 33-percent body fat at base. These are the heaviest boys. These are boys who would be classified as overweight or obese. We did not see an effect in the total sample. We wouldn't expect that in the healthier boys, but we're starting to see a benefit in especially those boys who are obese and who are at greater risk for cardiovascular problems and other problems later in life. We don't see the same effect for the girls in this model.

The success of Action Schools B.C., I guess, is really due to a number of factors, a number of really key champions and the Ministry of Health. Andy Hazlewood and Penny Ballem are amongst those. They have been hugely supportive, and they have invested substantially in the success of models like this. The political will is definitely in place.

Collaborative team. I interact with lots and lots of people. Again, there is huge buy-in for this model and others like it. Schools and teachers were partners in the design. That seems to be working. I'm not convinced we can ever go into a school necessarily and tell teachers what to do. I think that they need to be partners in helping us with the design of something they feel works for them. It is a shared common vision. I hear that from everyone. The model is flexible, and we had good evaluation data.

The next step for Action Schools B.C. is that it's currently being rolled out across the province. So now what we have is not a controlled model within ten schools; we've got a dissemination model whereby we're now measuring this in 36 schools across the province in four of the health authorities. There were insufficient funds to go into the interior. I'll tell you a little bit about that.

Now the idea is: "Okay, we can do this in a controlled setting with lots of help and support by a central support team. Can we make this work across the province in a really diverse population, and what do we need to achieve that?" Again, ongoing monitoring needs to take place if we're able to continue to establish whether this works.

The pilot study for K-to-three and for middle school has just been completed. There is a discussion, and the next step is to develop a high school model.

Huge investment at this next phase into a healthy eating complement to the physical activity part. It was intentional in the first phase to just take a look at the physical activity component to see if we could see some change there. Now the healthy eating model is being developed and is being piloted in ten schools around the province.

This is due to the direction under the 2010 Legacies Now. Karen Strange and Meghan Day are rolling that out. Lisa Forster-Coull in the Ministry of Health is also key in the success and the development of this part of the Action Schools B.C. model.

We have a small amount of funding from Canadian Institutes of Health Research and Heart and Stroke to evaluate the dissemination of the Action Schools B.C. model. Again, the idea is to take a look at how the uptake is when there's no longer this really intense level of interaction with Action Schools B.C. facilitators.

We are in four health authorities. Our key in this rollout evaluation is to target communities where there's a high percentage of first nations children attending public schools. We are in the north. We're focusing on minority children; 60 percent of the children in the rollout are non-Caucasian. We have approximately 1,100 children enrolled in this evaluation.

To end with three key recommendations. My recommendation is really to provide kudos for the things that are already going right. Those are the interministerial partnerships that have already been formed; the partnerships that are being formed and that I'm part of, with the Union of B.C. Municipalities; the community partnerships. I have a really close working relationship with Suzanne Strutt and the B.C. Healthy Living Alliance. Kudos for this government for recognizing that those are important — to continue to develop and nurture those — and for us, continuing to think outside of the box.

These are not traditional relationships, as you all know way better than I do. I mean, this is your work. This is what you do. To bring the Ministry of Transportation and the Ministry of Agriculture on board and to create those partnerships and to give sort of a greater meaning to this is, I think, crucial.

I think it's important that we invest in models we know work. I think we're beyond trying something that makes individuals feel good just to be doing something. There's lots of evidence out there to support all kinds of different initiatives. I think we need to focus on those and really target evidence-based practices.

By evidence, I don't necessarily mean the tracking and monitoring that you heard from Dr. Millar. That's important, also, but really just evidence in that where you're targeting your dollars and the initiative in the schools and around the province — to measure those outcomes directly.

There has to be somewhere for these children to go. If they learn in preschool to be active, behaviour will stop if it is not maintained. Once we get them going in preschool, have a model in elementary school. We need a model in middle school, and we need a model in high school. It has to be something that exists across all these levels of development, especially in middle and high school, when girls, especially, are starting to leave physical activity. Community-based programs, as you heard from Suzanne Strutt, continue to invest in those.

I actually think that there needs to be a formal plan to integrate and engage across these various initiatives. I think there is some informal discussion across groups, but I think a formal integration plan to establish efficiencies will provide a greater opportunity for success.

I'm going to leave you with the idea that a big part of any program needs to be its evaluation. To be honest, and I'm being quite candid when I say this, I'm not sure exactly how this could be achieved. I think there are going to have to be some new strategies for this. I've suggested one here. It might be partnering with funding organizations like the Michael Smith Foundation for Health Research. Michael Smith, as you know, funds primarily personnel awards. I'm a senior scholar funded by Michael Smith to do research in this province.

They don't fund project-based initiatives like this, but they have actually set a precedent now by looking at health services and systems initiatives whereby that might be changed. Maybe it's about going to Michael Smith and saying: "Listen, how about an RFA that really supplements and goes hand in hand with some of the programmatic initiatives being promoted by this government? How about an RFA whereby you invite researchers to evaluate whether or not these things are working in this province?" Something like that might be a strategic way to go.

I think that we have potential for B.C., and I think it already is a world leader in evidence-based programs, practices and policies. As I said, I do travel around the world. I know that B.C. is on the map everywhere — in Australia, in Scandinavia and in South Africa. We've actually been approached to share with them a model like Action Schools B.C. I think we are probably pretty happy to do that.

We are being heard. We are being really posted as a bit of a poster child, if you will, at the moment as to what can work when lots of people get together and invest in initiatives like this.

R. Sultan (Chair): Well, thank you, Dr. McKay, for a truly tightly organized presentation on what, from all appearances, is a very tightly organized program. We compliment you for that.

Now, Charlie is getting a bit edgy, but I think we have time for one or two questions.

K. Whittred: Well, no. I was actually just sort of waving my hand, but I will ask a question. I think you alluded to it, Dr. McKay — the need for partnerships. I guess, to some extent, I have to confess my bias as a former teacher. I don't want anything misinterpreted from what I say, but I look, for example, at the process evaluation.

This is a program that's happening in the schools. Yet, out of all of the things that are being evaluated, there is one thing that has to do with schools and about eight things that have to do with health. I'm not saying that's a bad thing. I guess I'm asking about your success in bridging that to schools. I'm sure schools are saying: "This is just one more thing that you're asking us to do. We not only have to teach stuff; we now have to be responsible for kids' health, their social well-being, their safety, etc."

H. McKay: I think that is absolutely key. That is exactly what we're hearing from teachers. They don't feel like they need one more thing on their plate. There is lots of evaluation that we're doing at the school level that I didn't present to this committee today. For example, we're doing a school health inventory, so we're looking at all the things that are currently in place in the schools. We're inviting and facilitating schools to change those, and looking at how they succeeded in doing that at a later date. There are lots of school-level initiatives.

We spend a lot of time with teachers, finding out from them. There was a whole committee comprised of

teachers and principals that helped us to design this model. We're listening to them as to what can work for them. I think that's why we've had such a big buy-in for this model.

I agree with you that it's the first thing we encounter — that we've got too much going on. The flip side of that is that once they're engaged and get this going, you cannot get them off this. They are seeing effects like decreased bullying in their classrooms. They're seeing that children, once they've had an activity break, are much more ready to focus in and do the work. I think the rewards, once we have that buy-in, are really outweighing some of the perceived disadvantages ahead of that buy-in.

M. Sather: On the partnerships with the municipalities and some of the things you said about greening, making walkways and parks more user-friendly…. I think that's a good idea. I think there are a lot of things that municipalities can do to aid in that process, like having tree by-laws that help make areas more green.

I think there's also, though, a bit of a barrier in terms of perception. In B.C. in general we have a belief that there's a lot of green space out there. Here you've got the North Shore. Where I live, in Maple Ridge, we have Golden Ears Park, and we have our dikes and so on.

But most people are automobile-dependent. If you've got ten minutes or a half-hour to go for a walk, you're not going to get out there. We don't tend to have enough city parks in our community. Because of that, I think it's hard. There is a lot of large green space a little bit out there. In effect, it makes this a little less user-friendly.

The other thing I think, though, when I look at our municipal parks, is that I can just imagine city planners and people in general worrying: "Well, what about the homeless? They're going to congregate in our park. What about the drug dealers that are coming into our parks? We can't really have parks because of these problems." So it becomes a multifaceted sort of issue to bring user-friendliness in terms of physical activity to municipal space. There are a lot of factors involved, and it's interesting — the web of interconnectedness.

H. McKay: I couldn't agree with you more. I was quite naive when I began my discussion. I met with Judy Rogers, who is the city manager, as you know. I'm quite naive as to what can be done, but I was saying: "Can policies like staircases being visible…? Can something like that happen, so I don't have to search around the store or whatever to find out how to get up the stairs?" It's much easier to find an elevator.

It's the width of sidewalks. It's the lighting around sidewalks. It's about building, I guess, an environment that's conducive to moving in ways other than with a vehicle. But you can do small things in some municipalities that don't have a huge price tag and also provide some safety.

R. Sultan (Chair): Dr. Heather McKay, let us thank you again for coming and spending time with us and describing the philosophy and planning behind all that exercise we had this morning. I think I'll feel it in my knees tonight.

C. Wyse: I hope I have grasped what we had in mind for the comments that I'm bringing here. From my perspective, I maybe should have a brief introduction on the demonstrated need.

R. Sultan (Chair): You're talking, just to clarify, about the interim report that we're talking about producing, maybe in July, for this committee — not to be confused with the final report, which is due in November. Okay, carry on.

C. Wyse: I think we should have a section that demonstrates that all the reports have shown the need for this particular topic. There's one aspect I've become quite convinced of through the presentations we've received. Under the broad topic of "places: where to promote," and trying to come up with solutions for the obesity issue in children…. Obviously, the school becomes a place where children are at.

We have received a number of suggestions around the school environment that could be used to obtain that. However, there also is the community at large, whether that be recreation programs, whether it be involved in planning within our communities for the infrastructure — items of that nature — and also in the broad area of our transportation systems.

Now, that ran through linking these things together. There was the need for coordination across the various levels of government as well as including the education departments. One aspect to target to our various groups that were contained within the reports, where there is a more known requirement for us to be supportive…. We've had some of these groups identified, whether they are the lower economics, the mentally ill. There were references made to different ethnicities that were contained in the conversation.

There was a statement that has come up at least twice, and it may prove to be beyond the level of our parameters. However, this aspect of low income contributing to obesity — and poverty is one of the underlying base causes of obesity…. We may want to include some general statement and reference back to government once more emphasizing the need for getting rid of this stovepipe approach across various ministries,

One of the major things that I've added to my list today was the demonstrated need for a long-range commitment. If we are going to be recommending on how to get along and make improvements in this area, we're not talking about something that is going to be a flash in the pan. It seems to me that it is an exceptionally important statement to be made when we report back to the Legislature. Either the Legislature is committed over a very long period of time to this particular problem, or it will simply be a waste of resources in order to take it on in the short term.

My last point isn't to be contained here in the report, Chair, but I would like to leave it with the committee where we are, partway along in an evidence-gathering aspect of it. In my judgment, we still have to put some attention onto the more rural component. So far we have met, if you like, basically on the Island, and we've met here in Vancouver. We haven't given much attention yet to the wider geographical part of the province.

Likewise, the socioeconomic component, so that we do provide opportunities from across the spectrum. For example, today we took a tour to West Vancouver. I found it very enjoyable. However, a personal observation would be that it likely is an area in which we would be providing support to a community that has already bought into what we're talking about, versus other parts of the province, where we may be more into introducing from an education standpoint.

Finally, I believe we should also be providing an opportunity for hearing from these targeted groups — ethnicity, for example; possibly people who have expertise in the area of mental illness, and so on — so that we get some advice from the experts in those areas on

how we may be able to be more effective in our final report in making recommendations.

With that, Chair, I thank you for putting me first. I will excuse myself and look forward to meeting with everybody again.

R. Sultan (Chair): Thank you, Charlie. Those are excellent suggestions, and I will endeavour to see that we can carry out a good many of them.

A quick question before you leave: if we come to Williams Lake, is it feasible, for example, to have a meeting and get input from the first nations? I appreciate that it's tricky.

C. Wyse: I believe the answer to that, without speaking on their behalf, would be yes. There are other ethnic groups that likewise could be approached.

I guess we should have a two-minute break. We have rather abruptly cut off Dr. McKay, and we all need a two-minute break.

We want to talk about some planning issues for the committee, which probably are not of general public interest. I'm suggesting that we have a motion to adjourn.

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	1)	Marie Demers, Author: Walk for Your Life! Restoring Neighborhood Walkways to Enhance Community Life, Improve Street Safety and Reduce Obesity
	2)	Dr. Tom Warshawski, Childhood Obesity Foundation of British Columbia
	3)	Janice Macdonald and Suzanne Allard Strutt, BC Healthy Living Alliance
	4)	Alvin Wasserman, President and Andeen Pitt, Vice President, Wasserman & Partners Advertising
	5)	Dr. Charles Weinberg, Sauder School of Business, University of British Columbia
	6)	Dr. Heather McKay, Action Schools! BC

Committee Staff:	Jonathan Fershau (Committee Research Analyst)

REPORT OF PROCEEDINGS (Hansard)

SELECT STANDING COMMITTEE ON HEALTH

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH