Re: Recommendations for Canada’s long-term recovery plan
Dear Prime Minister Trudeau,
We would like first to thank and commend you for your leadership throughout this pandemic. Your government’s
efforts have helped many people in Canada during this unprecedented time and have prevented Canada from facing
outcomes similar to those seen in other countries experiencing significant pandemic-related hardship and suffering.
We are writing to you with recommendations as you develop a plan for Canada’s long-term recovery and the
upcoming Speech from the Throne on September 23rd.
The COVID-19 pandemic has further exposed and amplified many healthcare shortfalls in Canada such as care for
older adults and mental health-care. Added to that, the economic fallout is impacting employment, housing, and
access to education. These social determinants of health contribute to and perpetuate inequality, which we see the
pandemic has already exacerbated for vulnerable groups. Action is needed now to address these challenges and
improve the health-care system to ensure Canada can chart a path toward an equitable economic recovery.
To establish a foundation for a stronger middle class, Canada must invest in a healthier and fairer society by
addressing health-care system gaps that were unmasked by COVID-19. We firmly believe that the measures we are
recommending below are critical and should be part of your government’s long-term recovery plan:
1. Ensure pandemic emergency preparedness
2. Invest in virtual care to support vulnerable groups
3. Improve supports for Canada’s aging population
4. Strengthen Canada’s National Anti-Racism Strategy
5. Improve access to primary care
6. Implement a universal single-payer pharmacare program
7. Increase mental health funding for health-care professionals
We know the months ahead will be challenging and that COVID-19 is far from over. As a nation, we have an
opportunity now, with the lessons from COVID-19 still unfolding, to bring about essential transformations to our
health-care system and create a safer and more equitable society.
1. Ensure pandemic emergency preparedness
We commend you for your work with the provinces and territories to deliver the $19 billion Safe Restart Agreement
as it will help, in the next six to eight months, to increase measures to protect frontline health-care workers and
increase testing and contact tracing to protect Canadians against future outbreaks. Moving forward, as you develop a
plan for Canada’s long-term recovery, we strongly recommend the focus remains in fighting the pandemic. Beyond
the six to eight months rollout of the Safe Restart Agreement, it is critical that a long-term recovery plan includes provisions to ensure a consistent and reliable availability of personal protective equipment (PPE) and large-scale
capacity to conduct viral testing and contact tracing.
2.Invest in virtual care to support vulnerable groups
The sudden acceleration in virtual care from home is a silver lining of the pandemic as it has enabled increased
access to care, especially for many vulnerable groups. While barriers still exist, the role of virtual care should
continue to be dramatically scaled up after COVID-19 and Canada must be cautious not to move backwards. Even
before the pandemic, Canadians supported virtual care tools. In 2018, a study found that two out of three people
would use virtual care options if available.i During the pandemic, 91% of Canadians who used virtual care reported
We welcome your government’s $240 million investment in virtual health-care and we encourage that a focus be
given to deploying technology and ensuring health human resources receive appropriate training in culturally
competent virtual care. We also strongly recommend accelerating the current 2030 target to ensure every person in
Canada has access to reliable, high-speed internet access, especially for those living in rural, remote, northern and
3.Improve supports for Canada’s aging population
Develop pan-Canadian standards for the long-term care sector
The pandemic has exposed our lack of preparation for managing infectious diseases anywhere, especially in the longterm
care sector. The result is while just 20% of COVID-19 cases in Canada are in long-term care settings, they
account for 80% of deaths — the worst outcome globally. Moreover, with no national standards for long-term care,
there are many variations across Canada in the availability and quality of service.iii We recommend that you lead the
development of pan-Canadian standards for equal access, consistent quality, and necessary staffing, training and
protocols for the long-term care sector, so it can be delivered safely in home, community, and institutional settings,
with proper accountability measures.
Meet the health-care needs of our aging population
Population aging will drive 20% of increases in health-care spending over the next years, which amounts to an
additional $93 billion in spending.iv More funding will be needed to cover the federal share of health-care costs to
meet the needs of older adults. This is supported by 88% of Canadians who believe new federal funding measures
are necessary.v That is why we are calling on the federal government to address the rising costs of population aging
by introducing a demographic top-up to the Canada Health Transfer. This would enhance the ability of provinces and
territories to meet the needs of Canada’s older adults and invest in long-term care, palliative care, and community
and home care.
4.Strengthen Canada’s National Anti-Racism Strategy
Anti-Black racism exists in social structures across Canada. Longstanding, negative impacts of these structural
determinants of health have created and continue to reinforce serious health and social inequities for racialized
communities in Canada. The absence of race and ethnicity health-related data in Canada prevents identification of
further gaps in care and health outcomes. But where these statistics are collected, the COVID-19 pandemic has
exploited age-old disparities and led to a stark over-representation of Black people among its victims. We are calling
for enhanced collection and analysis of race and ethnicity data as well as providing more funding under Canada’s
National Anti-Racism Strategy to address identified health disparities and combat racism via community-led
5. Improve access to primary care
Primary care is the backbone of our health-care system. However, according to a 2019 Statistics Canada surveyvi,
almost five million Canadians do not have a regular health care provider. Strengthening primary care through a teambased,
interprofessional approach is integral to improving the health of all people living in Canada and the
effectiveness of health service delivery. We recommend creating a one-time fund of $1.2 billion over four years to
Page 3 of 4
expand the establishment of primary care teams in each province and territory, with a special focus in remote and
underserved communities, based on the Patient’s Medical Home visionvii.
6. Implement a universal single-payer pharmacare program
People across Canada, especially those who are vulnerable, require affordable access to prescription medications that
are vital for preventing, treating and curing diseases, reducing hospitalization and improving quality of life.
Unfortunately, more than 1 in 5 Canadians reported not taking medication because of cost concerns, which can lead
to exacerbation of illness and additional health-care costs. We recommend a comprehensive, universal, public system
offering affordable medication coverage that ensures access based on need, not the ability to pay.
7.Increase mental health funding for health-care professionals
During the first wave of COVID-19, 47% of health-care workers reported the need for psychological support. They
described feeling anxious, unsafe, overwhelmed, helpless, sleep-deprived and discouraged.viii Even before COVID-
19, nurses, for instance, were suffering from high rates of fatigue and mental health issues, including PTSD.ix
Furthermore, health-care workers are at high risk for significant work-related stress that will persist long after the
pandemic due to the backlog of delayed care. Immediate long-term investment in multifaceted mental health supports
for health-care professionals is needed.
We look forward to continuing to work with you and your caucus colleagues on transforming the health of people in
Canada and the health system.
Tim Guest, M.B.A., B.Sc.N., RN
Canadian Nurses Association (CNA)
Tracy Thiele, RPN, BScPN, MN,
Canadian Federation of Mental Health
Lori Schindel Martin, RN, PhD,
Canadian Gerontological Nursing
E. Ann Collins, BSc, MD
Canadian Medical Association (CMA)
Canadian Support Workers Association
Dr. Cheryl L. Cusack RN, PhD
Community Health Nurses of Canada
Lenora Brace, MN, NP
Nurse Practitioner Association of
~ r. Cheryl
Hon. Chrystia Freeland, Minister of Finance
Hon. Patty Hajdu, Minister of Health
Hon. Deb Schulte, Minister of Seniors
Hon. Navdeep Bains, Minister of Innovation, Science and Industry
Ian Shugart, Clerk of the Privy Council and Secretary to Cabinet
Dr. Stephen Lucas, Deputy Minister of Health
Dr. Theresa Tam, Chief Public Health Officer of Canada
Subject: Improving Long-term Care for People in Canada
Dear Minister Hajdu and Minister Schulte,
We are writing to you with recommendations for responding to the staggering effects COVID-19 has had on our health-care system, particularly in long-term care (LTC) homes across Canada. These recommendations were recently unveiled by the Canadian Nurses Association (CNA) on May 27 through a report entitled 2020 Vision: Improving Long-term Care for People in Canada (attached to this letter). We invite you to read it and consider the proposals we are bringing forward.
As you know, Canada has had unacceptable rates of COVID-19-related deaths in LTC; by late April, 79% of the country’s deaths due to COVID-19 were linked to outbreaks in these homes. These tragic numbers are in part a result of decades of neglect of the LTC sector and a growing mismatch between the level of care required by people living in those settings, and the level of care available. Furthermore, the recent reports from the military deployed to Ontario and Quebec’s long-term care homes have emphasized the shocking and horrific conditions that exist in some nursing homes in Canada.
We applaud the Prime Minster’s recent commitment to work closely and support the province’s efforts to improve standards of care for older people in long-term care
homes across the country. Moreover, further decisive action needs to be undertaken. To address the flaws COVID-19 has revealed in the support and care systems available to Canada’s older people, we recommend that your Government take immediate action on three important fronts:
The Government of Canada should immediately appoint a commission of inquiry on aging;
Federal public health leaders must work with provincial, territorial and Indigenous governments and public health leaders to review the country’s COVID-19 response and organize preparations for the next pandemic;
Federal, provincial and territorial governments must increase investments in community, home and residential care to meet the needs of our aging population.
As the Prime Minister indicated last week, providing support in the short term and having broader discussions in the long term is critical. We believe many solutions can be put in place now in some long-term care homes if they had better funding, for example. In the long term, a deeper look to identify the best models for delivering better health and social services will support safe and dignified aging for every person in Canada.
We recognize the challenges involved to address the issues in the support and care systems for older people in Canada. The benefits of redesigning how we provide care for older people (Canada’s largest growing demographic) and others with complex continuing care needs will go beyond improving their lives and health. A good long-term care system, in tandem with effective, well-organized community and home care, will ease pressure on the acute-care system and eliminate many of the gaps in the continuum of care that too often result in previously independent older people landing in the hospital or long-term care.
Acting on these three recommendations will help to provide a solid foundation on which to build a safe and dignified future for Canada’s older people. Canada is known
for its humanitarian work around the world. It’s time we brought those values home, to care for the people to whom this country and each one of us owes so much.
We look forward to discussing these proposals with you and your staff as soon as possible. Sincerely,
RN, MN, PhD, CCHN(C) President Canadian Nurses Association
RN, BSN, MN, PhD(c) President,
Canadian Association for Rural and Remote Nursing
Canadian Association of Social Workers
RN, BN, ASMH, Med President Canadian Family Practice Nurses Association
RPN, MN, PhD(c)President,
Lori Schindel Martin,
RN, PHD President
Canadian Gerontological Nursing Association
BN, RN, CPMHN(C) Past President
Canadian Federation of Mental Health Nurses
RN, BScN, President
Canadian Indigenous Nurses Association
MD CCFP (PC) FCFP President Canadian Medical Association
Canadian Public Health Association
Miranda R Ferrier
MD CM, CCFP, FCFP, CAE, ICD. D
Executive Director & Chief Executive Officer College of Family Physicians of Canada
Ontario Personal Support Workers Association
Canadian Support Workers Association
RPN-GPNC(C), BAHSc (Hons), MHSc(c)
Professional Advocacy Director
Gerontological Nursing Association
MN, NP, President NPAC-AIIPC
Nurse Practitioner Association of Canada
Dear Minister Freeland:
We are a national consortium of experts who serve and advocate for the needs and rights of older people. We are delighted by the recent appointment of a new Minister of Seniors, and send our congratulations to the Honourable Filomena Tassi. We are also encouraged by our Government’s commitment to support the health and economic well-being of all Canadians, and heartened by your promise to listen to, and to be informed by feedback from Canadians. It is in this spirit that we are writing today regarding the need for Canada to provide support and leadership with a goal of developing and ratifying a United Nations (UN) Convention on the Rights of Older Persons.
In the context of massive global demographic shifts and an aging population, insightful and careful reflection by the leaders of our organizations has led to universal and strong support for the creation and implementation of a UN Convention to specifically recognize and protect the human rights of our older persons.
A UN Convention on the Rights of Older Persons will:
enshrine their rights as equal with any other segment of the population with the same legal rights as any other human being;
categorically state that it is unacceptable to discriminate against older people throughout the world;
clarify the state’s role in the protection of older persons;
provide them with more visibility and recognition both nationally and internationally, which is vitally important given the rate at which Canadian and other societies are ageing;
advance the rights of older women at home and as a prominent factor in Canada’s foreign policy;
have a positive, real-world impact on the lives of older citizens who live in poverty, who are disproportionately older women, by battling ageism that contributes to poverty, ill-health, social isolation, and exclusion;
support the commitment to improve the lives of Indigenous Peoples; members of the LGBTQ community, and visible and religious minorities; and,
provide an opportunity for Canada to play a leadership role at the United Nations while at the same time giving expression to several of the Canadian government’s stated foreign policy goals.
We have projected that the cost and impact of not having such a Convention would have a significant negative impact on both the physical and mental health of older Canadians. The profound and tragic consequence would have a domino effect in all domains of their lives including social determinants of health, incidence and prevalence of chronic diseases, social and psychological functioning, not to mention massive financial costs to
society. There is recognition of this need internationally and ILC-Canada, along with other Canadian NGOs and organizations have been active at the UN to help raise awareness of the ways a UN Convention on the Rights of Older Persons would contribute to all countries.
Changes have already been implemented by our Government that are consistent and aligned with a UN Convention, such as improving the income of vulnerable Canadian seniors, funding for long term care and support for community based dementia programs. These initiatives are all in keeping with support for a Convention on the Rights of Older Persons. They are also reflective of our country’s commitment to engage more fully with the United Nations and provide Canada the stage to demonstrate leadership on a vital international issue. It is an opportunity to champion the values of inclusive government, respect for diversity and human rights including the human rights of women.
Scientific evidence demonstrates that human rights treaties help to drive positive change in the lives of vulnerable groups of people. In many countries in the world, older people are not adequately protected by existing human rights law, as explicit references to age are exceedingly rare. Even in countries like Canada, where there are legal frameworks that safeguard older people, a Convention would provide an extra layer of protection, particularly if the Convention has a comprehensive complaints mechanism.
Older adults need to be viewed as a growing but underutilized human resource. By strengthening their active role in society including the workforce, they have tremendous capacity, knowledge, and wisdom to contribute to the economy and general well-being of humankind.
We are requesting you meet with our representatives, to discuss the vital role of a UN Convention on the Rights of Older Persons and the role your government could play in improving the lives of older people in Canada and around the world. The fact that Canada is ageing is something to celebrate. We are all ageing, whether we are 20 or 85. This is a ”golden opportunity” to showcase Canada as a nation that will relentlessly pursue doing the “right thing” for humanity by supporting a UN Convention that ensures that our future is bright.
Please accept our regards, and thank you for your attention to this request. We await your response. Sincerely,
Margaret Gillis, President, International Longevity Centre Canada
Dr. Kiran Rabheru, Chair of the Board, International Longevity Centre Canada
Linda Garcia, Director, uOttawa LIFE Research Institute
cc: The Right Honourable Justin Trudeau Prime Minister of Canada
The Honourable Filomena Tassi Minister of Seniors
The Honourable Jean Yves Duclos
Minister for Families, Children and Social Development
Ambassador Marc-Andre Blanchard
Permanent Representative to Canada at the United Nations
The Honourable Ginette Petitpas Taylor
International Longevity Centre Canada
Dr. Kiran Rabheru
Chair of the Board, International Longevity Centre Canada
Linda Garcia, PhD
LIFE Research Institute
Dr. Laurent Marcoux
Canadian Medical Association
Andrew Padmos, BA, MD, FRCPC, FACP
Chief Executive Officer
Dani Prud’Homme Directeur général FADOQ
Peter Lukasiewicz Chief Executive Officer Gowling WLG
Dr. Dallas Seitz, MD, FRCPC
Dr. Frank Molnar
President, Canadian Geriatrics Society
Dr. David Conn
Canadian Coalition for Senior’s Mental Health
Director - Canadian Coalition for Seniors’ Mental Health
Chief Executive Officer, Speech-Language & Audiology Canada
President Canadian Nurses Association
Janice Christianson-Wood, MSW, RSW Title/Organization: President, Canadian Association of Social Workers / Présidente, l’Association canadienne des travail-
Chief Executive Officer/Chef de la direction
Ondina Love, CAE
Chief Executive Officer Canadian Dental Hygienists Association
National Association of Federal Retirees /Association nationale
des retraités fédéraux
Laura Tamblyn Watts
National Initiative for the Care of the Elderly
Dr. Keri-Leigh Cassidy
Founder Fountain of Health
Dr. Beverley Cassidy Geriatric Psychiatris Seniors Mental Health
Dalhousie University Dept of Psychiatry
Jenny Neal and Janet Siddall
CO Chairs, Leadership Team Grandmothers Advocacy Network (GRAN)
President and CEO
Dr. Becky Temple, MD, CCFP, CCPE
Medical Director Northeast, Northern Health Medical Lead Privilege Dictionary Review, BCMQI
J. Van Aerde, MD, MA, PhD, FRCPC
Clinical Professor of Pediatrics - Universities of Alberta & British Columbia, Canada
Associate Faculty - Leadership Studies - Royal Roads Univ, Victo- ria, BC, Canada
Past-President - Canadian Society of Physician Leaders Editor-in-Chief / Canadian Journal of Physician Leadership
Dr. Rollie Nichol, MD, MBA, CCFP, CCPE
Associate Chief Medical Officer, Alberta Health Services
Dr. Shannon Fraser, MSc, FRCSC, FACS
Secretary / Treasurer, CSPL Chief General Surgery Jewish General Hospital
Linda Gobessi MD FRCPC
Geriatric Psychiatry Community Services of Ottawa Ottawa
Executive Director / Directrice générale
Services communautaires de géronto- psychiatrie d’ Ottawa Geriatric Psychiatry Community Services of Ottawa
Ging-Yuek Robin Hsiung, MD MHSc FRCPC FACP FAAN
Ralph Fisher and Alzheimer Society of BC Professor Director of Clinical Research
Director of Fellowship in Behavioural Neurology UBC Hospital Clinic for Alzheimer and Related Disorders
Division of Neurology, Department of Medicine University of British Columbia
Senior Social Worker Baycrest Health Sciences
Harinder Sandhu, D.D.S., Ph.D
Professor and Past Director
Schulich Dentistry & Vice Dean, Schulich School of Medicine & Dentistry
Dr. Christopher Frank,
Chair of Geriatric Education and Recruitment Initiative
Jennie Wells, MD
Associate Professor, University of Western Ontario Department of Medicine
Chair/Chief Division of Geriatric Medicine Parkwood Institute
Laura Diachun, MD
Program Director, Undergrad Geriatric Education University of Western Ontario
Department of Medicine, Division of Geriatric Medicine Parkwood Institute
Sheri-Lynn Kane, MD Program Director Internal Medicine Dept of Medicine Education Office
Niamh O’Regan, MB ChB,
Assistant Professor, University of Western Ontario Parkwood Institute
Michael Borrie, MB ChB, FRCPC
Professor, University of Western Ontario Department of Medicine, Division of Geriatric Medicine
Jenny Thain, MRCP (Geriatrics)
Assistant Professor, University of Western Ontario Department of Medicine, Division of Geriatric Medicine Victoria Hospital
Peter R. Butt MD CCFP FCFP
Assoc. Professor, Department of Family Medicine, College of Medicine,
University of Saskatchewan
Mamta Gautam, MD, MBA, FRCPC, CCPE Dept of Psychiatry, University of Ottawa Psychiatrist, Psychosocial Oncology Program, The Ottawa Hospital
President and CEO, PEAK MD Inc.
Dr. Shabbir Amanullah
Arun V. Ravindran, MBBS, MSc, PhD, FRCPC, FRCPsych
Professor and Director, Global Mental Health and the Office of Fellowship Training, Department of Psychiatry,
Graduate Faculty, Department of Psychology and Institute of Medical Sciences, University of Toronto
Sarah Thompson, MD, FRCPC Geriatric Psychiatrist Seniors’ Mental Health Team
Addictions and Mental Health Program
Louise Plouffe, Ph.D.
Director of Research, ILC Canada (retired)
Kimberley Wilson, PhD, MSW
Assistant Professor, Adult Development & Aging, Department of Family Relations & Applied Nutrition, University of Guelph
Andrew R. Frank M.D. B.Sc.H. F.R.C.P.(C)
Cognitive and Behavioural Neurologist Medical Director, Bruyère Memory Program Bruyère Continuing Care
Diane Hawthorne Family Physician BSc, MD, CCFP, FCFP
Dr. Ken Le Clair
Prof Emeritus Queens University and. Lead Policy Physician Consultant to Ontario. Seniors Behavioral Support Initative Queens University
Health equity is created when individuals have the opportunity to achieve their full health potential; equity is undermined when preventable and avoidable systematic conditions constrain life choices.1 These conditions are known as the social determinants of health. The World Health Organization (WHO) defines the social determinants of health as the circumstances in which people are born, develop, live and age.2 In 2002, researchers and policy experts at a York University conference identified the following list: income and income distribution; early life; education; housing; food security; employment and working conditions; unemployment and job security; social safety net; social inclusion/exclusion; and health services. 3
Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.4 Any actions to improve health and tackle health inequity must address the social determinants and their impact on daily life.5
THE SOCIAL DETERMINANTS OF HEALTH AND HEALTH STATUS
Social status is one of the strongest predictors of health at the population level. There is a social gradient of health such that those with higher social status experience greater health than those with lower social status. The social gradient is evident not only when comparing the most disadvantaged to the most advantaged; within each strata, even among those holding stable middle-class jobs, those at the lowest end fare less well than those at the higher end. The Whitehall study of civil servants in the United Kingdom found that lower ranking staff have a greater disease burden and shorter life expectancy than higher-ranking staff.6 Differences in medical care did not account for the differences in mortality.7 This gradient has been demonstrated for just about any health condition.8
Hundreds of research papers have confirmed that people in the lowest socio-economic groups carry the greatest burden of illness.9 In 2001, people in the neighbourhoods with the highest 20% income lived about three years longer than those in the poorest 20% neighbourhoods (four years for men; two years for women).10 Dietary deficiencies, common in food insecure households, can lead to an increased chance of chronic disease and greater difficulty in disease management. It is estimated that about 1.1 million households in Canada experience food insecurity, with the risk increasing in single-parent households and in families on social assistance.11
Studies suggest that adverse socio-economic conditions in childhood can be a greater predictor of cardiovascular disease and diabetes in adults than later life circumstances and behavioural choices.12 Effective early childhood development offers the best opportunity to reduce the social gradient and improve the social determinants of health,13 and offers the greatest return on investment.14
Low income contributes not only to material deprivation but social isolation as well. Without financial resources, it is more difficult for individuals to participate in cultural, educational and recreational activities or to benefit from tax incentives. Suicide rates in the lowest income neighbourhoods are almost twice as high as in the wealthiest neighbourhoods.15 This social isolation and its effects are most striking in Canada's homeless population. Being homeless is correlated with higher rates of physical and mental illness. In Canada, premature death is eight to 10 times higher among the homeless.16
The gradient in other social determinants can have an adverse impact as well. A study conducted in the Netherlands estimated that average morbidity and mortality in the overall population could be reduced 25-50% if men with lower levels of education had the same mortality and morbidity levels as those men with a university education.17 Employment status also follows this gradient, such that having a job is better than being unemployed. 18 Unemployment is correlated with increased blood pressure, self-reported ill health, drug abuse, and reductions in normal activity due to illness or injury.19 Unemployment is associated with increases in domestic violence, family breakups and crime. Finally, job security is relevant.20 Mortality rates are higher among temporary rather than permanent workers.21
Canada's Aboriginal people face the greatest health consequences as a result of the social determinants of health. Poverty, inadequate or substandard housing, unemployment, lack of access to health services, and low levels of education characterize a disproportionately large number of Aboriginal peoples.22 The crude mortality rate for First Nations is higher and life expectancy lower than the Canadian average.23 Aboriginal peoples experience higher rates of chronic disease, addictions, mental illness and childhood abuse.24 Aboriginal peoples have higher rates of suicide, with suicide being the leading cause of potential years of life lost in both the First Nations and Inuit populations.25
THE SOCIAL DETERMINANTS OF HEALTH AND CANADA'S HEALTH SYSTEM
These differences in health outcomes have an impact on the health care system. Most major diseases including heart disease and mental illness follow a social gradient with those in lowest socio-economic groups having the greatest burden of illness.26 Those within the lowest socio-economic status are 1.4 times more likely to have a chronic disease, and 1.9 times more likely to be hospitalized for care of that disease.27 Chronic diseases such as diabetes account for 67% of direct health care costs and 60% indirect costs.28
Research has shown that Canadians with low incomes are higher users of general practitioner, mental health, and hospital services.29 People in the lowest income group were almost twice as likely as those in the highest income group to visit the emergency department for treatment. 30 Part of this may be caused by differences in access to care. Low-income Canadians are more likely to report that they have not received needed health care in the past 12 months.31 Those in the lowest income groups are 50% less likely than those in the highest income group to see a specialist or get care in the evenings or on weekends, and 40% more likely to wait more than five days for a doctor's appointment.32
Barriers to health care access are not the only issue. Research in the U.K.33 and U.S.34 has found that compliance with medical treatment tends to be lower in disadvantaged groups, leading to pain, missed appointments, increased use of family practice services and increased emergency department visits, and corresponding increases in cost. In the U.S., non-adherence has been attributed to 100,000 deaths annually.35 Researchers have reported that those in the lowest income groups are three times less likely to fill prescriptions, and 60% less able to get needed tests because of cost.36
These differences have financial costs. In Manitoba for example, research conducted in 1994 showed that those in the lowest income decile used services totaling $216 million (12.2%). In the same year, those in the highest income decile consumed $97 million (5.5%) of expenditures. If expenditures for the bottom half of the population by income had been the same as the median, Manitoba would have saved $319 million or 23.1% of their health care budget. 37 According to a 2011 report, low-income residents in Saskatoon consume an additional $179 million in health care costs than middle income earners.38
To reduce the burden of illness and therefore system costs, Canada needs to improve the underlying social and economic determinants of health of Canadians. However, until these changes have time to improve the health status of the population, there will still be a large burden of illness correlated to these underlying deficiencies. As a result, the health system will need to be adequately resourced to address the consequences of the social determinants of health.
AREAS FOR ACTION
The WHO Commission on the Social Determinants of Health identified four categories through which actions on social determinants can be taken. These include:
* reducing social stratification by reducing inequalities in power, prestige, and income linked to socio-economic position;
* decreasing the exposure of individuals and populations to the health-damaging factors they may face;
* reducing the vulnerability of people to the health damaging conditions they face; and
* intervening through health care to reduce the consequences of ill health caused by the underlying determinants.39
All of these areas offer possibilities for action by the physician community. The following section provides suggestions for action by the medical profession through: CMA and national level initiatives; medical education; leadership and research; and clinical practice.
CMA and national level initiatives
Despite the strong relationship between the social determinants of health and health, little in the way of effective action has resulted. CMA and its partners can and should, advocate for research and push for informed healthy public policy, including health impact assessments for government policies. Additionally, targeted population health programs aimed at addressing the underlying determinants should be supported.
All Canadians need a better understanding of the health trends and the impacts of various social and economic indicators. Information about the differences in specific health indicators, collected over time,40 is essential to the task of describing underlying health trends and the impacts of social and economic interventions. Data within primary care practices could be assembled into (anonymous) community-wide health information databases, to address this need.
CMA recommends that:
1. The federal government recognize the relationship of the social determinants of health on the demands of the health care system and that it implement a requirement for all cabinet decision-making to include a Health Impact Assessment.
2. Options be examined for minimizing financial barriers to necessary medical care including pharmaceuticals and medical devices necessary for health.
3. Federal and provincial/territorial governments examine ways to improve the social and economic circumstances of all Canadians.
4. Efforts be made to educate the public about the effect of social determinants on individual and population health.
5. Appropriate data be collected and reported on annually. This data should be locally usable, nationally comparable and based on milestones across the life course.
Medical education is an effective means to provide physicians with the information and tools they require to understand the impact of social determinants on the health of their patients and deal with them accordingly.41 In 2001, Health Canada published a report in which they stated that the primary goal of medical education should be the preparation of graduates who know how to reduce the burden of illness and improve the health of the communities in which they practice.42 Among the report's recommendations was a call for greater integration of the social determinants in medical curricula.43 Although the CanMEDS framework has been a part of the Royal College of Physicians and Surgeons of Canada's accreditation process since 2005, challenges to the integration of these competencies remain.44
The report called for a greater emphasis on providing medical students with firsthand experiences in the community and with distinct populations (service learning),45 which addresses the difficulties in teaching the social aspects of medicine within a traditional classroom or hospital setting.46 Many such programs exist across the country.47 However, these programs are still limited and there is a need to increase the availability of longitudinal programs which allow students to build on the skills they develop throughout medical school.
Increasingly residency programs which focus on the social determinants of health are being offered.48 These programs are a means of providing physicians with the proper tools to communicate with patients from diverse backgrounds49 and reduce behaviours that marginalized patients have identified as barriers to health services.50 It also provides residents with physician role models who are active in the community. However, medical residents note a lack of opportunities to participate in advocacy during residency.51 Further, while experiential programs are effective in helping to reduce barriers between physicians and patients from disadvantaged backgrounds, greater recruitment of medical students from these marginalized populations should also be explored and encouraged.
Finally, physicians in practice need to be kept up to date on new literature and interventions regarding the social determinants. Innovations which help address health equity in practice should be shared with interested physicians. In particular, there is a need for accredited continuing medical education (CME) and a means to encourage uptake.52
CMA recommends that:
6. Greater integration of information on the social determinants and health inequity be provided in medical school to support the CanMEDS health advocate role
7. All medical schools and residency programs offer service learning programs, to provide students with an opportunity to work with diverse populations in inner city, rural and remote settings, and to improve their skills in managing the impact of the social determinants on their patients.
8. CME on the social determinants of health and the physician role in health equity be offered and incentivized for practising physicians.
Leadership and research
Within many communities in Canada, there are physicians who are working to address social determinants and health equity within the patient populations they serve. This is done in many cases through collaboration with partners within and outside of the health care system. Providing these local physician leaders with the tools they need to build these partnerships, and influence the policies and programs that affect their communities is a strategy that needs to be explored.
Evidence-based research about health equity, the clinical setting and the role of physicians is underdeveloped. Interested physicians may wish to participate in research about practice level innovations, as a means of contributing to the evidence base for 'health equity' interventions or simply to share best practices with interested colleagues. Further, physicians can provide the medical support to encourage the adoption of early childhood development practices for example, which support later adult health. In time, research will contribute to training, continuing medical education and potentially to clinical practice guidelines.
Physicians can provide leadership in health impact assessments and equity audits within the health care system as well. Data is essential to identify health equity challenges within a program, to propose and test measures that address the issues underlying the disparities. Formal audits and good measurement are essential to develop evidence-based policy improvements.53 Innovative programs such as those within the Saskatoon Health Region and the Centre for Addiction and Mental Health in Toronto are examples of using these tools to improve access and reduce inequities.
CMA recommends that:
9. Physicians who undertake leadership and advocacy roles should be protected from repercussions in the workplace, e.g., the loss of hospital privileges.
10. Physician leaders explore opportunities to strengthen the primary care public health interface within their communities by working with existing agencies and community resources.
11. Physician leaders work with their local health organizations and systems to conduct health equity impact assessments in order to identify challenges and find solutions to improve access and quality of care.
12. Physicians be encouraged to participate in or support research on best practices for the social determinants of health and health equity. Once identified, information sharing should be established in Canada and internationally.
In consultation with identified health equity physician champions, a number of clinical interventions have been identified which are being undertaken by physicians across the country. These interventions could be undertaken in many practice settings given the right supports, and could be carried out by various members of the collaborative care team.1
First, a comprehensive social history is essential to understand how to provide care for each patient in the context of their life.54 There are a number of tools that can be used for such a consultation and more are in development.55 However, consolidation of the best ideas into a tool that is suitable for the majority of health care settings is needed. There is some concern that asking these questions is outside of the physician role. The CanMEDS health advocate role clearly sees these types of activities as part of the physician role.56 The 'Four Principles of Family Medicine' defined by the College of Family Physicians of Canada, affirms this role for physicians as well.57
Community knowledge was identified as a strategy for helping patients. Physicians who were aware of community programs and services were able to refer patients if/when social issues arose.58 Many communities and some health providers have developed community resource guides.59 For some physicians, developing a network of community resources was the best way to understand the supports available.
As a corollary, physicians noted their work in helping their patients become aware of and apply for the various social programs to which they are entitled. The programs vary by community and province/territory, and include disability, nutritional supports and many others. Most if not all of these programs require physicians to complete a form in order for the individual to qualify. Resources are available for some of these programs,60 but more centralized supports for physicians regardless of practice location or province/territory are needed.
Physicians advocate on behalf of their patients by writing letters confirming the medical limitations of various health conditions or the medical harm of certain exposures.61 For example, a letter confirming the role of mold in triggering asthma may lead to improvements in the community housing of an asthmatic. Additionally, letters might help patients get the health care services and referrals that they require. As identified leaders within the community, support from a physician may be a 'game-changer' for patients.
Finally, the design of the clinic, such as hours of operation or location, will influence the ability of people to reach care.62
CMA recommends that:
13. Tools be provided for physicians to assess their patients for social and economic causes of ill health and to determine the impact of these factors on treatment design.
14. Local databases of community services and programs (health and social) be developed and provided to physicians. Where possible, targeted guides should be developed for the health sector.
15. Collaborative team-based practice be supported and encouraged.
16. Resources or services be made available to physicians so that they can help their patients identify the provincial/territorial and federal programs for which they may qualify.
17. Physicians be cognizant of equity considerations when considering their practice design and patient resources.
18. All patients be treated equitably and have reasonable access to appropriate care, regardless of the funding model of their physician.
Socio-economic factors play a larger role in creating (or damaging) health than either biological factors or the health care system. Health equity is increasingly recognized as a necessary means by which we will make gains in the health status of all Canadians and retain a sustainable publicly funded health care system. Addressing inequalities in health is a pillar of CMA's Health Care Transformation initiative. Physicians as clinicians, learners, teachers, leaders and as a profession can take steps to address the problems on behalf of their patients.
1 A full review of the consultations is provided in the companion paper The Physician and Health Equity: Opportunities in Practice.
1 Khalema, N. Ernest (2005) Who's Healthy? Who's Not? A Social Justice Perspective on Health Inequities. Available at: http://www.uofaweb.ualberta.ca/chps/crosslinks_march05.cfm
2 World Health Organization (2008) Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Available at: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf
3 Public Health Agency of Canada (N.D.) The Social Determinants of Health: An Overview of the Implications for Policy and the Role of the Health Sector. Available at: http://www.phac-aspc.gc.ca/ph-sp/oi-ar/pdf/01_overview_e.pdf
4 Keon, Wilbert J. & Lucie Pépin (2008) Population Health Policy: Issues and Options. Available at: http://www.parl.gc.ca/Content/SEN/Committee/392/soci/rep/rep10apr08-e.pdf
5 Friel, Sharon (2009) Health equity in Australia: A policy framework based on action on the social determinants of obesity, alcohol and tobacco. The National Preventative Health Taskforce. Available at: http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/0FBE203C1C547A82CA257529000231BF/$File/commpaper-hlth-equity-friel.pdf
6 Wilkinson, Richard & Michael Marmot eds. (2003) Social Determinants of Health: The Solid Facts: Second Edition. World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf
7 Khalema, N. Ernest (2005) Who's Healthy?...
8 Dunn, James R. (2002) The Health Determinants Partnership Making Connections Project: Are Widening Income Inequalities Making Canada Less Healthy? Available at: http://www.opha.on.ca/our_voice/collaborations/makeconnxn/HDP-proj-full.pdf
10 Wilkins, Russ; Berthelot, Jean-Marie; and Ng E. . Trends in Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996. Health Reports 13 [Supplement]: pp. 45-71
11 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health: The Canadian Facts. Available at: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf
12 Raphael, Dennis (2003) "Addressing The Social Determinants of Health In Canada: Bridging The Gap Between Research Findings and Public Policy." Policy Options. March 2003 pp.35-40.
13 World Health Organization (2008) Closing the gap in a generation...
14 Hay, David I. (2006) Economic Arguments for Action on the Social Determinants of Health. Canadian Policy Research Networks. Available at: http://www.cprn.org/documents/46128_en.pdf
15 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
17 Whitehead, Margaret & Goran Dahlgren (2006) Concepts and principles for tackling social inequities in health: Levelling up Part 1. World Health Organization Europe. Available at: http://www.euro.who.int/__data/assets/pdf_file/0010/74737/E89383.pdf
18 Wilkinson, Richard & Michael Marmot eds. (2003) "Social Determinants of Health...
19 Ferrie, Jane E. (1999) "Health consequences of job insecurity." In Labour Market Changes and Job Security: A Challenge for Social Welfare and Health Promotion. World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98411/E66205.pdf
20 Marmot, Michael (2010) Fair Society Healthy Lives: The Marmot Review: Executive Summary. Available at: http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLivesExecSummary.pdf
21 World Health Organization (2008) Closing the gap in a generation...
22 Aboriginal Healing Foundation, Frequently Asked Questions (Ottawa: Canadian Government Publishing Directorate, 2009) Available at: http://www.ahf.ca/faq
23Health Council of Canada, "The Health Status Of Canada's First Nations, Métis And Inuit Peoples", 2005, Available at:http://healthcouncilcanada.ca.c9.previewyoursite.com/docs/papers/2005/BkgrdHealthyCdnsENG.pdf
24 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
25Health Council of Canada, (2005)"The Health Status Of Canada's First Nations, Métis And Inuit Peoples...
26 Dunn, James R. (2002) The Health Determinants Partnership...
27 CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions. http://secure.cihi.ca/cihiweb/products/PHC_Experiences_AiB2012_E.pdf
28 Munro, Daniel (2008) "Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the Socio-Economic Determinants of Health." The Conference Board of Canada. Available at: http://www.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb
29 Williamson, Deanna L. et.al. (2006) "Low-income Canadians' experiences with health-related services: Implications for health care reform." Health Policy. 76(2006) pp. 106-121.
30 CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians...
31 Williamson, Deanna L. et.al. (2006) "Low-income Canadians'...
32 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
33 Neal, Richard D. et.al. (2001) "Missed appointments in general practice: retrospective data analysis from four practices." British Journal of General Practice. 51 pp.830-832.
34 Kennedy, Jae & Christopher Erb (2002) "Prescription Noncompliance due to Cost Among Adults with Disabilities in the United States." American Journal of Public Health. Vol.92 No.7 pp. 1120-1124.
35 Bibbins-Domingo, Kirsten & M. Robin DiMatteo. Chapter 8: Assessing and Promoting Medication Adherence. pp. 81-90 in King, Talmadge E, Jr. & Margaret B. Wheeler ed. (2007) Medical Management of Vulnerable and Underserved Patients...
36 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
37 Dunn, James R. (2002) The Health Determinants Partnership...
38 Saskatoon Poverty Reduction Partnership (2011) from poverty to possibility...and prosperity: A Preview to the Saskatoon Community Action Plan to Reduce Poverty. Available at: http://www.saskatoonpoverty2possibility.ca/pdf/SPRP%20Possibilities%20Doc_Nov%202011.pdf
39 World Health Organization (2005) Action On The Social Determinants Of Health: Learning From Previous Experiences. Available at: http://www.who.int/social_determinants/resources/action_sd.pdf
40 Braveman, Paula (2003) "Monitoring Equity in Health and Healthcare: A Conceptual Framework."Journal of Health, Population and Nutrition. Sep;21(3):181-192.
41 Royal College of Physicians (2010) How doctors can close the gap: Tackling the social determinants of health through culture change, advocacy and education. Available at: http://www.marmotreview.org/AssetLibrary/resources/new%20external%20reports/RCP-report-how-doctors-can-close-the-gap.pdf
42 Health Canada (2001) Social Accountability: A Vision for Canadian Medical Schools. Available at: http://www.medicine.usask.ca/leadership/social-accountability/pdfs%20and%20powerpoint/SA%20-%20A%20vision%20for%20Canadian%20Medical%20Schools%20-%20Health%20Canada.pdf
44 Dharamsi, Shafik; Ho, Anita; Spadafora, Salvatore; and Robert Woollard (2011) "The Physician as Health Advocate: Translating the Quest for Social Responsibility into Medical Education and Practice." Academic Medicine. Vol.86 No.9 pp.1108-1113.
45 Health Canada (2001) Social Accountability: A Vision for Canadian Medical Schools...
46 Meili, Ryan; Fuller, Daniel; & Jessica Lydiate. (2011) "Teaching social accountability by making the links: Qualitative evaluation of student experiences in a service-learning project." Medical Teacher. 33; 659-666.
47 Ford-Jones, Lee; Levin, Leo; Schneider, Rayfel; & Denis Daneman (2012) "A New Social Pediatrics Elective-A Tool for Moving to Life Course Developmental Health." The Journal of Pediatrics. V.160 Iss. 3 pp.357-358; Meili, Ryan; Ganem-Cuenca, Alejandra; Wing-sea Leung, Jannie; & Donna Zaleschuk (2011) "The CARE Model of Social Accountability: Promoting Cultural Change." Academic Medicine. Vol.86 No.9 pp.1114-1119.
48 Cuthbertson, Lana "U of A helps doctors understand way of life in the inner city." Edmonton Journal Dec 22, 2010. Available at: http://www2.canada.com/edmontonjournal/news/cityplus/story.html?id=943d7dc3-927b-4429-878b-09b6e00595e1
49 Willems, S.; Maesschalck De, S.; Deveugele, M.; Derese, A. & J. De Maeseneer (2005) "Socio-economic status of the patient and doctor-patient communication: does it make a difference?" Patient Education and Counseling. 56 pp. 139-146.
50 Bloch, Gary; Rozmovits, Linda & Broden Giambone (2011) "Barriers to primary care responsiveness to poverty as a risk factor for health." BioMed Central Family Practice. Available at: http://www.biomedcentral.com/content/pdf/1471-2296-12-62.pdf; Schillinger, Dean; Villela, Theresa J. & George William Saba. Chapter 6: Creating a Context for Effective Intervention in the Clinical Care of Vulnerable Patients. pp.59-67. In King, Talmadge E, Jr. & Margaret B. Wheeler ed. (2007) Medical Management of Vulnerable and Underserved Patients.
51 Dharamsi, Shafik; Ho, Anita; Spadafora, Salvatore; and Robert Woollard (2011) "The Physician as Health Advocate...
52 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
53 Meili, Ryan (2012) A Healthy Society: How A Focus On Health Can Revive Canadian Democracy. Saskatoon: Canada. Purich Publishing Limited. pp.36
54 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
55 Bloch, Gary (2011) "Poverty: A clinical tool for primary care "Family & Community Medicine, University of Toronto. Available at: http://www.healthprovidersagainstpoverty.ca/system/files/Poverty%20A%20Clinical%20Tool%20for%20Primary%20Care%20%28version%20with%20References%29_0.pdf ; Bricic, Vanessa; Eberdt, Caroline & Janusz Kaczorowski (2011) "Development of a Tool to Identify Poverty in a Family Practice Setting: A Pilot Study." International Journal of Family Medicine. Available at: http://www.hindawi.com/journals/ijfm/2011/812182/ ; Based on form developed by: Drs. V. Dubey, R.Mathew & K. Iglar; Revised by Health Providers Against Poverty (2008) " Preventative Care Checklist Form: For average-risk, routine, female health assessments." Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders ; Based on form developed by: Drs. V. Dubey, R.Mathew & K. Iglar; Revised by Health Providers Against Poverty (2008) " Preventative Care Checklist Form: For average-risk, routine, male health assessments." Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders
56 Frank, Dr. Jason R. ed. (2005) "The CanMEDS 2005 Physician Competency Framework: Better standards. Better physicians. Better Care." Office of Education: The Royal College of Physicians and Surgeons of Canada. Available at: http://rcpsc.medical.org/canmeds/CanMEDS2005/CanMEDS2005_e.pdf
57 Tannenbaum, David et.al. (2011) "Triple C Competency-based Curriculum: Report of the Working Group on Postgraduate Curriculum Review-Part 1
58 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
59 Doyle-Trace L, Labuda S. Community Resources in Cote-des-Neiges. Montreal: St Mary's Hospital Family Medicine Centre, 2011. (This guide was developed by medical residents Lara Doyle-Trace and Suzan Labuda at McGill University.); Mobile Outreach Street Health (N.D.) Pocket MOSH: a little MOSH for your pocket: A Practitioners Guide to MOSH and the Community We Serve. Available at: http://www.cdha.nshealth.ca/mobile-outreach-street-health
60 Health Providers Against Poverty (N.D.) Tools and Resources. Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders
61 Meili, Ryan (2012) A Healthy Society: How A Focus...pp.61; UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
62 Rachlis, Michael (2008) Operationalizing Health Equity: How Ontario's Health Services Can Contribute to Reducing Health Disparities. Wellesley Institute. Available at: http://wellesleyinstitute.com/files/OperationalizingHealthEquity.pdf
Restricting Marketing of Unhealthy Foods and Beverages to Children and Youth in Canada: A Canadian Health Care and Scientific Organization Policy Consensus Statement
Federal government to immediately
begin a legislative process to restrict all
marketing targeted to children under the
age of 13 of foods and beverages high in
saturated fats, trans-fatty acids, free
sugars or sodium and that in the interim
the food industry immediately ceases
marketing of such food to children.
PURPOSE OF STATEMENT
This policy consensus statement was developed to
reflect the growing body of evidence linking the
promotion and consumption of diets high in
saturated fats, trans-fatty acids, free sugars or
sodium1 to cardiovascular and chronic disease
(hypertension, dyslipidemia, diabetes mellitus,
obesity, cancer, and heart disease and stroke)—
leading preventable risk factors and causes of death
and disability within Canada and worldwide. (1-3)
(1) For the remainder of the document, reference to foods
high in saturated fats, trans-fatty acids, free sugars or
sodium will be framed as foods high in fats, sugars or
The current generation of Canadian children is
expected to live shorter, less healthy lives as a
result of unhealthy eating. (4) Canadians’
overconsumption of fat, sodium and sugar, rising
rates of childhood obesity, growing numbers of
people with cancer, heart disease and stroke, and
the combined strain they exert on the health care
system and quality of life for Canadians necessitates
immediate action for Canadian governments and
policy-makers. Restricting the marketing of
unhealthy foods and beverages directed at children
is gaining increasing international attention as a
cost-effective, population-based intervention to
reduce the prevalence and the burden of chronic
and cardiovascular diseases through reducing
children’s exposure to, and consumption of,
disease-causing foods. (2,5,6)
In May 2010, the World Health Organization (WHO
released a set of recommendations on the
marketing of foods and non-alcoholic beverages to
children (5) and called on governments worldwide
to reduce the exposure of children to advertising
messages that promote foods high in saturated fats,
trans-fatty acids, free sugars or sodium and to
reduce the use of powerful marketing techniques. In
June 2012, the follow-up document, A Framework
for Implementing the Set of Recommendations on
the Marketing of Foods and Non-Alcoholic
Beverages to Children, (7) was released.
The policy aim should be to reduce the impact
on children of marketing of foods high in
saturated fats, trans-fatty acids, free sugars,
WHO (2010): Recommendation 1
What this policy consensus statement offers is the
perspective of many major national health care
professional and scientific organizations to guide
Canadian governments and non-government
organizations on actions that need to be taken to
protect the health of our future generations, in part
by restricting the adverse influence of marketing of
foods high in fat, sugar or sodium to Canadian
children and youth.
SUMMARY OF EVIDENCE AND RATIONALE
-Young children lack the cognitive ability to
understand the persuasive intent of marketing
or assess commercial claims critically. (8) in
1989 the Supreme Court of Canada ruled that
“advertisers should not be able to capitalize
upon children’s credulity” and “advertising
directed at young children is per se
-The marketing and advertising of information or
products known to be injurious to children’s
health and wellbeing is unethical and infringes
on the UN Convention on the Rights of the Child
which stipulates that, “In all actions concerning
children … the best interests of the child shall
be a primary consideration.” (9)
- Unhealthy food advertising during children’s
television programs in Canada is higher than in
many countries, with children being exposed to
advertisements for unhealthy foods and
beverages up to 6 times per hour. (10)
- Unhealthy food and beverage advertising
influences children’s food preferences,
purchase requests and consumption patterns
and has been shown to be a probable cause of
childhood overweight and obesity by the WHO.
- The vast majority of Canadians (82%) want
government intervention to place limits on
advertising unhealthy foods and beverages to
- The regulation of food marketing to children is
an effective and cost-saving population-based
intervention to improve health and prevent
- Several bills have been introduced into the
House of Commons to amend the Competition
Act and the Food and Drug Act to restrict
commercial advertising, including food, to
children under 13 years of age. None have yet
been passed. (15)
- Canada’s current approach to restricting
advertising to children is not effective and is not
in line with the 2010 WHO recommendations on
the marketing of foods and beverages to
children, nor is it keeping pace with the direction
of policies being adopted internationally, which
ban or restrict unhealthy food and beverage
marketing targeted to children. (16,17)
The Supreme Court of Canada concluded
that “advertising directed at young
children is per se manipulative”
Irwin Toy Ltd. v. Québec (AG), 1989
FOOD MARKETING TO CHILDREN: A TIMELY
OPPORTUNITY FOR CANADA
Childhood obesity and chronic disease prevention
are collective priorities for action of federal,
provincial and territorial (F/P/T) governments.
Strategy 2.3b of the 2011 Federal, Provincial and
Territorial Framework for Action to Promote Healthy
Weights stipulates “looking at ways to decrease the
marketing of foods and beverages high in fat, sugar
and/or sodium to children. “(5, p. 31)
The 2010 Sodium Reduction Strategy for Canada
has also identified the need to “continue to explore
options to reduce the exposure of children to
marketing for foods that are high in sodium" as a
key activity for F/P/T governments to consider. (19,
In their 2010 set of recommendations, the WHO
stipulated that governments are best positioned to
lead and ensure effective policy development,
implementation and evaluation. (6)
To date, there has been no substantive movement
by the federal government to develop coordinated
national-level policies that change the way
unhealthy foods and beverages are produced,
marketed and sold. Current federal, provincial and
industry-led self-regulatory codes are inconsistent
in their scope and remain ineffective in their ability
to sufficiently reduce children’s exposure to
unhealthy food marketing, nor have they been
adequately updated to address the influx of new
marketing mediums to which children and youth in
Canada are increasingly subjected.
Quebec implemented regulations in 1980 restricting
all commercial advertising. (20) Although the ban
has received international recognition and is viewed
as world leading, several limitations remain, in part
due exposure of Quebec children to marketing from
outside Quebec, weak enforcement of the
regulations and narrow application of its provisions.
Accordingly, the undersigned are calling on the
federal government to provide strong leadership
and establish a legislative process for the
development of regulations that restrict all
commercial marketing of foods and beverages high
in saturated fats, trans-fatty acids, free sugars or
sodium to children.
Strong federal government action and commitment
are required to change the trajectory of chronic
diseases in Canada and institute lasting changes in
public health. Specifically:
Efforts must be made to ensure that
children…are protected against the impact
of marketing [of foods with a high content
of fat, sugar and sodium] and given the
opportunity to grow and develop in an
enabling food environment — one that
fosters and encourages healthy dietary
choices and promotes the maintenance of
healthy weight. (7, p. 6)
Such efforts to protect the health of children must
go beyond the realm of federal responsibility and
involve engagement, dialogue, leadership and
advocacy by all relevant stakeholders, including all
elected officials, the food and marketing sector,
public health, health care professional and scientific
organizations, and most importantly civil society.
The undersigned support the development of
policies that are regulatory in nature to create
national and/or regional uniformity in
implementation and compliance by industry.
“Realizing the responsibility of governments
both to protect the health of children and to
set definitions in policy according to public
health goals and challenges — as well as to
ensure policy is legally enforced — statutory
regulation has the greatest potential to achieve
the intended or desired policy impact.”
WHO (2012), p. 33
The following outline key definitions and
components of an effective and comprehensive
policy on unhealthy food and beverage marketing
to children and should be used to guide national
policy scope and impact.
- Age of Child: In the context of broadcast
regulations, the definition of “age of child”
typically ranges from under 13 years to under
16 years. In Canada, Quebec’s Consumer
Protection Act (20) applies to children under
13 years of age. Consistent with existing
legislation, this report recommends that policies
restricting marketing of unhealthy foods and
beverages be directed to children less than
13 years of age at a minimum.
While the science on the impact of marketing on
children over 13 is less extensive, emerging
research reveals that older children still require
protection and may be more vulnerable to newer
forms of marketing (i.e., digital media ), in which
food and beverage companies are playing an
increasingly prominent role. (21-23) Strong
consideration should be given to extending the
age of restricting the marketing of unhealthy
food and beverage to age 16.
- Unhealthy Food and Beverages: In the absence
of a national standardized definition for “healthy”
or “unhealthy” foods, this document defines
unhealthy foods broadly as foods with a high
content of saturated fats, trans-fatty acids, free
sugars or sodium, as per the WHO
recommendations. (5) It is recommended that a
robust and comprehensive definition be
developed by an interdisciplinary stakeholder
- Focus on Marketing: Marketing is more than
advertising and involves:
…any form of commercial communication or
message that is designed to, or has the
effect of, increasing the recognition, appeal
and/ or consumption of particular products
and services. It comprises anything that acts
to advertise or otherwise promote a product
or service. (6, p. 9)
This definition goes beyond the current legal
definition of advertisement outlined in the Food
and Drug Act as “any representation by any
means whatever for the purpose of promoting
directly or indirectly the sale or disposal of any
food, drug, cosmetic or device.” (24)
- Marketing Techniques, Communication Channels
and Locations: Legislation restricting unhealthy
food marketing needs to be sufficiently
comprehensive to address the broad scope of
marketing and advertising techniques that have a
particularly powerful effect on children and
youth. This includes, but is not limited to, the
. Direct electronic marketing (email, SMS)
. Mobile phones
. Video and adver-games
. Characters, brand mascots and/or celebrities,
including those that are advertiser-generated
. Product placement
. Point-of-purchase displays
. Cinemas and theatres
. Competitions and premiums (free toys)
. Children’s institutions, services, events and
activities (schools, event sponsorship)
. “Viral and buzz marketing” (25,26)
. Directed to Children: The criteria used by the
Quebec Consumer Protection Act (20) to
determine whether an advertisement is “directed
at children” offers a starting point in developing
national legislation regarding child-directed
media. The loopholes in the Quebec Consumer
Protection Act criteria, namely allowing
advertising of unhealthy foods and beverages
directed at adults during children’s programming,
will necessitate the development of an
alternative approach or set of criteria that
reflects the range of media to which children are
exposed and when they are exposed, in addition
to the proportion of the audience that is made up
Quebec Consumer Protection Act
To determine whether or not an
advertisement is directed at persons under
thirteen years of age, account must be taken
of the context of its presentation, and in
a)the nature and intended purpose of the
b)the manner of presenting such
c)the time and place it is shown.
1. Federal Government Leadership
1.1 Immediately and publicly operationalize the
WHO set of recommendations on the marketing
of foods and non-alcoholic beverages to
In working toward the implementation of the
WHO recommendations, the federal
government is strongly urged to accelerate
implementation of the WHO Framework for
Implementing the Set of Recommendations on
the Marketing of Foods and Beverages to
Children. To this end, the Government of
Canada is urged to:
1.2 Convene a Federal, Provincial and Territorial
Working Group on Food Marketing to Children
to develop, implement and monitor policies to
restrict unhealthy food and beverage marketing
to children. As stipulated within the WHO
The government-led working group should
ultimately reach consensus on the priorities
for intervention, identify the available policy
measures and decide how they best can be
implemented. (7, p.13)
1.3 In developing policies, it is recommended that
the working group:
- Develop standardized criteria and an
operational definition to distinguish and
classify “unhealthy” foods. Definitions
should be developed using objective,
evidence-based methods and should be
developed and approved independent of
- Develop a set of definitions/specifications
that will guide policy scope and
implementation. Consistent with the WHO
recommendations, the working group is
encouraged to apply the policy
specifications identified above.
- Set measurable outcomes, targets and
timelines for achievement of targets for
industry and broadcasters to restrict
unhealthy food marketing to children in all
forms and settings. It is recommended that
policies be implemented as soon as possible
and within a 3-year time frame.
- Establish mechanisms for close monitoring
and enforcement through defined rewards
and/or penalties by an independent
regulatory agency that has the power and
infrastructure to evaluate questionable
advertisements and enforce penalties for
(2) Such an infrastructure could be supported
though the Canadian Radio-television and
Telecommunications Commission (CRTC), similar
to the authority of the US Federal Trade
Commission (FTC), the Canadian Food
Inspection Agency or the Food and Drug Act via
the development of an advertising investigation
The nature and extent of penalties imposed should be sufficiently
stringent to deter violations. Enforcement
mechanisms should be explicit, and infringing
companies should be exposed publicly.
- Develop evaluation mechanisms to assess
process, impact and outcomes of food
marketing restriction policies. Components
should include scheduled reviews (5 years or
as agreed upon) to update policies and/or
strategies. To showcase accountability,
evaluation findings should be publicly
1.4 Provide adequate funding to support the
successful implementation and monitoring of
the food marketing restriction policies.
1.5 Collaborate with the Canadian Institutes of
Health Research and other granting councils to
fund research to generate baseline data and
address gaps related to the impact of marketing
in all media on children and how to most
effectively restrict advertising unhealthy foods
to children. (27)
1.6 Fund and commission a Canadian economic
modeling study to assess the cost-effectiveness
and the relative strength of the effect of
marketing in comparison to other influences on
children’s diets and diet-related health
outcomes. Similar studies have been
undertaken elsewhere and highlight cost–
benefit savings from restricting unhealthy food
1.7 Call on industry to immediately stop marketing
foods to children that are high in fats, sugar or
2. Provincial, Territorial and Municipal
2.1 Wherever possible, incorporate strategies to
reduce the impact of unhealthy food and
beverage marketing to children into provincial
and local (public) health or related strategic
action plans, and consider all settings that are
frequented by children.
2.2 Pass and/or amend policies and legislation
restricting unhealthy food and beverage
marketing to children that go beyond
limitations stipulated in federal legislation and
regulations and industry voluntary codes.
2.3 Until federal legislation is in place, strike a P/T
Steering Committee on Unhealthy Food
Marketing to Children to establish
interprovincial consistency related to key
definitions and criteria and mechanisms for
enforcement, as proposed above.
2.4 Collaborate with local health authorities, non-
governmental organizations and other
stakeholders to develop and implement
education and awareness programs on the
harmful impacts of marketing, including but not
limited to unhealthy food and beverage
2.5 Call on industry to immediately stop marketing
foods to children that are high in fats, sugar or
3. Non-governmental Organizations
(NGOs), Health Care Organizations,
Health Care Professionals
3.1 Publicly endorse this position statement and
advocate to all Canadian governments to
restrict marketing of unhealthy foods to
children and youth in Canada.
3.2 Collaborate with governments at all levels to
facilitate implementation and enforcement of
federal/provincial/municipal regulations or
3.3 Wherever possible, incorporate and address
the need for restrictions on unhealthy food
and beverage marketing to children into
position papers, strategic plans, conferences,
programs and other communication mediums.
3.4 Support, fund and/or commission research to
address identified research gaps, including the
changing contexts and modes of marketing
and their implications on the nutritional status,
health and well-being of children and youth
3.5 Call on industry to immediately stop the
marketing of foods high in fat, sugar or
4. Marketing and Commercial Industry
4.1 Immediately cease marketing foods high in fats,
sugar or sodium.
4.2 Amend the Canadian Children’s Food and
Beverage Advertising Initiative (CAI) nutrition
criteria used to re-define “better-for-you
products” to be consistent with currently
available international standards that are
healthier and with Canadian nutrient profiling
standards, once developed.
BACKGROUND AND EVIDENCE BASE
Non-communicable diseases (diabetes, stroke,
heart attack, cancer, chronic respiratory disease)
are a leading cause of death worldwide and are
linked by several common risk factors including high
blood pressure, high blood cholesterol, obesity,
unhealthy diets and physical inactivity. (1,2,3 28)
The WHO has predicted that premature death from
chronic disease will increase by 17% over the next
decade if the roots of the problem are not
Diet-related chronic disease risk stems from long-
term dietary patterns which start in childhood
(8,28). Canadian statistics reveal children, consume
too much fat, sodium and sugars (foods that cause
chronic disease) and eat too little fiber, fruits and
vegetables (foods that prevent chronic disease). (3)
There is evidence that (television) advertising of
foods high in fat, sugar or sodium is associated with
childhood overweight and obesity. (6,11) Children
and youth in Canada are exposed to a barrage of
marketing and promotion of unhealthy foods and
beverages through a variety of channels and
techniques – tactics which undermine and
contradict government, health care professional
and scientific recommendations for healthy eating.
Available research indicates that food marketing to
children influences their food preferences, beliefs,
purchase requests and food consumption patterns.
(8,29) A US study showed that children who were
exposed to food and beverage advertisements
consumed 45% more snacks than their unexposed
counterparts. (30) Similarly, preschoolers who were
exposed to commercials for vegetables (broccoli
and carrots) had a significantly higher preference
for these vegetables after multiple exposures (n=4)
compared to the control group. (31)
Economic modeling studies have shown that
restricting children’s exposure to food and beverage
advertising is a cost effective population based
approach to childhood obesity prevention, with the
largest overall gain in disability adjusted life years.
(13,14). Canada has yet to conduct a comparable
Marketing and Ethics
Foods and beverages high in fats, sugars or sodium
is one of many health compromising products
marketed to children. It has been argued that policy
approaches ought to extend beyond marketing of
unhealthy foods and beverages to one that restricts
marketing of all products to children, as practiced in
Quebec (7,26,32). Article 36 of the Convention on
the Rights of the Child, to which Canada is a
signatory, states that, “children should be protected
from any activity that takes advantage of them or
could harm their welfare and development.” (9)
Restricting marketing of all products has been
argued to be the most comprehensive policy option
in that it aims to protect children from any
commercial interest and is grounded in the
argument that children have the right to a
commercial-free childhood (7, 25,26,32). The focus
on restricting unhealthy food and beverage
marketing was based in consultations with national
health organizations whose mandates, at the time
of writing, were more aligned with a focus on
unhealthy foods and beverages.
This policy statement is not opposed to, and does
not preclude further policy enhancements to
protect children from all commercial marketing, and
therefore encourages further advocacy in this area.
In order to inform the debate and help underpin
future policy direction, further research is needed.
Canada’s Food and Beverage Marketing
Television remains a primary medium for children’s
exposure to advertising, with Canadian children
aged 2–11 watching an average of 18 hours of
television per week. (26) In the past two decades,
the food marketing and promotion environment has
expanded to include Internet marketing, product
placement in television programs, films and DVDs,
computer and video games, peer-to-peer or viral
marketing, supermarket sales promotions, cross-
promotions between films and television programs,
use of licensed characters and spokes-characters,
celebrity endorsements, advertising in children’s
magazines, outdoor advertising, print marketing,
sponsorship of school and sporting activities,
advertising on mobile phones, and branding on toys
and clothing. (25,26)
A systematic review of 41 international studies
looking at the content analysis of children’s food
commercials found that the majority advertised
unhealthy foods, namely pre-sugared cereals, soft
drinks, confectionary and savoury snacks and fast
food restaurants. (33) In an analysis of food
advertising on children’s television channels across
11 countries, Canada (Alberta sample) had the
second-highest rate of food and beverage
advertising (7 advertisements per hour), 80% of
which were for unhealthy foods and beverages
defined as “high in undesirable nutrients and/or
Illustrating the influence of food packaging in
supermarkets, two Canadian studies found that for
six food product categories 75% of the products
were directed solely at children through use of
colour, cartoon mascots, pointed appeals to parents
and/or cross-merchandising claims, games or
activities. Of the 63% of products with nutrition
claims, 89% were classified as being “of poor
nutritional quality” due to high levels of sugar, fat,
or sodium when judged against US-based nutrition
criteria. Less than 1% of food messages specifically
targeted to children were for fruits and vegetables.
Food is also unhealthily marketed in schools. A
recent study of 4,936 Canadian students from
grades 7 to 10 found that 62% reported the
presence of snack-vending machines in their
schools, and that this presence was associated with
students’ frequency of consuming vended goods.
(36) In another Canadian analysis, 28% of
elementary schools reported the presence of some
form of advertising in the school and 19% had an
exclusive marketing arrangement with Coke or
Pepsi. (37) Given children’s vulnerability, a key
tenant of the WHO recommendations on marketing
to children is that “settings where children gather
should be free from all forms of marketing of foods
high in saturated fats, trans-fatty acids, and free
sugars or sodium.” (6, p.9) and need to be included
in development of food marketing policies directed
The Canadian public wants government oversight in
restricting unhealthy food marketing to children. A
nation-wide survey of over 1200 Canadian adults
found 82% want limits placed on unhealthy food
and beverage advertising to children; 53% support
restricting all marketing of high-fat, high-sugar or
high-sodium foods aimed directly at children and
Canada’s Commercial Advertising Environment
Internationally, 26 countries have made explicit
statements on food marketing to children and 20
have, or are in the process of, developing policies in
the form of statutory measures, official guidelines
or approved forms of self-regulation. (38) The
differences in the nature and degree of these
restrictions is considerable, with significant
variation regarding definition of child, products
covered, communication and marketing strategies
permitted and expectations regarding
implementation, monitoring and evaluation. (38,39)
With the exception of Quebec, Canada’s advertising
policy environment is restricted to self-regulated
rather than legislative measures with little
monitoring and oversight in terms of measuring the
impact of regulations on the intensity and
frequency of advertising unhealthy foods and
beverages to children. (39)
Nationally, the Food and Drug Act and the
Competition Act provide overarching rules on
commercial advertising and (loosely) prohibit selling
or advertising in a manner that is considered false,
misleading or deceptive to consumers. These laws,
however, contain no provisions dealing specifically
with unhealthy food advertising or marketing to
children and youth. (26) The Consumer Package
and Labeling Act outlines federal requirements
concerning the packaging, labeling, sale,
importation and advertising of prepackaged non-
food consumer products. Packaging and labels,
however, are not included under the scope of
advertising and therefore not subject to the
administration and enforcement of the Act and
Such loopholes have prompted the introduction of
three private member's bills into the House of
Commons to amend both the Competition Act and
the Food and Drugs Act. Tabled in 2007, 2009 and
2012, respectively, none of the bills have, to date,
advanced past the First Reading. (15)
The Canadian Code of Advertising Standards (Code)
and the Broadcast Code for Advertising to Children
(BCAC) together cover Canadian broadcast and non-
broadcast advertising. (23) While both have explicit
provisions/clauses to cover advertising directed to
children (12 years and younger), neither address or
explicitly cover unhealthy food and beverage
advertising. Further excluded are other heavily
used and persuasive forms of marketing directed to
children, including in-store promotions, packaging,
logos, and advertising in schools or at events, as
well as foreign media. (40)
Formed in 2008, the Canadian Children’s Food and
Beverage Advertising Initiative (CAI) defines
marketing standards and criteria to identify the
products that are appropriate or not to advertise to
children under 12 years old. Under this initiative,
participating food companies (N=19) are
encouraged to direct 100% of their advertising to
children under 12 to “better-for-you” products. (41)
In 2010, the scope of CAI was expanded to include
other media forms, namely video games, child-
directed DVDs and mobile media.
Despite reportedly high compliance by CAI
participants, (41) several fundamental loopholes
undermine its level of protection and effectiveness,
- Participation is voluntary, exempting non-
participators such as President’s Choice,
Wendy’s and A&W, from committing to CAI core
- Companies are allowed to create their own
nutrient criteria for defining “better-for-you” or
“healthier dietary choice” products. (32) A 2010
analysis revealed that up to 62% of these
products would not be acceptable to promote to
children by other countries’ advertising nutrition
- Companies are able to adopt their own
definition of what constitutes “directed at
children” under 12 years. (32) Participants'
definitions of child audience composition
percentage range from 25% to 50%, significantly
more lenient than current Quebec legislation
and other international regulatory systems.
- The initiative excludes a number of marketing
and advertising techniques primarily directed at
children, namely advertiser-generated
characters (e.g., Tony the Tiger), product
packaging, displays of food and beverage
products, fundraising, public service messaging
and educational programs. (26,27)
The Quebec Consumer Protection Act states that
“no person may make use of commercial
advertising directed at persons under thirteen years
of age.” (26) Despite its merits, the effectiveness of
the Quebec ban has been compromised. In its
current form, the ban does not protect children
from cross-border leakage of child-directed
advertisements from other provinces. (40) One
study found that while the ban reduced fast food
consumption by US$88 million per year and
decreased purchase propensity by 13% per week,
the outcomes primarily affected French-speaking
households with children, not their English-speaking
counterparts. (44) A more recent study looking at
the ban’s impact on television advertising arrived at
similar conclusions and found that Quebec French
subjects were exposed to significantly fewer candy
and snack promotions (25.4%, p<0.001) compared
to the Ontario English (33.7%) and Quebec English
(39.8%) groups. (40)
The ban has further been criticized for having a
weak definition of “advertisement”, which allows
adult-targeted advertisements for unhealthy foods
during children’s programming (37) and having
weak regulatory and monitoring structures. (37,40)
In assessing the effectiveness of Quebec’s
legislation in reducing children’s exposure to
unhealthy food advertising, it is important to note
that the ban was not developed to target or reduce
the marketing of foods and beverages specifically,
but rather to reduce the commercialization of
Public Policy: The Way Forward
Several legislative approaches have been
undertaken internationally to restrict unhealthy
food and beverage marketing. (7,43,45) While
more research is needed with regards to the impact
of restricting unhealthy food and beverage
marketing on child health outcomes (i.e., obesity), a
US study estimated that between 14-33% of
instances of childhood obesity could be prevented
by eliminating television advertising for unhealthy
food. (46) An Australian study found that a
restriction on non-core-food advertisement
between 7am and 8:30pm could reduce children’s
exposure to unhealthy food advertising by almost
80%. (47) An evaluation of the UK regulations
which restricts television advertising of all foods
high in fat, sugar and sodium found that since its
introduction there has been a 37% reduction in
unhealthy food advertisement seen by children.
Restrictions on food marketing are being
increasingly advocated internationally. A 2011
International Policy Consensus Conference
identified regulating marketing to children as a key
policy strategy to prevent childhood obesity. (48) A
similar recommendation was made at the
September 2011 United Nations high-level meeting
on the prevention and control of non-
communicable diseases. Restrictions on television
advertising for less healthful foods has also been
identified as an effective (Class I; Grade B)
population-based strategy to improve dietary
behaviors in children by the American Heart
Within Canada, non-governmental and other health
organizations are assuming an equally active role.
Among others, the Chronic Disease Prevention
Alliance of Canada, the Dietitians of Canada, the
Alberta Policy Coalition for Chronic Disease
Prevention, the Simcoe Board of Health, the
Thunder Bay and District Board of Health and the
Kingston, Frontenac, Lennox and Addington Board
of Health have issued position papers or statements
urging the federal government to implement more
stringent regulations on food and beverage
marketing to children. (26,42,48)
The current voluntary, industry self-regulated and
ineffective system of restricting the marketing and
advertising of foods and beverages fails to protect
Canadian Children and thereby contributes to the
rising rates of childhood obesity and the likelihood
of premature death and disability in our children’s
and future generations. Strong federal government
leadership and nationwide action from other levels
of government and other key stakeholders are
needed. Regulation restricting unhealthy food
advertising is internationally supported, with a
growing evidence base for expanding such
regulation to all forms of food marketing.
This policy statement offer an integrated, pragmatic
and timely response to the national stated priorities
of childhood obesity and chronic disease prevention
in Canada and supports the F/P/T vision of making
Canada, “…a country that creates and maintains the
conditions for healthy weights so that children can
have the healthiest possible lives.” (4)
This policy statement was funded by The Heart and Stroke
Foundation of Canada (HSFC) and the Institute of
Circulatory and Respiratory Health (CIHR) Chair in
Hypertension Prevention and Control, prepared with the
assistance of an ad hoc Expert Scientific Working Group,
reviewed and approved by the Hypertension Advisory
Committee and endorsed by the undersigned national
HYPERTENSION ADVISORY COMMITTEE
Manuel Arango, Heart and Stroke Foundation of Canada
Norm Campbell, Canadian Society of Internal Medicine
Judi Farrell, Hypertension Canada
Mark Gelfer, College of Family Physicians of Canada
Dorothy Morris, Canadian Council of Cardiovascular Nurses
Rosana Pellizzari, Public Health Physicians of Canada
Andrew Pipe, Canadian Cardiovascular Society
Maura Rickets, Canadian Medical Association
Ross Tsuyuki, Canadian Pharmacists Association
Kevin Willis, Canadian Stroke Network
Norm Campbell, HSFC/CIHR Chair in Hypertension
Prevention and Control, Chair
Tara Duhaney, Policy Director, Hypertension Advisory
1. World Health Organization. Diet, Nutrition, and the
Prevention of Chronic Diseases. WHO Technical
Report Series No. 916. Geneva, WHO; 2003.
http://www.who.int/hpr/NPH/docs/who_fao_expert_report.pdf. Accessed December 2011
2. World Health Organization. 2008-2013 Action Plan
for the Global Strategy for the Prevention and
Control of Noncommunicable Diseases. Geneva:
WHO; 2008. Available at:
2008.pdf. Accessed December 2011
3. Public Health Agency of Canada. Tracking Heart
Disease and Stroke in Canada. Ottawa, 2009.
Available at: http://www.phac-
eng.pdf. Accessed January 2012
4. Olshansky SJ, Passaro DJ, Hershow RC et al. A
potential decline in life expectancy in the United
States in the 21st century. N Engl J Med. 2005;
5. Public Health Agency of Canada. Curbing Childhood
Obesity: A Federal, Provincial and Territorial
Framework for Action to Promote Healthy Weights.
Ottawa, PHAC; 2011 Available at: http://www.phac-
Accessed January 2012
6. World Health Organization. Set of recommendations
on the marketing of foods and non-alcoholic
beverages to children. Geneva: WHO; 2010.
http://www.who.int/dietphysicalactivity/publications/recsmarketing/en/index.html. Accessed December 2011
7. World Health Organization. A Framework for
Implementing the Set of Recommendations on the
Marketing of Foods and Non-Alcoholic Beverages to
Children. Geveva: WHO; 2012. Available at:
http://www.who.int/dietphysicalactivity/MarketingFramework2012.pdf. Accessed June 2012
8. Kunkel D, Wilcox B, Cantor J, Palmer E, Linn S,
Dowrick P. Report of the APA Taskforce on
Advertising and Children. Washington: American
Psychological Association; 2004. Available at:
http://www.apa.org/pi/families/resources/advertising-children.pdf. Accessed January 2012
9. United Nations. Convention on the Rights of the
Child. Geneva: United Nations, 2009 Available at:
Accessed February, 2012
10. Kelly B, Halford JCG, Boyland E, Chapman K, Bautista-
Castaño I, Berg C, et al. Television food advertising to
children: A global perspective. Am J Public Health.
2010;100:1730-5. Available at:
11. McGinnis JM, Gootman JA, Kraak VI (Eds.) Food
Marketing to Children and Youth: Threat or
Opportunity? Committee on Food Marketing and the
Diets of Children and Youth. Washington, DC: IOM;
12. Ipsos Reid. Canadians’ Perceptions of, and Support
for, Potential Measures to Prevent and Reduce
Childhood Obesity. Prepared for the Public Health
Agency of Canada. Ottawa, November 2011.
http://www.sportmatters.ca/files/Reports/Ipsos%20Obesity%202011.pdf. Accessed February 2012
13. Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-
Barron V, Chisholm D. Tackling of Unhealthy Diets,
physical inactivity, and obesity: Health effects and
cost-effectiveness. Lancet 2010; 376 (9754): 1775-
84 Available at:
14. Magnus A, Habby MM, Carter R, Swinburn B. The
cost-effectiveness of removing television advertising
of high fat and/or high sugar food and beverages to
Australian children. Int J Obes.2009; 33: 1094-1102.
15. Parliament of Canada. Private Member’s Bills.
Accessed April 2012
16. Conrad S. Innovations in Policy Evaluation:
Examining the food and beverages included in the
Canadian Children’s Food and Beverage Advertising
Initiative. Ottawa: Public Health Agency of Canada;
17. Alberta Policy Coalition for Cancer Prevention. Using
Public Policy to Promote Healthy Weights for
Canadian Children. Submission to the “Our Health,
Our Future – National Dialogue on Healthy Weights”
18. Public Health Agency of Canada. The integrated pan-
Canadian healthy living strategy. 2005. Available at:
strat/pdf/hls_e.pdf. Accessed January 2012
19. Health Canada. Sodium Reduction Strategy for
Canada: Recommendations of the Sodium Working
Group. Ottawa, Ontario, July 2010. Available at:
http://publications.gc.ca/collections/collection_2010/sc-hc/H164-121-2010-eng.pdf. Accessed December
20. Quebec Consumer Protection Office. The Consumer
Protection Act: Application Guide for Sections 248
and 249. Quebec, 1980
21. Montgomery K, Chester J. Interactive Food and
Beverage Marketing: Targeting Adolescents in the
Digital Age. J Adolesc Health. 2009: S18-S29.
22. Harris JL, Brownell KD, Bargh JA. The Food Marketing
Defense Model: Integrating Psychological Research
to Protect Youth and Inform Public Policy. Soc Issues
Policy Rev. 2009; 3(1): 211-271. Available at:
23. Pechman C, Levine L, Loughlin S, Leslie F. Impulsive
and Self-Conscious: Adolescents' Vulnerability to
Advertising and Promotion. Journal of Public Policy
and Marketing. 2005; 24 (2): 202-221. Available at:
24. Health Canada. Food and Drugs Act . R.S., c. F-27.
Ottawa: Health Canada; 1985. Available at:
Accessed February 2012
25. Mackay S, Antonopoulos N, Martin J, Swinburn B. A
comprehensive approach to protecting children from
unhealthy food advertising. Melbourne, Australia:
Obesity Policy Coalition; 2011. Available at:
email1%20final%2013.04.11.pdf. Accessed January
26. Cook B. Policy Options to Improve the Children’s
Advertising Environment in Canada. Report for the
Public Health Agency of Canada Health Portfolio Task
Group on Obesity and Marketing. Toronto; 2009.
27. Toronto Board of Health. Food and Beverage
Marketing to Children. Staff Report to the Board of
Health. Toronto: Board of Health; 2008. Available at:
http://www.toronto.ca/legdocs/mmis/2008/hl/bgrd/backgroundfile-11151.pdf. Accessed January 2012
28. The Conference Board of Canada. Improving Health
Outcomes: The Role of Food in Addressing Chronic
Diseases. Conference Board of Canada, 2010.
177_FoodandChronicDisease.pdf. Accessed June 2012
29. Cairns G, Angus K, Hastings G, Caraher M.
Systematic reviews of the evidence on the nature,
extent and effects of food marketing to children. A
retrospective summary. Appetite. 2012 (in press).
30. Harris JL, Bargh JA, Brownell KD. Priming Effects of
Television Food Advertising on Eating Behavior.
Health Psychol. 2009; 28(4):404-13. Available at:
31. Nicklas TA, Goh ET, Goodell LS et al. Impact of
commercials on food preferences of low-income,
minority preschoolers. J Nutr Educ Behav. 2011;
32. Elliott C. Marketing Foods to Children: Are We
Asking the Right Questions. Child Obes. 2012; 8(3):
33. Hastings G, Stead M, McDermott L, Forsyth A,
Mackintosh AM, Rayner M, Godfrey C, Caraher M,
Angus K. Review of research on the effects of food
promotion to children. Final Report to the UK Food
Standards Agency. Glasgow, Scotland: University of
Strathclyde Centre for Social Marketing; 2003.
http://www.food.gov.uk/multimedia/pdfs/promofoodchildrenexec.pdf. Accessed February 2012
34. Elliott C. Marketing fun foods: A profile and analysis
of supermarket food messages targeted at children.
Can Public Policy. 2008; 34:259-73
35. Elliott C. Assessing fun foods: Nutritional content
and analysis of supermarket foods targeted at
children. Obes Rev. 2008; 9: 368-377. Available at:
36. Minaker LM, Storey KE, Raine KD, Spence JC, Forbes
LE, Plotnikoff RC, McCargar LJ. Associations between
the perceived presence of vending machines and
food and beverage logos in schools and adolescents'
diet and weight status. Public Health Nutr. 2011;
37. Cook B. Marketing to Children in Canada: Summary
of Key Issues. Report for the Public Health Agency of
Canada. 2007. Available at:
Accessed January 2012
38. Hawkes C, Lobstein T. Regulating the
commercial promotion of food to children: a
survey of actions worldwide. Int J Pediatr
Obes. 2011; 6(2):83-94.
39. Hawkes C, Harris J. An analysis of the content of
food industry pledges on marketing to children.
Public Health Nutr. 2011; 14:1403-1414. Available
40. Potvin-Kent M, Dubois, L, Wanless A. Food
marketing on children's television in two
different policy environments. Int J of Pediatr
Obes. 2011; 6(2): e433-e441. Available at:
41. Advertising Standards Canada. Canadian children’s
food and beverage advertising initiative: 2010
compliance report. Available at:
2010ComplianceReport.pdf. Accessed March 2012
42. Dietitians of Canada. Advertising of Food and
Beverage to Children. Position of Dietitians of
Canada. 2010. Available at:
paper.aspx. Accessed January 2012
43. Hawkes C. Marketing food to children: a global
regulatory environment. World Health Organization.
2004(b). Available at:
http://whqlibdoc.who.int/publications/2004/9241591579.pdf. Accessed February 2012
44. Dhar T, Baylis K. Fast-food Consumption and the Ban
on Advertising Targeting Children: The Quebec
Experience. Journal of Marketing Research. 2011; 48
(5): 799-813. Available at:
45. World Health Organization. Marketing of Food and
Non-Alcoholic Beverages of Children. Report of a
WHO Forum and Technical Meeting. Geneva: WHO;
2006. Available at:
pdf. Accessed January 2012
46. Veerman JL, Van Beeck, Barendregt JJ, Mackenbach
JP. By how much would limiting TV food advertising
reduce childhood obesity? Eur J Public Health. 2009;
19(4): 365-9. Available at:
47. Kelly B, King L, Mauman A, Smith BJ, Flood V. The
effects of different regulation systems on television
food advertising to children. Aust N Z J Public
Health. 2007; 31(4): 340-343.
48. Alberta Policy Coalition for Chronic Disease
Prevention. Canadian Obesity Network -
International Consensus: Take Action to Prevent
Childhood Obesity (Press Release). 2011. Available
49. Mozaffarian D, Afshin A, Benowitz NL et al.
Population Approaches to Improve Diet, Physical
Activity, and Smoking Habits: A Scientific Statement
From the American Heart Association. Circulation.
Hockey is one of the most popular sports for Canadian children and youth. While the health benefits of physical activity and sport participation are well recognized, there is increasing concern around the frequency and severity of hockey-related injuries, particularly concussion. Studies consistently identify bodychecking as the primary mechanism associated with youth hockey injuries, including concussion. Policy to delay bodychecking until bantam league play (when participants are 13 to 14 years of age) will reduce the risks of injury and concussion in young ice hockey players. Bodychecking should be eliminated from non-elite youth ice hockey. The age at which bodychecking is introduced in competitive hockey leagues must be reconsidered. Both initiatives require policy change in many provinces/territories, and must be re-evaluated prospectively in light of emerging research.
More than 4.5 million Canadians are involved in ice hockey, as coaches, officials, administrators or direct volunteers, and hockey is the most popular winter sport among Canadian children and youth. Hockey Canada reported over 550,000 registered players under the age of 19 in 2008, and participation rates are increasing, especially among girls and young women. While the health benefits of physical activity and sport participation are well recognized, there is increasing concern around the frequency and severity of hockey-related injuries in youth, particularly concussion. The American Academy of Pediatrics (AAP) classifies hockey as a collision sport because of unintentional and intentional body contact, including bodychecking.
The AAP published a policy statement on youth ice hockey in 2000, recommending that bodychecking not be allowed for children younger than 15 years of age. There is passionate debate about the risk factors for injury in youth hockey and the relative merits of early or later introduction of bodychecking. Because bodychecking is not allowed in girls' or women's hockey in Canada, the present statement pertains to play in boys' and men's hockey leagues. It reviews the scientific literature on bodychecking injuries, outlines positions in the current debate and makes recommendations on when bodychecking should be introduced into the game.
DEFINING BODY CONTACT AND BODYCHECKING
Body contact is an individual defensive tactic designed to legally block or impede the progress of an offensive puck carrier. The defensive player moves to restrict action by the puck carrier anywhere on the ice, by skating, angling and positioning. The defensive player cannot hit the offensive player by travelling in an opposite direction to him or by physically extending toward him in an effort to initiate contact. There must be no action where the puck carrier is pushed, hit or shoved into the boards. In contrast, bodychecking is an individual defensive tactic designed to legally separate the puck carrier from the puck. The defensive player physically extends his body toward the puck carrier while moving in an opposite or parallel direction, a deliberate and forceful move not solely determined by the movement of the puck carrier. Bodychecking is taught based on a four-step skill development program outlined by Hockey Canada, with progression through positioning and angling, stick checking, body contact and bodychecking skills. Instruction in bodychecking includes techniques for receiving bodychecks, adhering to rules, and safe play.
Hockey Canada groups children and adolescents by age into six play levels: initiation (5 to 6 years of age), novice (7 to 8 years), atom (9 to 10 years), peewee (11 to 12 years), bantam (13 to 14 years), and midget (15 to 17 years). Historically, from the early 1980s until the 2002/2003 season, bodychecking was introduced at age 12 years in Canadian boys' ice hockey. In 2003, four of 13 provincial/territorial branches allowed checking for players as young as nine years old. Hockey Canada mandated the introduction of bodychecking in peewee leagues (ages 11 to 12) in 2009. Quebec has delayed bodychecking until bantam (age 14 from 1978 to 2002, then age 13 following an age change mandated nationally).
Despite lack of evidence, proponents of bodychecking argue that it is a fundamental skill which, learned early, may prevent future injuries. However, the evidence supports that bodychecking is the most common mechanism of injury. The Canadian Academy of Sports Medicine recommends that bodychecking be introduced only in boys' competitive hockey, and no earlier than the bantam (ages 13 to14) or midget (ages 15 to 17) level. The AAP recommends a ban on bodychecking for male players younger than 15 years of age. The present statement marks the first CPS position on this issue.
BODYCHECKING AND INJURY
Hockey is recognized as a high-risk sport. The speed of play, body contact and bodychecking all contribute to injury risk. The injury rate is also high, with Canadian data suggesting that hockey injuries account for 8% to 11% of all adolescent sport-related injuries. Unfortunately, serious injuries such as concussion, other brain injuries and spinal cord trauma are not uncommon in hockey. The incidence of traumatic brain injury appears to be rising. Ice hockey-related fatality rates are double those reported in American football, and catastrophic spinal cord and brain injury rates are almost four times higher for high school hockey players than for high school and college football players. Bodychecking is the predominant mechanism of injury among youth hockey players at all levels of competition where it is permitted, accounting for 45% to 86% of injuries.- Several published studies, including two recent systematic reviews, reported on risk factors for injury (including bodychecking) in youth hockey. Emery and colleagues conducted a systematic review of 24 studies and a meta-analysis including only studies which examined policy allowing bodychecking as a risk factor for injury. Policy allowing bodychecking was found to be a risk factor for all hockey injuries, with a summary incidence rate ratio (IRR) of 2.45 (95% CI 1.7 to 3.6). Furthermore, policy allowing bodychecking was found to be a risk factor for concussion, with a summary OR of 1.71 (95% CI 1.2 to 2.44). These data confirm that bodychecking increases the risk of all injuries and the risk of concussion specifically. Nine of ten studies examining policy allowing bodychecking provided evidence to support a greater risk in bodychecking leagues. The second systematic review found the RR of injury associated with policy allowing bodychecking ranged from 0.6 to 39.8; all but one of these studies found an increased risk of injuries associated with bodychecking.
Since the publication of these systematic reviews there have been five additional studies. A Canadian prospective cohort study compared injury rates between peewee ice hockey players in a league where bodychecking is permitted at age 11 years (Alberta) versus players in a league where bodychecking is not permitted until age 13 (Quebec). During the 2007/2008 season, a validated injury surveillance system was used to capture all injuries requiring medical attention and/or time loss from hockey (ie, time between injury and return to play) in 2154 players. There was a threefold increased risk of all game-related injuries (IRR =3.26 [95% CI; 2.31 to 4.60]) and of injury resulting in >7 days time lost from sport (IRR=3.30 [95% CI; 1.77 to 6.17]) in 11- to 12- year-old peewee players from Alberta when compared with Quebec. There was also an almost fourfold increased risk of game-related concussion (IRR=3.88 [95% CI; 1.91 to 7.89]) in Alberta peewee players. Further evidence was reported in a five-year cohort study (2002 to 2007) including all age groups, which demonstrated that injury risk increases 3.75 times (IRR=3.75 [95% CI; 1.51 to 9.74]) in leagues that allow bodychecking compared with those that do not.
A second prospective cohort study by Emery et al examined whether the introduction of bodychecking at 11 years of age (Alberta) or 13 years of age (Quebec) affected injury rates in later years (at 13 to 14 years of age). During the 2008/09 season, the same injury surveillance system cited above was used to study 1971 bantam players (13- to 14-year-olds). There was no reduction in game-related injury risk (all injuries) for this age group (IRR=0.85 [95% CI 0.63 to 1.16]), of concussion specifically (IRR=0.84 [95% CI 0.48 to 1.48]), or of concussions resulting in >10 days time lost from sport (IRR=0.6 [95% CI 0.26 to 1.41]) in the Alberta league, compared with Quebec. In fact, the concussion rate found in Alberta peewee players was higher than in bantam players in either province. Injuries to bantam players resulting in >7 days time lost from sport were reduced by 33% (IRR=0.67 [95% CI 0.46 to 0.99]) in the Alberta league, where players had had two years of bodychecking experience. However, these findings must be interpreted in light of the three- to fourfold greater injury and concussion risk among peewee players in Alberta, along with a possibly higher 'survival effect' among peewee players moving on to bantam in Quebec when compared with Alberta, where bodychecking is allowed in peewee league play.
Recent retrospective studies have examined the influence of policy change based on the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) surveillance data. Injury rates among boys presenting to emergency departments in the Kingston, Ontario area both before and after the 2002 rule change to allow bodychecking in younger players, were reported. There was no change between bodychecking injury rates in 1997 to 2002 (with bodychecking introduced at 11 years of age) and 2003 to 2007 (when bodychecking was introduced at nine years of age). Overall rates of injury actually declined over the later period. However, this retrospective study may also be biased by stronger rule enforcement, better coaching certification and temporal declines in emergency department use for this type of injury over that period. In contrast, retrospective research of CHIRPP data from 1994 to 2004 in five Ontario hospitals examined injury risk following a rule change in 1998 that allowed bodychecking in nine- and 10-year-old hockey players. A 2.2 times greater risk of injury in atom players (9 and 10 years of age) after the rule change was reported (OR=2.2 [95% CI 1.7 to 2.84]). Another retrospective study using CHIRPP data (from 1995 to 2002) compared hockey injuries in children 10 to 13 years of age playing in Ontario, where bodychecking was allowed, with data from Quebec, where bodychecking was not allowed. There was a 2.6 times greater risk of bodycheck-related injuries reported for this age group when bodychecking was allowed (OR=2.65 [95% CI 2.21 to 3.18]).
OTHER RISK FACTORS
After policy that permits bodychecking, the most commonly investigated risk factors for injury in the scientific literature are: age, session-type (ie, a practice versus a game), level of play, player position, physical size, and a previous history of injury and/or concussion. Most studies examining age found that injury risk increased with age; others suggest no elevated injury risk in older age groups.- Relative age has been examined to "describe the potential advantages (or disadvantages) that result from age differences between peers within one age group". One study examining relative age among hockey players found no evidence that younger (or older) players within a grouping were at elevated injury risk. Additional research supports this finding at the peewee level, where no increased risk was found in first-year players. In bantam leagues, however, there was a 40% greater risk of injury in first-year players when compared with players in their second year.
Based on session-type, injury risk is reported to be consistently higher in games than in practices, with RR estimates ranging from 2.45 to 6.32. One study also indicated that injury rates were higher in regular season play than during preseason, postseason or tournament games.
In general, studies examining level of play have found that injury risks rise with increasing skill levels across all age groups. However, one study reported that only peewee players in the highest skill division were at the greatest risk of injury, with no significant increase by skill level in other age groups. Larger cohort studies confirmed a consistently greater risk of injury among peewee players who were more highly skilled, but this trend was not observed in the bantam age group.
When examining player position, some researchers found that forwards were at higher risk of injury than defencemen or goalies,  while others reported the relative risk of injury was 2.18 times higher for defencemen than forwards. In all three studies, goalies were shown to be at much lower risk than other players. Additional research shows a consistent protective effect for goalies at both the peewee and bantam levels.
Research on player size has shown conflicting results, with some studies citing increased risk for smaller players in some age groups. Prospective Canadian data show a significantly greater risk of injury in peewee players in the lowest 25th percentile by weight,  though this finding was not reflected in the bantam cohort. However, additional research has found lighter bantam players to be at greater risk, while other studies report a significant weight difference, at all levels, between players who sustained a bodychecking-related injury and those who did not. Other research examining body weight as a risk factor for shoulder injuries found that heavier players were at greater risk for these injuries. One study looked at height as a possible risk factor for injury and found no evidence of effect among bantam players.
By contrast, a history of previous injury or concussion is consistently reported as a significant risk factor for reinjury and further concussion, respectively. One recent Canadian peewee cohort study showed that the risk of injury doubled for players who reported being injured within the past year (IRR=2.07 [95% CI 1.49 to 2.86]), while the risk of concussion tripled for players reporting any previous concussion (2.76 [95% CI 1.1 to 6.91]). The bantam cohort also showed greater risk of reinjury and concussion in players reporting previous injury within the past year (IRR=1.39 [95% CI 1.13 to 1.71]) or any previous concussion (IRR=1.87 [95% CI 1.19 to 2.94]), respectively.
INJURY PREVENTION AND RISK REDUCTION
Injury prevention and risk reduction programs have been implemented but have not been evaluated rigorously. The STOP (Safety Towards Other Players) program (www.safetytowardsotherplayers.com) is supported by the Ontario Minor Hockey Association (www.omha.net), and includes an education component and the "STOP patch", which is sewn on the back of players' uniforms to remind opponents not to hit from behind. A study evaluating another injury prevention program, "Fair Play", which awards points for sportsmanlike play (based on penalty minutes), suggests an approximate 60% reduction in the risk of injury (OR=0.41 [95% CI 0.11 to 1.47]) where the program is in effect, but the results were not statistically significant.
Players, parents, coaches, officials and trainers must be mindful of the potential risks of playing hockey. Hockey Canada has player development, coaching, education and safety promotion programs and resources for coaches, officials, players and parents at www.hockeycanada.ca. Concussion awareness is vital. Athletes and all those involved in their care need to know about the risks, symptoms/signs and how to manage concussive injuries. The CPS statement on concussion evaluation and management is essential reading , with additional information available from the Canadian Academy of Sport and Exercise Medicine (www.casm-acms.org), ThinkFirst Canada (www.thinkfirst.ca) and the US Centers of Disease Control and Prevention (www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm).
Studies consistently identify bodychecking as the primary mechanism of hockey-related injuries, including concussion. It is expected that delaying the introduction of bodychecking until the bantam level and restricting bodychecking to elite leagues for older age groups will reduce the risks of injury and concussion substantially. Delaying bodychecking until bantam will have a clear benefit in reducing the risks of injury and concussion in young ice hockey players. Bodychecking should be eliminated from recreational youth ice hockey and the age at which it is introduced in competitive hockey leagues should be reconsidered. Both initiatives require policy change in many provinces/territories in Canada, and policy changes will need to be evaluated on a regular basis in light of emerging research.
The Canadian Paediatric Society recommends the following:
* Eliminating bodychecking from all levels of organized recreational/non-elite competitive male ice hockey. (Grade II-2A evidence) *
* Delaying the introduction of bodychecking in elite male competitive leagues until players are 13 to 14 years of age (bantam level) or older. (Grade III-C evidence)*
* Implementing Hockey Canada's four-stage skill development program for bodychecking (body positioning, angling, stick checking and body contact) for all leagues.
* Educating coaches and trainers, schools, and policy-makers in sport about the signs and symptoms of common hockey injuries, especially concussion.
* Improving injury surveillance to better identify the risk factors for, and mechanisms of, hockey injuries.
* Policies to reduce injury and promote fair play in hockey, for all age groups and league levels.
Clinicians who see young hockey players in their practice should offer the following advice:
* Girls and young women should continue participating in non-bodychecking leagues.
* Boys should play in recreational/non-elite hockey leagues that do not allow bodychecking.
* Elite male players should play in hockey leagues that introduce bodychecking later, when players are 13 to 14 years of age (bantam level) or older.
* All players should adhere to fair play and a non-violent sport culture.
* Parents and caregivers should learn injury prevention and risk reduction strategies, including concussion prevention, recognition and management.
*The levels of evidence and strength of recommendations are based on the Canadian Task Force on Preventive Health Care (See Table 1). 
TABLE 1: [SEE PDF]
Levels of evidence and strength of recommendations
Level of evidence
Evidence obtained from at least one properly randomized controlled trial.
Evidence obtained from well-designed controlled trial without randomization.
Evidence obtained from well-designed cohort or case-controlled analytical studies, preferably from more than one centre or research group.
Evidence obtained from comparisons between times and places, with or without the intervention. Dramatic results in uncontrolled experiments could also be included in this category.
Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.
There is good evidence to recommend the clinical preventive action.
There is fair evidence to recommend the clinical preventive action.
The existing evidence is conflicting and does not allow a recommendation to be made for or against use of the clinical preventive action; however, other factors may influence decision-making.
There is fair evidence to recommend against the clinical preventive action.
There is good evidence to recommend against the clinical preventive action.
There is insufficient evidence to make a recommendation; however, other factors may influence decision-making.
This statement was reviewed by the Community Paediatrics and Injury Prevention Committees of the Canadian Paediatric Society. Thanks to Drs. Claire MA LeBlanc, Stan Lipnowski, Peter Nieman, Christina G Templeton and Thomas J Warshawski for their input as past members of the CPS Healthy Active Living and Sports Medicine Committee.
HEALTHY ACTIVE LIVING AND SPORTS MEDICINE COMMITTEE
Members: Catherine Birken MD; Tracey L Bridger MD (Chair); Mark E Feldman MD (Board Representative); Kristin M Houghton MD; Michelle Jackman MD; John F Philpott MD
Liaison: Laura K Purcell MD, CPS Paediatric Sports and Exercise Medicine Section
Principal authors: Kristin M Houghton MD; Carolyn A Emery PT PhD
1. Hockey Canada, Annual report 2008: www.hockeycanada.ca/index.php/ci_id/55192/la_id/1.htm (Accessed July 4, 2012).
2. Rice SG; American Academy of Pediatrics, Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics 2008;121(4):841-8.
3. American Academy of Pediatrics, Committee on Sports Medicine and Fitness. Safety in youth ice hockey: The effects of body checking. Pediatrics 2000;105(3 Pt 1):657-8.
4. Hockey Canada. Teaching checking: A progressive approach. 2002: www.omha.net/admin/downloads/Teaching%20Checking.pdf (Accessed July 4, 2012).
5. Canadian Academy of Sport Medicine. Position Statement: Violence and injuries in ice hockey. 1988. www.casm-acms.org/forms/statements/HockeyViolEng.pdf (Accessed July 4, 2012).
6. Emery CA, Risk factors for injury in child and adolescent sport: A systematic review of the literature. Clin J Sport Med 2003;13(4):256-68.
7. Caine D, Caine C, Maffulli N. Incidence and distribution of pediatric sport-related injuries. Clin J Sport Med 2006;16(6):500-13.
8. Emery CA, Meeuwisse WH. Injury rates, risk factors, and mechanisms of injury in minor hockey [comment]. Am J Sports Med 2006;34(12):1960-9.
9. Emery CA, Meeuwisse WH, McAllister JR. Survey of sport participation and sport injury in Calgary and area high schools. Clin J Sport Med 2006;16(1):20-6.
10. Emery C, Tyreman H. Sport participation, sport injury, risk factors and sport safety practices in Calgary and area junior high schools. Paediatr Child Health 2009;14(7):439-44.
11. Tator CH, Carson JD, Cushman R. Hockey injuries of the spine in Canada, 1966-1996 [comment]. CMAJ 2000;162(6):787-8.
12. Proctor MR, Cantu RC. Head and neck injuries in young athletes. Clin Sports Med 2000;19(4): 693-715.
13. Kelly KD, Lissel HL, Rowe BH, Vincenten JA, Voaklander DC. Sport and recreation-related head injuries treated in the emergency department. Clin J Sport Med 2001;11(2):77-81.
14. Mueller FO, Cantu RC. Catastrophic injuries and fatalities in high school and college sports, fall 1982-spring 1988. Med Sci Sports Exerc 1990;22(6):737-41.
15. Cantu RC, Mueller FO. Fatalities and catastrophic injuries in high school and college sports, 1982-1997: Lessons for improving safety. Phys Sportsmed 1999;27(8):35-48.
16. Brust JD, Leonard BJ, Pheley A, Roberts WO. Children's ice hockey injuries. Am J Dis Child 1992;146(6):741-7.
17. Bernard D, Trudel P. Marcotte G. The incidence, types, and circumstances of injuries to ice hockey players at the bantam level (14 to 15 years old). In: Hoerner E, ed. Safety in Ice Hockey. Philadephia: American Society for Testing and Materials, 1993:44-55.
18. Benson B, Meeuwisse WH. Ice hockey injuries. In: Maffulli N, Caine DJ, eds. Epidemiology of Pediatric Sports Injuries: Team Sports. Basel: S Karger AG, 2005:86-119.
19. Warsh JM, Constantin SA, Howard A, Macpherson A. A systematic review of the association between body checking and injury in youth ice hockey. Clin J Sport Med 2009;19(2):134-44.
20. Emery CA, Hagel B, Decloe M, Carly M. Risk factors for injury and severe injury in youth ice hockey: A systematic review of the literature. Inj Prev 2010;16(2):113-8.
21. Emery CA, Kang J, Shrier I, et al. Risk of injury associated with body checking among youth ice hockey players. JAMA 2010;303(22):2265-72.
22. Darling, SR, Schaubel DE, Baker JG, Leddy JJ, Bisson LJ, Willer B. Intentional versus unintentional contact as a mechanism of injury in youth ice hockey. Br J Sports Med 2011;45(6):492-7.
23. Emery C, Kang J, Shrier I, et al. Risk of injury associated with bodychecking experience among youth hockey players. CMAJ 2011;183(11):1249-56.
24. Kukaswadia A, Warsh J, Mihalik JP, Pickett W. Effects of changing body-checking rules on rates of injury in minor hockey. Pediatrics 2010;125(4):735-41.
25. Cusimano M, Taback N, McFaull S, Hodgins R, Tsegaye B; Canadian Research Team in Traumatic Brain Injury and Violence. Effect of bodychecking on rate of injuries among minor hockey players. Open Medicine 2011;5(1):e59: www.openmedicine.ca/article/view/246/389 (Accessed July 4, 2012).
26. Macpherson A, Rothman L, Howard A. Body-checking rules and childhood injuries in ice hockey. Pediatrics;117(2):e143-7 [Erratum in Pediatrics. 2006;117(6):2334-6].
27. Stuart MJ, Smith AM, Nieva JJ, Rock MG. Injuries in youth ice hockey: A pilot surveillance strategy. Mayo Clin Proc 1995;70(4): p. 350-6.
28. Mölsä, J, Kujala U, Myllynen P, Torstila I, Airaksinen O. Injuries to the upper extremity in ice hockey: Analysis of a series of 760 injuries. Am J Sports Med 2003;31(5):751-7.
29. Björkenheim JM, Syvähuoko I, Rosenberg PH. Injuries in competitive junior ice-hockey. 1437 players followed for one season. Acta Orthop Scand 1993;64(4):459-61.
30. Wiggins W. Implication of introducing body checking in ice hockey at different ages. OpenThesis. Lakehead University, 1998: www.openthesis.org/documents/Implication-introducing-body-checking-in-182710.html (Accessed July 4, 2012).
31. Wattie N, Cobley S, Macpherson A, Howard A, Montelpare WJ, Baker J. Injuries in Canadian youth ice hockey: The influence of relative age. Pediatrics 2007;120(1):142-8.
32. Roberts WO, Brust JD, Leonard B. Youth ice hockey tournament injuries: Rates and patterns compared to season play. Med Sci Sports Exerc 1999;31(1):46-51.
33. Williamson IJS. An epidemiological investigation of concussion in youth ice hockey. Simon Fraser University: MSc thesis, 2006.
34. Smith AM, Stuart MJ, Wiese-Bjornstal DM, Gunnon C. Predictors of injury in ice hockey players. A multivariate, multidisciplinary approach. Am J Sports Med 1997;25(4): 500-7.
35. McKay C, Emery CA, Campbell T, Meeuwisse W. The effect of premature return to play on re-injury risk in elite adolescent ice hockey and associated psychosocial predictors [Abstract]. Br J Sport Med 2008;42(6):532-3.
36. Willer B, Kroetsch B, Darling S, Hutson A, Leddy J. Injury rates in house league, select, and representative youth ice hockey. Med Sci Sports Exerc 2005;37(10):1658-63.
37. Finke RC, Goodwin Gerberich S, Madden M, et al. Shoulder injuries in ice hockey. J Orthop Sports Phys Ther 1988;10(2):54-8.
38. Brunelle JP, Goulet C, Arguin H. Promoting respect for the rules and injury prevention in ice hockey: Evaluation of the fair-play program. J Sci Med Sport 2005;8(3):294-304.
39. Canadian Paediatric Society, Healthy Active Living and Sports Medicine Committee. Identification and management of children with sport related concussion (Principal author Laura K Purcell). Paediatr Child Health 2012;17(1):31 www.cps.ca/en/documents/position/concussion-evaluation-management.
40. Canadian Task Force on Preventive Health Care, New grades for recommendations from the Canadian Task Force on Preventive Health Care for specific clinical preventive actions. CMAJ 2003;169(3):207-8.
41. Canadian Task Force. Quality of Published Evidence. www.canadiantaskforce.ca/_archive/index.html (Accessed July 19, 2012).
Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.
The Canadian Medical Association will revise its proposed framework for a National Dementia Strategy to include education on the assessment and management of pain prior to the initiation of anti-psychotic therapy.
The Canadian Medical Association will revise its proposed framework for a National Dementia Strategy to include education on the assessment and management of pain prior to the initiation of anti-psychotic therapy.
The Canadian Medical Association will revise its proposed framework for a National Dementia Strategy to include education on the assessment and management of pain prior to the initiation of anti-psychotic therapy.