Tensions and contractions in Canada’s childhood obesity strategy

Canada is a world leader in health promotion, and has championed ground breaking international strategies on population health including the Ottawa Charter. The country has taken important steps to tackle non-communicable diseases (NCDs) and their risks factors: There is a national integrated framework as well as specific strategies to address key diseases and their associated risks factors including obesity. Equally important, with the endorsement of the United Nations Declaration on NCDs (UNGA), Canada has recognized the global dimension of the NCDs challenge as well as committed to work towards better integrated, holistic, unified and coordinated approaches.

 Yet despite increased efforts, prevalence of NCDs remains stubbornly high even when compared to peers. Overweight and obesity, important predictors of  chronic health problems like diabetes are at record high. Latest estimates from the OECD, an industralized country club, show that two out of three people are overweight and one in four obese. Canada ranks top, in proportion of obese people, just behind USA and England. An even worrying trend, is the growing number of expanded waist circumference in children. A  self-reported study of obesity among youths aged 12 to 17 years, showed 6.8 percent prevalence for boys and 2.9 percent for girls. Below are key tensions, contradictions and conflicts in the childhood obesity strategy adopted by Federal, Provincial and Municipal health authorities.

Political tension

National versus subnational

While the ‘epidemic’ rise of obesity is a nation-wide burden, mobilizing all levels of governments to join forces together, is complex and even more so, a major political challenge. A central question is matching authority for actions with jurisdictional autonomy. The UNGA declaration underscores the need for joint efforts at all levels. While this may appear less challenging for many countries where central government is the locus of actions, in a federal system like Canada, public health is a shared competence—responsibility is divided between municipalities, provinces and the federal government. According to Canadian Constitution Act, authority for public health and healthcare management resides primarily with the ten provinces. But the Federal government has often used its powers over cross jurisdictional issues like trade and security to legislate on specific and limited number of public health issues.

The multinational identity of Canada—Anglophone and Francophone communities— further complicates decision-making. Because of ‘’secessionist’’ tendencies, the French-speaking province of Quebec, by nature, strongly oppose any perceived encroachment by the federal government into its constitutionally-guaranteed policy space. For example, while Quebec aligns with the principles and spirit behind the framework document, it has not endorsed the pan-Canadian strategy to tackle childhood obesity adopted jointly between the federal government and the other provinces.

Human rights versus corporate rights

Effective interventions to tackle non-communicable diseases and their risks factors may overlap with multiple dimensions of rights including human and corporate rights in a way that engenders tensions and conflicts[1]. Like the UNGA declaration, the Canadian childhood obesity strategy makes reference to human rights: insisting that public health interventions ‘’must reach children throughout the various developmental phases of childhood where they live, learn and play— in the family, school and community.’’

The language, however, is weak when it comes to protecting  human rights to ‘’health-enhancing’’ information. And silent on how to balance children’s rights to healthy food choices against market rights of food companies— to promote their products without restrictions, employing the most efficient and effective tools, and media available, reaching maximum number of target consumers including children. The strategy only encourages rather than insists upon provinces to take strong actions to reduce exposure of children to ‘’the marketing of foods and beverages high in fat and sugar or sodium.’’While there’s strong evidence that television advertisements influence children’s behaviors[2], only Quebec province has taken steps to ban marketing of junk foods to children.

Political lifespan versus interventions horizons

In democracies like Canada, the four-year electoral cycle often misaligns incentives for formulating decades-long interventions that hold promise for public health. Without quick fix solutions, effective and sustained NCD interventions are politically unattractive. The complex nature of risks factors, uncertainties about their  interactions and attributions of causality as well as lack of a range of specific and effective interventions combine, further complicate decision-making.

At present, the cost of  implementing long-term sustainable solutions is far greater to politicians than society as whole. Policy makers have incentives to elect band-aid solutions and sub-optimal actions that could win them votes, while avoiding forward-looking comprehensive interventions, which are likely invisible to electorates. Tackling social determinants of NCDs  require stronger upstream actions including government playing tough with the food industry, a politically expensive strategy.  Also transforming transportation and urban planning by prioritizing walkways, mass transportation and discouraging car ownership, will likely come up against entrenched interests in the car industry, a mass employer.

Governance challenges

Social determinants versus health care systems

Where to allocate limited resources involves not just efficiency and value-based considerations but also conflicting interests. Should efforts be devoted to address determinants of overweight and obesity or should they be directed at strengthening the treatment-oriented healthcare system? While the strategy adopts a life-course approach, it is unclear about what to do with the significant number of obese children who require treatments—and are projected to rise rapidly in the future, regardless of any preventive interventions in the short-term.

 Even when armed with consistently strong evidence about cost-effectiveness of prevention[3], it will require almost revolutionary political will to redirect significant resources away from healthcare into public health, against entrenched structures and vested interests. With 11.2 percent of GDP devoted to healthcare, Canada spends more than its peers— the OECD average is 9.7 percent. And even more importantly, for every one dollar spend on health, only five cents go to preventive public health interventions[4]

Personal behaviour or social determinants

Assume more resources flow into prevention, where to invest is no simple political calculation. Should attention be focus on changing behaviours or addressing broader social determinants?  While the strategy underscores a web of ‘’ complex and interacting system of factors,’’ including those of environment and social dimensions, obesity, framed as a ''crisis,'' suggests chronic shortage of ''willpower'' on a national scale. Canadians exercise too little and eat too much. Most discussions in the media, which influence public policy, tend to blame ‘’irresponsible’’ parenting while ignoring other important upstream forces including the pervasive power of the global food industry that are beyond the control of  individuals, families or communities. Often, individuals do not have full control over what they eat. Many obese people are not lazier. And for some of them, excessive weight gain, is just inevitable: a consequence of adapting to modern lifestyle, that premiums never ending consumption.

Which setting: family, school or community? The strategy prioritizes efforts at ‘’making social and physical environments where children live, learn and play more supportive of physical activities and healthy eating.’’ However, even if there are enough resources to go around, without coordinated efforts, the sum of individual interventions in varied settings may not add up in an optimal way. A study in Connecticut, USA for example, demonstrated that replacing low-nutritious food in schools with healthier options resulted in decreased consumption of unhealthy beverages and salty snacks, but failed to change students’ behaviours away from consuming unhealthy foods back at home[5].  And for already overweight children, research further shows that nutritional education, nutritional skills-training and physical education combine do not have a significant impact on childhood adiposity-fatness[6].  More research, in fact, is needed to identify specific range of cost-effective interventions.

Horizontal versus vertical approaches

While good health is a joint product, how to influence non-health sectors— like agriculture, infrastructure— is a major governance challenge. Canadian Ministers of health committed through the strategy to champion health promotion across all sectors and levels of government. But even with enough resources, they are unlikely to change health outcomes, in a significant way, on their own. The ministries with far more impact on health, may not have the interest, knowledge or capacity to change the way they do their business. And advocating  a ''health in all policies'' approach may come up against perception of ‘’imperialism.’’

However, a few provinces like Quebec have taken important steps to position health as a horizontal priority, subjecting policy proposals from government departments and agencies to mandatory health impact assessments (HIA). While HIA popularity is growing, there are key challenges to realizing its full potential. For example, the pathways by which other sectors impact health, are complex and not fully understood. It is often difficult to predict if an outcome will definitely be good or bad for the health of a population.

Command and control versus self regulations

While there is a compelling case for regulations, how to proceed raise both political and operational challenges. The strategy calls for regulation of the marketing of junk foods and beverages to children, but remains unclear on how to go about it. Should it be top down with the government exercising authority to design and enforce laws? Can the food industry effectively police its own self? While the industry is taking efforts to self-regulate, it is unclear whether efficiency is the underlying motivation or it is a delaying tactics to forestall future efforts to effectively regulate the sector.

The strategy is a progressive step, but without properly addressing key tensions and contradictions, it is unlikely to reverse the runaway epidemic of childhood obesity in Canada.

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[1] Vendkatapuram S et al (2012) Ethical Tensions in Dealing with NonCommunicable Diseases Globally, Bulletin of the World Health Organization, vol 11,

[2] Committee on Food Marketing and the Diets of Children and Youth. Food Marketing to Children and Youth: Threat or Opportunity? Washington, DC, United States: Institute of Medicine; 2006.

[3] OECD 2013 report on obesity in Canada, indicates that

[4] Canadian Institute for Health Information (CIHI). 2012b. National Health Expenditures Trends, 1975–

2012.

[5] Schwartz M, Novak S, Fiore S. The impact of removing snacks of low nutrient value from middle schools. Health Educ Behav 2009;36(6):999-1011

[6] Connelly JB, Duaso MJ, Butler G. A systematic review of controlled trials of interventions to prevent childhood obesity and overweight: A realistic synthesis of the evidence. Public health 2007;121(7):510-7