Health — Issue No. 10 — Tuesday, June 20, 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

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:	Barbara Crocker (Vancouver Coastal Health Authority) Dr. Heather Manson (Vancouver Coastal Health Authority) Dr. Brian O'Connor (Vancouver Coastal Health Authority) Kathy Romses (Vancouver Coastal Health Authority) Kay Wong (Vancouver Coastal Health Authority)

R. Sultan (Chair): I would like to call this meeting to order. Good morning. Welcome to the meeting of the Select Standing Committee on Health of the British Columbia Legislature. My name is Ralph Sultan, and we will be welcoming today many experts on the assigned topic that we've been given by the British Columbia Legislature to examine the many dimensions of the important public policy issue of childhood obesity.

This, in many ways, is the day for the Vancouver Coastal Health Authority to tell us their views on this important public health issue. Shortly I'll turn it over to Dr. Heather Manson who will conduct the meeting this morning.

Just to review the terms of reference of the committee: 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 British Columbia among all North Americans in healthy living and physical fitness.

In order to do that, we're empowered to conduct consultations, engage in special studies and, of course, hear from expert witnesses such as we will do shortly this morning. We can even subpoena witnesses to appear, should they not be willing to do so voluntarily. I don't think that will be necessary this morning.

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, the very competent staff over on my right. They are busy with their technology, recording every single word that we all say. A copy of that 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, right now. It's available on the committees website, being broadcast around the world so all those people waiting with bated breath in Africa and Asia to hear what we have to say this morning won't be disappointed. Wherever they might be, they can listen to these proceedings in real time.

Before I begin, I would just like the members of the committee and other staff to explain who we are, and then I will turn the meeting over to our experts for their contribution.

M. Sather: I'm Michael Sather. I'm the MLA for Maple Ridge–Pitt Meadows. I'm an opposition member, and my critic role is Intergovernmental Relations.

K. Whittred: I'm Katherine Whittred. I'm the MLA for North Vancouver–Lonsdale. My primary responsibility in caucus is to be chair of the social development committee.

D. Cubberley (Deputy Chair): I'm David Cubberley. I'm the MLA for Saanich South, and I'm the opposition Health critic.

I'm Ralph Sultan, the Chair of the committee. I'm the MLA for West Vancouver–Capilano.

C. James (Clerk Assistant and Clerk of Committees): I'm Craig James, Clerk Assistant and Clerk of Committees in the Legislative Assembly of British Columbia. I wear two hats: one as table officer, so when you turn the proceedings on and see the floor of the House, we're the people dressed in black robes. My other prime responsibility is being responsible for all the various parliamentary committees of the Legislative Assembly.

C. Wyse: I'm Charlie Wyse. I'm the MLA for Cariboo South. I'm the opposition critic for mental health and addictions.

R. Sultan (Chair): The meeting today has been organized and is at the invitation of the Vancouver Coastal Health Authority, and we express our thanks to the CEO of Vancouver Coastal, Ida Goodreau, for inviting us and making available key members of her staff this morning. As, I suppose, the largest health authority in the province — and I believe it is — and also the location of many specialized facilities serving all British Columbians, I think Vancouver Coastal plays a particularly key role in dealing with this important public policy issue.

The proceedings this morning will be conducted by Dr. Heather Manson, who's the vice-president of Health Services Integration. She in turn will introduce the various witnesses.

I would hope, Dr. Manson, that perhaps there'd be a little bit of time for some questions and answers as well. We have set aside two hours. With the technical delays and parking, we're starting a little bit late. I, as Chair, at least, would not be terribly perturbed if we run over a little bit past the scheduled noon quitting time, because I think it's very important that we allocate a full two hours to the people that you've lined up today. I would hate to cut any of them short because of the importance of their testimony. So without further ado, I'll turn it over to Dr. Heather Manson.

We have found it useful, Dr. Manson, if each of the expert witnesses just gives a one- or two- or three-sentence biography of who they are.

H. Manson: Okay. Thank you very much, Mr. Sultan and members of the Select Standing Committee.

I'll introduce myself, and then I think we'll actually do what you've just done and have each person present themselves first. Then we'll go through what the flow of the agenda is.

My name is Dr. Heather Manson, and my role is vice-president of Health Services Integration. My background: I actually have a very strong clinical background. I've practised internal medicine and hematology for many years and then went back and got some additional training in population health — public health.

My current role is at the Vancouver Coastal senior executive team, and it's really to enable, to build, to facilitate, to lead in the building of a full continuum of care around the needs of the people we serve, whether those are people with mental health and addictions, the well population or children and youth.

I'm here in the context of children and youth — that full population. My role today will be to basically be the host of this on behalf of Vancouver Coastal Health and Ida Goodreau and our board.

Maybe just a few more little bits of details before I go on further and introduce the rest of the team and let them talk a little bit about themselves. I wanted to mention that we did kind of put together an agenda so you'd have a rough sense of how much time each presentation would take. We have created a little package for you. It has the slides within it, in case you don't want to strain your necks looking over at the slides over by the wall there.

I'd like to introduce Dr. Brian O'Connor, Kay Wong, Barbara Crocker and Kathy Romses. Our representation here is from across our health authority. We've got Brian O'Connor, who is, of course, the medical health officer from the Coastal area over on the North Shore. Kay Wong is from Richmond. Barbara is from Vancouver HSDA, and Kathy, as well, is from Coastal HSDA. The excitement was such within Vancouver Coastal that we wanted to ensure that we had strong representation from all of our geographic areas.

My name is Dr. Brian O'Connor. I am the medical health officer for the North Shore within Vancouver Coastal. I have been so for nearly 20 years now.

My main interests at the present time are population health, approach and focus. Within that population health, approach and focus, my main interest is looking at the power of public policy in advancing health promotion and disease prevention strategies.

K. Wong: My name is Kay Wong. I'm a community nutritionist out in Richmond. I've been there for over 20 years.

Our practice in Richmond is about population health, mainly child and youth. That's the population that we're working with out there.

B. Crocker: My name is Barbara Crocker. I'm a community nutritionist in Vancouver.

Just a little bit about my background in terms of working in public health. I trained at UBC in nutrition and dietetics. To complete our training, we need to do a 12-month internship at a major hospital. I interned at Vancouver General Hospital. When I was there, I was overwhelmed with the disease and suffering of the patients and my role in helping people in a diseased state. During that internship I came into the community and learned about helping people stay well. I realized that was my passion — to promote health and work upstream.

I was very fortunate to get a job working here in Vancouver with the Vancouver health department. I worked in a pregnancy outreach program. In that program, I learned a lot about the social suffering that a lot of people deal with. For 13 years I worked as the school nutrition consultant here in Vancouver. I now work in the zero-to-five program in two community health areas. I'm also the chair of the nutrition practice committee for Vancouver.

K. Romses: My name is Kathy Romses. I live and work on the North Shore, and I have three children who were born and raised on the North Shore.

I'm very passionate about trying to prevent disease and promote wellness. I like to have my fingers in lots of pies, as you'll see when I give my presentation. I also work at the eating disorder clinic. I planned that for Lions Gate, and that does service the whole Coastal area. I have that slant to my work as well.

H. Manson: I'd like to just draw your attention to two other items. First of all, you'll notice that there are some posters on the walls. Those are posters that have been developed by our community nutritionists and others. We thought that perhaps during your lunch break, if you were interested, you could have a look.

Also, we've included for you in the package a number of handouts. Some of them relate to the programs we are providing or working in partnership with others to provide. In addition, there's a document called the Early Years Child Health Report that we just released, and a very important document, which is really the cornerstone of our population health strategy, called Towards a Population Health Promotion Approach: A Framework and Recommendations for Action.

In our presentation today, we've used the framework to create the framework for the presentation, so you'll actually see the framework in action — how a health authority works with others in partnership to promote population health. Without any further ado, I'll get on with the rest of our presentation.

This is our Vancouver Coastal vision statement. We are committed to supporting healthy lives in healthy communities with our partners through care, education and research. We've had this vision statement for about three and a half years now, and it's been very robust. It

has stood the test of time. There are some particular comments in here that I would like to bring out.

We're committed to supporting healthy lives, so right up front we're saying that health is not merely the absence of disease. We're also saying that we're committing to supporting healthy lives in healthy communities. There's a recognition in this vision statement that health is not achieved by simply the application of our services and programs — that health is achieved in the context of a healthy community. As we work through the various presentations today you'll see that theme recur again and again. If childhood obesity is going to be addressed, the addressing of that needs to occur in the context of a healthy community.

We do this. We support healthy lives in healthy communities with our partners. We recognize that we are not the people who provide health. Health is something that occurs in partnership, and we have many community partners, particularly around this issue of childhood obesity, whether they are schools, municipalities, parks and recreation, businesses or elected officials. We recognize that to address this problem of childhood obesity, we must work in partnership.

We do it not only through care, but also through education and research. That is really our vision statement. This is the underpinning for our presentation in our meeting with you today.

To give you a quick overview of the presentation: first of all, Dr. Brian O'Connor will be speaking about how we are going to apply our population health framework to this problem of childhood obesity. We hope this will be a useful tool for the standing committee as you move forward with your deliberations.

Then we'll speak about specific Vancouver Coastal initiatives, and we'll have each of the representatives from the health service delivery areas talk about specific initiatives in their own communities, once again going back to that whole notion that health, particularly an issue like childhood obesity, occurs in the context of a healthy community.

Then we'll move back to Dr. Brian O'Connor talking about some of the principles of change, and then move forward with some recommendations. That really summarizes how we have put together our presentation from Vancouver Coastal to the select standing committee.

Our feeling was that there probably wasn't a need for questions after my presentation, so I would like to turn it over to Dr. Brian O'Connor. Perhaps if you did have a specific question for me at the end, I could speak to that.

B. O'Connor: Thank you very much for inviting us here today again. You may have, in the course of your meetings, seen this particular slide that I think has a very telling message for us. That is: it is possible that if we do not do something now, this generation of children will be the first to have a shorter lifespan than their parents. That has significant implications.

The immediacy of dealing with this issue is very important. This would not only have implications in terms of chronic disease prevalence and incidence in terms of its effect on the health system, but if we start to have declining lifespan, it has effects in all aspects of our community and our daily lives, from the economy, the workforce and everything on down. I think it is really important for us to recognize that we need to take some immediate action to reverse this trend that we have been seeing.

Dr. Manson has already pointed out to you this document. This document is an important document within Vancouver Coastal Health. I will talk to it for a couple of slides.

I think it's important because it focuses on the things that decision-making bodies can do to support this issue — and many other issues, for that matter. The solution or resolution of childhood obesity and many other issues is not going to be accomplished through programs alone. It's not going to be accomplished through media strategies. These things are just not enough.

You cannot change behaviour one person at a time. It's just not cost-effective, and it's just not practical. What we really do need to look at are the systemic supports that only come from the wise, healthy public-policy-making of decision-making bodies. That requires those decision-making bodies to provide leadership, to build the appropriate partnerships, to engage in advocacy where appropriate and to support the healthy policy development. I'll speak to each one of these for a moment on the next slide.

We've outlined these strategies within our framework document there, and I think you'll find that it'll be an interesting document to take away. This document is a blueprint for all of our staff within Vancouver Coastal Health, but it is particularly, we hope, a blueprint for our senior executives and our board, because it is at that level that these strategies take on particular importance.

We're advocating that all of us within Vancouver Coastal Health should assume a leadership role. We should be champions for issues. We should recognize an issue, and we should be willing to take responsibility and be accountable for the resolution of that issue even if we don't control all the levers that can resolve it.

The reason for that is the second bullet, which is the partnership development. If you take accountability and responsibility, you can convene the tables of those necessary individuals and groups that can work together with you to try and resolve this issue. A very good example of that, actually, is the government's ActNow strategy. This is not an issue that is solely within the Ministry of Health; this is an issue of the entire government. As I understand it, the deputy ministers convene a cross-ministry meeting to discuss how they each can contribute to the promotion of ActNow in this province. I think that's just an example of what could and should be done on many issues.

The third bullet is advocacy. I know that sometimes, politically, that may be a charged word, because I'm sure many of you have been the subject of advocacy from time to time. But sometimes political action is necessary, and it need not be strident or in-your-face

political action or advocacy. It can be promoting your ideas in a thoughtful, rational way and trying to engage and encourage an audience for those thoughts and views. Sometimes it's just as simple as being a credible, recognizable person speaking out on an issue and putting your thoughts out there into the community at large.

The last one is probably the most important of all. That is policy development — creating the favourable environments for change. The environment in which people make behavioural choices is very, very important, so a supportive environment is critical. The healthy public policies that create those environments are probably the most effective and, I will say, cheapest way to improve health.

It's those things that change the system, that regulate the environment in which people make choices that aren't costly — like programs. They don't cost millions and millions of dollars. They are really a public policy that takes political will and the stroke of a ballpoint pen to put into place. Indeed, rather than trying, as I said earlier, to change behaviour one person at a time across this province and all the millions that it might take, those supportive public policies with the political will and the ability to enact that policy can have significant impact in terms of a strategy on childhood obesity.

I'm finished with my couple of remarks on these slides. I will return later to wrap up, and I'm going to turn it over now to Barbara Crocker.

B. Crocker: It is absolutely a privilege and an honour to be here and to talk about childhood obesity — and childhood obesity prevention, specifically. Thank you so much for this opportunity.

I also need to say that the ActNow initiative is very exciting for people who work in public health. We're thrilled with the provincial goals, their public health goals at a large level. It's wonderful to see this new lens of readiness to commit to the health of the population.

I would like to start in terms of leadership and looking at promoting healthy lifestyles and creating supportive environments. If we think about public health practice, public health practice is about working upstream. It's before people get sick. If we're focusing on children who are healthy, encouraging them to stay healthy right from birth…. We have prenatal supports to ensure that that baby is born at a healthy birth weight and is launched into life at a healthy place, and then the supports for that child and the family and the community to promote health.

In terms of healthy lifestyles, what we want to do, very first up, is look at breastfeeding support. This is so important because breast milk is a living fluid. It is the best nutrition. It's the gold standard of feeding babies. All of the supports that happen right across the health authority in our infant, child and youth programs support women to breastfeed their babies and to launch those babies really well.

To give you an example, I have moms phoning me, who stop breastfeeding. They have family pressure to stop. They're going back to work. They're stopping early. Why are they stopping? They don't have the supports, the knowledge and so on. I think we do well with early supports around breastfeeding, but there's more to do with breastfeeding supports. It's a very important launch for that baby early in life.

If we move on, and adding to that, if we think about healthy eating education and supports for children from zero to five, here babies have never had solid food. They're learning for the first time about foods to eat. How do parents struggle with that when they don't know how to cook? They don't know what to feed their child.

Last week I had a mom come in to see me whose two-year-old was still eating pureed foods. She was coming in to see me because she was worried that her child was eating pureed, jarred baby food at two, and she couldn't get her child to eat regular food. What was happening in the family were issues around eating sweets and treats and candies from the grandma and the dad. I said: "Can we do some counselling with the whole family to look beyond this? This child is at risk for childhood obesity, given the lens of moving off of purees and on to candies and sweets." So it's a really interesting example of what's going on for some young families.

Breastfeeding support is really important, and then all of the education that we provide for the zero-to-five years. This is the time to actually create those healthy habits, learn to crunch carrots, to bite an apple and to eat chewy, crunchy things, which is very different from eating french fries that are mushy and salty and fatty. It creates a mouth feel, and you create those healthy behaviours for the types of foods that a child would eat.

Now, how we do that in terms of supporting people…. We do develop a number of fact sheets. In your package you have a couple of examples. One is on healthy snacks for children. This one is for 18 months to five years. What are appropriate snacks? Are they the sweets and candies that the child last week was being exposed to at two, or is it healthier choices? How do we support parents? Through our various programs, community groups, parent support groups where we are able to provide them with health information.

Also, there's one on hunger and satiety regulation. What does hunger and satiety regulation have to do with prevention of childhood obesity? I have parents force-feeding their children. They're worried that their child isn't eating enough. They don't know about natural hunger and satiety cues. They have the grandparents chasing the child trying to overfeed them. They want big, fat babies and overfed children. So how do we help them around hunger and satiety cues? This is an example on feeding babies, on hunger and satiety cues.

Feeding toddlers. We even have a message in here on: how do you set limits when that toddler wants candies and sweets? How do you set limits and say no and feel okay about that as a parent? These are some really important early messages. This is an example on feeding toddlers — the transition from nine months to 18 months.

Another one is the art of feeding. We can tell what to feed, but how do you feed a child? It's just as important as what you feed them. We've developed a number of videos to help parents and to communicate those messages — and print material, as well, that's also translated. We have a lot of families coming from other countries that don't actually read English or speak English. So we've translated materials. We have videos that have been translated, as well, to communicate some of those messages.

Another one in the way of print materials is on television. Again, we think about those early years. What is happening to our children? It's one thing to feed nutritious foods and to have information about that and about how to parent around food and setting limits around food.

Another is screen time. Screen time is huge. TV is the babysitter. How do we educate parents around the power of TV and screen time and what that means around physical activity? Also, the type of television advertising on children's programming — it's all about junk food. It's promoting poor-quality food.

I did a group a few weeks ago. It was a Somalian women's group. We actually did a supermarket tour. We talked about appropriate beverages, breakfast cereals, breads and so on, and the women said to me: "Well, Barbara, we eat these nutritious choices, but the children want junk cereals and poor-quality drinks." These children were from six to 12 years. They've already been programmed by TV and all of the stuff that the big food corporations are doing, and parents don't know. So we need to help them with media literacy around issues of television and being sedentary, promoting a sedentary lifestyle and the wrong-quality food.

Moving on from breastfeeding, healthy eating and education supports in those early years. This is hopefully launching children with healthy lifestyles, healthy food choices, physical activity and recreation into the school years. If we think about school-based initiatives — and you'll hear about a number of them in a few minutes — the school years are a wonderful opportunity. We've got a captive audience of all these children. Is that environment supportive of children?

Food security is our final bullet here. Food security is a very important broad brush. Food security is important in terms of access to a safe, nutritious, culturally appropriate, accessible food supply that is available in a dignified manner and that is environmentally sustainable. There are a lot of issues around our local food supply: supporting local agriculture, having grocery stores available, people having adequate income to buy appropriate foods. Maybe that's all I'll say there.

Interesting in terms of the link with obesity. In a document that I have here, 50 percent of low-income women were reported as having difficulty putting nutritious food on the table; 50 percent of those women were obese — overweight — versus 34 percent who were overweight and food-secure and had difficulty putting nutritious food on the table in their homes.

Another study — this is a Canadian study — looked at the 6.8 percent of children in the wealthiest quartile who were obese versus 12.8 percent of children in the poorest quartile who were obese. If we think about access to nutritious food, what are some of the key ingredients in nutritious food that are markers for growth versus getting calories that don't necessarily promote growth but excess weight?

In terms of partnership, this is how we operate in community health. We work in partnership with community groups, with the NGOs — people like the Heart and Stroke Foundation, the Cancer Society, the Vancouver Food Bank and so on — and all of those partnerships with schools. We've got a lot of very keen people in schools to work with us. Parks and rec, local community centres, research…. We have opportunities for evaluation and to study and work with our academics on issues — and of course, our municipalities. We work with the city of Vancouver on child care policies, on issues of food access within communities.

All of these partnerships, you'll see in the examples as we move forward, are really critical to how we work in community health. We do not do it in isolation.

In terms of advocacy, in the area of education there are a number of reports. In your package there is a highlight of the Cost of Eating report. This is the outcome of a food-costing survey that we've been doing for five years now. I'll just pull it out for you to see — The Cost of Eating in B.C. This is from 2004. It really profiles the issue of access to adequate income so that people can purchase adequate food. When you're on limited income or income assistance, our food dollars get taken up with other expenses, so people then don't have the food dollars to buy the groceries.

We've been doing this for about five years as a provincial network of community nutritionists to raise awareness of the importance of access to adequate income to sustain people so they can buy food.

We have the food banks that started in 1980. Here we are in 2006, 26 years later. Child hunger is real, and people are using food banks to feed children. So we're really looking at the issue of access to adequate income for feeding children and families.

Another important advocacy document is Making the Connection. It's a food security and public health document that was developed by community nutritionists, again, for decision-makers, to help understand the power of food and nutrition in the health…. Childhood obesity is like the canary in the coalmine. It is the high marker before we get all of the other diseases — diabetes, heart disease, renal failure, etc. This was meant to help educate people about the power of food and nutrition in terms of health.

Healthy choices. We've got a provincial guideline on food and beverage sales in B.C. for schools. This was just launched in the fall and has been an excellent tool to support schools and a tool for community nutritionists to work with schools.

Vancouver Food Bank. Again, we've set up baby-food tables. In reality, children are being fed through

food in food banks. Do they have appropriate infant formulas? What types of foods are available? So we've worked with them.

Building capacity — working with the parent advisory committees, which are the PACs, to help create local champions with parents in local schools.

Moving on to policy. With a number of years of food security work in Vancouver, the various local groups and people working together have been able to launch a Vancouver Food Policy Council with the city of Vancouver. It was launched in 2004. There's an actual coordinator within the city of Vancouver around food policy. They're working on a number of initiatives within the Food Policy Council — a food charter.

We've developed a growth-monitoring manual, and this is really important if we actually want to intervene early with children that might be having weight issues in the preschool years. When are we screening? When do our community health nurses weigh and measure children? How do we support families? So this is a tool and a standard manual for our community health nurses on weighing and measuring infants and young children and looking at growth monitoring of children.

Finally, Vancouver Coastal vending machine policy — I actually read our draft last night; it's moving forward — to really look at as a role model within our organization for vending and small kiosks. What is the quality of the foods that we have available in that setting?

H. Manson: Mr. Sultan, I wanted to give an opportunity for the select standing committee to ask any questions of Dr. O'Connor or Barbara, particularly around this whole population framework that we've got with leadership, advocacy, partnership and policy development.

K. Whittred: Thank you, Heather and Barbara. Very, very informative. It's really good to get a presentation that's sort of: "Right, this is what we're doing on the ground. This is how it works."

I have two questions. One of the things that we've heard several times from different presenters is that people don't know how to cook. I find this a bit amazing, but I also know that it is true. We've heard a lot of discussion recently about the need to bring back compulsory phys ed. What about bringing back compulsory home ec? I mean, I really hate to date myself, but in my day, every single woman…. I must say it was very sexist. Girls got home ec; boys got shop. That perhaps needs to be changed, but every single person did get home ec and learned the basis of cooking — the basic, standard methods — nutrition, etc. I wondered if you ever discussed that in any of your discussions.

B. Crocker: In terms of looking at a high school level or that grade eight level, they do actually have a course now — and maybe it's changed since I've worked with the schools — where all of the students would have access to some nutrition and some food skill and food prep. But labelling it as home ec doesn't work. We need to look at sports nutrition. We need to look at chef training. We need to go to a totally new way of operating around how we teach children and youth around food and nutrition, and it could be fantastic.

There may be some models that I'm not aware of. Certainly in England they've done a huge piece of work around foods in the schools. I think there's a huge opportunity for us to do things differently, but not calling it home ec.

K. Whittred: I wasn't meaning necessarily calling it home ec. You can call it anything, but the basic….

B. Crocker: Yeah, but it does need to be re-marketed. It's how we market those messages. Kids love cooking, and you'll see some of the programs that we've launched at the elementary level. Kids love it, but it's how we package it, and that does need some attention.

K. Whittred: Thank you. My second question really had to do with your last comment around growth monitoring. This is another thing that we've heard — that there isn't a lot of data. I'm just wondering if you can tell us exactly what kind of data your community health nurses do keep and how that manifests itself over the lifetime of a child.

B. Crocker: In terms of the growth-monitoring manual, this is very new. It came out in September. I actually just did a training with some of my staff to look at how we monitor children in the early years.

Babies are monitored; we actually monitor the growth for a newborn and in those early months. Then it's about who comes into our clinics and when they're screened. If they're having their babies immunized through Public Health, we'd actually be monitoring their growth within Public Health, or the family physicians are monitoring growth in those clinics or family doctors' offices. We maybe don't see that.

In terms of collation of that and looking at trends, we aren't actually doing that. It's more on an individual teaching basis that that tool is used, and then as a screen for any concerns in terms of growth.

M. Sather: I want to second what Katherine said around cooking. I'm not so sure about young people today, but I expect it's about the same as when I grew up. A lot of males, in particular, don't have those skills. I think about the number of separated families now. Oftentimes the children are with their father, and it would be good if he had some cooking skills so that he's preparing nutritious and adequate meals for the kids. I really encourage any of those kinds of programs in schools, to teach those skills.

I had a question around intergovernmental relations and the issue of food security. It comes up in

various forms and through a number of presentations that we've had, such as having local agriculture, as you made mention of, and the availability of that. Well, as you probably know, in the lower mainland in particular there's a tremendous amount of pressure on our agricultural lands for development. I'm wondering: does Vancouver Coastal have any discussions with the Ministry of Agriculture, for example, about food security and about the necessity of supporting agriculture in its many dimensions?

B. Crocker: At the Community Nutritionists Council last fall, actually, we had one of the agrologists attend our provincial nutritionists meeting to present his lens of work around agriculture and the food supply, and we'd absolutely be in partnership with them. In terms of moving it to Vancouver Coastal, I would move it over to the Vancouver Food Policy Council. Certainly we have agriculture folks involved in that, and various sectors are involved in the Vancouver Food Policy Council.

Within Vancouver Coastal Health, though, we don't have a strategic alliance with agriculture. Yet I think we're all very aware of the importance of having local agriculture, partnering with agriculture, supporting buy-local campaigns. We've done all that sort of thing historically. You'll see it on some of our fact sheets; we actually say: "Buy local." There'll be some little tag line there, "Choose foods that are grown in B.C. first," so that we can support our economy and our food system. It is very much interrelated.

C. Wyse: Thank you for the presentation. Would you mind elaborating a little further on your method of targeting groups that would be more susceptible? If I was able to follow you correctly, you mentioned issues around the poor and quickly tried to work through single parents, ethnic groups and so on. Would you mind elaborating more specifically on how you go after those groups that show those tendencies toward obesity, including in the area of children?

B. Crocker: Absolutely. I can think of a great example. Last week I did a parent group. Actually, I did two groups last Thursday. I had 45 women at a parent-infant drop-in at one of our community centres that's run by our community health nurses. My talk was all about the introduction of solids, hunger, satiety cues, etc. That's where parents will come up to me afterwards and ask individual questions.

In the afternoon I did a group that's run through our Healthiest Babies Possible program. All of these women are Spanish-speaking, coming from Mexico and Central America. Within the community there are various cultural supports. We have a program called Building Blocks, which reaches out to various cultural groups to support women with young children or families with young children.

Within that, they target Vietnamese-speaking, Chinese-speaking, Spanish-speaking…. There's a number of different programs and different agencies that run programs. First nations groups. A few weeks ago I did a group of parents within the first nations community. Those groups exist, and that's part of our partnership and how we provide access to information, working with cultural brokers and with the liaisons of those various groups.

D. Cubberley (Deputy Chair): Dr. O'Connor, you mentioned in your short presentation the importance of policy interventions as a cost-effective way of doing things. Barbara Crocker was talking about that with a little bit of reference to school food policy guidelines and other things.

I may have missed it, but I didn't hear any specific interventions around what's showing up in schools, in particular some of the toxic — from the point of view of obesity — drinks and foods that are readily available in schools. I wondered if you wanted to comment. Does Coastal Health have a policy? Are you urging schools to drop the pop? How are you dealing with that?

B. O'Connor: That's to come. We still have three more presentations. You're going to hear all about the initiatives in schools. I tried to stay fairly high level and focus on the early years, because the next three presentations will focus on a lot of the school initiatives.

R. Sultan (Chair): That's a good introduction to our next presentation. We'll turn it back over to Dr. Manson.

H. Manson: And I will turn it over to Kathy. Kathy, come right up, and we'll just move right on.

K. Romses: That was an interesting comment, because that was the topic of a press release just sent out that said: "North Vancouver school district drops the pop." I am in the fortunate position of working in partnership with the North Vancouver school district, which co-funds my position, and I've got a renewal for next year.

The previous year I worked with the West Van school district. As I said, I live and work on the North Shore and have children on the North Shore, so I'm very passionate about this. I want to congratulate the government of British Columbia on showing a leadership role in providing the food and beverage guidelines for schools.

That has been a huge advocacy tool for me in my position. What happens at the schools is that you quite often have two camps of parents or two camps of teachers who are saying, "We make money on chips and pop," and then another camp that says: "We need to support our children and learning and our health of the future."

The B.C. government, by providing the guidelines, has shown a leadership role. Now they can say: "Look. This is a provincial initiative, and we have to fall in line with what the government is saying." So thank you very much for showing a leadership role.

We are the first school district in the province to fully comply with the guidelines for food and beverage

sales in B.C. schools. I was involved in the request for proposal that went out to companies, and I have to say I was a little bit nervous. I thought: I don't know how many choices we can have in these vending machines that meet the guidelines.

One of the other side effects or positive effects of something that the B.C. government has done is your school fruit and vegetable project. We now have small packages of fresh B.C. fruit that can be sold in vending machines — apples, pears. We've got carrots with dip, peppers, phenomenal B.C.-grown products.

I've also heard that the kiwi farmers on the Island were going to plow under their fields because they could not compete with the products that were coming, let's say, from China. That has been another positive side effect. We've been able to promote B.C. products. We've got products now that we can sell in the vending machines.

If you go into the vending machines in the schools right now, I agree that it is toxic. One of the government guidelines is to have more fruits and vegetables. Go to a vending machine in schools and find out how many fruit and vegetable products you can have, and it's pretty well nonexistent. I want to thank the government, again, for showing the leadership and having some of those positive effects that have resulted.

I do work with a multidisciplinary team. I am the community nutritionist, but we have dental health, tobacco and mental health. We have the community health nurses, who are really the front-line people.

I'm in charge of 76 schools on the North Shore. It's not possible for me to really liaise with all of those schools, so I rely on the community health nurses who work with a family of schools to do a lot of my advocacy work.

These are some of the activities that I've been involved with in the North Vancouver school district. There was a community forum. We are actually introducing a school health promotion policy at the school board meeting this evening. There have been big changes to the school cafeteria. We were also in the news in November on the North Shore when the provincial guidelines were launched. We've taken a step to offer healthier choices in the cafeteria as well.

I've actually sat and watched the students buy the foods, and now there's quite a change. Burgers are one of the lowest-selling items. Now there are meal packages that come with milk and some sort of salad. Pastas and rice are quite popular. When my daughter came home and said, "You know, there are too many vegetables in the rice at school," I went, "Yes," because she's not a big fan of vegetables, and we're incorporating them into products that the youth like.

I am also a big believer in presenting to the parent advisory councils, because they are the same volunteers who are out in the community at the sports concessions as well.

I have a monthly Health Matters newsletter that goes out to the schools, which covers a variety of topics. You will have a copy of one that I did in January, and you will see my lens of the eating disorder there. I think that if we focus too much on childhood obesity, we have parents who are very concerned when normal changes happen.

When children are ready to really grow up, in their adolescent years, quite often they do put on weight. If we have parents that panic because they think, "Oh my gosh, here goes my child," I think it's really important that we give them the tools. This was a newsletter that went out, and 94 percent of the schools that were surveyed actually used the newsletter.

I do nutrition education workshops, as well, for teachers because, again, they are the leaders. When I talk to them, they're going to present to their students year after year, so it's a very cost-effective way of working. We do something called the Eat Well, Play Well Olympics on the North Shore. We started that three years ago. We had 4,400 elementary school students involved.

I'm a big believer in tying in with the family, because it's one thing to say to the students, "You need to offer healthier choices," but it's usually the parents who are buying those foods. The Health Matters newsletter connects with families. The Eat Well, Play Well Olympics also has a newsletter that goes out to families, and the students take an active role.

The winner this year was Eastview Elementary School in North Vancouver, and the students played a big role. They made announcements every day during the week. The students got points for bringing fruits or vegetables or milk products to school and a point for a half-hour of activity after school.

It created a lot of fun and excitement. I had parents giving me feedback, saying: "My children are actually taking over making their lunch, and they're asking for fruits and vegetables so that they can get points at school." It created some fun and a positive way of getting that message out.

I have the Energize Me! pamphlet that I created. We've handed out, I think, 8,000 copies of this to schools. This is a simplified version of the B.C. food and beverage guidelines. It lists the foods into the four categories: choose most, choose sometimes, choose least and not recommended. If you'll notice, this is similar to another handout that I developed called Energizing Snack Choices. Families will put this up on their fridges. The ones that are not recommended are on the back, so all of the foods that you want the students to be having are on the front of the brochure.

I've spoken to about a thousand athletes on the North Shore, and the really positive effect — this has quite often been as a volunteer parent, because I have three active children — is that I'm working with youth. This is the why: why is it important for you to choose healthier food choices? Because you want to give them the winning edge. You want to give them the tips for eating for peak performance.

The really gratifying side effect of this is that the kids are changing their behaviour. When I pick them up after school, where they haven't had much time, they've made a fruit smoothy, and they're in the car, and we're off to hockey practice. So it's actually chang-

ing the behaviour, and they are becoming advocates for change. Youth listen to youth, so this has been very popular.

Then this is just a sport concession guideline. Again, it's even more simplified — one page on how to offer healthier choices. When I go to the tournament concession stands and have to spend my little two-hour stint as a parent, it drives me crazy when I have to be handing out pop and chips. They used to get a coupon, and you'd get a hot dog, chips and a pop. Things are starting to change as a result.

Brian O'Connor and I worked together. We sent out concussion guidelines, because as a parent I would watch the kids get a concussion, and they'd be put right back on the rink or out on the playing field. We worked together, sent out a newsletter to schools and to all of the youth organizations on the North Shore, the sport organizations, and some B.C. groups. As a result, some of them have put it on their websites.

The B.C. Injury Prevention Unit that sent information to Brian O'Connor on concussions was used, and they put the sports concession guidelines and the Eating for Peak Performance on their CDs that were handed out at a convention in March. Again, it's those partnerships.

We also have a fabulous network on the North Shore called the Active North Shore network. It's promoting individual and community health and wellness. We have multiple partners. They include both of the school districts, both of the recreation commissions, Heart and Stroke Foundation, Canadian Cancer Society, North Shore Credit Union, Action Schools, North Shore News, Park Royal shopping centre and Internet consulting. There's the website.

I've actually seen a change in the culture of those organizations. What happens is that we all work together. When I spoke about the Eat Well, Play Well Olympics, the West and North Vancouver recreation centres provided a one-month fitness membership to participating schools to be used as a draw prize, as well as certificates for individual students to go and be active at the local recreation centre.

You do have a "Play And Be Active Game Card!" that was the North Van Recreation Commission. The community health nurses and myself had input into all of the aspects of health — for mind and activity and healthy eating. It's really a cultural shift, and the West Van community services used to have a barbecue with the standard pop, chips. They've changed it. The kids get a card, and they actually track. At the barbecue they are modelling what they want the kids to do. There are healthier choices.

Another fantastic thing is that Park Royal — which, again, is one of the partners — is where a lot of youth hang out. We've got a healthy eats program that was just launched at Park Royal recently, and they've got quite a few vendors now who offer a lot healthier choices. They have got nutrition facts information for some of the healthier products.

Then Action Schools and North Van school district partner together. They have this fabulous program where they have high school students going into elementary schools using the Action Schools to get kids more active. Those kids, again, mentored the younger kids in the elementary schools. The older students got credit for their portfolio requirements. It's those partnerships that are fabulous to see. This is the example of the "play and be active" part. It's: eat well; play well; stay active. Those messages are being used by all of our partners.

The Edible Garden Project on the North Shore is a fantastic project with goals to utilize local land to produce food; increase access to fruits and vegetables, particularly in populations that have barriers to access; increase knowledge and skills in food preservation; and increase community ability to respond to the high demand for locally grown produce. It is funded by ActNow, a B.C. community initiative.

There are even more partners than are listed on this slide. It's both the city and district of North Vancouver, the district of West Vancouver, North Shore Neighbourhood House, some of the community garden groups, and the Queen Mary School community garden. That's a high-risk group. They work with North Shore Harvest. They work with Salvation Army.

I think there are going to be a lot of positive spinoffs, not just in terms of providing food. Katherine Whittred and Michael Sather were mentioning that the skills of cooking…. They're actually including that. The food preservation is part of this project. I think it also develops a sense of community, so people who have extra garden space are partnered with people who are interested in growing more local produce. Also, for those who have a garden and want to grow an extra row, it's then donated to the Salvation Army. Again, it's creating that sense of community and developing partnerships and more fruit and vegetables.

As Barbara mentioned, it's also very important to focus on the early years, when habits are developed. On the North Shore there was a Healthy Start for Life resource kit that's on display on the side here. We had workshops in the fall. It was funded by the Ministry of Children and Family Development for parents and early childhood educators that work in day care centres and so on. It's learning more about nutrition and physical activity needs of preschoolers.

It was based on the Healthy Start for Life that Dietitians of Canada developed, and it uses resources that were developed both in the United States and in Canada. Rather than reinventing the wheel, some of those best practices have been put together in a resource kit. It's housed at the North Shore Child Care resource centre on the North Shore, and there are going to be more workshops in the fall.

This is another campaign that was in Fit Fest in Bella Coola. It was a two-month campaign to motivate and challenge people to work toward a healthier and more active body, mind and spirit. The thing I really liked about this particular project is that it had two coordinators. There's a large aboriginal community in Bella Coola, and one of the coordinators was from the Nuxalk community.

It ran from mid-February to mid-April, and there was lots of excitement and fun. We want to create a positive feeling in the community and with students about being active. It's fun to be active, and it's fun to eat healthy foods.

You'll see some of the things that come out as far as aboriginal…. They had a sweat lodge. Basketball is big with the aboriginal youth up in Bella Coola. They had toddler Olympics, and brought out 200 parents, infants, toddlers and preschools. This is a fairly small community, so I was very impressed by what they were able to do up there.

This is another project in the Sunshine Coast–Powell River–Sea to Sky area, called Dodge Diabetes. It was Health Canada funding for preventing type 2 diabetes. The goal was to promote active living and healthy eating for children, youth and families. They had some phenomenal things that went on throughout this whole area. They had advocates in education workshops, a media campaign. There were freeing tools and brochures. I've got the Pump Up Your Health book that was done for grade four, and a poster.

The thing that I really liked…. I was actually filling in on the Sea to Sky area for this dietitian who was on leave. They had mini-grants, so $500 grants went out to the community for a project that's focused on active living and healthy eating. Some of those have continued.

When I was in there — I was at Squamish — they had the recreation centre, and all these partners from the community and all these families and youth came to learn aboriginal dances, to have healthy foods, to learn about early childhood education. Those partnerships that were established by these small mini-grants have continued.

M. Sather: Kathy, an issue came up in our community of Maple Ridge this week vis-à-vis the school district, which put out a letter-to-parents document. In there was an advertisement for Wendy's — no disrespect, Mr. Chair, to one of our legislative colleagues.

What is your thought? Obviously, school districts talk about this issue, whether it be vending machines or an ad like this. It's extra revenue that they say they need. What are your thoughts, as you deal with school districts a lot, on how that can be dealt with, what sort of strategies they can use — anything that you can throw into the mix that might be an idea of how that ongoing problem could be dealt with?

K. Romses: Okay. I am going to put a condition on this. I'm going to say that this is my personal viewpoint and that this has been developed because I was in my daughter's classroom doing nutrition education as a volunteer parent. Doing a three-day food record with the kids, I thought: "Oh my gosh. My kids are right. They are bringing pop and chips and chocolate bars, and they aren't meeting the minimum number of milk products and fruits and vegetables."

I've really changed my viewpoint. Adults, who are really modelling for our kids, are low in milk products and fruits and vegetables, and children are as well. I used to think, you know, every once in a while it's okay to have Wendy's and so on, but school is a learning environment. We are teaching our kids how to be healthy, productive citizens.

I have really changed my focus now, and I am really quite against getting money, to raise funds, to buy whatever — computers or even athletic equipment. I've said as a parent when I looked at the money we could get from companies — revenue for vending or revenue from Wendy's: "It's less than the cost of a cup of coffee per month that they're getting in revenue. To me, they're creating these lifelong consumers of their products. I personally feel that in schools it is not the best thing to be doing."

I really feel that we're investing in the future of our children when we look at the big picture and think: "You know what? We're in trouble. That canary is singing." We have to recognize that school is a learning environment.

C. Wyse: Kathy, I was a little surprised when all of a sudden you took me up to Bella Coola, which is getting very close to where my riding is, and the Sunshine Coast, with targeted groups again. I had asked earlier: with the diversity, how do you get targeted so that the education gets out right throughout all of the different communities? The more educated and having wealth…. That's very enabling. The other parts of the communities that don't have maybe even either of those — how do you make sure that information gets into those groups?

K. Romses: I agree. What we try to do is to reach everyone. When we're working with schools, it's a fantastic avenue, because you're reaching all of those communities. So that is working with both those who have and those who don't.

I think it's really important to try to focus on initiatives that reach those communities that really need help. In the Dodge Diabetes project, one of the things that happened — again, tying into that food preparation — was that the aboriginal community in Sechelt, which unfortunately I've forgotten the name of, got some money and they started a Kids in the Kitchen project. The young children were taught how to prepare the food. Also, they have food delivered to the community, and sometimes they have no idea what to do with the food in that box of food they get.

With that Kids in the Kitchen project, they actually taught the community, who also was involved — the elders and the young children — how to use those foods. So there are some targeted interventions, and that is one of the things that Vancouver Coastal Health is trying to do. We're trying to look at everyone and move everyone along the continuum, but we are trying to focus on those high-risk people.

Another thing that I do…. We've got a fairly new addictions treatment for youth on the North Shore. I have worked with that group to say that when you're working with these youth and moving them into more

positive behaviours, make sure that you're also offering them healthy food choices. That's my plan for the summer now that school has stopped. I want to go in and work more with them and give them those food skills, because those are very high-risk youth who are just on the edge of homelessness or are homeless. They need those skills that quite often they don't have.

C. Wyse: Thank you. If I may, Chair, a couple of follow-up questions with the programs in Bella Coola and the Sunshine Coast.

If I follow you correctly, these were some target funds that came in — some startup funds. Are those programs still active and ongoing in Bella Coola?

K. Romses: Bella Coola is actually going to be an annual event. It was a public health nurse promotion or education fund that provided…. I spoke to the dietitian up there, and she is saying that this is going to be an annual event. Because it was so successful, it's going to continue on.

The same with the things on the Sunshine Coast. Those Dodge Diabetes projects — a lot of those are continuing. They created community partnerships, and they were able to see how successful they were. A lot of those projects are continuing.

C. Wyse: Thank you. More than likely you already told me this, but I missed it. When was the activity in Bella Coola?

K. Whittred: Thank you, Kathy. It's always a pleasure to see how well-resourced we are in North Vancouver.

I wanted to ask you a little bit about targeted schools. I'm thinking there about what your approach would be, for example, in working with Queen Mary or Norgate as opposed to Cleveland or Sherwood Park or some of the other schools.

K. Romses: For those schools I would actually spend more time. I haven't been able to that much this year. Margaret Broughton also works on the North Shore, and she has been working with the Edible Garden Project, so Queen Mary is one of those schools that is involved.

I've actually gone and spoken to the parent advisory council at Norgate, but those are schools that do need more support. I've told the school board, as well, that if…. I can't actually go into individual classrooms because I'm in charge of 76 schools and, whatever multiplied, how many classrooms. But with those schools, I will go in because those are high-risk schools.

H. Manson: I'll introduce Kay Wong, who's a community nutritionist in Richmond, which is actually where I live. Richmond is a very different community. It's got a different geography. It's got a different kind of demographic, so you're going to hear a different approach now from Kay.

K. Wong: What Kathy was saying is we always work as a team. In Richmond it's the same. The team of people when I'm talking about all these programs includes community health nurses, physicians, dental hygienists, psychiatrists, psychologists, mental health workers, speech, audiologists, so I'm not talking in terms of just nutrition. It involves all these other people that have been working in all these programs.

It truly is about partnerships, because we can't do all this work by ourselves. When we have true partnerships, our partners will take on…. Truly, this is our problem. This is not, you know, yours or yours, but it's ours. We often do something about it. I'm chatting about some of these initiatives and examples of what's going on in Richmond. I just want to make sure that gets across, basically.

The first one that I have up here is the school board. The school board has actually put through just now, in the last June meeting…. They're looking at promoting a healthy school policy, and the trustees actually accepted that. Through this next year the schools are all going to be basically looking at a vision statement for their own school about what it means to have a healthy school and supporting kids in a learning environment. So that's going to be happening, and they're going to be doing a lot more work in terms of looking at tools that will help schools do that.

The other part of that is the Action Schools B.C., which is actually happening in Richmond and all over the province as well. At last count, I think, about 90 percent of all the elementary schools were signed up. They're all registered. I think Richmond was actually involved in the first pilot projects, and so now everybody is coming on board. All that stuff is working together. It's all falling into place.

That leadership is really what's important. It enables the schools to say, "Yeah, we need to do this," and "This is truly what we're here for — for the kids." We want to make sure that we enable them to learn, and we want to keep these environments really healthy for all our kids. That's something that's going on all over the province, and in Richmond that's what is happening.

In Richmond we're still doing healthy-schools grants. We have about $5,000, and we invite kids and schools to make applications so that they can have a little bit of seed money to make their schools healthier, basically. This last year we had about 14 applications, and ten of them were either nutrition or physical activity in nature.

It actually comes from the kids, and a lot of it was: "What can we do at lunchtime and at recess time to stay healthy and active?" So it was those sorts of programs. We had other groups in one of the high schools looking at hungry kids and how we help our friends, our neighbours to make sure that nobody is hungry in their schools.

We have a real mix of programs and some mixing in terms of a high school and elementary schools and some of that stuff that was going on as well. That truly is a partnership with the school board and ourselves. We've done this for the last five years. We've done it over and over, and it's worked pretty well.

Edible school gardens is very much like what Kathy was talking about. This partnership is with the city because they offered us the land. We have all this land out there with the fruit tree sharing project and our Food Security Committee.

At this point they're really trying to get the kiddies to start some gardens out at the community gardens but also at their own schools as well. So that's getting going. We've mainly got a lot of elementary schools doing this, as well as one of the high schools. I couldn't get a picture of their tomato garden, but I hear they've got a patch of lots of tomatoes. That's just getting started.

We're working with different individual schools. They're at different places. Some are moving straight ahead, and others are getting there. This is happening because of the ActNow fund and the guidelines. I think the guidelines were the push that people needed, and so that was very helpful.

Along with that, we've also got the food security funding. That delves into the Good Food Grub and the Colts programs. Those programs are for youth.

In our community centres we have a program called the Night Shift, and once a month the kids have a cooking session where they do their own cooking and have a meal together. It's really popular. Part of it is skill-building. When you talked about home ec classes, this is the skill-building on the kids' terms, at their time and with their kinds of foods. They're learning how to prepare some of the foods.

The Colts program is based in schools. Again, it's skill-building, and it's young parents. We talked about getting that grocery bag, "What am I going to do with this stuff? This squash — what am I supposed to do with it? This kale?" and not knowing what to do with it. So this is part of the skill-building that we're starting there.

The travelling road show and the vending machine are just one of the projects that the nurses have been doing and that we worked together to develop. It goes into the schools, and it's a partnership with the schools, with the parks and rec.

The vending machine itself is just a replica of a vending machine, and the kids get to choose one of the snacks. What comes out is a cartridge telling you if it's a healthy or a not-so-healthy choice. The kids just crowd around this machine, and what really worked well is that we had the kids operating it. The learning that goes on is just wonderful. It's just great.

The last item I have there is supporting baby-friendly initiatives. I know that Vancouver Coastal Health is talking about…. We're doing our planning right now to do it for the whole region, to make it a baby-friendly environment so that breastfeeding is the norm.

In Richmond we have a smaller community committee with all kinds of players — La Leche, the hospitals there, Richmond health department. We've got our moms on that as well, trying to increase the awareness in the community and make breastfeeding the norm. You're going to see more and more about that. Especially, we've talked about it in terms of our social determinants of health and how it relates to all of that.

This is "Got to Move! Eat Good Food!" This is our bookmark contest that we did. We've done it for a couple of years. Last year it was "Feed the Body, Feed the Mind." We did nutrition and literacy. This year it's activity and nutrition. These are just the three first-place winners that we had.

I was only able to find…. All of them are gone, but I've got you one. This is what I have. I've got all the PDF files, if people are really interested, and we can print more.

It's basically staying active and eating more fruits and vegetables. The school board was our partner, and parks and rec in Richmond, the public library and Richmond Children First. We had over 1,800 entries. At the last school board meeting they honoured all the winners. The little kids got their plaques, and it was wonderful.

Energize with 5. This is the sheet we've put into your packages. It came out of our partnership with the bookmarks and working with our parks and recreation department. It is, basically, to get kids to eat more fruits and vegetables and to stay active during the summer.

We did a lot of planning with parks and rec. Over the summer they have all these summer programs for elementary kids. Part of what they're going to do is model to the kids about what it means to have healthier snacks. They will only serve healthy snacks in all their programs. At the same time, we're working with parks and rec to look at their vending machines, and using the guidelines as well.

You can see that it's morphing over to everywhere, and people are using them. They're really very helpful. This is going to happen over the summer.

I think people love the colours for the different vegetables. We would go through it and think: I don't know what that is. People start looking for this. We get lots of questions, even from our own staff as well. The pot of gold is the activity, and kids get to colour that.

D. Cubberley (Deputy Chair): I would be kind of interested for you to draw out just a little further the difference between Richmond and the approach there and the other communities we've heard about.

K. Wong: The approach is still population health. We truly do believe in working with partners to do the work. Our community was a farming community, but it's not anymore. We have very small pockets of farmland. A few months ago it came up, and people were

talking about that, especially the lands. It's still a concern in our community.

One-third of our population — their first language is not English. We look at our programming, and we look at the partners we have. We just make sure that we have those partners to help us in terms of our programming. For example, SUCCESS is one of our partners in a lot of these programs. They weren't here on my slides, but they are.

R. Sultan (Chair): If the Chair may be allowed a question. You have a high ESL population in Richmond. Is it your observation that people come to Canada from other countries and learn all of our bad North American habits and that diet goes downhill from there?

R. Sultan (Chair): Or is it the other way around? They come with bad habits, and we have to improve them.

K. Wong: I think a little bit of both happens. For new immigrants, everybody wants to fit in. Look at our ads, our media. What's our favourite drink? Is it milk? Is it water? It's pop. You've basically learned that if you want to fit in, you need to drink these fluids. We need to change our environment, basically, to make the really healthy choices healthy for people so that they're available and so that they're cheaper. Pricing matters, you know.

We have so many different food styles in Richmond, and that really has enriched our lives. We get to buy veggies, fruits and vegetables and things all year round, and the access is wonderful. The community as a whole really learns from that, too, to get to try different things. It works both ways.

M. Sather: Yes, on your colour chart. My wife is an artistic soul, and when we're making dinner, she always says: "Oh, we can't have the same colour of vegetables on the plate. They have to be different colours." I always thought it was an artistic thing. Is there actually some nutritional benefit to having different-coloured vegetables together?

K. Wong: Coloured vegetables means lots of nutrients, basically, so the brighter the colours, the more vitamins and minerals you have. Then there are phytochemicals and antioxidants and all those sorts of things thrown into the mix. But, yeah, if you get lots of bright veggies and fruits on your plate, you're going to get more vitamins and minerals, so you're going to do better that way. It looks better on the plate, too, you know.

B. O'Connor: I just want to make a point about the immigrant population. I think we're going to see a large change because of what we call the globalization of health. In other words, the North American lifestyle, and particularly the American lifestyle, is now readily exported to just about every corner of the world in terms of KFC and McDonald's and Coca-Cola and Pepsi.

The generation that's on the other end of this information technology's ability to translate all these lifestyles of the American population and to actually place these products in their home countries is really going to change the immigrant population and the obesity epidemic. This is a global epidemic.

H. Manson: I'll introduce Barbara Crocker, who is from Vancouver Community. You've heard from her once, but she's going to speak now specifically about some of the initiatives in Vancouver Community. She has only one slide, but she's going to speak at large to give you a lot more information.

The profile here is to look at the initiatives in Vancouver, just thinking about the differences between Vancouver, Richmond, the North Shore, Bella Coola, the Coast Garibaldi areas…. Vancouver is culturally diverse, as we know, and I've answered a question before about working with these various ethnic groups. There are a lot of services and supports for a variety of ethnic groups, and working with interpreters is part of that lens.

We also have a magnitude of child poverty. If I go back to the late 1980s, the Vancouver school board in 1988 launched hot lunch programs in four inner-city schools. It took them ten years to launch that. We had teachers and administrators working in our four core inner-city schools that saw children coming in without lunch. They had tummy aches. They had headaches. Well, how could they address it? It took ten years.

The hot lunch program was launched in 1988. In 1989 I became the school nutrition consultant, just as the wave of hot lunch programs was coming on the scene in Vancouver. It became the model for the province for the hot lunch programs that were launched in 1992. Vancouver went from those four schools to five schools to nine schools to 13 schools to 26 schools having a hot lunch program, and those programs do continue today.

In those early years the reports back were that fewer children going to see the nurse, sitting in the nurse's room, had tummies and headaches. The power of child hunger, the issue of food security, is real and alive. I mentioned earlier the issue of the Vancouver

Food Bank, which started in 1980, then in 1988 we started with hot lunch programs.

We have non-profit groups that sponsor breakfast programs in ten or 12 inner-city schools. During my years working with the Vancouver school board and schools, the lens was child hunger. My focus was inner city, looking at those communities and how we could provide supports.

In 1992 there was a child health promotion research competition. Premier Mike Harcourt announced it at an international congress for child health here in Vancouver. I sat there in the audience, and I said: "Yes, we need to apply for money." We had, like, a halo. We were feeding all these kids, but my question was: were we really meeting all of the families' food and nutrition needs by having a hot lunch program? There was kind of a glow that we had met all of the needs.

We had the opportunity to go in and embrace two communities in a very broad way with cultural groups. We had a meeting with the eight translators, the parent groups, the school principal and so on, and in these two schools, we ended up developing cooking programs and recreation programs. One school had a hot lunch program, and one school did not have a hot lunch program.

It was very interesting to go in with that. We worked with academics. We had UBC involved to help us with the process, which was very much a community development process, and hear the voice — what were families needing? — by asking teachers, etc. That led to this first model, Cooking Fun for Families.

As you've heard from Kathy and Kay about cooking clubs and cooking, and we mentioned the high school years, children love cooking. Families do not have the cooking skills. They come to Canada, and they want to cook Canadian, which is pizza, burgers, fries, pop, etc. This is Canadian food, and the parents want to cook those foods for their kids because their kids ask for it. They want to fit in. As Kay said, the kids want to fit in and have those foods.

We launched Cooking Fun for Families. It was basically the spinoff of the program. Our handbook, Cooking Fun for Families, illustrates the two models. One had sports clubs and cooking clubs that were run by parents. This model for inner-city schools actually had paid staff.

With Cooking Fun for Families, basically, I left it open for schools to approach me. In 1997 we finished the program. In 1998 school administrators started phoning. The reason the inner-city schools wanted this is that it was a way of welcoming parents into the school. They know that children are more successful in school when their families are connected to the schools.

From an educational lens, having families involved in the school was very important, and this was an excellent way to bring families in. What we found, in subsequent times, was that those parents went on to the literacy program, have gotten involved in the parent advisory committees and have really joined the community.

The other thing about Cooking Fun for Families is that we've been able to branch out with skills for them around FoodSafe, becoming leaders of groups and with the opportunity for them to launch beyond that.

We did a second study — that's one of our posters here — and it did create social supports. Now, we have parents coming into the school, and it created social support for families who are new to the country, who don't know other people, don't know the school system, by having a place that was safe and welcoming.

If we take off our hats and think about food in our families, about sharing a meal and what it means for families to come together for a meal…. In Washington State they have a program called Eat Together, Eat Better. They know it's not causal, but there's an association for families who eat together more often.

The children do better in school. They're more socially connected, and they feel better. The more we can get families eating together, the healthier it is for those children. This model is about families coming in and cooking, sharing a meal and taking food home, learning those skills within those schools. We've worked with a total of 12 schools.

Okay, today. We've had a coalition over the past year to look at sustainability. We actually have six schools, I believe, that are now being funded by the Community Food Action Initiative, which is wonderful.

Hike to Health also was a pilot project. It was funded through the Ministry of Health a number of years ago. It was basically looking at a response of prevention of cardiovascular disease and what we could do in communities. Hike to Health was helping those same inner-city-type schools.

We worked in one school, parks and rec, to help parents get to the community centre, go skating, go swimming, go hiking on the North Shore mountains, go snowshoeing, go berry-picking — to get into the great outdoors. Parks and rec provided transportation. They had a healthy snack. It was a Saturday recreation program for families.

School gardens. You've heard about some of the other programs looking at edible gardens and getting people connected. The vision for Vancouver inner-city schools is that all ten of those inner-city schools would have school gardens. We have two up and running. I believe a third one, Britannia, is wanting to have a garden.

Children don't know where food comes from, and it's actually really fun to grow food. I don't know if any of you garden, but the excitement of seeing those flowers bloom or picking those cherry tomatoes and eating them….

When I do work with young families, and they say, "Barbara, my child won't eat fruits or vegetables," I'll tell them: "Go to the farmers market, get involved in a community garden, and get the kids picking the cherry tomatoes and eating them. Grow them yourself. Cook them." These are the ways that kids become more familiar with food — through growing it, going to a market, tasting it, cooking it themselves.

Gardens are very exciting things. We have a number of community gardens, as well, in Vancouver, and we launched farmers' markets in 1994 in Vancouver.

We had a big forum, and we invited the community and invited farmers. That led to the East Vancouver farmers' market. We now have three farmers' markets, and there's a provincial network of farmers' markets.

A unique lens with that is that coupons were provided to the women who were part of the Healthiest Babies Possible program. This is our pregnancy outreach program for women at risk of having low–birth weight infants. This was a way for the women who were interested to increase their access to fresh fruits and vegetables, to come out to the market and be part of that view. Then when they have their children, they'll know the farmers' markets — which is, again, promoting fruits and vegetables.

The Healthiest Babies Possible program also launched something called the Good Food bag — access to fresh, local, organic fruits and vegetables. The parents help to bag them, etc. It was so popular within Healthiest Babies Possible that they wanted to move it out into the broader community. The nutritionist and a number of people worked to create the Good Food box, which ran for a number of years but is now stopped. It may have another generation, but it's just in a hiatus right now.

Back to cooking skills and the community kitchens coordinator. Back in the early '90s we had a woman from Montreal talking about collective kitchens, bringing people together to socialize around food — food as a social thing — and to use food to help bring people together for social means as well as skill-building.

Through the work with the REACH community health clinic, the Vancouver Food Bank, Vancouver Coastal Health and Terasen Gas, which actually funded the community kitchen coordinator that we've had in place for the last ten years…. That position has enabled us to go from no community kitchens to over 100 community kitchens, and that's enhancing our environment.

A number of years ago, in 2002, we piloted a summer salad bar in five inner-city summer break programs. In the inner city in Vancouver, there aren't safe places for children. When we think about kids playing, you can't let your kids just run around in the neighbourhood. They'll run in the apartment buildings, and even that is not safe.

Safe havens were created — Strathcona Community Centre and four schools, the KidSafe society — running five different programs in summer break. We thought: what a great opportunity to pilot a salad bar, looking at the opportunity to move that into the schools in the school year. The kids loved it.

We had a partnership with the UBC farm. The kids went out to the farm on a field trip during the program. They ate salads every day during the summer program and loved it. They self-served, and they did the whole thing, eating all of this great stuff. The opportunity for salad bars, I think, is excellent.

Healthy Attitudes program. This is a little bit of a different lens. This is about interventions. When we think about promoting health and wellness, which has been most of what we've presented, we have to realize that in our community, there's a huge dieting culture. It's a multibillion-dollar dieting industry that's encouraging women, children, youth to go on diets.

Diets don't help. They make the problem worse. They want people to buy special products. It's generating this huge machine and this huge engine, and part of the outcome here is that we have body image concerns. We have children dieting. We have eating disorders, and we're all aware of eating disorders.

The Healthy Attitudes program is an early intervention program to provide support to young people who are dieting, who have body image issues. We have a counsellor, a physician, a nutritionist and a community health nurse working as a team to support that.

On the other end, we do have obesity issues. For 20 years now we've had no supports for families and children struggling with weight issues. Our nutritionist at the South Community Health office partnered up with the physician and the counsellor in the Healthy Attitudes program and launched the shapedown intervention program.

Based on a California model, it's a family intervention program to support families, to deal with parenting issues, to deal with the complexity of what's happening in the families of these children who have these weight issues. It's now moved to Children's Hospital. It's part of the Provincial Health Services Authority, and there is a lens and a desire to move that out into all of the health authorities.

What I understand from Arlene is that Fraser Health is interested in taking out their…. Apparently, a lot of children are coming in. It's interesting, talking to Arlene, on the concern for multicultural populations. We've mentioned people moving around the world. What does it mean, in terms of health, to have a really well-fatted, chubby child as opposed to a skinny one? I think there's a lot we could learn that way.

Finally, the Healthy Living Alliance, just to mention it in terms of launching in Vancouver last year. We had an initiative held in April. We had parks and rec, the Vancouver school board, Vancouver Coastal Health and the Canadian Cancer Society partnering with the Healthy Living Alliance to look at our schools.

They had a campaign, or a launch, and they had over 200 people out in April to look at healthier food choices for schools. All of the schools were welcomed. It was our launch to the work that's happening this year to look at school food policy.

We've just hired a nutritionist in January. She works 0.45 with Vancouver school district to look at the healthy schools food policy. Kitsilano is a pilot site where they want to look at food, as well as Churchill Secondary. We're just underway to look at some of the initiatives we're seeing in Richmond and North Shore.

R. Sultan (Chair): Thank you. Maybe we have time for brief questions, one or two at the most.

B. O'Connor: I think you've probably heard the most interesting part of the presentation with all of the wonderful things that are happening right out in the field within our communities in this vast health authority. I'm going to move back now and probably move us up to a different level here.

There are some opportunities within our health authority and other health authorities. We definitely have credibility. From the comments of the nutritionists who have spoken to you this morning, you can hear that there is a great deal of credibility in that particular discipline and in other disciplines within Vancouver Coastal.

We have some credibility because, as has been pointed out again, we have the willingness to role-model. In terms of a vending machine policy, we want to demonstrate that we are leaders in this area.

There's been an awful lot in the popular press about the obesity epidemic, for sure. We have been able to demonstrate to you today, I think, the ability of ourselves and others to engage in partnerships. There's a lot of community interest in this issue, and there are a lot of willing partners who want to work towards this.

We've talked a little bit about parks and recreation. I think municipalities are excellent partners for the future. It indicates here on the slide that the original roots for public health came from community planning around the issues of things like sanitation, water quality, pollution, overcrowding and things like that.

We're natural partners with the planners within our communities. It is within those communities that we create livable environments — where walking is encouraged, cycling is encouraged and zoning issues are dealt with so that we can put schools in the right places and so that we're all working together to enable and support healthy people in a healthy place.

We have some challenges within a health authority. Certainly, there are limits on our influence, particularly if we see that the issue of childhood obesity is only a health or medical issue with only a health or a medical solution. I think we've demonstrated to you this morning that it is, indeed, not the case.

This is a multifaceted problem that health in and of itself will never ever resolve. We've mentioned here, and you've heard it before, the competing priorities for fundraising, the revenue generation of the vending machines, vis-à-vis the choices that are presented to the students. This is a very complex issue.

The third bullet in the first limits of influence is, I think, an incredibly important bullet. It is the issue of not enough investment to deliver an adequate dose. This adequate dose I refer to as the preventive dose, which is doing the right thing in the right amount to the right audience or people.

You can see that with this issue, many of our programs are never going to be…. Certainly, they're the right thing, but they're never going to be in the right amount and will not necessarily reach all of the right people. We're probably going to be able to reach only a segment of the population that, necessarily, will need it, so I think we harken back to the system supports that are required to create this synergy.

We need to look at the issue of everyone jumping on the bandwagon to say something. We're going to start to confuse the public unless we make sure we have a consistent, rational, reasonable and easily understood message. We must guard against diluting the message and confusing people. It's noted here that it's a much more complex issue than tobacco, and I'll certainly speak to that in a moment.

I think this is an important slide. These next few slides come from the United States Institute of Medicine report on childhood obesity. What they're recommending and what we have spoken to is an environmental and behavioral synergy. It's down here that we work on the behaviour change, the behaviour modification — trying to get individuals to modify and adopt the appropriate behaviours.

But it has to have synergy with all of the rest of the community, right back to the social norms and values, the policies that support this — those things that shape the environment in which these individuals make their personal choices.

Individual strategies in isolation are limited both in their benefits and in the results. Complementary policy initiatives and community approaches will pay the best results. Supportive environments and sound social and economic policies are things we need to put in place to support people in these choices.

In terms of the environmental-behavioral synergy, some of the expected outcomes would be those things that are listed on the slide. If we were able to achieve that environmental-behavioral synergy, we would see more children walking and biking not just because they want to, but because the community had the foresight to plan for the recreation and active living infrastructure that permits that.

The issue of safety — both personal safety, because that is an issue, as well as the right infrastructure to make safe walking or safe cycling — has been addressed as well. This is the environmental-behavioral synergy we're talking about. It's very complex, and all these issues are very much intertwined.

On this slide here, on environmental-behavioral synergy: improve access to and affordability of fruits and vegetables for low-income populations. I think this is a very important issue as well. This is the issue of health equity. There are inequities in health status between individuals of sound economic means and those who are living in poverty or close to poverty. There's already a health status inequity.

What we don't want to do with our programs and our media messages is compound the issue by not allowing the individuals in those marginalized groups to have the same access to affordable food and therefore compound the health status detriment that already currently exists. We must work, too, with industry, with the agriculture department, with farmers and others to make sure that they are in partnership with us and making sure, as I said, of this access to fresh fruits and vegetables.

The whole issue of individual responsibility versus collective action — that is the right balance between the

behavioral and environmental systems. Social norms definitely need to be addressed in some manner.

Changing social norms is a very difficult thing. We haven't gotten to this point without there being a huge investment on the part of the food industry, for instance, in changing the values and norms of our society around eating — where we eat, taking meals out of the home and the types of food we eat. To redress that is going to be a very significant effort.

The very last point there is learning from other public health experiences. Tobacco was a very successful public health strategy. The same principles apply: the principles of leadership, being responsible and accountable, forming partnerships to address the tobacco industry. Advocacy was a very major point, and obviously, public policy development in terms of regulation and legislation was indeed critical.

These principles apply to both issues, but there is a big difference between tobacco and the food industry. It is that tobacco in its intended use will kill you. Food will not, in its intended use, kill you. We cannot characterize food or the food industry as bad, and the food industry cannot be demonized as we have, if you will, demonized the tobacco industry.

They call it denormalization of the tobacco industry, making them the bad guys. We have to work with the food industry. We can't demonize the food industry, because food, if used as intended, likely will not kill you.

Questions about the food industry. The role of the food industry is very critical. It does need to be an active partnership, but we are uncertain as to how that will work because, obviously, there's an economic side to this. The public good and the economies of scale for the food industry will need to be addressed.

The problem is very multifactorial, so we need to avoid the glib and simple solutions. This is a very comprehensive, intersectoral issue that needs to be addressed and dealt with in that way. Certainly, we need more evidence on best practice and effective interventions.

In terms of leadership from those of us in this room and others, recognize that this is indeed childhood obesity — a critical priority. It is a societal issue. It's not owned by anyone. It's particularly not owned by, for instance, the Ministry of Health or the health system, but the fact that no one owns it sometimes means that it gets lost. No one stands up and becomes the champion around it or becomes the leader for dealing with it.

It requires a strong and long-term commitment from the highest levels of government, and it requires that evidence-based policy be invoked, as well as evidence-based programming, and a personal commitment to role-modelling at all levels and by all individuals.

As I mentioned before, ActNow is a great start to some of the partnerships around dealing with childhood obesity. We need to build partnerships with the business community at those highest levels. The business community is an important player in our communities. They provide employment opportunities. They're the funders and supporters of community agencies and organizations. They can provide workplace wellness programs.

We also have to ask business and particularly the food industry: "What is your accountability, and what is your responsibility around these social values?" They need to stand up and be accountable for answering those questions.

We have some opportunities for 2010. I would make note of the fact that one of the major sponsors of 2010 is McDonald's. As I understand it, McDonald's appears within the confines of the athletes village. I think it's important for VANOC and others at the highest levels to work with McDonald's to ensure that their image of providing healthy choices pertains there.

I would just make note too. You may have seen in the paper a week or two ago where Ronald McDonald appeared in some of our schools promoting active living and sound nutrition. There weren't any messages about the McDonald's products, but their main corporate logo identifier was standing there as Ronald McDonald. He's identified as fries and burgers.

I think it was rather an insidious way of doing marketing right at the coal face, if you will, where the children are learning, on the presumption that this was really talking about being active and healthy and eating good foods.

You've heard about the need to build partnerships with the multicultural community leaders. In terms of advocacy, we need to provide the tools for our elected officials, board members and others to be champions of this issue, and providing a lot of the information that we have today and that you've heard in your other meetings is some of the necessary information for you to be internal advocates within government and within the Legislature.

Our communications, public messaging and media campaign strategies are opportunities, and certainly, you've heard many times today, working with the food industry. We have a couple of notes here that smaller portions do not necessarily mean less profit. Healthy vending machines have actually showed an increase in profits.

So these are not things that necessarily need to be of great concern to the food industry. It can work. It has been shown to work, so they should be encouraged by that. We need more research dollars. We need to have better data. We need to be able to better track our interventions.

Now, this whole issue of the built environment is an incredibly important one. We certainly need roads and bridges, but we need to start looking at our roads and bridges through a health lens. We need to look at: are we providing bicycle trails? Are we providing walking ways?

We need to go even further back. Why are we building all these roads and bridges? It's because all of our people have to live way up the valley and commute into Vancouver to work. We need to be looking at community planning in the lens that says: "Let's build self-sustaining communities and not have to do all this travelling." If we start to think about it and if we start to apply this childhood obesity lens or the health lens to things, we might do things in a significantly differ-

In terms of obesity in the built-up environment, I'm just going to give you this one slide from Dr. Laurence Frank. I think you have been recommended to hear from him. He has an outstanding presentation. His research is all on the effects of the built environment on physical activity, obesity and health.

I'm just taking this one slide, which shows that he has found from his research that every additional 30 minutes spent driving per day translates into a 3-percent increase in the likelihood of obesity. The time spent driving increases as walkability decreases. If you live up the valley and you're two hours in your car, you're going to spend less time walking.

Every additional kilometre walked translates into a 4-percent reduction in the likelihood of being obese. Distances walked increase with walkability, so those communities where the grocery store is just across the road, where the library is just down the block and the school is right out the back are the sorts of areas where people are active and moving about in their community.

Some future strategies. Within our own health authority and other health authorities and in partnership with other levels of government and other agencies, we suggest that increasing interdisciplinary planning on obesity prevention needs to be done.

We've heard that we need to develop more strategies for multicultural communities, and we can use some new public health funding to focus prevention strategies. These are just two programs that have been developed in California and which could easily be done here with the appropriate amount of funding.

Some of the future strategies again. These would require partnerships at more macro levels. Develop strategies to support ActNow B.C. goals, with the zero-to-five and the children and youth populations specifically. Advocate for a ban on food advertising during child TV programming time. This is a very big issue. If any of you have young children and turn the TV on, on a Saturday morning, an awful lot of food products are advertised directly towards our children. We need to discuss that and talk about it with the food industry in a very sensible and rational way. Following and flowing from that is this whole idea of media literacy for parents, children and youth. We need to teach parents, children and our youth to be media literate around the messages that are being sent to them, like when Ronald McDonald actually appears in their classroom.

Summary messages. This is my last slide here, and it's probably just going to draw in some of the points that have been said earlier. With respect to poverty and nutrition, I think we do realize and we need to realize that sometimes the most important impact is on those on the margins of our society. It's the poor and maybe those of different cultures and others. Often they are missed by whatever programs are developed and sometimes missed by the directed, targeted media campaigns. We need to really be aware that those populations of individuals who live on the margins need to be captured within whatever we are doing, because we don't want to broaden that health-status gap.

In terms of the individual and the society…. I've probably said enough about that, but I want to read one last quote that comes from the California Journal of Health Promotion. It says:

Lastly, I would just draw us back to the original comments I made around our document on the population health framework. It is that the policies with respect to education, income assistance, housing, access to food — all of those things — are incredibly important strategies in helping to reduce the childhood obesity issue. It requires us to use the tools of leadership, being champions, engaging in those partnerships, being advocates and, most of all, developing the healthy public policies that support environments for choice.

C. Wyse: I'm not certain that I have a question here, but I found quite interesting your aspect about advising us to ensure that we address poverty and nutrition. At the same time, the marketing of the fast-food products doesn't miss those very targets. I heed the advice that you've shared with us.

B. O'Connor: Often those marginalized populations — and I'm sure that people at this end of the table can speak more wisely to it than I can — are the ones who show the most poor food choice behaviour.

B. Crocker: Just to comment on that. If you look at neighbourhoods…. I think Brian mentioned that in a healthy neighbourhood you're going to have a grocery store. We have families that live in the inner city where you need to get on a bus to get to some of the larger grocery stores where you get better prices. So their grocery stores are corner stores.

Just a story. I was at a program, and the first solid that the child was given as a finger food: a cheezie. You buy that at a corner store — okay? What are we giving a young baby as a finger food? I mean, it's kind of shocking. It's the access. You can have television advertising that promotes these foods, but where do parents have to shop? So if they're getting their food through food banks, and then to add to the food banks corner stores, because they really don't have the ability to get to other grocery stores…. It's looking at: how do we

have a supportive environment when we've got good grocery stores and a good food supply?

C. Wyse: Thank you. I really did appreciate you helping me understand the complexity of the issue here. It strikes me there's not one silver bullet in what we're talking about here.

B. O'Connor: Absolutely not. It's a very complex, interdigitated issue with all sorts of potential partners, from the food industry to all the levels of government to a health system to a community — many, many players.

C. Wyse: Just to close, I found the presentations here very informative for me, and thank you.

D. Cubberley (Deputy Chair): That was a powerful presentation all around and a really fitting and, I think, stimulating conclusion to it.

I was very appreciative of the fact that you mentioned the built environment. More than mentioned it, you indicate — if I can summarize — that we've managed to engineer activity out of daily life and now we're going to have to engineer it back in, and that is going to require the modification of our living space. I truly appreciate that, because it's often referenced but rarely focused on by people who are presenting to us.

The other thing, too, and I'm glad you said it — it gets right up my nose — is this business with McDonald's, number one, being the Olympic sponsor, which I am deeply ambivalent about. But to have the corporate entity show up in front of kids and to use this opportunity to get the logo in front of people…. The logo means the food. The logo does not mean that you can get a salad or a fishwich at McDonald's, because people don't go there to eat that. If you're insistent on making another choice, you can find something at the margin at McDonald's.

It's the unholy trinity: chips, burgers and pops. They sell them as a package, and they use the salt in the chips to make you want to drink that amount of pop.

That brings me back to what I want to get to, because I sensed a certain ambivalence in your presentation in and around the analogy between tobacco and food. You're saying that we do have to learn from tobacco, but we can't demonize food. I want you to help me with that a bit, because I don't see food as one thing and I do see tobacco as a single substance. I see good food and bad food.

Let's pick one part that's quite prominent: pop, for example, which is liquid sugar. It really is a demon, and I don't see a good reason not to choose that as one of the vectors for obesity that we need to deglamorize. I want to just ask you for a comment on that.

B. O'Connor: Sure. I'm not ambivalent about it. I think they are two different things. I think that the tobacco product, when used directly and actually as they intended, will kill you or has the potential to kill you.

Maybe I should say, rather than foods, the food industry. We need to be partners with them, because food is not like tobacco. There are some foodstuffs, food products that probably aren't as good for you as other things are, but the food industry itself…. We can't denormalize the food industry and say: "The food industries are the bad guys. They need to be treated as the tobacco executives and corporate folks were." I mean, we need to have them as partners so that they do, where appropriate, put the healthful choices forward. So it's these two industries.

D. Cubberley (Deputy Chair): Let me take that one step further, because I was involved in the tobacco campaign for a long time. It was relatively late in the day that we actually demonized the makers of tobacco. What we did first was demonize tobacco — the actual thing itself. It was later in the day that these shadowy entities that were the suppliers of the drug were picked on as a target. They were a very easy target by the time we got to that, because tobacco had started to decline in public esteem.

I'm not arguing for demonizing a specific manufacturer, but I'm looking at the substance and saying that I'm not sure if pop is food. I know there's fructose in it, but I'm not sure it's food. I look at it, and I think: it's borderline toxic, and it's addictive. It's a low-level addictive substance. Stuff that's based on fructose is mildly addictive and, I think, especially to kids. There's a habituation and then a needing for sugar syrup. I look at that, and I think that's something we should take aim at.

B. O'Connor: Well, we're not doing it in a concerted public health strategy such as with tobacco, but I think you've heard from the nutritionists here that we're certainly not promoting soft drinks and are trying to replace them with water and things. I think it's a question of how you take on the producers, the manufacturers, the industry.

B. Crocker: Just a comment on this last. My reflection when I compare the tobacco industry and the excellent work that has been done over the years around tobacco and tobacco reduction…. I think that with food and healthy eating, we're a generation behind. You know, we started this work around tobacco 25 years ago with increasing taxation on tobacco, multileveled strategies.

Only now, really, food is getting the attention that it needs. I think we're about a generation behind where tobacco is. I think we really can learn, as Brian said, from the tobacco industry and move forward. There are lots of strategies we need to deal with.

K. Whittred: Just a couple of questions. First of all, on your remarks about the health lens, I just wanted to share with the panel a story. I was flitting around the TV, and I caught the city council meeting. They were discussing the new all-weather field and track at a particular location in my community, and they managed to discuss that for about half an hour without once mentioning activity or exercise or the value to the

community or anything like that. It was all about noise for the neighbours and so on. So, I mean, I really concur with that.

My real question was around business accountability. What are some of the things that government can actually do? We talked about leadership, and I wondered…. You avoided actually making any recommendations. What are your feelings around a sin-tax on things like pop and potato chips or around further regulating?

One of my little pet peeves is that governments put in regulations about the labelling of what must be in it, and when you actually look at it, I guess you have to have some kind of vision that I don't have to actually read these little tiny, tiny…. I don't know how they get something printed so small.

On what I consider to be the mislabelling, you'll see all kinds of products in stores now with a big sign on that says: "Zero trans fat." Well, they never had any trans fat to start with, but what they've got is about 57 grams per ounce of some other kind of fat, and sugar and everything else. Just what would be your advice? Do you have any feelings around what sorts of specific things that government should do?

B. Crocker: Certainly, in terms of food and taxation on certain foods, you can pay up front for that, or we pay later. Right now the system is to pay later in terms of disease and illness. If we look at the federal level — I'm not sure what we can do provincially, and you folks know better in terms of taxation around food supply — on labelling, there are national laws around food labelling and access to information, but you do have to know how to read a label.

I go back to one of my groups, last week, and here's a picture. It looks like there's all this fruit. There's no fruit in it. You have to read the ingredient list. There's a beautiful picture, but it's not there. We do need labelling education and media literacy. We could use some legislation to ban the advertising. That has a huge effect on children, and they ask the parents to get the food. That's what ends up in the homes, because the kids say: "Come on, mom. Buy me that." I think, certainly, taxation on some of our food products….

B. O'Connor: We did mention the issue of advertising towards children. That's probably a federal responsibility, I would expect, but I think that's an area….

B. O'Connor: That's one area where we could probably make inroads in terms of regulation and legislation.

M. Sather: In the discussions the food banks have been mentioned a few times. In my community an issue has come up that food was not being issued, and perhaps still isn't — I'm not sure if the policy has changed — to people without a fixed address. I'm just wondering, in Vancouver Coastal, whether that policy ever applies or how that's dealt with, because concern…. I mean, it's a broader-based issue around social problems, homelessness and so on and so forth. It's probably different in my community, but I just wondered how it's addressed in Vancouver Coastal.

B. Crocker: I'm actually not sure what they require in terms of people using the food back and if they actually have to give them a fixed address. That's a good policy detail. I don't know.

K. Wong: I know that in Richmond, you have to just have a letter or a bill that says you live in Richmond, and you have access.

K. Whittred: Sorry. I meant to ask this, actually, of one of the previous speakers. In the hot lunch programs, and any one of you can answer this, how do you determine who gets the hot lunch? Does everybody get it? Do certain people who are lower-income…? Are they given vouchers? Just what is the process that is followed?

B. Crocker: I can talk about Vancouver schools. Vancouver has a system of assessing which school would be deemed inner-city, the core that would get complete inner-city funding, partial funding. Those schools then would get the school meal program.

It's a universal program, so all students in the school are allowed to apply and be part of the lunch program. Every month they're asked to pay $50 or what they can afford to pay. So families who can afford to pay the full amount will pay the full amount. Families who can pay half will pay half, and families who pay nothing…. It's universal, and it's a sealed envelope so people don't know who pays what.

K. Romses: I think that's really important with those programs, that children are not stigmatized. We do have that in North Vancouver, as well, where there are certain schools that are deemed to be at risk because there are low-income areas, but all children…. They are not stigmatized.

There is a national program called breakfast for living, which I forgot to mention. I actually worked with the first nations group in one of the schools where those kids were having trouble fitting in. We got funding for a breakfast program.

H. Manson: I think all I'd like to do is really emphasize — and you can hear it here — the sincere and deeply felt commitment to improve childhood obesity, to create communities where we've got healthy kids who are able to walk and bike to school and who make healthy choices with their families. What I've heard, which I really appreciate, is that this is echoing with the select standing committee. So I want to thank you all — thank the presenters first of all — for your attention and for your excellent questions. Thanks.

R. Sultan (Chair): Thank you, Dr. Manson. Let me just say that I think Vancouver Coastal Health Authority is superbly represented today. It's a $2 billion enterprise and one of the largest health service organizations in the country. Obviously, as witnessed here today, we're being well-served along many dimensions, including this important public policy affecting childhood obesity.

Again, I would like to thank the CEO, Dr. Ida Goodreau, for having created this important forum. I would also like to mention, which is not on the record in Hansard, an earlier meeting this morning that we had with the Vancouver obesity clinic. I wanted to thank Dr. Tom Elliott, who is the chief medical officer of that facility, who gave us a lecture on the type 2 diabetes consequences of childhood obesity. I must say that his alarming account of blindness, amputation, heart disease and stroke gave us all pause. Obviously, a great deal of work is being done over there, which is very helpful.

In conclusion, I'd also like to make some comments about the need and obligation of the Select Standing Committee on Health to hear from representatives from the food industry. We have extended some very tentative feelers, perhaps poorly targeted on our part, and have not received a great deal of encouraging response.

I'd remind anybody who lacks such a life that they spend time reading our Hansard records for entertainment that this committee does have subpoena powers, and if necessary would exercise them. But there are two sides to the story, and I think we have an obligation to balance the views being expressed.

Finally, Charlie Wyse has sort of an invitation to the committee that he wanted to put on the record, so I'd like to turn it over to Charlie.

C. Wyse: Recognizing trying to get a balance, I would offer my constituency assistant to work along with the committee, to see whether we can identify presenters up in Cariboo South. There are at least ten groups that I'm aware of. However, whether they have a presenter becomes the issue. I believe, at least in part, that by making the offer here to the committee, we can then maybe see one of these disparities when we get into the more rural areas. The ability to even come in front of the community may speak volumes. I would like to make that offer here.

R. Sultan (Chair): I understand, Charlie, that that would perhaps include some first nations presenters as well.

C. Wyse: What I have in mind to suggest, of course, would be our own health agency, the school district, an Indo-Canadian, first nations. We have Métis; local government; a collection around food banks, Salvation Army, church — to give an idea of that aspect of it; child development centre; Boys and Girls Club; as well as mental health groups.

There are ten areas. If it is satisfactory with the group, we would see whether we can get presenters to be in front of us.

R. Sultan (Chair): I'm passed a note by our Clerk of Committees that the correct term is "witnesses." You have all been witnesses today — witnesses for obesity.

R. Sultan (Chair): We shall explore that further. Thank you for that invitation, Charlie. It would be delightful to return to the wonderful community of Williams Lake, where I spent many, many months of my life. Good, solid people. We will explore that possibility further.

I think we have exhausted ourselves. While I don't hear any stomach rumblings, I think we are intruding upon everybody's luncheon hour. We have stretched your endurance to give witness to this committee beyond the official closing hour of 12 o'clock by a considerable margin.

Once again, I'd like to thank Dr. Heather Manson and her team for a wonderfully productive morning and much valuable information and advice. Thank you.

Hansard Services publishes transcripts both in print and on the Internet.
Chamber debates are broadcast on television and webcast on the Internet.
Question Period podcasts are available on the Internet.

	1)	Dr. Heather Manson, Vice President, Health Services Integration
	2)	Dr. Brian O’Connor, Medical Health Officer, North Shore
	3)	Barbara Crocker, Community Nutritionist, Vancouver
	4)	Kathy Romses, Community Nutritionist, North Shore
	5)	Kay Wong, Community Nutritionist, Richmond



CONTENTS

		Page

Presentations		147
	H. Manson
	B. O'Connor
	K. Wong
	K. Romses
	B. Crocker

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