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Active Transportation

https://policybase.cma.ca/en/permalink/policy9483
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Population health/ health equity/ public health
Text
The major diseases affecting the quality and quantity of life of Canadians, which include obesity, diabetes, coronary artery disease, depression and cancer, are all linked to physical inactivity. In Canada, 69% of women and 68% of men in Canada are considered physically inactive.(1) The cost of this inactivity and obesity was estimated at $4.3 billion in 2001.(2) A 10% increase in physical activity could potentially reduce direct health care expenditures by $150 million a year. This does not include indirect costs such as lost productivity due to illness, premature death or a range of other factors, including mental illness and poor quality of life.(3) Thus far, efforts to increase physical activity by changing the behaviour of individuals have had limited success. One reason is that many people have difficulty sustaining behaviours that involve additional time commitments. That is one reason for the increasing emphasis being placed on active transportation, which is any human-powered form of transportation, such as walking and cycling. Walking and cycling can be efficient alternatives to automobile travel. Cycling is usually the fastest mode of travel door to door for distances under five km, and for up to 10 km in city cores. Walking is simpler and nearly as fast for distances up to two km. When travel times are similar for active and motorized transportation, physical activity is gained with no net time lost, and at much lower cost. The cost of operating a motor vehicle is typically $10,000 per year,(4) while operating costs for a bicycle are much lower. Communities that have sidewalks, enjoyable scenery, street lights and nearby stores have improved levels of active transportation and physical activity. However, in recent decades communities have often been designed around the automobile. Street design, parking space, sidewalks and distance to retail destinations have all been planned assuming motorized transportation, and this often makes it difficult to move around communities by walking or cycling. Although individual decision-making remains important in any strategy for increasing active transportation, there is an essential role for communities and governments to play. Major improvements in the health of Canadians in the past 200 years have been due to improved sanitation, access to clean water and injury prevention. The role of individual decision-making in effecting these changes is dwarfed by the impact of the public health measures and infrastructure involved. Just as potable tap water is a health issue, so are decisions about land use, transportation policy and infrastructure. Community design is a major determinant of whether people use active transportation, whether they are physically active and whether they are obese. Canadians need communities that make it easy to be physically active in their daily living. Communities can create an environment in which the physically active choice is the easy choice. They can do this via sidewalks, trails, bicycle lanes and bicycle paths, and by providing pedestrian-friendly intersections, parks and green spaces, and safe bicycle parking spaces. They can also arrange zoning so that retail destinations are within walking or cycling distance of residential areas. This process also includes dedicating a sufficient portion of their street maintenance budget (including snow clearing) to maintaining active transportation routes as well as routes for motorized vehicles. It may include redesigning intersections, giving up vehicle lanes or parking spaces, or increasing the price of parking. Additional benefits to designing communities for pedestrians and cyclists. * a stronger sense of community with greater civic involvement by citizens * increased property values and retail activity * less noise pollution * lower crime rates * less smog and other air pollution * less greenhouse gas production * decreased risk of injury to pedestrians and cyclists * decreased costs of roadway and parking construction. A role for everyone Other sectors can support communities in making active transportation choices easy choices: * Businesses can create a work environment friendly to active transportation, including a corporate culture friendly to physical activity. They can incorporate active transportation planning into building design and create an environment friendly to physical activity. These steps could include making bicycle parking, showers and lockers available, and providing stairs that are pleasant and easier to access than elevators. They can also incorporate a culture of physical activity in decisions about where and how to hold meetings, and what people are allowed to wear to work. * School boards can develop policies to promote active transportation to and from school. These include building and maintaining secure bicycle parking, ensuring safe walking routes within communities, and assisting parents in walking their children to school. * Citizens can use active transportation themselves and treat with respect those who are already making active transportation choices. They can also lobby governments to make their community safer and easier places for cycling and walking. * Physicians can encourage patients to use active transportation as a way to boost their physical activity levels and improving their health. They can also lead by example and use active transportation themselves. Recommendations The CMA recommends that all sectors (government, business and the public) work together, as a matter of priority, to create a culture in their communities that supports and encourages active transportation. The CMA urges governments to: * Commit to long-term plans for active transportation networks that are in keeping with these goals and that include specific benchmarks to measure progress. * Require that active transportation be part of all infrastructure renewal projects, with investment in active transportation vs. motorized transportation in proportion to targeted active transportation use. (Some cities have achieved active transportation rates of up to 15%.) * Develop an awareness campaign to help Canadians to recognize the value of active transportation in their communities. * Require public health impact assessments for all land-use and transportation decisions, including the impact on the chemical environment and on physical activity. * Assess the impact that changes in the "built" environment can have on public health, and which interventions are most safe and effective. 1 Tremblay MS, Katzmarzyk PT, Willms JD. Temporal trends in overweight and obesity in Canada, 1981-1996. Int J Obes Relat Metab Disord 2002;26(4):538-43. 2 Katzmarzyk PT, Janssen I. The economic costs associated with physical inactivity and obesity in Canada: an update. Can J App Phys 2004;29(1):104. 3 Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada. CMAJ 2000;163(11): 1435-40. 4 Canadian Automobile Association. Driving Costs: 2005 Edition. Available: www.carpool.ca/pdf/CAA-driving-costs-05.pdf (accessed 2007 Feb. 2).
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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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Healthy behaviours - promoting physical activity and healthy eating

https://policybase.cma.ca/en/permalink/policy11523
Date
2015-05-30
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Date
2015-05-30
Replaces
Promoting Physical Activity and Healthy Weights
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) supports the promotion of healthy lifestyles in order to improve individual health and well-being and the overall health status of the population. Healthy lifestyles refer to patterns of individual practices and personal behavioural choices that are associated with optimal health. Two of the most important behaviours to create or maintain optimum health are healthy eating and physical activity. For many Canadians, their diet and physical activity levels can have a negative rather than positive impact on their overall health. There is a particular concern for children and youth who are growing up in increasingly obesogenic environments that reinforce practices that work against a healthy lifestyle.1 Childhood obesity research tells us that overweight and obese children are more likely to stay the same into adulthood.2 To reverse this trend, determined action is required for children and youth to learn and acquire healthy behaviours that they will maintain throughout their life. Healthy lifestyles are central to successful aging and improving the likelihood of recovery after poor health.3 This policy paper discusses the importance of physical activity and healthy eating, and the role that individuals and families, schools, workplaces, communities, the food industry and all levels of governments can play in promoting healthy lifestyles. We know that collaborative action is required to make it easier for Canadians to incorporate healthy eating and physical activity into their daily lives - to make the healthy choice the easy choice. What are the health impacts of unhealthy diets and physical inactivity Diet is the leading risk factor for death, disability and life-years lost; being estimated to cause over 65,000 deaths and 864,000 life years lost in Canada in 2010.4 Unhealthy diet has been consistently linked with cardiovascular diseases (heart disease, stroke, hypertension, diabetes, dyslipidemia) and some cancers,5 which constitutes the majority of the disease burden in Canada. An estimated 80% of hypertension, which affects over 7 million Canadians, is directly or indirectly attributed to unhealthy diet.6 An estimated 60% of Canadian adults and close to one-third of children are overweight or obese, largely caused by unhealthy diets.7 Overweight and obesity (and the lifestyle choices associated with them) are contributors to more than 18 chronic conditions.8 This includes diabetes, cardiovascular disease, hypertension and liver disease, as well as breast, colon and prostate cancer. Obesity is a public health issue not unique to Canada as the rates are increasing worldwide. Obesity is generally attributed to the fact that, as a society, we are increasing our calorie intake while at the same time burning less energy in physical activity. While it is difficult to determine how many deaths are directly attributable to obesity, we know that obesity often co-exists with other risk factors such as the lack of physical activity. Exercise is one of the top modifiable risk factor for chronic disease.9 Regular physical activity is associated with a reduced risk of cardiovascular disease, some types of cancer, diabetes, obesity, hypertension, bone and joint diseases, and depression.10 The risk for many of these conditions is reduced by 20 - 40% in adults with the highest levels of physical activity compared to those with the lowest levels of physical activity. Recent research has shown that a sedentary lifestyle is associated with higher risk for chronic conditions such as obesity, diabetes and cancer independent of physical activity levels.11 According to the most recent Canadian Health Measures Study physical activity levels for children and youth are low with 6 out of 10 waking hours devoted to sedentary pursuits. Obesity is rising and physical fitness is declining.12 Canadians who do not achieve adequate levels of physical activity or eat unhealthy foods are vulnerable to preventable chronic diseases, premature death, and contribute to high health care costs. For instance, in 1999, $2.1 billion or 2.5% of the total direct health care costs were attributable to physical inactivity.13 To understand why the rates of obesity and overweight are rising, it may be helpful to look at what we already know about healthy eating and physical activity. What we know about healthy eating While modern science has allowed us to expand our knowledge of the impact of nutrients and food on human health we continue to be beset with illness and disease caused by the foods we consume. Having the right amount and type of food recommended in Canada's Food Guide is a first step towards healthy eating. But Canadians self-reported dietary intakes do not meet national dietary recommendations despite high reliance on public education concerning healthy eating and healthy diets. Children and adults are under-consuming the recommended servings of vegetables and fruits, an established proxy for healthy eating habits, and exceeding daily recommended intakes of sodium.14,15 As the links between nutrition and disease, and the impact on the health of our society are revealed it is more important than ever to understand what influences healthy eating behaviours. Food choices are structured by a variety of individual determinants of behaviour, ranging from one's physiological state, food preferences, nutritional knowledge, perceptions of healthy eating and psychological factors. Many processed foods have become popular due to their accessibility and 'convenience factor', but these features have changed the way food and in particular these products are consumed compared to unprocessed foods: increased 'grazing', eating alone or eating while carrying out other activities such as work or driving. In addition, many calories consumed come in liquid form.16 Growth in the production and consumption of ultra-processed foods has increased drastically in the last decades in both higher and lower-income countries.17 A number of studies have shown that because less healthy foods are cheaper than healthier food, individuals from lower socioeconomic classes tend to be more dependent on unhealthy foods for nourishment.18 Other determinants for healthy eating include a wide range of contextual factors, such as the interpersonal environment created by family and peers, the physical environment, which determines food availability and accessibility, the economic environment, in which food is a commodity to be marketed for profit, and the social environment. Within the social environment, social status (income, education and gender) and cultural milieu are determinants of healthy eating that may be working "invisibly" to structure food choice.19 What we know about physical activity Canada's Physical Activity Guidelines recommend that children and youth aged 5 to 17 get at least 60 minutes of moderate-to-vigorous physical activity (MVPA) per day; and adults get 150 minutes of physical activity per week.20 In fact, about 94% of Canadian children and youth do not meet minimum physical activity guidelines.21 Furthermore, about 85% of Canadian adults do not meet the minimum guidelines. Physical activity includes but is not limited to sports and recreation. Using active transportation to get to work as well as being active at work is an alternative form of MVPA and can also lead to improved health. For most Canadians, the average day is spent on passive activities such as TV viewing, computer and game-console use, workplace sitting, and time spent in automobiles. Moreover, the sprawling suburban communities, in which many live, do not encourage physical activity. Emerging research suggests that prolonged sitting time is associated with an increased health risk.22 These findings mean that one can meet the minimum physical activity guidelines and still not engage in a healthy lifestyle. Spending a few hours a week at the gym or otherwise engaged in moderate or vigorous activity doesn't seem to significantly offset the risk. Hence too much sitting is a risk distinct from too little exercise. While further research is required to identify which methods of exercise promotions work best for individuals,23 it is clear that supportive environments and infrastructures are essential for Canadians to make physical activity part of their daily lives. CMA's policies about the Built Environment and Active Transportation support the role of the environment on our physical activity patterns. How we can promote physical activity and healthy eating A sedentary lifestyle is a cue for physician advice.24 Physical activity is a vital sign that may require as much attention as other traditional vital signs25 - weight, blood pressure, or smoking history. Physicians are eager to initiate these conversations, especially with patients living with chronic diseases. A message must be repeated many times in order to effect a change in lifestyle. Physicians can reiterate the medical importance of physical activity and healthy eating by reinforcing this message during each office visit, and writing the recommendation on a prescription pad.26 For instance, in British Columbia, physicians are prescribing exercise on specially-designed pads, distributing free pedometers, and hosting free walking events for their patients and the public. In the Edmonton area, Primary Care Networks are prescribing free access passes or a free month of access at local municipal recreation facilities. And in Nova Scotia, physicians have been running a free provincial running program for over 10 years that benefits thousands of kids in elementary school. Nonetheless these clinical interventions alone cannot shape healthier food consumption patterns and lifestyle choices. An obvious starting point to develop a comprehensive policy is to understand the interplay between individual and environmental determinants that influence our behaviours. In this regard, CMA has developed policies on Active Transportation and the Built Environment and Health which recognize the role of neighborhood design and alternative modes for transportation for an active lifestyle. This approach is also at the heart of the Integrated Pan-Canadian Healthy Living Strategy (PCHLS)27, approved in 2005 by all levels of government. CMA commends the efforts put in the PCHLS to prioritize healthy eating and physical activity. What we recommend CMA looks forward to working with others in making options for physical activity and healthy eating more available and accessible to all Canadians. The following recommendations highlight the potential contributions of the following sectors: health professionals, all levels of government, communities, workplaces, schools, the food industry and individuals and families. Health Professionals CMA encourages physicians to promote healthy eating and physical activity inside and outside their office. Physicians are lifestyle change agents and remain the preferred source of information about health for many people. Physicians, who are committed to physical activity, are role models whose advice on healthy living is more likely to be adopted.28 CMA encourages physicians to address any work-imposed limitations - such as the lack of time, motivation, or tiredness - that could also influence their own exercise and eating habits. In clinical practice, physicians can help patients start or maintain a healthy lifestyle by: * assessing nutrition and physical activity as part of routine assessments; * determining the factors that influence individual patient's nutrition and physical activity levels; * assessing patient's readiness to change and tailoring interventions and support to their current situation; * providing an exercise prescription to encourage physical activity to maintain or improve health status, and * working in inter-professional teams to provide patient education with other health care providers such as dieticians. Medical students and residents, while reporting a high level of importance for exercise prescription concede a low level of expertise in this area upon graduation.29,30,31 As knowledge develops, physicians and other health professionals should be kept updated and encouraged to incorporate the most effective interventions into their practices. The CMA encourages the development of continuing medical education courses on issues related to physical activity and healthy eating. Within the healthy living approach, there are multiple opportunities to extend the role of physicians into the community as observed in Nova Scotia, British Columbia and Edmonton area. Physicians can establish strong community norms for a healthy lifestyle by: * establishing and reinforcing healthy food policies in hospital cafeterias or at health-related meetings and conferences * using, facilitating and advocating for the use of active transportation in their communities * working within the community to ensure that recreation centres and other facilities are available and patients can be referred to the services most appropriate to their needs Federal, Provincial, and Territorial Governments CMA calls on federal, provincial, territorial and municipal governments to commit to a long-term, well-funded Canada-wide strategy for healthy living beyond 2015. In 2005, Canada's federal, provincial, and territorial governments endorsed a 10-year Healthy Living Strategy Framework, whose initial priorities included the promotion of healthy eating and physical activity. The national strategy addressed information and support for Canadians to help them make healthy choices; support for physicians and other health professionals in counselling patients on healthy weight and in treating existing obesity; community infrastructures that make healthy living easier; and public policies that encourage healthy eating and physical activity. The federal and provincial / territorial governments have undertaken a number of activities in the intervening years to promote physical activity and healthy eating but much remains to be done. CMA believes that all levels of governments have a continuous obligation to provide public guidance on healthy eating and to promulgate policies, standards, regulations and legislations that support the availability and accessibility of healthy and affordable food and beverage choices. CMA calls on governments to improve access to nutritious food at affordable prices for all Canadians. The price of milk, fresh produce and other healthy foods can vary greatly across Canada. In many remote areas, they are often more expensive than processed, nutrition-poor foods because of high transportation costs. Governments should implement effective programs to offset the impact of transportation costs on food prices in northern and remote communities. Even in urban areas, nutritious food may be unaffordable for people on low incomes. School meal programs, social assistance rates that take into account the cost of purchasing healthy food, access to urban farmers' markets can help to ensure that all Canadians have access to healthy foods at a reasonable price. CMA calls on governments to ban marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger. The typical Canadian child may be exposed to as many as 40,000 advertisements for food a year.32 This does not include point-of-sale promotions, such as displays of candy bars at convenience-store counters. CMA's policy on marketing of unhealthy foods and beverages to children and youth calls for a ban on marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger. CMA calls on governments to set rigorous standards for front of package food labeling and for the advertising of health claims for food. Brand-specific advertising is a less than optimal way to provide health information to consumers, who should be encouraged to seek out objective information sources for answers to their questions about physical activity and healthy eating. To improve the quality of information received through commercial channels, the CMA recommends that health claims made for foods be strictly regulated to ensure that they are based on the best available scientific evidence and that they are accurately communicated to consumers. Food advertisements should be pre-cleared before airing in the media, and the provisions against deceptive advertising in the Food and Drug Act should be strengthened. CMA recommends that governments at all levels invest in evidence-based research on healthy eating and physical activity and share the results of this research with all Canadians. CMA encourages all levels of governments to continue to fund and support research for healthy lifestyles. There is a clear need to invest in research to strengthen the evidence base about physical activity and healthy eating, particularly on:
best measures for assessing overweight and obesity;
the effectiveness of weight management and treatment programs; and
the effect of policy interventions on healthy eating and physical activity on rates of obesity and obesity-related disease. Food Industry CMA encourages governments to continue to work with the food industry to improve the food environment in Canada. The partnership and collaboration of food manufacturers is needed to help Canadians make healthier food choices. The food industry can work with governments to:
reduce the salt, sugar, saturated fat, trans fat and calorie content of processed foods and pre-prepared meals;
provide information about the calorie and nutrition content on restaurant menus;
restrict advertising and in-store promotion of high-sugar, high-salt, high-fat foods, particularly those aimed at children;
provide user-friendly consumer information about their products, including and accurate health and advertising claims;
improve the nutrition fact table to make it more user friendly and increase the amount of information for example, by identifying the amount of free sugars. Communities CMA calls on municipal governments to create environments that encourage healthy and active living and on federal, provincial and territorial governments to support them in this endeavour. Communities have an important role to play to promote healthy behaviours for children, youth, and adults. They shape how many Canadians decide to live, work and play in their daily life. Through mixed-use land planning and building design, communities can create walking-friendly environments, and reduce the time people spend in cars. To achieve this, communities should consider:
developing and maintaining a community-wide network of walking and cycling paths;
zoning communities in such a way that amenities are within walking distance of homes; and
revising building codes to make stairs accessible, pleasant and safe, so that people have an alternative to taking the elevator. Canadians are considerably more physically active in the summer than in the winter and this could have an impact on obesity trends.33 Communities could improve pathways to healthy lifestyles year-round by improving access to indoor sport and recreation facilities, especially during winter. Where possible, communities should consider partnering with schools to share the use of gymnasiums, playgrounds, fields, courts, and tracks with the public after school hours and on weekends. In doing so, communities are ensuring the best use of time and resources, but also sharing liability for the development, operation, and maintenance of the facilities. Community food security can happen if local residents have equal access to safe, affordable and nutritious food. Communities have a role to play in advocating for healthier food options in schools and workplaces, encouraging community kitchens to teach cooking skills, and supporting local agriculture and farmers markets. This, in turn, would encourage individuals to eat more healthy foods. Workplaces CMA encourages employers to actively promote the health of their employees by providing opportunities for physical activity, and healthy food choices in cafeterias. Prolonged, unbroken time spent sitting in front of a screen is very common in the workplace. In addition, four out of five commuters sit daily in their private vehicles to go to work.34 As Canadians spend most of their adult life at work, it is important to reduce workplace sitting. CMA encourages employers, especially in sedentary occupational groups, to increase opportunities for physical activity. For example, employers can promote healthy behaviours by:
Building on-site fitness facilities or entering into agreements with off-site fitness centres to provide programs for their employees
Providing showers, bike racks and other amenities for employees for those who want to commute to work on foot or by bike. Healthier food options in cafeteria and vending machines can promote and encourage healthy eating by employees. Schools Schools, where children spend most of their time outside of home, present an excellent opportunity to instil healthy behaviours at an early age. They could, for example, provide comprehensive nutrition education, serve nutritious food in their cafeterias and promote physical activity by providing formal instruction and informal recreation time. Schools can provide the most effective and efficient way to reach not only the children themselves, but their parents, teachers, and other community members.35 CMA encourages school boards to provide at least 60 minutes of active daily physical education for all primary and secondary grades. Only 26% of Canadian schools reported that they had implemented daily physical education classes for their students.36 There is some evidence that school-based physical activity can increase physical activity levels and reduce time spent watching television at home. 37 For instance, schools can promote physical activity through unstructured out-of-home play, structured sports, or active transportation (e.g. walking to school). Children who are physically active and spend less time watching television after school are less likely to become overweight before age 12.38 CMA recommends that schools provide access to attractive, affordable, healthy food choices, provide nutrition education, and initiate programs aimed at encouraging healthy food consumption and skills to prepare meals from scratch. CMA calls for restrictions on the sale of high-calorie, high fats, sugars or salts foods/drinks in recreational facilities frequented by young people. Fast food restaurants and convenience stores can be an important influence on children's eating habits and food choices.39 Children attending schools within a short distance of fast food restaurants eat fewer fruits and vegetable servings, and drink more soft drinks than others who did not have similar establishments within proximity.40 To encourage effective school-based nutrition interventions, it is therefore important to educate students about the nutrition value of foods, healthy food choices, and provide healthy canteens or cafeterias. Individuals and families CMA recommends that all Canadians work toward achieving and maintaining health by:
educating themselves about their dietary needs and about the caloric and nutrition content of foods; and
engaging in physical activity, with the goal of at least 60 minutes of moderate activity per day for children and youth, and 150 minutes per week for adults. Ultimately, healthy eating and physical activity require that individuals take action to make healthy choices in their lives. To inform these choices, Canadians should be supported with appropriate resource materials with consistent information about healthy eating and physical activity. For instance, many young children do not choose what they consume; their parents buy and prepare the food for them. Research suggests that mothers and children appear to have divergent attitudes towards food and mealtimes.41 In this regard, it is important for parents to be well-informed and able to explain the tangible benefits of foods and their nutritional components to their children before they reach adulthood. What we conclude Healthy behaviours are easier to maintain through life if acquired in childhood and encouraged by the family. Therefore Canadian families should be supported in efforts to ensure that both children and adults eat nutritiously and exercise daily. We believe there is a role for everyone in promoting healthy behaviours - including health professionals, individuals, families, schools, workplaces, communities, the food industry and all levels of governments. Popular approaches seek to provide individuals with information and options about healthy lifestyles choices. However, individual choice is not sufficient to ensure healthy behaviours. Many barriers to the adoption of healthy behaviours and lifestyle choices can be met through a targeted population health approach, and evidence-based policy and regulatory controls. A comprehensive change in culture and mindset, political endorsement and multifaceted strategies are needed to promote and facilitate change to improve the dietary practices and physical activity levels of Canadians. Summary of Recommendations 1. The Canadian Medical Association encourages physicians to promote healthy eating and physical activity inside and outside their office. 2. The Canadian Medical Association calls on federal, provincial, territorial and municipal governments to commit to a long-term, well-funded Canada-wide strategy for healthy living beyond 2015. 3. The Canadian Medical Association calls on governments to improve access to nutritious food at affordable prices for all Canadians. 4. The Canadian Medical Association calls on governments to ban marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger. 5. The Canadian Medical Association calls on governments to set rigorous standards for front of package food labeling and for the advertising of health claims for food. 6. The Canadian Medical Association recommends that governments at all levels invest in evidence-based research on healthy eating and physical activity and share the results of this research with all Canadians. 7. The Canadian Medical Association encourages governments to continue to work with the food industry to improve the food environment in Canada. 8. The Canadian Medical Association calls on municipal governments to create environments that encourage healthy and active living and on federal, provincial and territorial governments to support them in this endeavour. 9. The Canadian Medical Association encourages employers to actively promote the health of their employees by providing opportunities for physical activity, and healthy food choices in cafeterias. 10. The Canadian Medical Association encourages school boards to provide at least 60 minutes of active daily physical education for all primary and secondary grades. 11. The Canadian Medical Association recommends that schools provide access to attractive, affordable, healthy food choices, provide nutrition education, and initiate programs aimed at encouraging healthy food consumption and skills to prepare meals from scratch. 12. The Canadian Medical Association calls for restrictions on the sale of high-calorie, high fats, sugars or salts foods/drinks in recreational facilities frequented by young people. 13. The Canadian Medical Association recommends that all Canadians work toward achieving and maintaining health by: * educating themselves about their dietary needs and about the caloric and nutrition content of foods; and * engaging in physical activity, with the goal of at least 60 minutes of moderate activity per day for children and youth, and 150 minutes per week for adults. References 1 Swinburn B, Egger G. The runaway weight gain train: too many accelerators, not enough brakes. 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Canadian health measures survey: directly measured physical activity of Canadians, 2007 to 2011. The Daily. Ottawa: Statistics Canada; 2013 May 30. Available: www.statcan.gc.ca/daily-quotidien/130530/dq130530d-eng.pdf (accessed 2014 Jan 20). 22 Owen N, Healy GN, Matthews CE, et al. Too much sitting: the population health science of sedentary behavior. Exerc Sport Sci Rev. 2010;38(3):105-13. 23 Foster C, Hillsdon M, Thorogood M, Kaur A, Wedatilake T. Interventions for promoting physical activity. Cochrane Database Syst Rev. 2013 (1). Review. 24 Glasgow RE, Eakin EG, Fisher EB, et al. Physician advice and support for physical activity results from a national survey. Am J Prev Med. 2001;21(3):189-96. 25 Salis R. Developing healthcare systems to support exercise: exercise as the fifth vital signs. Br J Sports Med. 2011;45(6):473-4. 26 Andersen RE, Blair SN, Cheskin LJ, et al. Encouraging patients to become more physically active: the physician's role. Ann Intern Med. 1997;127(5):395-400. 27 Public Health Agency of Canada. Overview of the Pan-Canadian Healthy Living Strategy. 2010. Available: www.phac-aspc.gc.ca/hp-ps/hl-mvs/ipchls-spimmvs-eng.php (accessed 2014 Jan 20). 28 Lobelo F, Duperly J, Frank E. Physical activity habits of doctors and medical students influence their counselling practices. Br J Sports Med. 2009;43(2):89-92. 29 Rogers LQ, Gutin B, Humphries MC, et al. Evaluation of internal medicine residents as exercise role models and associations with self-reported counseling behavior, confidence, and perceived Success. Teach Learn Med. 2006;18(3):215-21. 30 Connaughton AV, Weiler RM, Connaughton DP. (May-June 2001). Graduating medical students' exercise prescription competence as perceived by deans and directors of medical education in the United States: implications for Healthy People 2010. Public Health Rep. 2001;116:226-34. 31 Vallance JK, Wylie M, MacDonald R. Medical students' self-perceived competence and prescription of patient-centered physical activity. Prev Med. 2009;48(2):164-6. DOI: 10.1016/j.ypmed.2008.12.006 32 The Kaiser Family Foundation. The role of media in childhood obesity. Menlo Park (CA): The Foundation; 2004 Feb. Available: http://kaiserfamilyfoundation.files.wordpress.com/2013/01/the-role-of-media-in-childhood-obesity.pdf (accessed 2014 Mar 19). 33 Merchant AT, Dehghan M, Akhtar-Danesh N. Seasonal variation in leisure-time physical activity among Canadians Can J Public Health. 2007;98(3):203-8. 34 Statistics Canada. Commuting to work. National Household Survey. 2011. Available: https://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-012-x/99-012-x2011003_1-eng.cfm (accessed 2014 Jan 20). 35 Perez-Rodrigo C. School-based nutrition education: lessons learned and new perspectives. Public Health Nutr. 2001;4(1A):131-9. 36 Canadian Fitness and Lifestyle Research Institute. Policies related to physical activities. 2011 opportunities for physical activity at school survey. 2012 Aug 14. Available: http://www.cflri.ca/sites/default/files/node/1054/files/Schools%202011%20Bulletin%2012%20-%20Policy%20EN.pdf (accessed 2013 Sep 15). 37 Dobbins M, Husson H, DeCorby K, et al. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18. Cochrane Database Syst Rev. 2013;2:CD007651. 38 O'Brien M, Nader PR, Houts RM, et al. The ecology of childhood overweight: a 12-year longitudinal analysis. Int J Obes (Lond). 2007;31(9):1469-78. 39 Howard PH, Fitzpatrick M, Fulfrost B Proximity of food retailers to schools and rates of overweight ninth grade students: an ecological study in California. BMC Public Health. 2011;11(68). 40 Davis B, Carpenter C. Proximity of fast-food restaurants to schools and adolescent obesity. Am J Public Health. 2009;99(3):505-10. 41 Le Bigot Macaux A. Eat to live or live to eat? Do parents and children agree? Public Health Nutr. 2001;4(1A):141-6.
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Multi-stakeholder Position Statement: Toward an Environmentally Responsible Canadian Health Sector

https://policybase.cma.ca/en/permalink/policy9580
Last Reviewed
2017-03-04
Date
2009-05-31
Topics
Population health/ health equity/ public health
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Policy document
Last Reviewed
2017-03-04
Date
2009-05-31
Topics
Population health/ health equity/ public health
Text
Health, health care and the environment are linked inextricably. Environmental contaminants have been associated with compromised health status, including cancer, birth defects, respiratory and cardiovascular illness, gastrointestinal ailments and death - and an increased demand for a range of health care services. The health sector is a significant part of Canada's economy, contributing approximately 10% of gross domestic product (GDP). Thus, the sector uses considerable energy, consumes large quantities of plastics, paper and other resources, and produces significant solid, liquid and gaseous waste. With the improvement of health care technologies and a growing awareness of environmentally responsible practices, there is an increased opportunity for reducing the health sector's environmental footprint. Although there are important health, financial and ethical reasons for adopting such practices in the health sector, a number of challenges exist, including financial, technical and administrative challenges. Vision We envision the health sector as a leader in integrating environmentally responsible practices into the delivery of health care. We also see it as an advocate in sharing information on best practices and encouraging Canadians and Canadian organizations to limit their environmental footprint. In a green health sector, minimizing negative impact on the environment would be a priority for all organizations and individuals in their day-to-day practices and at all levels of decision-making. A collaborative approach Achieving our vision requires a collaborative approach to delivering environmentally responsible health care. For example:1 Greener health infrastructure * support investment in renewing physical plant infrastructure that allows for the retrofit of facilities that function more efficiently, use cleaner technologies and meet new environmental standards for energy efficiency, water management and waste management Best practices * educate staff and the public on the link between health and the environment and on the health impact of environmental degradation, and help in the development, dissemination and implementation of knowledge and best practices * support and encourage research on health and the environment, and on environmentally responsible practices in a variety of health care settings * implement energy-conserving techniques and products * request rationalized packaging and other environmentally responsible actions from vendors of health care products * promote safer substitutes to reduce exposure to toxic substances * reduce waste by reusing and recycling when possible * practise safe disposal practices for biomedical and infectious waste, outdated medications, and polyvinyl plastics, mercury and other toxic substances * establish green teams to support the practice of ecologic stewardship We recognize that our efforts to achieve a greener health sector must fit into broader societal and global actions to improve the environment. The health sector plays a role in supporting the efforts of all Canadians to find environmentally responsible ways to perform their daily activities by contributing to the management of global environmental issues, such as greenhouse gas emissions and toxic waste disposal. Calls to Action We call on governments and policymakers at all levels to understand and address links between health and the environment and to incorporate these links into policy decisions through legislative and budgetary actions. We call on all health care organizations to pledge to minimize the negative impact of their activity on the environment and to seek solutions to existing barriers. We call on individuals working in the health sector to both model and advocate for environmentally responsible approaches to delivering health care without compromising patient safety and care. Association of Canadian Academic Healthcare Organizations Canadian Coalition for Green Health Care Canadian College of Health Service Executives Canadian Dental Association Canadian Healthcare Association Canadian Medical Association Canadian Nurses Association Canadian Pharmacists Association Canadian Public Health Association David Suzuki Foundation Developed by a working group of the above organizations 1 Canadian Nurses Association/Canadian Medical Association. Joint position statement: Environmentally responsible activity in the health care sector. Ottawa. 2009
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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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