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Advance care planning

https://policybase.cma.ca/en/permalink/policy13694

Date
2017-05-27
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Date
2017-05-27
Replaces
Advance care planning (2015)
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
Text
With the advent of technology allowing for the extension of life, and as a result of the increasing importance of personal autonomy, decisional capacity, and informed consent and the growing awareness of issues related to quality of life and dying, Canadians have become increasingly interested in expressing their wishes regarding their health care and having more input into decisions about their care should they become incapable. Advance care planning (ACP) can help patients to achieve these goals. The CMA supports development of a strategy for ACP1 in all provinces and territories. ACP leads to better concordance between patients' wishes and treatments provided,2,3 decreased anxiety for families,4 decreased moral distress for health care providers,5 decreased hospitalization rates of nursing home residents3 and fewer unnecessary medical treatments.3,6,7 ACP is at the intersection of the provision of health care, ethical values and legal rights and duties. In particular, it involves the acknowledgement of essential aspects of autonomy, informed consent, and respect of patients' care wishes now and in the future, and their intentions if they become incapable.8,9 The balancing of the need to obtain informed consent for a treatment option in the present with the need to respect health care preferences that were stated in the past has been addressed using various clinical, legal and institutional approaches across Canadian jurisdictions." Physicians10 can play a significant role in ACP throughout the course of the patient-physician relationship, including in the pediatric setting. At any time, outcomes of the planning process can be documented and/or the patient can appoint a substitute decision-maker in writing. These documents can be identified as advance directives, personal directives or powers of attorney for personal care11 (hereinafter all will be referred to as advance directives). An advance directive does not remove the need for a physician to obtain consent before providing a treatment to a patient, except in an emergency. As stated in the Canadian Medical Protective Association's consent guide: "[U]nder medical emergency situations, treatments should be limited to those necessary to prevent prolonged suffering or to deal with imminent threats to life, limb or health. Even when unable to communicate in medical emergency situations, the known wishes of the patient must be respected."12 While much of the focus of ACP is on making care decisions and nominating proxy decision-makers in case the patient becomes incapable of making decisions in the future, ACP has much more utility. ACP conversations13 can assist patients in determining treatment trajectories and making decisions about the intensity level of interventions in their current care. Providers can have discussions with patients and their families about proposed treatments in the context of the patient's communicated goals and wishes. The process of ACP also helps patients and their families to become familiar with the language and processes used to make cooperative health care decisions. SCOPE OF POLICY This policy aims to provide guidance on key considerations pertinent to ACP in a way that is consistent with a physician's ethical, professional and legal obligations. This is a complex subject: physicians should be aware of the legislation in the jurisdiction in which they practise, the standards and expectations specified by their respective regulatory authority, as well as the policies and procedures of the setting(s) in which they practise (e.g., regional health authority, hospital). GENERAL PRINCIPLES 1. ACP is a process of (a) respecting patients' wishes through reflection and communication, (b) planning for when the patient cannot make health care decisions and (c) discussion with friends, family and professionals; (d) it may result in a written document.5 It informs the substitute decision-maker and provides information for the clinician to consider in the provision of care within the bounds of the law. 2. Although often associated with the end of life, ACP represents the expression of a patient's wishes for any future health care when the patient is incapable. It expresses the patient's values and beliefs regarding current care decisions and provides information that can inform any decisions that must be made during an emergency when the patient's consent cannot be obtained. For these reasons, ACP should occur throughout a person's lifetime. 3. Respect for patients' dignity and autonomy is a cornerstone of the therapeutic physician-patient relationship. Patients' right to autonomous decision-making has become embedded in ethical frameworks, consent legislation and case law.14 Respect for the wishes of an incapable patient constitutes a preservation of autonomy and promotes trust between the physician and patient.15 4. The way in which the act of obtaining consent is weighed against the patient's stated wishes as outlined during the ACP process varies according to the jurisdiction in which the patient and physician are located. EDUCATION 1. Given the practical, ethical and legal complexities of ACP, physicians, medical learners should be supported in becoming familiar with ACP and comfortable in engaging in the process with their patients. To this end, CMA supports the development of training in ACP and efforts to make it available to all physicians and medical learners.16 For practising physicians and residents, many resources are available, for example: a. Advance Care Planning in Canada: A National Framework b. Facilitating Advance Care Planning: An Interprofessional Educational Program c. Information from the Health Law Institute of Dalhousie University on the regulatory policies and legislation of individual provinces and territories d. A comprehensive collection of Canadian resources compiled by the Speak Up campaign of the Advance Care Planning in Canada initiative e. Pallium Canada's Learning Essential Approaches to Palliative Care module on ACP In the case of medical students, the CMA supports the position of the Canadian Federation of Medical Students that end-of-life training is an essential facet of undergraduate medical education. 2. The issue of the supervision of medical learners practising ACP should be clarified, as considerable ambiguity currently exists.17 Medical learners would benefit from unified national guidelines concerning the nature of their participation in ACP, especially regarding end-of-life care. In the case of medical students, the CMA agrees with the recommendation of the Canadian Federation of Medical Students that supervision be mandatory during conversations about end-of-life care. 3. The CMA calls for more research on the outcomes associated with the provision of ACP training to physicians and medical learners. 4. The CMA recommends that governments and institutions promote information and education on ACP to patients and their substitute decision-makers. PROFESSIONAL AND LEGAL RESPONSIBILITY 1. While respecting patients' values, all physicians are expected to encourage their patients to engage in ACP with them. ACP is not a one-time event. The nature of the conversation between the physician and the patient and the regularity with which they discuss the subject will depend on the patient's health status. Family physicians and physicians have ongoing care relationships with chronically ill patients are particularly well placed to have regular discussions with their patients about their beliefs, values and wishes. An effective exchange of information between family physicians (and other physicians who work in the community with outpatients) and acute or tertiary care physicians would assist in ensuring patient's wishes are considered. 2. ACP, in particular advance directives, are at the intersection of medicine and the law. Physicians should recognize this and ask patients whether they have an advance directive or have done any ACP. 3. There is wide variation across jurisdictions in terms of the requirements and procedures for ACP; therefore, physicians should inform themselves about any relevant legislation and the scope of the requirement to obtain consent within that jurisdiction when carrying out ACP. INSTITUTIONS 1. The CMA supports institutional processes that recognize and support ACP. Support for ACP includes developing a consistent process for the exchange of information about patients' wishes and advance directives among health care providers, as patients traverse sectors and locations of care. Patients with a written advance directive must be identified and the advance directive integrated fully within the patient's records18 so that it is available across the institution (and ideally the health care system). The CMA advocates for the inclusion of advance care directive functionality as a conformance and usability requirement for electronic medical record vendors.19 Provinces and territories should be encouraged to establish robust organizational processes and resources for patients in all locations of care and strong province- or territory-wide policy, such as in Alberta.20 2. Institutions and other organizations should encourage health care providers to ask patients to bring their advance directive to appointments at the same time they ask them to bring a list of their medications or other medical information. 3. The CMA supports institutional/organizational audits of structures, processes and outcomes related to ACP as an important step in improving the quality and frequency of ACP activities. ROLE FOR GOVERNMENTS 1. The CMA supports infrastructures enabling ACP, including funding that will support ACP and other end-of-life discussions. 2. The CMA promotes the incorporation of ACP into future federal and provincial/territorial senior strategies and dementia and/or frailty strategies. 3. The CMA supports the development of ACP metrics and their future inclusion in Accreditation Canada standards. GLOSSARY Advance care planning (ACP) Advance care planning is a term used to describe a process of reflection, communication, conversation and planning by a capable individual with family, friends and professionals about their beliefs, values and wishes for a time when they no longer have the mental capacity to make decisions about their health care. ACP can also involve the naming of a substitute decision-maker.8 Advance directive The legislated term "advance directive" has different names, definitions and legal authority across the country. For example, in British Columbia an advance directive is a written legal document that provides a mechanism for capable patients to give directions about their future health care once they are no longer capable. 21 As such, in BC an advance directive may, under certain circumstances, be considered "equivalent to consent to treatment and may be acted upon directly by a health care provider without consultation with an SDM [substitute decision-maker]." 8 In Alberta it is called a personal directive. In Ontario, "advance directive" is a generic non-legal term and refers to communications that may be oral, written or in other forms.8 In Quebec, advance care directives are legally binding, as set out in the Act respecting end-of-life care, which recognizes "the primacy of freely and clearly expressed wishes with respect to care. . ."22 Current legislation does not allow for medical assistance in dying to be requested by an advance directive.23 The CMA acknowledges that considerable public, expert and legal debate exists around the issue. Informed consent To obtain informed consent, physicians must provide adequate information to the patient or capable decision-maker about the proposed procedure or treatment; the anticipated outcome; the potential risks, benefits and complications; and reasonable available alternatives, including not having the treatment; and they must answer questions posed by the patient. Consent is only informed if there is disclosure of matters that a reasonable person in the same circumstances would want to know.24 Consent must be given voluntarily, must not be obtained through misrepresentation or fraud, must relate to the treatment and must be informed. Substitute decision-maker (SDM or agent or proxy) A substitute decision-maker is a capable person who will make health care decisions on behalf of an incapable individual. In all jurisdictions the health care provider must take reasonable steps to become aware of whether or not there is a substitute decision-maker before providing health treatment to an incapable patient. Legally there are implementation differences across the country. For example, in BC a substitute decision-maker is appointed through a representation agreement, in Alberta through a personal directive and in Ontario through a power of attorney for personal care. Approved by the CMA Board of Directors May 2017 1 Canadian Medical Association. Policy resolution GC14-25 - strategy for advance care planning, palliative and end-of-life care. Ottawa (ON): The Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 Oct 17) 2 Houben CHM, Spruit MA, Groenen MTJ, et al. Efficacy of advance care planning: a systematic review and meta-analysis. J Am Med Dir Assoc 2014;15:477-89. 3 Martin RS, Hayes B, Gregorevic K, et al. The effects of advance care planning interventions on nursing home residents: a systematic review. J Am Med Dir Assoc 2016;7:284-93. 4 Mack JW, Weeks JC, Wright AA, et al. End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences. J Clin Oncol 2010;28(7):1203-8. 5 Canadian Hospice Palliative Care Association. Advance care planning in Canada: national framework. Ottawa; The Association; 2010. 6 Teo WSK, Raj AG, Tan WS, et al. Economic impact analysis of an end-of-life programme for nursing home residents. Palliat Med 2014;28(5):430-7. 7 Zhang B, Wright AA, Huskamp HA, et al. Health care costs in the last week of life: associations with end-of-life conversations. Arch Intern Med 2009;169(5):480-8. 8 Wahl J, Dykeman MJ, Gray B. Health care consent and advance care planning in Ontario. Toronto (ON): Law Commission of Ontario; 2014. 9 Canadian Medical Association. CMA Code of Ethics (update 2004). Ottawa: The Association; 2004. 10 Physician involvement is not mandatory in the process. However, it is important for physicians to engage with their patients in ACP as this can facilitate change in patients' ACP behaviour and understanding. 11 Wahl JA, Dykeman MJ, Walton T. Health care consent, advance care planning, and goals of care practice tools: the challenge to get it right. Improving the last stages of life. Toronto (ON): Law Commission of Ontario; 2016. 12www.med.uottawa.ca/sim/data/Images/CMPA_Consent_guide_e.pdf 13 Frank C, Puxty J. Facilitating effective end-of-life communication - helping people decide. CJS Journal of CME 2016;6(2). Available: http://canadiangeriatrics.ca/wp-content/uploads/2017/02/Facilitating-Effective-End-of-Life-Communication---Helping-People-Decide.pdf (accessed 2017 April 25). 14 Fleming v Reid (1991) 82 DLR (4th) 298 (CA ON); Cuthbertson v Rasouli, 2013 SCC 53; Malette v Shulman (1990), 72 OR (2d) 417; Starson v Swayze (2003) 1 SCR 722. 15 Harmon SHE. Consent and conflict in medico-legal decision-making at the end of life: a critical issue in the Canadian context. University of New Brunswick Law Journal 2010;60(1):208-29. 16 Canadian Medical Association. Policy resolution GC13-69 - training in advance care planning. Ottawa (ON): The Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 May 26). 17 Touchie C, De Champlain A, Pugh D, et al. Supervising incoming first-year residents: faculty expectations versus residents' experiences. Med Educ 2014;48(9):921-9. 18 Canadian Medical Association. Policy resolution GC14-19 - advance care plans. Ottawa (ON): The Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 May 26). 19 Canadian Medical Association. BD14-05-163 Advance care directive functionality. Ottawa (ON): The Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 May 26). 20 Conversations matter. Edmonton (AB): Alberta Health Services. Available: http://goals.conversationsmatter.ca.s3-website-us-east-1.amazonaws.com/ (accessed 2017 May 19). 21 Health Care (Consent) and Care Facility (Admission) Act, RSBC 1996, c 181, s.3 22 Act respecting end-of-life care, S-32.0001. Government of Quebec. Available : http://legisquebec.gouv.qc.ca/en/ShowDoc/cs/S-32.0001 23 An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying) S.C. 2016, c.3. Ottawa: Government of Canada; 2016. Available: http://canlii.ca/t/52rs0 (accessed 2016 Oct 17) 24 Riebl v Hughes, [1980] 2 SCR 880; Hopp v Lepp, [1980] 2 SCR 192.

Documents

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Physician health

https://policybase.cma.ca/en/permalink/policy13739

Date
2017-10-21
Topics
Health human resources
Ethics and medical professionalism
  3 documents  
Policy Type
Policy document
Date
2017-10-21
Replaces
PD98-04 Physician health and well-being
Topics
Health human resources
Ethics and medical professionalism
Text
The term physician health encompasses the prevention and treatment of acute or chronic issues of individual physicians, as well as the optimization of interconnected physical, mental and social factors to support health and wellness.1 Attributable to a range of personal, occupational and system-level factors, physicians and learners alike are increasingly voicing distress and calling for resources and support. As a central issue for Canadian physicians, and a growing concern within the medical profession, physician ill-health is being increasingly understood as a set of risk-management practices,2 including the use of strategies rooted in organizational psychology and occupational medicine, as well as intensified oversight by professional bodies, and the integration of maintaining personal health as a core medical competency.3 Physician health, is important to the long-term sustainability of the physician workforce and health systems.4 As a quality indicator5-6 addressing the complex array of related issues is a shared responsibility of individual physicians and the systems in which they work.2,4,5 This involves efforts from individuals as well as system-level influencers, such as stakeholder groups from areas including academic medicine, medical education, practice environments, accrediting and regulatory bodies, provincial and territorial medical associations, regional and local health authorities, national medical associations and their affiliates, governments and other decision-making bodies. Meaningful, system-wide change can only occur via deliberate and concerted efforts on a national scale5 to address personal, workplace, and cultural barriers and normalize the promotion of opportunities and conditions for optimizing health and wellness. Although considerable progress has been made, it is necessary to continue working towards a more coordinated and sustained system of health promotion, illness prevention and tertiary care to build on these successes.4-5 This policy aims to provide broad, aspirational recommendations to help guide stakeholders at all levels of the health system to promote a healthy, vibrant, and engaged profession - including a healthy practice and training culture, and work environment. RECOMMENDATIONS Individual level The CMA recommends that physicians and learners: * demonstrate a commitment to physician health and well-being as part of their responsibilities under the CanMEDS Professional Role, including: Exhibiting self-awareness and managing influences on personal well-being (e.g., self-regulation and assessment, mindfulness, resilience); managing personal and professional demands for a sustainable practice throughout the career life cycle; and promoting a professional culture that recognizes, supports, and responds effectively to colleagues in need;3 * actively engage in fostering supportive work and training environments; * assume responsibility for individual actions and behaviours that may contribute to negative culture and stigma;5 * foster relationships with family and friends, as well as interests outside of medicine, and ensure sufficient rest (including time-off); and * have a family physician and visit him or her regularly for comprehensive and objective care. System level The CMA recommends that: * national-level advocacy be undertaken to address issues related to physician and learner health; * efforts to address physician health incorporate individually targeted initiatives and optimize learning and practice environments, including cultivating a healthy culture,6-7 and that stakeholders collaborate (including input from physicians and learners) to develop and promote initiatives that strengthen physician health at both the individual and system levels; * health systems adopt an understanding of their obligation to the health of physicians that is similar to the obligation of other Canadian employers to their workers (e.g., psychological safety, work hours, employee resources, standards and expectations); * policies aiming to cultivate a healthy culture be modelled, and behaviours not conducive to supporting and enabling a healthy culture dealt with in an effective manner; * physician and health system leaders acknowledge and demonstrate that physician health is a priority, and continually assess whether actions and policies align with desired values and culture;4 * physician and health system leaders be better equipped to identify and address behaviours that are symptomatic of distress (e.g., psychological) and receive more comprehensive training to address with colleagues, including within teams; * mechanisms and opportunities for physicians and learners to access existing services and programs (e.g., provincial, institutional) are maximized, and that these resources are regularly promoted and barriers to access addressed in a timely manner;5,8 * standards, processes and strategies be developed to address occupational barriers to positive health8 (at a minimum, these should address the meaningful integration of occupational and personal life, provision of resources to enhance self-care skills,4 and prioritization of opportunities for adequate rest, exercise, healthy diet and leisure;8 * wellness (including enhancement of meaning, enjoyment and engagement) be promoted, instead of an exclusive focus on reduction of harm;5 * physicians and learners be encouraged to have a family physician, and that barriers to access such care be identified and addressed; * physicians, particularly those providing primary care to other physicians, have access to training in treating physician colleagues; * physicians and learners be given reasonable access to confidential assistance in dealing with personal and professional difficulties, provided in a climate free of stigmatization; * programs and services be accessible to physicians and learners at every stage of their diagnosis and treatment, and that seeking treatment should not feel punitive or result in punitive consequences; * physicians and learners have supportive learning and work environments free of discrimination, and for processes which provide reasonable accommodations to physicians and learners with existing disabilities, while allowing for safe patient care, to be bolstered; and * practices which enable safe and effective patient care, and support workflow and efficient capture of information (e.g., electronic medical records), do not create excessive work and time burdens on physicians. Physician organizations, professional associations and health authorities The CMA recommends that: * all physicians and learners have access to a robust and effective provincial physician health program (PHP), and for long-term, sustained efforts to be made to maintain and enhance physician health, including a commitment to resourcing PHPs5 via the provision of stable funding through provincial and territorial medical associations, or the negotiation of such funding from provincial governments; * training programs, hospitals, and other workplaces ensure appropriate programs, services, and policies are developed, in-place, and enforced for physicians and learners to get help to manage health and behavioural issues, support the need for treatment, and facilitate return to work or training while protecting individual confidentiality, privacy, as well helping the institution manage risk; * the range of continuing medical education offerings aimed at personal health be expanded (content should develop individual skills and extend to training for leaders and administrators that targets improved training and practice environments and culture); * continuing education credits for physicians' efforts to enhance their personal wellness or that of colleagues be established and promoted, free of conditions requiring links to patient care; * emerging champions from learner and early-career segments be identified and supported; and * the unique health and wellness challenges faced by physicians and learners in rural, remote, or otherwise under-serviced regions (including the Canadian territories) be recognized, and for access to services and other resources to be enhanced. Medical schools, residency training programs, and accreditation bodies The CMA calls for: * accreditation standards for health and wellness programs and initiatives for medical faculties and training programs, and health authorities to be raised, reviewed in an ongoing manner and that standards and competencies be enforced; * action to bring meaningful change to the 'hidden curriculum' by aligning formal and 'hidden' curriculums that promote and reinforce positive conduct, and for accreditation bodies to consider this in their review and enforcement of standards for training programs; and * formal health and wellness curricula to be integrated and prioritized at the undergraduate and postgraduate levels, including but not limited to training around how to recognize and respond to distress or illness in oneself and colleagues, as well as self-management strategies (e.g., resilience and mindfulness). Medical regulatory authorities The CMA calls for medical regulatory authorities to: * work with provincial and territorial medical associations, PHPs, governments and other key stakeholders to; (a) create a regulatory environment that protects the public (their explicit duty) while limiting barriers for physicians seeking diagnosis and treatment,5 and (b) promote resources for early self-identification of potential health issues; and * while maintaining their duty to protect the public, review their approach to mental health challenges to ensure that focus is placed on the existence of impairment (illness interferes with ability to engage safely in professional activities,9 and not the mere presence of a diagnostic label or act of seeking of care5 (in order to ensure that physicians and learners who are appropriately caring for their health not be impacted in their ability to work). Governments The CMA calls for: * governments to acknowledge the adverse impact their policies and processes can have on the health of physicians, and to adopt and enforce health and wellness standards through a lens of occupational health for physicians that are similar to those afforded to other Canadian workers; * governments to work with employers and key stakeholders to create more effective systems that provide better practice and training conditions;5 and * enhanced support for provincial PHPs, institutions (e.g., medical schools, training programs), and other providers of physician health services.5 Researchers The CMA recommends that: * national and regional data for major health and wellness indicators be assessed at regular intervals to establish and compare norms and to better target and assess initiatives; * a national research strategy be developed through collaboration among relevant stakeholders to identify priorities, coordinate efforts, and promote innovation (consider the specific recommendations from a 2016 research summit to improve wellness and reduce burnout,10 including: Estimating economic impacts; using common metrics; developing a comprehensive framework for interventions with individual and organizational components; and sharing the best available evidence); and * further research in a range of areas including, but not limited to: efficacy of programs, strategies, and systems for promoting and managing health and wellness; examination of the factors exerting the greatest influence on physician health; and system-level interventions.5 Approved by the CMA Board of Directors October 2017 See also Background to CMA Policy on Physician Health REFERENCES 1 World Medical Association (WMA). WMA Statement on physicians well-being. France: WMA; 2015 Oct. Available: https://www.wma.net/policies-post/wma-statement-on-physicians-well-being/ (accessed 2017 Oct 30). 2 Albuquerque J, Deshauer D. Physician health: beyond work-life balance. CMAJ 2014;186:E502-503. Available: https://doi.org/10.1503/cmaj.140708 (accessed 2017 Oct 30). 3 Frank JR, Snell L, Sherbino J, Royal College of Physicians and Surgeons of Canada (RCPSC). CanMEDS 2015 physician competency framework. Ottawa: RCPSC; 2015. Available: http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf (accessed 2017 Oct 30). 4 Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017;92:129-6. Available: https://doi.org/10.1016/j.mayocp.2016.10.004 (accessed 2017 Oct 30). 5 Canadian Medical Association (CMA). Physician health matters: A mental health strategy for physicians in Canada. Ottawa: CMA; 2010. Available: https://www.cma.ca/Assets/assets-library/document/en/practice-management-and-wellness/Mentalhealthstrat_final-e.pdf (accessed 2017 Oct 30). 6 Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21. Available: https://doi.org/10.1016/S0140-6736(09)61424-0 (accessed 2017 Oct 30). 7 Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham C, et al. Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Intern Med 2017;177:195-205. Available: https://doi.org/10.1001/jamainternmed.2016.7674 (accessed 2017 Oct 30). 8 Ruotsalainen JH, Verbeek JH, Mariné A, Serra C, Ruotsalainen JH, Verbeek JH, et al. Preventing occupational stress in healthcare workers. Sao Paulo Medical Journal 2016;134:92-92. Available: https://doi.org/10.1590/1516-3180.20161341T1 (accessed 2017 Oct 30). 9 Rondinelli RD, Genovese E, Brigham CR, American Medical Association (AMA). Guides to the evaluation of permanent impairment. Chicago: AMA; 2008. Available: https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod1160002 (accessed 2017 Oct 30). 10 Dyrbye LN, Trockel M, Frank E, Olson K, Linzer M, Lemaire J, et al. Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout. Ann Intern Med 2017;166:743-4. Available: https://doi.org/10.7326/M16-2956 (accessed 2017 Oct 30). BACKGROUND TO CMA POLICY PHYSICIAN HEALTH See also CMA Policy on Physician Health In recent decades there has been growing recognition of the impact of physician health on systemic outcomes and patient-care.1,2 Physician health encompasses the prevention and treatment of acute or chronic issues of individual physicians, as well as the optimization of of interconnected physical, mental and social factors to support health and wellness.3 It is also being increasingly understood as a set of risk-management practices aimed at shifting perceptions of health from being an individual (private) matter to more of a shared resource.4 In Canada evidence for this includes the use of strategies adapted from organizational psychology and occupational medicine to change physician behaviour, as well as intensified oversight by professional bodies, and the inclusion of maintaining personal health as a core competency for physicians.4,5 Despite concerted efforts to promote and protect the health and wellness of physicians, the collective state of physician health remains a significant threat to the viability of Canada's health system.1 Physician distress is emerging as an important quality indicator in medical practice,4,6 and both individual- and system-level factors are well-established contributors to compromised physician health.2,7 As such, the advancement of a model of shared responsibility - targeting the relative roles of individual physicians and system-level influencers8 - represents a robust response to this reality. 1. The state of learner and physician health Poor health may develop before or during training and persist into medical practice. Medical school and residency training are particularly challenging times, when a myriad of competing personal and professional demands threaten learner health. In Canada, it has been reported that most students suffer from at least one form of distress over the course of their training9,10 and recent national data point to higher rates compared to their age and education-matched peers. With respect to burnout, characterized by a high level of emotional exhaustion and/or high level of depersonalization (at least weekly), overall rates are reportedly 37%.11,12 Similarly higher levels of depression, anxiety and burnout are reported among American medical students than in the general population.13 While both residents and physicians are reported to be physically healthier than the general population, their mental and social health are cause for concern.1,14 Compared with the general population, physicians are at a higher risk of experiencing adverse outcomes such as depression and burnout15,16 - the latter of which is nearly twice as common among physicians compared with workers in other fields, even after adjusting for age, sex, education level, relationship status, and work hours.17 Results from the 2017 CMA National Physician Health Survey18 showed that 49% of residents and 33% of physicians screened positive for depression, and high burnout rates were reported in 38% of residents 29% of physicians. Furthermore, although the mental health, addiction and substance-use problems, including alcohol, among physicians are not dissimilar to those in the general population, the abuse of prescription drugs (e.g., opioids) is reportedly higher.1,19 Although most physicians referred to monitoring programs have been diagnosed with substance use disorders, an increasing number are being referred for recurrent mood disorders, often stemming from workplace concerns.20,21 1.1 Contributing factors Adverse health outcomes among learners and physicians are linked to a range of contributing factors, including intrinsic ones (e.g., personality characteristics22 and other personal vulnerabilities) and extrinsic ones (e.g., excessive workloads, excessive standards of training and practice, excessive duty hours, lack of autonomy, disruptive behaviour, poor work-life integration, increasing demands with diminishing resources, systemic failures, financial issues, and the practice and training environment).2,15,23 Moreover, the management of risk that many physicians are involved with as it relates to the treatment and management of their patients can be challenging and impacts their health4. A dearth of recent data on the health status of physicians in Canada represents a critical gap in knowledge and limits future efforts to refine, select and assess initiatives. 2. Consequences 2.1. Impact on learners and physicians Compromised physician health can result in decreased personal and professional satisfaction, dysfunctional personal and professional relationships, increased attrition and increased rates of suicide and suicidal ideation.6,24,25 Perhaps most troubling, completed suicide rates among physicians are 1.4-2.3 times higher than in the general population - between 300 and 400 physicians annually in the United States.26 In Canada, suicidal ideation among physicians (including residents) has been recently reported at 19% (lifetime) and 9% (in the last year)18, while Canadian medical student data report 14% (lifetime) and 6% (in the last year).11 Overall, ideation rates are higher among both physicians and learners than in the general population.27 2.2. Impact on patient care The impact of the mental and physical health of physicians extends to the quality of care provided to patients.16,28,29 For instance, physicians suffering from burnout are reportedly two to three times more likely to report their conduct with their patients as sub-optimal.24 Indeed, physicians remain a primary source of health information for patients, and they act as both role models and health advocates.15 Characteristics of burnout (e.g., poor communication and reduced empathy) run counter to the core principles of patient-centred care,30 and physicians who maintain healthy lifestyles are more likely to focus on preventive strategies with their patients.31,32 Although deficits in physician health can negatively affect patient care, it is notable that evidence linking the health of physicians to medical errors is incomplete, if not difficult to establish. Nevertheless, studies have reported a relationship between medical error and specific adverse outcomes such as burnout.17,33 2.3 Impact on health system Issues that are associated with compromised physician health, such as reduced productivity, increased turnover, absenteeism and the likelihood of early retirement,25,34 contribute to the strained state of the health system. Given that physicians represent a significant proportion of the Canadian medical workforce, more attention must be paid to physician health if the health system is to be sustainable.2 Encouragingly, studies have shown that resources and services such as workplace wellness programs produce investment returns,35,36 such as decreases in medical leave and absenteeism2,36,37 Implementing strategies from occupational medicine are also being increasingly employed to ensure patient safety when doctors return to work after illness.4 This contributes to helping balance the need of institutions and medical regulatory agencies to minimize the risk while maximizing quality of patient care, with the desire of individual physicians to help their patients while leading healthy, fulfilling lives.4 Although there are moral grounds for addressing physician and learner ill-health, an economic case can also be made to support and guide initial and ongoing investment to address the problem.7,18 In navigating the many external challenges facing the Canadian the health system, it is critical that system-level leaders not neglect internal threats, including physician distress and dissatisfaction6,7, and challenges in navigating complex work environments.24 To this end, although there are many positive and supportive elements within medical culture, it is also important to acknowledge aspects that contribute to poor health. 2.4 Impact on the culture of medical practice and training and on the workplace Enduring norms within the culture of medicine are directly contributing to the deterioration of the health of Canadian learners and physicians.2 Culturally rooted impediments, such as the reluctance to share personal issues or admit vulnerability, discourage the medical profession from acknowledging, identifying and addressing physician health issues.7 Physicians and learners alike face pressure not to be ill, to care for patients regardless of their personal health and even to attempt to control their own illness and treatment by self-medicating.1,38 Indeed, physicians are often portrayed as being invincible professionals who put patient needs above all else, including their own needs.39,40 Although the CMA Code of Ethics encourages physicians to seek help from colleagues and qualified professionals when personal or workplace challenges compromise patient care41 physicians tend to delay or avoid seeking treatment, especially for psychosocial or psychiatric concerns. Moreover, nearly 33% of Canadian physicians are not registered with a family physician.42 which means they are among the lowest users of health services.43 Providing care to physician colleagues is both complex and challenging, yet this is an area where formal training has not been explicitly or systematically provided on a national scale.1 There is a need to identify physicians willing to treat colleagues, to develop or adapt existing approaches that encourage help-seeking and to help physicians to navigate the treatment of colleagues. Stigma around mental health within medical practice and training acts as a significant barrier to early intervention.1,44 In a localized study of Canadian physicians, 18% reported distress, but only 25% considered getting help and only 2% actually did.39 Similarly, national CMA data reported that 'feeling ashamed to seek help' was identified (76%) as a major reason for physicians not wanting to contact a physician health program.18 Indeed, common concerns include not wanting to let colleagues or patients down, believing seeking help is acknowledging weakness, being apprehensive about confidentiality, and fearing negative reprisals (e.g., from colleagues, supervisors, regulatory bodies, other licence-granting bodies, insurers)1,45 Fear of retribution is also a frequent reason why physicians may feel hesitant to report impaired colleagues, even if supportive of the concept.46 From the outset of training, medical learners are introduced to system-wide cultural aspects and values of the medical profession, which they then internalize and pass on to others.2 Extensive literature on the "hidden curriculum" points to a performance culture that includes norms such as the view that adversity is character building and the valorization of emotional repression (e.g., mental toughness).2,47 Culture-related issues are being increasingly addressed as a function of medical professionalism. For instance, commitment to physician health, collegiality and support have been established as key competencies within the Professional Role of the CanMEDS Framework,5 the most widely accepted and applied physician competency framework in the world.48 This involves a commitment to exhibiting self-awareness and managing influences on personal well-being and professional performance; managing personal and professional demands for a sustainable practice throughout the physician life cycle, and promoting a professional culture that recognizes, supports, and responds effectively to colleagues in need. In support of these commitments to personal care, physicians must develop their capacity for self-assessment and monitoring, mindfulness and reflection, and resilience for sustainable practice.5 Intra-professionalism, characterized by effective clinical and personal communication among physicians,49 significantly influence job satisfaction, which in turn has been shown to predict physician health outcomes.50 Furthermore, peer support can buffer the negative effects of work demands;39 collegial, professional environments are known to be healthier for both providers and patients.51 Conversely, unprofessional behaviour is associated with physician dissatisfaction,50 and dysfunctional workplaces and poor collegiality are linked to burnout.52 Unprofessional workplace behaviour is tolerated, and in fact is often customary, within medical training and practice environments.53 Of particular concern, such behaviour carried out by more senior physicians has been shown to encourage similar conduct among learners,54 highlighting the importance of promoting effective professional role modelling.55 Unfortunately, poor supervisory behaviour, and even mistreatment of learners, is common within the medical training environment.56 Although expectations for professional behaviour are increasingly being incorporated into both undergraduate and postgraduate teaching, issues related to a lack of professionalism persist in both training and practice.51 System-wide efforts are needed to counter what is perceived to be an eroding sense of collegiality and to promote professionalism as a way to address physician burnout and enhance engagement.7,39 3. Treatment and preventive approaches 3.1 Physician health services The scope of physician health services has expanded from focusing primary focus on identifying treating and monitoring physicians with substance abuse issues to more recent efforts to de-stigmatize poor physician health and integrate proactive resources to complement tertiary approaches.1 In Canada, there are multiple services to support the health needs of learners and physicians. These can be conceptualized along a continuum of approaches,1 including the following: health-promoting environments (e.g., efforts to ensure balanced workloads, provide more support staff, and encourage physicians to make sure they get adequate exercise, nutrition and sleep in training and practice); primary prevention (e.g., resilience training, stress-reduction groups, fatigue management programs, strategies to enhance teamwork and collaborative care); secondary prevention (e.g., access to assessment and counselling; services and workshops on coping with adverse events, litigation and career transitions and on managing difficult behaviour); and tertiary prevention (e.g., more intensive outpatient counselling, inpatient treatment). Many of these approaches, including those at the system level, focus on assisting the individual physician rather than addressing more contextual issues. Most jurisdictions in Canada have consolidated a number of services under the banner of a provincial physician health program (PHP).These range from counselling, treatment and/or peer support to fitness-to-practice and return-to-work assessments, workplace behaviour management and relationship management. The services available to physicians in a given area vary greatly.1,15 More established and resourced programs often offer services across the continuum, while less established programs tend to focus on secondary and tertiary services.2 Provincial PHPs have been shown to produce positive outcomes1,20,21,48 and are generally considered to be effective in addressing user issues,57 however but many physicians remain reluctant to access them.58 In addition to provincial programs, many learners and physicians in Canada can access support and treatment from other sources, including medical school and faculty wellness programs, employee assistance or workplace programs, and more individual-led options such as physician coaches.1 There has been a steady accumulation of evidence on the positive returns of workplace health and wellness programs,35 as well as indications that even modest investments in physician health can make a difference.17 In response to challenges posed by the considerable diversity in the organizational structure of provincial PHPs, the ways in which PHPs classify information, the range of services they offer, the mechanisms of accountability to stakeholders and the manner in which they pursue non-tertiary activities (e.g., education and prevention work)59 a consortium of PHPs released a preliminary Descriptive Framework for Physician Health Services in Canada in 2016. Through this framework a series of core services (and modes of activity within each) were defined.59 Potential users of the framework include PHPs, academic institutions, medical regulators, national associations, hospitals and health authorities, as well as other local groups. The framework may serve a range of purposes, including program reviews and planning, quality improvement, resource allocation, advocacy, stakeholder consultation and standards development.59 Initiatives such as this framework help address a persistent gap in Canada around equity of and access to services. Overall, fulfilling the needs of all learners and physicians through enhanced service quality and functional equivalence is an ongoing challenge for provincial PHPs and other service providers, and it must be a priority moving forward. 3.2 Individual primary prevention Prevention and promotion activities can help mitigate the severity and decrease the incidence of adverse outcomes associated with physician health issues among learners and physicians.3 Although secondary and tertiary services are critical components of any health strategy, complementary, proactive, preventive initiatives promote a more comprehensive approach. Some of the best-documented strategies include attuning to physical health (e.g., diet, exercise, rest), psychosocial and mental health (e.g., mindfulness and self-awareness, resilience training, protecting and maintaining cultural and recreational interests outside of medicine, and protecting time and relationships with family and friends).60 For instance, resilience has been identified as an indicator of physician wellness61 and as a critical skill for individuals working in health care environments.39 Innovative, coordinated approaches such as resilience and mindfulness training are instrumental in helping physicians overcome both anticipated and unexpected difficulties, to position them for a sustainable career in medicine. Many internal (e.g., personal) and external (e.g., occupational) factors can interfere with a physician's capacity to consistently maintain healthy lifestyle behaviours and objectively attend to personal health needs. Although the emergence of individually targeted proactive and preventive activities is encouraging, a greater focus on system-level initiatives to complement both proactive and tertiary approaches is needed. This also aligns with recent CMA member data indicating that medical students (61%), residents (55%), physicians (43%) and retired physicians (41%) want more access to resources to ensure their emotional, social and psychological well-being.62 Such an approach is increasingly important in light of physicians' professional responsibility to demonstrate a commitment to personal health.5 4. Physician health as a shared responsibility Although physicians are a critical component of Canadian health systems, those systems do not necessarily promote health in the physician community. It cannot be overstated that many health challenges facing learners and physicians are increasingly systemic in nature.1 Despite increasing challenges to the cultural norm that health-related issues are an individual-physician problem,2 system-level factors are often ignored.1,7 Although solutions targeted at the individual level (e.g., mindfulness and resilience training) are important proactive approaches and are a common focus, they often do not address occupational and organizational factors.7 Intervention exclusively at the individual level is unlikely to have meaningful and sustainable impacts. Interventions targeting individual physicians are likely most effective when paired with efforts to address more systemic (e.g., structural and occupational) issues.63 Moreover, organization-directed interventions have been shown to be more effective in reducing physician burnout than individual-directed interventions, and meaningful reductions in negative outcomes have been linked to system-level interventions.22,34 Concerted efforts at the system level will ultimately drive substantive, meaningful and sustainable change. This includes coordination among leaders from national, provincial and local stakeholders as well as individual physicians.16,22,64 Potential influencers include medical schools and other training programs, regulatory bodies, researchers (and funding bodies), professional associations and other health care organizations, as well as insurers.1 Indeed, addressing the complex array of issues related to physician health is a shared responsibility. A clear mandate exists to guide individuals and leaders in promoting and protecting the health of learners and physicians.1,7 5. Conclusion Physician health is a growing priority for the medical profession. Medical practice and training present complex occupational environments34, in which leaders play a central role in shaping training, practice and organizational culture through the implicit and explicit ways in which they communicate core values.2 When promoting physician health across the career lifecycle it is also important to consider the unique challenges and experiences of physicians who are not actively practicing (e.g., on leave; have non-clinical roles) as well as those who are retired. Notwithstanding the impact on patient care or health systems, promoting the health of individual physicians and learners is in and of itself worthy of attention. Indeed, leaders in the health system have a vested interest in helping physicians to meet the personal and professional challenges inherent in medical training and practice as well as in promoting positive concepts such as wellness and engagement.7 The increasingly blurred lines between physician health, professionalism and the functioning of health systems40 suggest that leaders at all levels must promote a unified and progressive vision of a healthy, vibrant and engaged physician workforce. This involves championing health across the career life cycle through advocacy as well as promoting solutions and outcomes through a lens of shared responsibility at both individual and system levels. Broad solutions skewed towards one level, without requisite attention given to the other level, are unikely to result in meaningful change. Moving from rhetoric to action, this next frontier integrates the promotion of self-care among individuals, support for healthy and supportive training and practice environments - both physical and cultural - as well as continued innovation and development of (and support for) physician health services. This constellation of efforts will ultimately contribute to the success of these actions. October 2017 See also CMA Policy on Physician Health REFERENCES 1 Canadian Medical Association (CMA). Physician health matters: A mental health strategy for physicians in Canada. Ottawa: CMA; 2010. Available: https://www.cma.ca/Assets/assets-library/document/en/practice-management-and-wellness/Mentalhealthstrat_final-e.pdf (accessed 2017 Oct 30). 2 Montgomery AJ. The relationship between leadership and physician well-being; A scoping review. Journal of Healthcare Leadership 2016;55:71-80. 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Available: https://doi.org/10.1001/jamainternmed.2016.7674 (accessed 2017 Oct 30). 35 Chenevert D, Tremblay MC. Analyse de l'efficacité des programmes d'aide aux employés : Le cas du PAMQ. Montreal: HEC Montreal; 2016. Available: http://www.professionsante.ca/files/2016/07/Rapport-Chenevert-VF.pdf (accessed 2017 Oct 30). 36 Morneau Shepell Ltd. Workplace mental health priorities report 2015. Toronto: Morneau Shepell Ltd.; 2015. Available: https://www.morneaushepell.com/ca-en/insights/workplace-mental-health-priorities-report (accessed 2017 Oct 30). 37 Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. Health Aff (Millwood) 2010;29:304-11. Available: https://doi.org/10.1377/hlthaff.2009.0626 (accessed 2017 Oct 30). 38 Harrison J. Doctors' health and fitness to practise: The need for a bespoke model of assessment. Occup Med (Lond) 2008;58:323-7. Available: https://doi.org/10.1093/occmed/kqn079 (accessed 2017 Oct 30). 39 Wallace JE, Lemaire J. On physician well being-you'll get by with a little help from your friends. Soc Sci Med 2007;64:2565-77. Available: https://doi.org/10.1016/j.socscimed.2007.03.016 (accessed 2017 Oct 30). 40 Lesser CS, Lucey CR, Egener B, Braddock CH, Linas SL, Levinson W. A behavioral and systems view of professionalism. JAMA 2010;304:2732-7. Available: https://doi.org/10.1001/jama.2010.1864 (accessed 2017 Oct 30). 41 Canadian Medical Association (CMA). CMA code of ethics. Ottawa: CMA; 2004. Available: https://www.cma.ca/Assets/assets-library/document/en/PD04-06-e.pdf (accessed 2017 Oct 30). 42 ePhysician Health. Primary care: Physician patient module. Ottawa: ePhysician Health; 2017. Available: http://ephysicianhealth.com/ (accessed 2017 Oct 30). 43 Sibbald B, Bojke C, Gravelle H. National survey of job satisfaction and retirement intentions among general practitioners in England. BMJ 2003;326:22. 44 Thompson WT, Cupples ME, Sibbett CH, Skan DI, Bradley T. Challenge of culture, conscience, and contract to general practitioners' care of their own health: qualitative study. BMJ 2001;323:728-31. 45 Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA 2010;304:1181-90. Available: https://doi.org/10.1001/jama.2010.1300 (accessed 2017 Oct 30). 46 DesRoches CM, Rao SR, Fromson JA, Birnbaum RJ, Iezzoni L, Vogeli C, et al. Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA 2010;304:187-93. Available: https://doi.org/10.1001/jama.2010.921 (accessed 2017 Oct 30). 47 Gaufberg EH, Batalden M, Sands R, Bell SK. The hidden curriculum: what can we learn from third-year medical student narrative reflections? Acad Med 2010;85:1709-16. Available: https://doi.org/10.1097/ACM.0b013e3181f57899 (accessed 2017 Oct 30). 48 Dupont RL, Skipper GE. Six lessons from state physician health programs to promote long-term recovery. J Psychoactive Drugs 2012;44:72-8. Available: https://doi.org/10.1080/02791072.2012.660106 (accessed 2017 Oct 30). 49 Beaulieu M-D, Samson L, Rocher G, Rioux M, Boucher L, Del Grande C. Investigating the barriers to teaching family physicians' and specialists' collaboration in the training environment: a qualitative study. BMC Med Educ 2009;9:31. Available: https://doi.org/10.1186/1472-6920-9-31 (accessed 2017 Oct 30). 50 Van Ham I, Verhoeven AAH, Groenier KH, Groothoff JW, De Haan J. Job satisfaction among general practitioners: a systematic literature review. Eur J Gen Pract 2006;12:174-80. Available: https://doi.org/10.1080/13814780600994376 (accessed 2017 Oct 30). 51 Bahaziq W, Crosby E. Physician professional behaviour affects outcomes: a framework for teaching professionalism during anesthesia residency. Can J Anaesth 2011;58:1039-50. Available: https://doi.org/10.1007/s12630-011-9579-2 (accessed 2017 Oct 30). 52 Cydulka RK, Korte R. 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Health equity and the social determinants of health: A role for the medical profession

https://policybase.cma.ca/en/permalink/policy10672

Last Reviewed
2020-02-29
Date
2012-12-08
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2012-12-08
Topics
Population health/ health equity/ public health
Text
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 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. Clinical practice 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. CONCLUSION 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. REFERENCES 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 9 Ibid 10 Wilkins, Russ; Berthelot, Jean-Marie; and Ng E. [2002]. 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... 16 Ibid. 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 43 Ibid. 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

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Restricting marketing of unhealthy foods and beverages to children and youth in Canada: A Canadian health care and scientific organization policy consensus statement

https://policybase.cma.ca/en/permalink/policy10676

Last Reviewed
2020-02-29
Date
2012-12-08
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2012-12-08
Topics
Population health/ health equity/ public health
Text
Restricting Marketing of Unhealthy Foods and Beverages to Children and Youth in Canada: A Canadian Health Care and Scientific Organization Policy Consensus Statement POLICY GOAL 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 sodium. 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, or sodium. 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 manipulative”.(5) -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. (1,8,11) - The vast majority of Canadians (82%) want government intervention to place limits on advertising unhealthy foods and beverages to children. (12) - The regulation of food marketing to children is an effective and cost-saving population-based intervention to improve health and prevent disease. (13,14) - 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) LEGISLATIVE RULING 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. (3,5,18,19) 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, p. 31) 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 POLICY/LEGISLATIVE SPECIFICATIONS 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 working group. - 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 following: . Television . Internet . Radio . Magazines . 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 . Cross-promotions . 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 of children. Quebec Consumer Protection Act Article 249 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 particular of: a)the nature and intended purpose of the goods advertised; b)the manner of presenting such advertisement; c)the time and place it is shown. ACTION RECOMMENDATIONS 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 children. 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 Implementation Framework: 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 commercial interests. - 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 non-compliance.(2) (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 arm. 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 disseminated. 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 marketing. (13,14) 1.7 Call on industry to immediately stop marketing foods to children that are high in fats, sugar or sodium. 2. Provincial, Territorial and Municipal Governments 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 advertising. 2.5 Call on industry to immediately stop marketing foods to children that are high in fats, sugar or sodium. 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 policies. 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 sodium. 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 addressed. (2) 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. (10,26) 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 analysis. 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 Environment 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 energy.” (10) 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. (34,35) 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 at children. 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 youth. (12) 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) Federal Restrictions 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 regulations. (26) 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) Industry Restrictions 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, namely: - Participation is voluntary, exempting non- participators such as President’s Choice, Wendy’s and A&W, from committing to CAI core principles. - 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 standards. (16) - 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. (7,42,43) - 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) Provincial Restrictions 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 childhood. (27) 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. (25) 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 Association. (49) 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) Conclusions 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 health organizations. 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