APPROACHES TO ENHANCING THE QUALITY OF DRUG THERAPY
A JOINT STATEMENT BY THE CMA ANDTHE CANADIAN PHARMACEUTICAL ASSOCIATION
This joint statement was developed by the CMA and the Canadian Pharmaceutical Association, a national association of pharmacists, and includes the goal of drug therapy, strategies for collaboration to optimize drug therapy and physicians' and pharmacists' responsibilities in drug therapy. The statement recognizes the importance of patients, physicians and pharmacists working in close collaboration and partnership to achieve optimal outcomes from drug therapy.
Goal of This Joint Statement
The goal of this joint statement is to promote optimal drug therapy by enhancing communication and working relationships among patients, physicians and pharmacists. It is also meant to serve as an educational resource for pharmacists and physicians so that they will have a clearer understanding of each other's responsibilities in drug therapy. In the context of this statement, a "patient" may include a designated patient representative, such as a parent, spouse, other family member, patient advocate or health care provider.
Physicians and pharmacists have a responsibility to work with their patients to achieve optimal outcomes by providing high-quality drug therapy. The important contribution of all members of the health care team and the need for cooperative working relationships are recognized; however, this statement focuses on the specific relationships among pharmacists, physicians and patients with respect to drug therapy.
This statement is a general guide and is not intended to describe all aspects of physicians' or pharmacists' activities. It is not intended to be restrictive, nor should it inhibit positive developments in pharmacist-physician relationships or in their respective practices that contribute to optimal drug therapy. Furthermore, this statement should be used and interpreted in accordance with applicable legislation and other legal requirements.
This statement will be reviewed and assessed regularly to ensure its continuing applicability to medical and pharmacy practices.
Goal of Drug Therapy
The goal of drug therapy is to improve patients' health and quality of life by preventing, eliminating or controlling diseases or symptoms. Optimal drug therapy is safe, effective, appropriate, affordable, cost-effective and tailored to meet the needs of patients, who participate, to the best of their ability, in making informed decisions about their therapy. Patients require access to necessary drug therapy and specific, unbiased drug information to meet their individual needs. Providing optimal drug therapy also requires a valid and accessible information base generated by basic, clinical, pharmaceutical and other scientific research.
Working Together for Optimal Drug Therapy
Physicians and pharmacists have complementary and supportive responsibilities in providing optimal drug therapy. To achieve this goal, and to ensure that patients receive consistent information, patients, pharmacists and physicians must work cooperatively and in partnership. This requires effective communication, respect, trust, and mutual recognition and understanding of each other's complementary responsibilities. The role of each profession in drug therapy depends on numerous factors, including the specific patient and his or her drug therapy, the prescription status of the drug concerned, the setting and the patient-physician-pharmacist relationship. However, it is recognized that, in general, each profession may focus on certain areas more than others.
For example, when counselling patients on their drug therapy, a physician may focus on disease-specific counselling, goals of therapy, risks and benefits and rare side effects, whereas a pharmacist may focus on correct usage, treatment adherence, dosage, precautions, dietary restrictions and storage. Areas of overlap may include purpose, common side effects and their management and warnings regarding drug interactions and lifestyle concerns. Similarly, when monitoring drug therapy, a physician would focus on clinical progress toward treatment goals, whereas a pharmacist may focus on drug effects, interactions and treatment adherence; both would monitor adverse effects.
Both professions should tailor drug therapy, including education, to meet the needs of individual patients. To provide continuity of care and to promote consistency in the information being provided, it is important that both pharmacists and physicians assess the patients' knowledge and identify and reinforce the educational component provided by the other.
Strategies for Collaborating to Optimize Drug Therapy
Patients, physicians and pharmacists need to work in close collaboration and partnership to achieve optimal drug therapy. Strategies to facilitate such teamwork include the following.
- Respecting and supporting patients' rights to make informed decisions regarding their drug therapy.
- Promoting knowledge, understanding and acceptance by physicians and pharmacists of their responsibilities in drug therapy and fostering widespread communication of these responsibilities so they are clearly understood by all.
- Supporting both professions' relationship with patients, and promoting a collaborative approach to drug therapy within the health care team. Care must be taken to maintain patients' trust and their relationship with other caregivers.
- Sharing relevant patient information for the enhancement of patient care, in accordance and compliance with all of the following: ethical standards to protect patient privacy, accepted medical and pharmacy practice, and the law. Patients should inform their physician and pharmacist of any information that may assist in providing optimal drug therapy.
- Increasing physicians' and pharmacists' awareness that it is important to make themselves readily available to each other to communicate about a patient for whom they are both providing care.
- Enhancing documentation (e.g., clearly written prescriptions and communication forms) and optimizing the use of technology (e.g., e-mail, voice mail and fax) in individual practices to enhance communication, improve efficiency and support consistency in information provided to patients.
- Developing effective communication and administrative procedures between health care institutions and community-based pharmacists and physicians to support continuity of care.
- Developing local communication channels and encouraging dialogue between the professions (e.g., through joint continuing education programs and local meetings) to promote a peer-review-based approach to local prescribing and drug-use issues.
- Teaching a collaborative approach to patient care as early as possible in the training of pharmacists and physicians.
- Developing effective communication channels and encouraging dialogue among patients, physicians and pharmacists at the regional, provincial, territorial and national levels to address issues such as drug-use policy, prescribing guidelines and continuing professional education.
- Collaborating in the development of technology to enhance communication in practices (e.g., shared patient databases relevant to drug therapy).
- Working jointly on committees and projects concerned with issues in drug therapy such as patient education, treatment adherence, formularies and practice guidelines, hospital-to-community care, cost-control strategies, sampling and other relevant policy issues concerning drug therapy.
- Fostering the development and utilization of a high-quality clinical and scientific information base to support evidence-based decision making.
The Physician's Responsibilities
Physicians and pharmacists recognize the following responsibilities in drug therapy as being within the scope of physicians' practice, on the basis of such factors as physicians' education and specialized skills, relationship with patients and practice environment. Some responsibilities may overlap with those of pharmacists (see The Pharmacist's Responsibilities). In addition, it is recognized that practice environments within medicine may differ and may affect the physician's role.
- Assessing health status, diagnosing diseases, assessing the need for drug therapy and providing curative, preventive, palliative and rehabilitative drug therapy in consultation with patients and in collaboration with caregivers, pharmacists and other health care professionals, when appropriate.
- Working with patients to set therapeutic goals and monitor progress toward such goals in consultation with caregivers, pharmacists and other health care providers, when appropriate.
- Monitoring and assessing response to drug therapy, progress toward therapeutic goals and patient adherence to the therapeutic plan; when necessary, revising the plan on the basis of outcomes of current therapy and progress toward goals of therapy, in consultation with patients and in collaboration with caregivers, pharmacists and other health care providers, when appropriate.
- Carrying out surveillance of and assessing patients for adverse reactions to drugs and other unanticipated problems related to drug therapy, revising therapy and, when appropriate, reporting adverse reactions and other complications to health authorities.
- Providing specific information to patients and caregivers about diagnosis, indications and treatment goals, and the action, benefits, risks and potential side effects of drug therapy.
- Providing and sharing general and specific information and advice about disease and drugs with patients, caregivers, health care providers and the public.
- Maintaining adequate records of drug therapy for each patient, including, when applicable, goals of therapy, therapy prescribed, progress toward goals, revisions of therapy, a list of drugs (both prescription and over-the-counter drugs) currently taken, adverse reactions to therapy, history of known drug allergies, smoking history, occupational exposure or risk, known patterns of alcohol or substance use that may influence response to drugs, history of treatment adherence and attitudes toward drugs. Records should also document patient counselling and advice given, when appropriate.
- Ensuring safe procurement, storage, handling, preparation, distribution, dispensing and record keeping of drugs (in keeping with federal and provincial regulations and the CMA policy summary "Physicians and the Pharmaceutical Industry (Update 1994)" (Can Med Assoc J 1994;150:256A-C.) when the patient cannot reasonably receive such services from a pharmacist.
- Maintaining a high level of knowledge about drug therapy through critical appraisal of the literature and continuing professional development.
Care must be provided in accordance with legislation and in an atmosphere of privacy, and patient confidentiality must be maintained. Care also should be provided in accordance with accepted scientific and ethical standards and procedures.
The Pharmacist's Responsibilities
Pharmacists and physicians recognize the following responsibilities as being within the scope of pharmacists' practice, on the basis of such factors as pharmacists' education and specialized skills, relationship with patients and practice environment. Some responsibilities may overlap with those of physicians (see The Physician's Responsibilities). In addition, it is recognized that, in selected practice environments, the pharmacists' role may differ considerably.
- Evaluating the patients' drug-therapy record ("drug profile") and reviewing prescription orders to ensure that a prescribed therapy is safe and to identify, solve or prevent actual or potential drug-related problems or concerns. Examples include possible contraindications, drug interactions or therapeutic duplication, allergic reactions and patient nonadherence to treatment. Significant concerns should be discussed with the prescriber.
- Ensuring safe procurement, storage, preparation, distribution and dispensing of pharmaceutical products (in keeping with federal, provincial and other applicable regulations).
- Discussing actual or potential drug-related problems or concerns and the purpose of drug therapy with patients, in consultation with caregivers, physicians and health care providers, when appropriate.
- Monitoring drug therapy to identify drug-related problems or concerns, such as lack of symptomatic response, lack of adherence to treatment plans and suspected adverse effects. Significant concerns should be discussed with the physician.
- Advising patients and caregivers on the selection and use of nonprescription drugs and the management of minor symptoms or ailments.
- Directing patients to consult their physician for diagnosis and treatment when required. Pharmacists may be the first contact for health advice. Through basic patient assessment (i.e., observation and interview) they should identify the need for referral to a physician or an emergency department.
- Notifying physicians of actual or suspected adverse reactions to drugs and, when appropriate, reporting such reactions to health authorities.
- Providing specific information to patients and caregivers about drug therapy, taking into account patients' existing knowledge about their drug therapy. This information may include the name of the drug, its purpose, potential interactions or side effects, precautions, correct usage, methods to promote adherence to the treatment plan and any other health information appropriate to the needs of the patient.
- Providing and sharing general and specific drug-related information and advice with patients, caregivers, physicians, health care providers and the public.
- Maintaining adequate records of drug therapy to facilitate the prevention, identification and management of drug-related problems or concerns. These records should contain, but are not limited to, each patient's current and past drug therapy (including both prescribed and selected over-the-counter drugs), drug-allergy history, appropriate demographic data and, if known, the purpose of therapy and progress toward treatment goals, adverse reactions to therapy, the patient's history of adherence to treatment, attitudes toward drugs, smoking history, occupational exposure or risk, and known patterns of alcohol or substance use that may influence his or her response to drugs. Records should also document patient counselling and advice given, when appropriate.
- Maintaining a high level of knowledge about drug therapy through critical appraisal of the literature and continuing professional development.
Care must be provided in accordance with legislation and in an atmosphere of privacy, and patient confidentiality must be maintained. Products and services should be provided in accordance with accepted scientific and ethical standards and procedures.
Auditing Physician Billings
The CMA has developed a set of guiding principles to assist in the formation and modification of provincial/territorial billing audit processes. These principles will ensure that billing audit systems are fair, transparent, effective and timely, and that they uphold their original objectives of ensuring the accountability of public expenditures and educating physicians on appropriate billing practices.
As payments to physicians are made through public monies, the integrity of the payment system is validated through physician billing audits and reviews. Audits and reviews are usually prompted by: billings that appear to be outside of the “norm,” patient complaints, physician complaints or a “focus” on a particular service/area of practice/group of physicians. Each province/territory is responsible for and has in place particular processes and procedures to review physician billings.
Billing audits can be stressful events that, regardless of the audit outcome, have had adverse effects on a physician’s health and practice. Although changes over the years in billing audit practices have occurred, they have not addressed all of the physicians’ concerns. Inadequacies in the existing procedures, such as the lack of a clear decision-making process, established review timelines and options for recourse still remain.
In response to this situation, many provinces/territories are reviewing and modifying their existing billing audit process. The CMA and Canada’s physicians believe in an open, accountable and transparent health care financing system. It is for this reason that the CMA has developed this set of principles related to the key components of the audit process to ensure it is fair, efficient, effective and serves the purpose it was originally intended – to ensure the accountability of public funds and to educate physicians on proper billing practices.
Education on proper billing practices:
The audit and review process must be undertaken as an educational exercise. In a fee based system, billing code use and interpretation are complex and can often lead to unintentional errors. If or when inconsistencies occur, the physician must be alerted and provided with the opportunity to explain his/her billing behaviour.
To assist in moving the audit and review process from under a cloud of perceived punishment to that of educational enlightenment, the repayment of any funds shall not commence until the audit and review process is complete and all appeal options have been exercised.
As part of this overall educational framework, it is recommended that all newly licensed physicians be offered an educational program on proper billing interpretations, procedures and practices, and of the audit process itself.
Fair, Transparent and Timely Process:
In order for the audit and review process to be perceived as fair, it must operate at arms length from governments and the Colleges. As a profession, physicians have been granted the privilege of self-regulation by society. Given that medicine is a highly complex art and science, physicians are the only group truly qualified to set and maintain standards and to uphold accountability in matters of professional behaviour.
The billing audit and review process must observe the principles of “Natural Justice” in that the:
audit findings must be both impartial and be seen to be impartial and
physicians affected by the findings must be offered a fair hearing by being given notice in writing of the findings; the opportunity to respond to the findings; all of the information to prepare a response; sufficient time to prepare a response; and an oral hearing if there is a dispute on factual matters or if requested by the physician.
Physicians should be informed that legal counsel and assistance can be retained at any stage of the audit and review process. Physicians should consult with their respective provincial/territorial division or the Canadian Medical Protective Association (CMPA) to see whether such assistance is available, or with lawyers who specialize in this field.
Specific time limits should be adhered to in the auditing and reviewing of a physician’s billings practice, particularly related to when the review period should commence and to the duration of the review period. For example, billings should not be reviewable more than 24 months after the service is rendered and the review period should not be greater than 12 months. These limitation periods recognize that physicians will not be able to recall, with certainty, the vast amount of information contained in a patient’s medical record over the past 10 years – the average length of time in which medical records must be held. It also ensures that audits and reviews are conducted in a timely fashion minimizing undue stress and hardship on the physician and, in light of the health human resources shortage, enabling them to re-focus their attention and energy on taking care of their patients.
Audits and reviews to determine whether there has been any incorrect or inaccurate billing should be undertaken solely by a physician’s peers, and where possible, consisting of physicians from the same specialty and subspecialty and with similar practice type, geography and demography. This peer review group shall consider age-gender distribution and the morbidity of the patients as well as other pertinent matters in arriving at its findings and conclusions.
Any conclusions and/or findings from an audit and review must be prepared in a written report and forwarded, in a timely manner, to the physician and the paying agency. If either party is not satisfied with the findings, they have the option of launching an appeal.
The preferred route would be to pursue and use Alternative Dispute Resolution processes since they tend to encourage a more co-operative climate resulting in fair and appropriate settlements, while avoiding the excessive financial, psychological and procedural costs that can be associated with formal court proceedings.
These guiding principles are the product of an international, provincial and territorial scan of billing audit practices. They have undergone extensive consultation with the provincial/territorial medical associations and national medical organizations.
They should be used to form the foundation of and to guide any reviews or modifications to existing provincial/territorial audit and review processes.
CMA Policy, Medical Professionalism, 2002.
Student Behaviour Guide_Natural.Justice.htm, Dec. 2002
I am writing in response to your letter inviting comment on the discussion paper Strengthening the Pan-Canadian Public Health System distributed in February 2004. The Canadian Medical Association (CMA) welcomes the opportunity to participate in this consultation process on a national public health system. Our country’s experience combating SARS brought home to all of us the critical need for a strong and effective public health system to ensure that we are never again found unprepared to deal with the consequences of an emerging infectious disease. The commitments to establish a strong and effective public health system, a Canada Public Health Agency and a Chief Public Health Officer detailed in the February 2, 2004 Speech from the Throne have raised expectations across the land, and particularly within the public health community.
In June 2003 CMA detailed a Public Health Action Plan in its submission to the National Advisory Committee on SARS and Public Health (Naylor Committee). The CMA’s Plan was further elaborated in our October 2003 submission to the Standing Senate Committee on Social Affairs, Science and Technology (Kirby Committee) hearing on public health governance and infrastructure. The CMA is also a founding member and active supporter of the Canadian Coalition for Public Health in the 21st Century. Both of the CMA submissions and the Coalition stress the need for strong leadership, capacity building and appropriate funding to ensure that Canada’s public health system is able to deal with the challenges ahead.
In this submission I will first focus on the responsibility and actions the federal government can take now to create a strong and effective public health system and then comment on issues raised in the Strengthening the Pan-Canadian Public Health System discussion paper.
The CMA believes that the country today has a rare opportunity to build a public health system for Canada that can take the best elements from the past while embracing new
innovative approaches to the future. But to achieve the Speech from the Throne commitment to “establish a strong and responsive public health system” strong leadership is needed now. The federal government has a critical role to play. In both the United Kingdom and the United States, national leadership has been instrumental in clearly defining health goals for the population and stating the role of the public health system, its key infrastructure elements and the development of strategies to attain them.
The CMA is pleased with your commitment and that of your government to the establishment of a Canada Public Health Agency (CPHA) but we can not stress strongly enough the need for you and your cabinet colleagues to take the bold steps needed to ensure that a national public health agency is truly independent. A CPHA that is not adequately funded and independent of the government bureaucracy will only result in a shuffling of the deck chairs.
A credible Chief Public Health Officer (CPHO) must be appointed to lead the Agency, be the federal government’s chief medical officer of health (CMOH) and the country's chief spokesperson for all public health issues.
The CPHA and the Chief Public Health Officer should have a central role in providing public health services to those areas falling under federal jurisdiction where local and provincial Chief Medical Officers of Health do not have access or authority. Airports, railways, military bases, aboriginal peoples living on reserve, federal meat packing plants and national parks are examples of areas under federal jurisdiction. The delivery of public health in these jurisdictions has been especially compromised by the lack of comprehensive coordination between provincial and federal systems. The federal CMOH should have all the powers and responsibilities of a provincial /territorial CMOH with respect to public health in federal jurisdictions.
While there is an urgent need for the federal government to address problems with the delivery of public health services within its own backyard, it also must enhance co-ordination within the various federal departments and agencies that address public health concerns.
In its submission to the National Advisory Committee on SARS and Public Health the CMA also called for federal leadership in times of national health emergencies. The enactment of a Canada Emergency Health Measures Act would enhance the federal government’s “command and control” powers in a measured way during times of national health emergencies. The Act would give the federal government specific authority to act for a pre-determined, temporary period of time, during a declared extraordinary health emergency. It would also provide the authority for development of a graduated health alert system with corresponding public health interventions to enable a rapid co-ordinated response as a public health threat emerges.1 A systematic approach to health emergencies outlining roles, responsibilities and authority of jurisdictions would go a long way to avoiding the chaos and confusion that surrounded the country’s emergency response to SARS.
The public health infrastructure is the foundation that supports the planning, delivery and evaluation of public health activities. In 2001, a working group of the Federal, Provincial and Territorial (F/P/T) Advisory Committee on Population Health assessed the capacity of the public health system through a series of key informant interviews and literature reviews. The consistent finding was that public health had experienced a loss of resources and there was concern for the resiliency of the system infrastructure to respond consistently and proactively to the demands placed on it.
It is essential that the federal government work with the provinces/ territories and municipalities to stop the hemorrhaging in public health across the country. We must stabilize and shore up the core public health capacity at the municipal, and provincial/territorial levels. At the federal level, in the short term, we must sustain our current capacity to tackle critical public health issues. The recent focus on infectious disease must not lead us to take monies from chronic disease prevention and health promotion to bolster efforts to manage outbreaks of infectious disease. Robbing Peter to pay Paul will only compound and exacerbate the challenges facing the public health system. All of the essential functions of public health must be recognized and resourced within a coherent public health strategy.
This will require an investment of at least $1.5 billion over the next five years, beginning with an immediate commitment of $200 million in the upcoming budget. There is also a critical need for additional resources to reach the frontline public health workers in the many local agencies across Canada. In this regard, on March 12, 2004 the CMA, the Canadian Nurses Association, Canadian Pharmacists Association and the Canadian Healthcare Association wrote to the Prime Minister urging him to consider adding the recent one-time $2 billion transfer into the Canada Health Transfer (CHT) funding base and ear-mark 10% of this amount for public health action.
The infusion of $1.5 billion over the next five years would go a long way to provide federal, provincial/territorial and municipal governments with the tools needed to rebuild capacity in the public health system. An area needing immediate attention is human resource capacity. For the essential functions of the public health system to be realized, we need a public health workforce with appropriate and constantly updated skills. Unfortunately that workforce is extremely thin today. We need to invest in additional training capacity in all of the public health disciplines. CMA has proposed an investment of $50 million in 2004/05 to begin to strategically rebuild human resource capacity.
To provide additional surge capacity CMA has further proposed the establishment of a Canadian public health emergency response service or Canadian Health Corps. The service would be made up of a core group of highly trained and mobile public health professionals, employed by the federal government, to be directed by the Chief Public Health Officer. A complementary ‘reserve pool’ or volunteer relief network would be made up of acute health care and public health professionals willing to be deployed anywhere in Canada on short notice to provide services during health emergencies. A predetermined and pre-licensed pool of professionals that can respond to a call to action in times of crisis is a critical resource that must be established before we are faced with another emergency situation.
Canadians expect the federal government to assume its responsibility to provide national leadership in public health. Visionary leadership, investment and capacity building are essential components of a reinvigorated public health system. It is within this context that CMA has reviewed the Strengthening the pan-Canadian public health system discussion paper.
Strengthening the pan-Canadian public health system
The discussion paper Strengthening the Pan-Canadian Public Health System unfortunately positions the planning assumptions for a national public health strategy within the traditional F/P/T process. While we are encouraged with the commitment of the F/P/T Ministers of Health to work collaboratively on the creation of a Pan-Canadian Public Health Network, it is not what Canadians or CMA envisioned in terms of providing leadership on the development of a national public health strategy and a consistent and co-ordinated approach to health emergencies.
The discussion paper is proposing that a CPHA be the centralized responsibility centre or ‘co-ordinating node’ of a Pan-Canadian Public Health Network that would develop national public health strategies and co-ordinate responses to public health emergencies. While the Network is necessary to facilitate intergovernmental co-operation, CMA believes that it is now time to move beyond traditional processes that, in the past, have often hindered the country’s ability to respond rapidly to address pan-Canadian problems.
Therefore in its briefs to both the Naylor and Kirby Committees, the CMA proposed the creation of an independent CPHA to provide leadership and comprehensive public health expertise in the development of a strategic pan Canadian approach to public health planning and services. These CMA briefs speak to many of the issues pertaining to the CPHA and CPHO that are raised in the federal discussion paper. CMA proposals for a CPHA as outlined below address the questions of mission and mandate, accountability and transparency posed by the paper.
The CPHA, as described by CMA, would become the lead national agency on public health matters with a broad mandate to co-ordinate all aspects of planning for national public health emergencies, provide ongoing national health surveillance and work closely with provinces/territories to reinforce other essential public health functions. To effectively carry out its mandate the CPHA structure must respect five guiding principles. It must be:
* Independent – At arm’s length from government, insulated from day-to-day vagaries of political pressures while remaining accountable to Canadians.
* Science-based – Adherence to the highest standards of risk assessment and decision-making with a view to safeguarding the health of Canadians.
* Transparent – Open to public scrutiny and encouraging public participation in its activities.
* Responsive – Characterized by a nimble decision-making process and a capability of deploying resources and expertise quickly and efficiently to any part of the country.
* Collaborative – Partnership-oriented, fostering collaboration with other federal, provincial and non-governmental partners.
CMA has recommended that the CPHA be established as an arms length, adequately resourced agency within the purview of the federal government. Under this approach, the CPHA would be structured on a corporate model in which decision-making powers are vested in an expert advisory board. The board, in turn, would be accountable to Parliament and the public for the exercise of these powers. The CPHA would be created through new federal legislation but would remain under the health portfolio, with accountability to Parliament through the health minister. The chief public health officer would head the CPHA, oversee the day-to-day operation of the office, be the federal government’s chief medical officer of health, and act as the lead scientific voice for public health in Canada.
This structure would mark a departure from the status quo in that the level of professional autonomy would increase and the level of ministerial involvement in professional issues would be reduced. This would contribute to making the CPHA more credible as a science-based organization. The board governance structure would encourage participation from the broader public health community and could therefore be more effective in creating partnerships with other key players.
The CMA commends you and the federal and provincial/territorial governments for the evident commitment to address the public health challenges facing this nation. It is unfortunate that it took a public health tragedy to bring this commitment to the forefront but never the less the public health community in Canada stands ready to work with governments to achieve a strong and responsive public health system.
As part of that community the medical profession is ready and willing to support initiatives that will improve public health programs and services that ultimately make
Canada a safer and healthier place to live. We do not support a continuation of the status quo. We must seize this opportunity to create a public health system that that can take the best elements from the past while embracing new innovative approaches to the future.
Sunil V. Patel, MB, ChB
1 Answering the Wake-Up Call: Canada’s Public Health Action Plan, June 2003. Available: http://www.cma.ca/cma/menu/displayMenu.do?tab=422&skin=432&pMenuId=1&pSubMenuId=2&pageId=/staticContent/HTML/N0/l2/where_we_stand/political/index.htm
Obesity and Cardiovascular Disease (Update 2004) (Applicable to Canadians aged 20-60 years)
Obesity is a chronic condition that is multi-factorial in origin, complex to treat, and is a major contributor to heart disease, type II diabetes, hypertension, stroke and some cancers. Due to the magnitude of the impact that obesity has on heart disease and stroke, and to the clustering of risk factors for cardiovascular disease that are often found in the obese patient, obesity is recognized as a major risk factor for cardiovascular disease.
The impact of obesity points to the importance of prevention through healthy behaviours including increased physical activity and a healthy nutritional diet beginning early in life, and continuing through all stages of life. Solutions require comprehensive approaches that are both education and environment based, and that target and assist individuals, the family, and communities to engage in healthy lifestyle patterns and behaviours. Solutions also require ongoing research to develop and evaluate comprehensive approaches to obesity prevention, management and treatment, and surveillance data that measures and tracks obesity and its impact in Canada.
The World Health Organization defines obesity as a condition of excessive body fat accumulation to an extent that health may be compromised.
Body Mass Index (BMI) is a widely accepted parameter used to distinguish between obese and non-obese adults aged 20 to 60 years and thus provides information about the subsequent risk of cardiovascular disease.
BMI is calculated by dividing the weight (in kilograms) by the square of the height (in metres).
BMI = weight (in kilograms)
height (in metres) * height (in metres)
A BMI equal to or greater than 30 kg/m2 is classified as obese, while a BMI in the range of 25 to 29.9 kg/m2 is classified as overweight.
Waist circumference (WC) provides an independent prediction of health risks over and above BMI. Increased waist (abdominal) circumference is associated with increased risk of cardiovascular disease, dyslipidemia, type II diabetes and hypertension. As waist circumference increases above 102 cm for men and 88 cm for women, the risks of health-related illnesses increase.
Populations at Increased Risk
Obese individuals with diabetes, hypertension, or dyslipidemias or who are physically inactive are at increased risk of cardiovascular disease, compared to individuals without these conditions.
A BMI between 25 and 29.9 kg/m2 (overweight) is associated with elevated risk of cardiovascular disease, type 2 diabetes, hypertension and dyslipidemia.
Weight gain during young adult life may be one of the most important determinants of future development of cardiovascular risk factors and cardiovascular disease. Adults who gain weight have increased risk of coronary heart disease compared to those with stable weight. Weight gain during adult life may contribute to future development of ischemic heart disease regardless of initial body weight (obese or non-obese).
Canadians of Aboriginal, Chinese, and South Asian (from India, Pakistan, Bangladesh, and Sri Lanka) descent have higher rates of obesity-related chronic diseases (for example diabetes, hypertension and cardiovascular disease).
Individuals with lower socio-economic status have higher rates of obesity than those with higher socio-economic status.
Promotion of Healthy Weights
In April 2002, the Public Health Approaches to the Prevention of Obesity (PHAPO) Working Group of the International Obesity Task Force (IOTF) identified that a comprehensive approach to obesity prevention should:
Address both dietary habits and physical activity patterns of the population
Address both societal and individual level factors
Address both immediate and distant causes
Have multiple focal points and levels of intervention (i.e. at national, regional, community and individual levels);
Include both policies and programs; and
Build links between sectors that may otherwise be viewed as independent.
Research is needed to:
Develop a standard definition and a standard measurement technique for determining obesity in children.
Develop obesity measures for older, ethnic and gender specific populations.
Identify and develop effective primary prevention methods for individuals, families and communities to reduce the prevalence of obesity in all stages of life.
Improve awareness and knowledge about the health effects of obesity and healthy living.
Develop effective primary prevention measures and strategies that are therapeutic, secondary and tertiary in nature.
Identify and track rates of obesity and overweight in Canada.
Assess the effectiveness of obesity prevention and treatment initiatives.
Identify and implement the most effective primary prevention strategies for ethnic populations.
Develop and implement effective healthy public policy for the prevention, treatment, and management of obesity.
Further, the surveillance of obese and overweight Canadians is necessary in order to assess the effectiveness of prevention and treatment initiatives. It is only through the combined action and resources of governments, non-governmental organizations, non-profit and private sectors to develop and implement a comprehensive approach to curb the growing trend of obesity in Canada.