Major initiatives related to childhood obesity and physical inactivity in Canada: the year in review.

Tremblay, Mark S.

Substantial increases in childhood obesity in Canada were observed several years ago (1) and have been confirmed on several occasions. (2,3) This is cause for concern because accumulating evidence shows that childhood obesity is related to morbidity and mortality in adulthood. (4) New, robust measures of the physical activity level of Canadian children indicate that only 4% of girls and 9% of boys (5) are meeting the new Canadian Physical Activity Guidelines (6) and Canada consistently receives failing grades on the Active Healthy Kids Canada Report Card which assesses the physical activity of Canadian children and youth. (7,8) Clearly, this is an important public health crisis and requires attention, resources and adaptations from all sectors. (9) The purpose of this review is to highlight 15 major initiatives that demonstrate the breadth and depth of efforts directed towards this issue in Canada between September 2010 and September 2011. The initiatives are presented in the order in which they occurred in the year in review. An attempt was made to include examples from several sectors but no systematic inclusion or exclusion criteria were applied and clearly many other important initiatives also occurred in this time period. Briefly summarizing these initiatives not only catalogues and consolidates these activities, but also provides information to other jurisdictions that are searching for possible solutions to the global challenge of childhood obesity and inactivity. A similar "year in review" was published in 2007. (10)

Major initiatives in Canada--September 2010 to September 2011

F-P-T Framework for Action to Promote Healthy Weights

In September 2010, the Federal, Provincial and Territorial (F-P-T) Ministers of Health and/or Health Promotion/Healthy Living adopted a framework for action to promote healthy body weights, with a particular emphasis on curbing childhood obesity. (11) The framework for action is meant to build on the principles identified in the Pan-Canadian Healthy Living Strategy (12) and Declaration on Prevention and Promotion (13) through three integrated strategies:

* making childhood overweight and obesity a collective priority for action among multiple government departments and sectors of Canadian society;

* coordinating efforts on three key policy priorities--supportive environments, early action, nutritious foods; and

* measuring and reporting on collective progress.

The framework has a vision where "Canada is a country that creates and maintains the conditions for healthy weights so that children can have the healthiest possible lives." (11) The Declaration on Prevention and Promotion (13) commits to pursuing this vision through five guiding principles articulating that: prevention is a priority; prevention is the hallmark of a quality health system; prevention is the first step in management; health promotion has many approaches that should be used; health promotion is everyone's business. Further details on the framework can be found at: http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/framework-cadre/indexeng.php.

Health Canada and FCPC Nutrition Labeling Initiative

In October 2010, Health Canada and the Food and Consumer Products of Canada (FCPC) announced the launch of a major nutrition labeling initiative. FCPC (http://www.fcpmc.com/home.asp) is the national industry association in Canada representing the food and consumer products industry. This government-industry collaboration includes a multi-faceted approach to explain the percent daily value to consumers, through messaging to appear on food packages, in-store, and in national media (print, television, online), directing Canadians to Health Canada's educational website. The website (www.healthcanada.gc.ca/dailyvalue) provides information and tips on how to use the percent daily value to make informed, healthy choices when purchasing food products by providing support to understand the nutrition labeling that clearly states the calories per serving and the percent of daily value of various macro- and micro-nutrients provided by one serving of the product. FCPC reports that 34 companies have joined the effort to provide Canadians with information they need to make informed food choices (http://www.fcpc.ca/ adult-education/index.html).

Launch of CBC "Live Right Now" Campaign

In early January 2011, CBC (Canada's National Public Broadcaster) with support and guidance from Advisory Board Partners representing stakeholder groups, healthy living program delivery partners and content expert groups, launched a comprehensive, integrated, corporate-wide media-based campaign to promote healthy active living and healthy body weights. The "Live Right Now" campaign is a national initiative designed to inspire Canadians to join together and change the health of the country. The idea is built around the small steps everyone can take in their life to improve their health. Omnipresent messaging and branding was achieved through the exceptional communication reach of CBC through television, radio and on-line media, in both official languages. A variety of semi-sensational efforts fueled the campaign, including:

* "Village on a Diet"--a weekly reality television program that followed the people of Taylor, British Columbia in their quest to lose one ton of body weight in 10 weeks.

* "Million Pound Challenge"--an on-line challenge to Canadians to collectively pledge and lose one million pounds.

* Daily Challenges--healthy active living challenges for individuals and groups to provide constant variety and motivation.

* Media personality involvement--well-known media personalities from CBC provide regular reminders during their programs and participate in awareness-raising events across the country (e.g., mall appearances, fitness challenges).

Details on the CBC "Live Right Now" campaign are available at http://www.cbc.ca/liverightnow.

PHAC Innovation Funding Announcement Related to Obesity

The Public Health Agency of Canada (PHAC), through its Innovation Strategy (http://www.phac-aspc.gc.ca/ ph-sp/fund-fonds/indexeng.php), released two strategic calls in 2010 for applications for government funding for Phase 1 projects (pilot or feasibility) aimed at preventing or managing obesity. In January 2011, the funding announcements were made for both strategic funding streams. The "Achieving Healthier Weights in Canadian Communities" call for proposals had a prevention focus and 37 projects were funded up to $250,000 each, with a 12-15 month project timeframe. The "Managing Obesity Across the Lifecycle: An Interventions Approach" call for proposals had an obesity treatment and management focus and 5 projects were funded up to $250,000 each, also with a 12-15 month project timeframe. Pending the feasibility and success of these Phase 1 projects, some will be eligible to apply for Phase 2 support (greater financial support over a longer period to extend the reach and/or scope of the project). More details on the solicitation process are available at http://www.phacaspc.gc.ca/ph-sp/ fund-fonds/ahwcc-apscc-eng.php.

Publication of CHMS Physical Activity Findings

The Canadian Health Measures Survey (CHMS) conducted by Statistics Canada is the most comprehensive direct health measures survey ever completed in Canada. (14) This nationally representative survey is now an ongoing cross-sectional survey. Cycle 1 was completed in 2007-2009 and included, for the first time, a direct measurement of the physical activity and sedentary behaviours of Canadians. Physical activity was measured for 7 consecutive days using Actical accelerometers. (15) In January 2011, the physical activity results were released through a media advisory and two peer-reviewed manuscripts: one focused on children (5) and one on adults. (16) The results indicated that 7% of children (5) were meeting the new Canadian Physical Activity Guidelines, (6) assessed as accumulating 60 minutes of moderate- to vigorous-intensity physical activity (MVPA) on at least 6 days per week. The findings also showed that boys are more active than girls (9% versus 4% meet the guidelines); physical activity declines with increasing age; physical activity declines with increasing adiposity in boys; and Canadian children and youth are sedentary for approximately 8.6 hours per day (62% of waking hours). (5) These findings help to substantiate the health-related fitness findings from the CHMS released in 2010 that demonstrated that Canadian children today are taller, heavier, fatter, rounder, weaker and less flexible than in 1981. (17)

Release of New Canadian Physical Activity and Sedentary Behaviour Guidelines

In January 2011, the Canadian Society for Exercise Physiology (http://www.csep.ca), in partnership with ParticipACTION (http://www.participACTION.com), released the new Canadian Physical Activity Guidelines for Children, Youth, Adults, and Older Adults. (6) These new guidelines were based on a rigorous, systematic and transparent review and consultation process (6) and provided an update to the previous guidelines released between 1998 and 2002. The guidelines were developed in consultation with domestic and international experts with an intention to harmonize the physical activity recommendations with other countries and jurisdictions. The new guidelines state:

"For health benefits, children (aged 5-11 years) and youth (aged 12-17 years) should accumulate at least 60 min of moderate- to vigorous-intensity physical activity daily. This should include:

* vigorous-intensity activities at least 3 days per week.

* activities that strengthen muscle and bone at least 3 days per week.

More daily physical activity provides greater health benefits." (6)

In February 2011, approximately 3 weeks after the release of the new Canadian Physical Activity Guidelines, the Canadian Society for Exercise Physiology released the first-ever Canadian Sedentary Behaviour Guidelines for School-aged Children and Youth. (18) These guidelines were prompted by the very high levels of sedentary behaviour among children and youth (5,7,8) and emerging evidence of the health risks associated with sedentary behaviour independent of physical activity. (19) The guidelines state that:

"For health benefits, children (aged 5-11 years) and youth (aged 12-17 years) should minimize the time they spend being sedentary each day. This may be achieved by:

* limiting recreational screen time to no more than 2 hours per day; lower levels are associated with additional health benefits.

* limiting sedentary (motorized) transport, extended sitting and time spent indoors throughout the day." (18)

The release of these new guidelines generated significant national media attention with nearly 100 million media impressions for the two releases combined. Dissemination strategies are in place with various stakeholder groups in an effort to maximize the public health impact of the release of the new guidelines. The new guidelines and related materials are available at http://www.csep.ca/english/view.asp?x=804.

Launch of ParticipACTION's "Think Again" Campaign

In January 2011, Canada's internationally renowned physical activity social marketing and communications organization "ParticipACTION" (20,21) launched its latest mass media campaign called "Think Again". ParticipACTION has an adult brand awareness of approximately 85% in Canada (20) and has been very successful in raising awareness of the importance of, and opportunities for, physical activity. The Think Again campaign is targeted to mothers of children aged 6-12 years and was created because most Canadian mothers are concerned about the level of inactivity in Canadian children, but think that it does not apply to their own children. Therefore, the campaign goals are to make mothers aware that it is likely that their own children are not active enough and to motivate them to take action to get their children more active. The campaign includes short television commercials, posters and online materials. More details on ParticipACTION and the Think Again campaign can be found at http://www.participaction.com/enus/Home.aspx.

Building Trust to Address the Epidemic of Obesity

In February 2011, a workshop was held in Toronto on "Building Trust to Address the Epidemic of Obesity and Chronic Diseases". The workshop included thought leaders from industry, government, academia and the not-for-profit sectors. This workshop was the latest in a series of discussions on the importance of authentic trust to improve the prospects for intersectoral and intrasectoral collaborations on obesity. The need for multisectoral approaches and partnerships is recognized and promoted, (9) yet the trust and motivation surrounding many partnerships and initiatives are questioned. (22) The discussions to date have expressed the need to move beyond the "cordial hypocrisy" that currently infects many public-private partnerships. A recently published commentary stated that "When they partner, health organizations become inadvertent pitchmen for the food industry. They would do well to remember that corporate dollars always introduce perceived or real biases that may taint or distort evidence-based lifestyle recommendations and health messages." (22) The "building trust" discussions aim to reduce the rate and incidence of obesity through more and better intersectoral and intrasectoral partnerships anchored on trust. More details on the building trust initiative can be found at http://www.youtube.com/watch?v=sZh8jAqeLAU.

A spinoff of the building trust initiative was the development of The Partnership Protocol, (23) a roadmap created by a multisectoral steering committee that documented the principles and approach for successful private/not-for-profit partnership in physical activity and sport. The Partnership Protocol, released in November 2010, explains seven guiding principles for effective partnerships (share each other's equity; stay true to who you are; acknowledge and manage risk; create compelling communications; inspire, motivate and activate your stakeholders; be clear; measure and evaluate) and outlines a three-phased approach to effective partnerships, including assessing potential partners, building partnerships and managing partnerships. The Partnership Protocol is designed to help organizations establish, build and sustain effective partnerships using the advice and best practices of a wide variety of experts from the world of academia, business and not-for-profit organizations. (23)

Canadian Pediatric Weight Management Registry Begins

Pediatric obesity researchers in Canada obtained research funding to develop a pan- Canadian pediatric weight management registry (CANPWR) to examine the health of obese youth, the effectiveness of pediatric weight management in Canada, and to create a research platform to enable future interventions to be examined. This prospective cohort study began enrolling patients in February-March 2011 who were newly referred to pediatric weight management programs across Canada. Children and adolescents presenting to Canadian pediatric weight management programs are approached for interest by the clinical teams and consent is obtained for those interested in being a part of the registry. This pilot and feasibility phase of CANPWR involves five sites (Vancouver, Edmonton, Hamilton, Ottawa, Montreal). Harmonized core measures are in place and include socio-demographic, medical history, anthropometric, clinical chemistry, lifestyle behaviour and psychosocial measures. The study objectives are to:

1) assemble a common database of health outcomes and their determinants in obese youth;

2) characterize health status, changes in health over time and key determinants of metabolic and psychosocial health status before and after intervention of obese children receiving weight management care; and

3) establish and pilot a multi-centre, web-based data platform of standardized measures and data management processes to support the national pediatric weight management registry.

More details on CANPWR are available at http://www.obesitynetwork.ca/ page.aspx?menu=51&app=225& cat1=577&tp=2&lk=no.

Our Health Our Future: A National Dialogue on Healthy Weights

Emanating from the first initiative described in this paper, the framework endorsed by multisectoral ministers (11) was followed by a launch, in March 2011, of Our Health Our Future: A National Dialogue on Healthy Weights, to engage Canadians in a discussion on physical activity, healthy eating and healthy weights, leading to a national summit in the fall of 2011. Our Health Our Future recognizes that a complex system of factors contribute to overweight and obesity, and that to address the causes of obesity we need to change the social and physical environments that influence children's and families' eating habits and physical activity levels. This initiative recognizes that all Canadians can play a role in identifying ways to create the conditions that support healthy eating, physical activity and healthy weights. The goal of Our Health Our Future is to kick-start a longer-term societal shift to support healthy weights by making the environments where children live, learn and play more supportive of physical activity and healthy eating.

Our Health Our Future works through an online idea forum and submissions centre (www.ourhealthourfuture.gc.ca) where youth, parents, caregivers and all Canadians can share their perspectives on the factors that contribute to childhood obesity and options that can influence and support healthy choices. Key stakeholders including youth, non-governmental organizations, national Aboriginal organizations, media and industry--were invited to face-to-face dialogues across the country to explore areas for joint and/or complementary action. The outcomes led to the development of a report and recommendations for action for the F-P-T Health/ Healthy Living Ministers.

In February 2011, the F-P-T Ministers of Sport, Physical Activity and Recreation (SPAR) announced a commitment to take action to support sport, physical activity and healthy weights. Ministers recognized that the after-school time period constitutes a prime opportunity for increased physical activity among children and youth. In an effort to achieve the 2015 physical activity targets for children and youth set in 2008, Ministers agreed to explore opportunities to work with other departments and stakeholders to identify shared approaches aimed at increasing physical activity in the after-school period. The Ministers also endorsed the Declaration on Prevention and Promotion and the document "Curbing Childhood Obesity: A FPT Framework for Action to Promote Healthy Weights," (13) and agreed to work with Ministers of Health and Health Promotion/Healthy Living who released these initiatives in September 2010. (11,13)

Release of Active Healthy Kids Canada Report Card

On April 26, 2011, Active Healthy Kids Canada released their seventh Annual Report Card on Physical Activity for Children and Youth. (8) The Active Healthy Kids Canada Report Card provides comprehensive, evidence-informed assessments of the "state of the nation" with respect to physical activity for Canadian children and youth. The preparation and distribution of the report card is meant to serve as an accountability index for all Canadians, a surveillance mechanism, an advocacy tool for physical activity leaders and organizations, a policy driver and a process for identifying research and surveillance needs. The 2011 Report Card indicated substantial room for improvement, assigning a failing grade overall, substantiated by evidence from the CHMS5 and the CANPLAY survey from the Canadian Fitness and Lifestyle Research Institute. (24) Active Healthy Kids Canada has a mandate to "power the movement to get kids moving" and the report card provides recommendations for action to "improve the grade", challenging all stakeholders to increase the physical activity of children and youth. The media attention the report card release receives each year has had an incredible impact, with between 100-160 million media impressions each of the past three years. Details of the report card process and evaluations are being published (25) and copies of all reports cards from the past seven years are available at https://www.activehealthykids.ca.

Canadian Obesity Network "National Obesity Summit"

In late April 2011, the Canadian Obesity Network hosted its 2nd National Obesity Summit (http://www.con-obesitysummit.ca). The four-day Summit attracted almost 800 delegates from across Canada and as far away as China, South Africa and Australia. Workshops, symposia, free communication sessions, poster presentations, social events and award ceremonies created ample opportunity for learning, discussion and networking. National, provincial and local media interest were strong, as was social media with almost 500 Tweets from the event reaching upwards of 80,000 people.

Nature Play Day and Sports Day in Canada

In his best-selling book Last Child in the Woods, Richard Louv coined the phrase "nature-deficit disorder" to describe the progressive withdrawal of contemporary-living children from nature and the outdoors. (26) The book served as a call to action and the Child and Nature Alliance of Canada (http://www.childnature.ca) responded with a number of initiatives, including an invitation to all Canadians and communities to celebrate outdoor play and join the Child and Nature Alliance for Nature Play Day. This Canada-wide day of playing in nature was about finding a simple way to connect with nearby nature in backyards, local parks, schoolyards, rooftop gardens, or wherever. Communities, schools, businesses and households across Canada were invited to participate and register Nature Play Day events on the Child and Nature Alliance map. The first annual Nature Play Day Canada was held on June 15, 2011. More details are available at http://www.childnature.ca/nature-play-day-canada.

On September 17, 2011, the second annual Sports Day in Canada celebrated sport, from grassroots to high-performance levels, in communities across Canada. Sports Day in Canada capped off a week of thousands of local sporting events and activities, open houses and try-it days showcasing sport at all levels, and included a special television broadcast on CBC Sports. Sports Day in Canada is presented by CBC Sports (http://www.cbc.ca/sports), ParticipACTION (http://www.Participaction.com) and True Sport (http://www.truesportpur.ca/en/home) and is guided by a committee of national sporting organizations and their networks of coaches, athletes and enthusiasts across the country. It is an opportunity for all Canadians to celebrate the power of sport to build community, fortify our national spirit and facilitate healthy, active living. For more details, see http://sportsday.cbc.ca.

Canadian Assessment of Physical Literacy Developed

The aim of physical education, community sport and active living initiatives is to systematically develop physical competence so that children are able to move efficiently, effectively and safely and gain an understanding of what they are doing. The outcome--"Physical Literacy"--is as fundamentally important to children's education and development as numeracy and literacy. Physical literacy is a construct that captures the essence of what a quality physical education or a quality community sport/activity program aims to achieve. It is the foundation of characteristics, attributes, behaviours, awareness, knowledge and understanding related to healthy active living and the promotion of physical recreation opportunities. (27,28) Physical literacy is deemed to have four core domains: a) physical fitness (cardio-respiratory, muscular strength and flexibility), b) motor behaviour (fundamental motor skill proficiency), c) physical activity behaviours (objectively-measured daily activity), and d) psychosocial/cognitive factors (awareness, knowledge and understanding). (27,28)

No aggregate assessment of physical literacy exists. For the past two years, the Healthy Active Living and Obesity Research Group (HALO) at the Children's Hospital of Eastern Ontario Research Institute (http://www.haloresearch.ca) has been working on developing the Canadian Assessment of Physical Literacy (CAPL) to address this assessment gap. This effort has required reviewing the existing literature, evaluating existing assessment protocols, developing new assessment protocols, pilot testing various iterations of the CAPL, and developing scoring and reporting systems. Funding has been received from many stakeholder groups and funding agencies, and this broad base of support is indicative of the need for such an instrument. To date, nearly 2,000 children have been tested using various iterations of the CAPL. A final version for children aged 9-12 years will be available in 2012.

Creation of "Active Canada 20/20"

Though Canada has the Pan-Canadian Healthy Living Strategy, (12) at present it has no national physical activity strategy. Led by ParticipACTION, and with broad sector involvement, Active Canada 20/20--A Physical Activity Strategy for Canada is the response to an urgent national need to increase physical activity and reduce sedentary living. Active Canada 20/20, which is nearing completion, will provide a clear vision and a change agenda describing what Canada must do to increase physical activity and reduce sedentary behaviour, thereby reducing future disease risk and achieving the many benefits of a society that is active and healthy. It is designed to engage decision makers and rally the collaborative, coordinated and consistent efforts of all stakeholders at every level to make a difference for the well-being and sustainability of our communities, our country, our social programs and, most importantly, our people. For more information on Active Canada 20/20, see http://www.activecanada2020.ca/home.

CONCLUSION

With concern over the increasing prevalence of non-communicable diseases (NCDs) worldwide, the United Nations convened a high-level meeting in New York on September 19, 2011 to endorse a declaration on the prevention and control of NCDs. (29) Canada, among many other countries, immediately endorsed the United Nations declaration. NCDs--chiefly cardiovascular diseases, cancers, chronic respiratory diseases and diabetes--now represent nearly two thirds of global deaths, with a disproportionate number of deaths occurring in developing countries. The declaration states that "prevention must be the cornerstone of the global response to NCDs". Resolving the global childhood obesity and inactivity crisis must in turn be the cornerstone of any global prevention initiative.

The diversity and intensity of activity surrounding the childhood obesity and inactivity "epidemic" in Canada is encouraging (see Table 1 for summary). To achieve success and to have a positive influence on the health of Canadian children and the environments where they live, learn and play, interventions and policy changes will need to be developed, implemented, monitored and evaluated; recommendations will need to be acted upon; ongoing research and surveillance will be required; and clinical practice will require adaptations. All sectors (governments, industry, health care, media, communities, schools, and families) must participate in an aggressive, informed and sustained movement to recalibrate the behaviours of Canadian children to achieve sustained and pervasive healthy living outcomes. Going forward, it will be important to assess the impact and implementation of the programs listed in this brief review while also holding various sectors and agencies accountable for the implementation of existing and future recommendations for action.

Conflict of Interest: None to declare.

Received: December 15, 2011

Accepted: February 21, 2012

REFERENCES

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Sarah B. Henderson, PhD, Tom Kosatsky, MD, Prabjit Barn, MSc

Mark S. Tremblay, PhD

Author Affiliations

Healthy Active Living and Obesity Research Group, Children's Hospital of Eastern Ontario Research Institute; Department of Pediatrics, University of Ottawa, Ottawa, ON

Correspondence: Mark S. Tremblay, Healthy Active Living and Obesity Research Group, CHEO, 401 Smyth Road, Ottawa, ON K1H 8L1, Tel: 613-737-7600, ext. 4114, Fax: 613-738-4800, E-mail: [email protected]

Table 1. Summary of Initiatives Highlighted in the Year in
Review

Policy

* F-P-T Framework for Action to Promote Healthy Weights
* Public Healthy Agency of Canada's innovation strategy funding
  related to obesity
* Active Canada 20/20--A National Physical Activity Plan
* Nutrition labeling initiative

Campaigns/Advocacy

* CBC "Live Right Now" campaign
* ParticipACTION's "Think Again" campaign
* Nature Play Day and Sports Day in Canada

Research/Research Dissemination/Guidelines

* Canadian Health Measures Survey physical activity findings
* Canadian Physical Activity and Sedentary Behaviour Guidelines
* Active Healthy Kids Canada Report Card on Physical Activity and
  Youth
* Canadian Pediatric Weight Management Registry
* Development of the Canadian Assessment of Physical Literacy

Conferences/Workshops/Consultations

* Workshop on building trust to address the epidemic of obesity
* National Obesity Summit
* Our Health Our Future: A national dialogue on healthy weights