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House of Commons Emblem

Standing Committee on Health



Tuesday, December 12, 2017

[Recorded by Electronic Apparatus]



     We'll call our meeting to order. Welcome, everybody, to meeting number 85 of the Standing Committee on Health.
    Today we're going to continue our study on Canada's food guide.
     We welcome all our witnesses, both those who are present and those who are here by video conference.
     Today our witnesses include, from the Heart and Stroke Foundation of Canada, Mr. Manuel Arango, director, health policy and advocacy; from Diabetes Canada, Joanne Lewis, director, nutrition and healthy eating; and, as an individual, Dr. Benoît Lamarche, chairholder of the chair in nutrition at Université Laval, by video conference from Quebec.
    Welcome, all of you. We'll go in the order mentioned, and we'll start with the Heart and Stroke Foundation. We like to have 10-minute opening statements at a maximum.
     If you'd like to start, you're on.
     In my role as the director of health policy and advocacy at Heart and Stroke, my team and I have had the pleasure of engaging with many of you at this committee one-on-one on the subject of Canada's healthy eating strategy. We appreciate the ongoing commitment to enhance Canada's food environment.
     We also applaud Health Canada's recent step to eliminate industrial trans fats in our food supply. Heart and Stroke is proud to have co-chaired the trans fat task force and to have worked with government and other partners to make this health policy a reality. This was an important step because trans fat levels are still high among certain vulnerable populations, including our children, in the food they consume. In foods such as processed baked goods and restaurant foods, levels are still high.
     On the study of Canada's food guide, the committee is hearing from some of our partners on this subject. Our common agreement is that the healthy eating strategy and particularly the soon to be revised Canada food guide provide an unprecedented opportunity to make meaningful changes to our food environment and to support Canadians to make healthy choices.
     In building on the comments made by my colleagues, my testimony today will focus on the following key components: the nutrition status of Canadians and the relationship between nutrition and chronic diseases; the importance of robust revisions to Canada's food guide; and, as well, Heart and Stroke's specific recommendations for the food guide.
    Nutrition is a key impetus for our work at Heart and Stroke. We know that up to 80% of heart disease and stroke can be prevented by adopting healthy behaviours, including a healthy diet. While the causes are numerous, poor diet, excess caloric intake, and inadequate access to important nutrients are leading factors driving chronic disease and obesity.
     The situation is not ideal in Canada. Currently, more than 60% of adult Canadians and more than 30% of children and youth are overweight or obese. Approximately 70% of Canadians age 18 years and above and youth 12 to 17 years of age did not eat the recommended servings of vegetables and fruits in 2016.
    Also very worrisome, ultra-processed food consumption is on the rise. Almost 50% of Canadians' energy intake comes from ultra-processed foods. It's even higher, 60%, for kids nine to 13 years of age. This was highlighted in a report that the Heart and Stroke commissioned through the University of Montreal just last week.
    What concerns Heart and Stroke in the context of today's discussion is that this could be the first generation of kids to have a shorter lifespan than that of their parents as a result of premature death related to chronic disease, including obesity.
    The annual cost of diet-related disease is $26 billion annually, and unhealthy diets are the number one risk for death in Canada in 2016. Without public policy intervention, the situation will only get worse.
     Whether you or your caucuses agree or disagree with how the food guide should be revised, we can all agree that in the last 10 years since the release of the last food guide, social behaviours and consumption habits have changed, technology and information access have evolved, and scientific evidence related to nutrition has also progressed, all of which necessitate a re-examination and revision of how Health Canada is advising Canadians to consume foods and beverages.
     Canada's food guide was once a central resource for Heart and Stroke, both for the development of policy papers and for the creation of consumer resources. However, in the last few years, we have increasingly moved away from utilizing and referencing the food guide due to inconsistencies between the food guide and Heart and Stroke's messages on healthy eating. We hope that will be resolved with the revision of the food guide.
    Heart and Stroke is supportive of and in agreement with many of the key principles proposed by Health Canada during the consultation phases for the food guide. Broadly speaking, we support the consumption of whole real foods, mostly plant-based foods, but certainly not at the exclusion of a moderate amount of some animal proteins, which can certainly be part of a healthy diet. Here, we're talking about fish, eggs, lean meat, low-fat milk, unsweetened milk, etc. We also support the proposals to limit or avoid highly processed and ready-made foods and beverages high in sodium, sugars or saturated fat, and to avoid all sugary drinks, because these are certainly not part of a healthy diet. Let me elaborate on some of the specifics.


    With respect to dairy, Heart and Stroke recommends that the food guide should contain a statement about including lower fat unsweetened milk, milk alternatives, and yogourt as part of your diet. We see value in ensuring that dairy products be identified for their efficient delivery of calcium and vitamin D. For example, we think whole milk should be encouraged for children one to two years of age who are not being breastfed. Furthermore, we recommend the continued monitoring of emerging evidence on the impact of high-fat dairy products on cardiovascular health.
    With respect to saturated fat, Heart and Stroke agrees that the government should promote the consumption of foods that contain mostly unsaturated fat, instead of foods that contain mostly saturated fat. Research clearly indicates that saturated fats raise the risk of heart disease and stroke, whereas the replacement of these saturated fats with other types of healthy fats decreases the risk of these conditions. Our advice to Canadians is that the best way to avoid unhealthy saturated fats is to avoid consuming highly processed foods. There is emerging evidence that it's not just the fat itself but the type of food that the fat is found in that can affect heart health. If Canadians are eating a balanced amount of whole real foods, cooking from scratch, and avoiding highly processed food, then they will likely have managed any risk posed by saturated fats.
    With respect to beverages, Heart and Stroke agrees with satisfying our thirst with water and plain milk. Safe, clean water should be readily available to all Canadians. Heart and Stroke firmly believes that sugary drinks of any sort, including 100% fruit juice, should not be included in dietary recommendations to Canadians. They should not be considered alternatives to fruit. Sugary drinks have little to no health benefits but many health risks. The 100% fruit juice is metabolized in virtually the same way other sugary drinks are, and juice can have the same amount of or up to 33% more sugar than soda pop does. Canadians should eat their fruit, not drink it. We know that excess sugar consumption is associated with adverse health effects.
    With respect to food preparation and ultra-processed foods, Heart and Stroke agrees that Canadians should be advised to limit their intake of highly processed or ready-made prepared foods. Ultra-processed foods are a major source of saturated fat, and are also high in calories, sodium, sugar, and sometimes trans fats. These all raise the risk for heart disease and stroke. Therefore, Heart and Stroke believes, it's important to have a clear definition of “processed foods”, since many foundational foods are minimally processed, such as frozen and canned unsweetened and unsalted fruits and vegetables. We need to advise Canadians that these are good foods to eat. It's important for the consumer to clearly understand which foods to limit.
    With respect to food knowledge, Canadians need support and education on planning and preparing healthy meals and snacks, and we hope that the revised food guide will do this. Additionally, having the food literacy skills to make healthy selections requires a good understanding of how to read and understand nutrition facts tables. We also support the federal government's efforts to institute front-of-package labelling that provides interpretive, simple, highly visible, and easy-to-understand information about the risks of products high in sodium, sugar, and saturated fat. Evidence from other jurisdictions indicates that front-of-package labelling is a necessary step toward making it easier for Canadians to eat healthy food.
    Finally, with respect to determinants of health, cultural diversity, and the environment, Heart and Stroke believes it is essential that any new or revised directive on eating habits in Canada take into account access to and availability of nutrition and food in a culturally appropriate manner. This includes acknowledging the importance of food sovereignty and reflecting cultural preferences and food traditions. As Health Canada works to develop the indigenous food guide, which, it is our understanding, will be tailored to include traditional and country foods, and will be translated into a host of indigenous languages, we strongly urge that the department work towards releasing both food guides simultaneously if possible. We also recommend that this committee hear from indigenous-led organizations about the progress of that document. Furthermore, in terms of the overall process, we also encourage Health Canada to publicly articulate their proposed schedule for releasing the various components of the revised food guide, and to ensure that the tools for Canadian consumers and the direction for health professionals be released concurrently.
    To conclude, consistent with our participation in the consultative process, Heart and Stroke supports the healthy eating strategy, including a robust updated food guide, front-of-package nutrition labelling, trans fat regulations, and restrictions on the marketing of unhealthy foods and beverages to kids in Canada. This strategy will help to reduce the number of heart attacks and strokes in Canada.


    Thank you very much for taking the time to listen to our input today. I welcome your questions.
    Thank you.
    I just had a question. What's an ultra-processed food?
    Ultra-processed foods are foods that really don't resemble their original state anymore. For example, if you take a piece of chicken, add additives, process it, add emulsifiers, etc., you end up with chicken nuggets. Chicken nuggets are ultra-processed foods. They contain really not that much of the original chicken anymore.
    That's one example of ultra-processed foods. It also includes sugary drinks, other ready-made or frozen meals, burgers, some sandwiches, etc.
    Thanks very much.
    Now we will go to Joanne Lewis from Diabetes Canada.
    Thank you for the opportunity to speak to you today about Canada's food guide, and respond to any questions that might assist you in your study.
     My name is Joanne Lewis. I am a registered dietitian and the director of nutrition and healthy eating for Diabetes Canada.
     Diabetes Canada is a national health charity representing the 11 million Canadians living with diabetes or prediabetes. A number of people at this table are already very well acquainted with the work of our organization and are diabetes champions themselves on the Hill and in their communities back in their constituencies.
    On behalf of all Canadians affected by diabetes or prediabetes, I'd like to thank all of you for your hard work and devotion to our cause, and for inviting me to be here today. We are so grateful for your support in helping us achieve our mandate to end diabetes. In particular, we wish to acknowledge the commitment of Sonia Sidhu, who is part of this committee and is also the chair of our all-party diabetes caucus.
     About one in three Canadians is living with diabetes or prediabetes. It is an astounding statistic. There is a new diabetes diagnosis being delivered to someone every three minutes. Globally, Canada's diabetes rate is among the highest in OECD countries. Our growing, aging, and ethnically-diverse population, high levels of overweight, and an increase in sedentary living have contributed to an over 50% increase in diabetes prevalence within the last 10 years. Ninety per cent of people with diabetes have type 2. Once a disease of older individuals, type 2 diabetes is now being diagnosed in Canadians at a younger age, impacting people in the prime of life. The rate of diabetes is projected to continue to rise over the next decade. It is estimated that close to 13 million Canadians will have diabetes or prediabetes in 2027, at a direct cost to the health care system of $4.6 billion.
     You have all heard of diabetes. It is well known but it is not known well. Few people fully realize the devastating consequences that this progressive illness can have on the health, mind, family, and pocketbook of those afflicted. Diabetes contributes to 30% of strokes, 40% of heart attacks, 50% of kidney failure requiring dialysis, and 70% of non-traumatic limb amputation. It is also the leading cause of vision loss and blindness. Furthermore, people with diabetes are at much greater risk of depression and other mental health challenges compared to the general population. It is a disease that people live with 24 hours a day, seven days a week, 365 days a year, with no breaks. Medication, equipment, devices and supplies required to treat diabetes can cost people thousands of dollars annually. The personal and economic toll is enormous.
    Prediabetes is a condition that is equally not known well. Those with prediabetes have abnormally elevated blood sugars that are not sufficiently high to constitute a diagnosis of diabetes. With lifestyle changes and modest weight reduction, half of the people with prediabetes can re-establish normal blood sugar levels and stave off diabetes.
    We know that regular physical activity is extremely important for chronic disease prevention and good health. However, to tackle the obesity and diabetes epidemics, we really must address our food and beverage intake and options in a serious way. Now more than ever Canadians need guidance to make healthy choices that will help to reduce the prevalence and burden of chronic disease in this country.
     In October 2016, Health Canada launched its healthy eating strategy. As part of this initiative, it undertook to revise Canada's food guide. Leading Canadian and international experts in nutrition, medicine, public health, and policy advised on the proposed new food guide, and developed population-level healthy eating principles that are based on rigorous scientific research. Diabetes Canada applauds Health Canada's efforts in this process. We endorse broad, meaningful stakeholder engagement in policy-making, and feel that consultations on the food guide to date have been extensive and inclusive of professionals, scientists, the private sector, and the Canadian public generally. As powerful a tool as it is, the food guide in isolation is not enough to turn the tide on diabetes and chronic disease in Canada. This is why Diabetes Canada supports the healthy eating strategy, a multi-pronged approach to safeguard the health of Canadians.


     More informative front-of-package labelling, an easier to use and understand nutrition facts table on food and beverages, restrictions on the marketing of unhealthy items to children and youth, and the elimination of industrially produced trans fats from the Canadian food supply, alongside the food guide, will help make the healthy choice the easy choice, and will slowly start to change the food environment in our country.
    The healthy eating strategy, including the food guide, must be directed to the population to reorient our society toward good health. People will always have the individual freedom to make decisions within the framework of their personal context. To see the bold results we so desperately need when it comes to improving the health of Canadians, change is needed and a population approach is required to facilitate this change.
     People with diabetes or prediabetes and those at high risk have a large stake in the food environment and healthy eating. Diabetes Canada has developed and disseminated clinical practice guidelines for the prevention and management of diabetes in Canada since 1992. This includes nutrition recommendations. The most recent guidelines say:
In general, people with diabetes should follow the healthy diet recommended for the general population in Eating Well with Canada's Food Guide. This involves consuming a variety of foods from the 4 food groups (vegetables and fruits; grain products; milk and alternatives; meat and alternatives), with an emphasis on foods that are low in energy density and high in volume to optimize satiety and discourage overconsumption. This diet may help a person attain and maintain a healthy body weight while ensuring an adequate intake of carbohydrate (CHO), fibre, fat and essential fatty acids, protein, vitamins and minerals.
    A balanced diet is good for Canadians and good for people with diabetes. The emphasis in the new food guide on whole foods consumption is one our organization strongly supports. The food guide recommends a regular intake of vegetables, fruits, and whole grains. Many of these foods are good sources of dietary fibre and have a low glycemic index. Studies have shown a diet that includes fibre-rich, low-glycemic index foods can help improve blood sugar control and may decrease cardiovascular risk, which is high among people with diabetes and prediabetes.
    The food guide supports intake of legumes and nuts. Regular consumption of these foods is associated with lower fasting blood glucose and hemoglobin A1c in people with and without diabetes, and improvements to blood lipids in those with diabetes. Lean meat, eggs, and dairy products are healthy items that can absolutely be included as part of a balanced diet as per the food guide.
    Diabetes Canada supports the recommendation to limit saturated fat and aim to consume unsaturated dietary fats. For people living with diabetes who are two to three times more predisposed to developing coronary artery disease, restricting saturated fat can help to mitigate this risk. Sodium, sugar, and saturated fat are nutrients of public concern. Diabetes Canada is strongly in favour of a reduced consumption of these in the Canadian diet. Eating patterns that feature foods low in sodium, sugar, and saturated fat have been associated with lower blood pressure, fasting blood glucose, weight and waist circumference, and unhealthy blood cholesterol in people with diabetes, compared to other eating patterns. Aiming for whole food, cooking at home more, and limiting intake of processed food will help Canadians to limit nutrients of concern.
    Healthy hydration is extremely important to Diabetes Canada. Sugary beverages represent the single greatest contributor of sugar in the Canadian diet and provide little to no nutritional value. Over the next 25 years, sugary drinks in Canada will be responsible for 300,000 cases of obesity, a million cases of diabetes, 300,000 cases of heart disease, 100,000 cases of cancer, 63,000 strokes, and $50 billion in health care costs. Diabetes Canada encourages water as the beverage of choice, and we are very pleased that Health Canada is also promoting this through the food guide.
    Diabetes Canada recognizes that enhanced knowledge and skills are needed to navigate the complex food environment. We are pleased the food guide will encourage Canadians to select nutritious food when shopping and eating, plan and prepare healthy meals and snacks, and share meals with family and friends whenever possible.


    In order for Canadians to be able to apply the food guide principles in their everyday lives, they require supports, resources, and infrastructure. Diabetes Canada wishes to ensure that there are systems in place to facilitate uptake of the food guide. To this end, we propose the following to the Government of Canada: ensure that the food guide and Agriculture and Agri-Food Canada's food policy for all complement one another; continue to partner with all levels of government to reduce the burden of food insecurity on Canadian households; work with the provinces and municipalities to increase the availability of clean, safe, free drinking water in homes and public spaces across the country.
    In conclusion, Diabetes Canada is supportive of the direction Canada's food guide is taking. As part of an integrated strategy, it has real potential to transform our obesogenic, disease-promoting environment and positively impact the eating decisions of Canadians, significantly influencing their heath trajectory. Imagine a Canada with less chronic disease, fewer health care costs, and a more productive society. That is within our reach. Diabetes Canada looks forward to continuing to work with Health Canada to promote healthy eating and improve the health and quality of life for all.
    Thank you.
    Thank you very much.
    Now we'll go to Dr. Lamarche by video conference.
    You have 10 minutes.
    Thank you very much. I would like to thank the Standing Committee on Health for this truly great opportunity to provide my perspective on the healthy eating strategy. I think this is a very significant step towards a better food system, and perhaps better health in the long term for Canada as well.
    I'm chair in nutrition at the Université Laval. I've been researching diet and health for 20 years. My main focus is on nutrition and heart disease, and obesity and diabetes. I do research from an epidemiological, big cohort perspective, clinical as well as mechanistic perspectives. I've studied all types of fat, as well as whole diets such as the Mediterranean diet, for example.
    I think it's important for transparency to disclose that I've been funded by industry in the past, by the dairy industry and the Canola Council of Canada, both as part of the Agriculture and Agri-Food Canada clusters. However, I want to also emphasize that I have no particular agenda regarding food and health. I'm not a vegetarian. I don't like milk particularly. I'm allergic to fish and seafood. These are my disclosures, I guess.
    I believe that my role as a researcher is to advance knowledge and to make sure the data are interpreted as they should be. For me, the revision process undertaken by Health Canada, which is based on the totality of evidence, is key. Again, as a researcher my role is to make sure we provide the best evidence possible for efforts like this to make the best decisions possible.
    Finally, before I go to my perspective on the healthy eating strategy and the food guide in general, I'll note that I was fortunate to be involved in the evidence review cycle undertaken by Health Canada in 2015, and I provided my perspective on the evidence on which these decisions are based.
    I commend Health Canada for undertaking this extensive review of the healthy eating strategy. This is not an easy task. There are high expectations. There are a lot of controversies in many of these areas. I'm sure that as consumers you're all aware of these controversies. This is not an easy task, and I think Health Canada.... It's been mentioned by the two previous speakers that the process—the transparency and the level of consultation—has been really amazing.
    What I want to do in the next few minutes is take the guiding principles and provide some perspective on each of them.
    The first relates to consuming a variety of nutritious foods and beverages as the foundation of healthy eating. There's a strong tendency around the world now to focus on food patterns, thereby promoting food patterns to the population. There are, of course, many different food patterns that can be healthy. I think this is well acknowledged. However, I don't understand how we can connect this strategy, which I think is great, to the focus that is given on each nutrient. We're going to hear a lot about food patterns—vegan patterns, the DASH type of diet, the Mediterranean diet—yet there will be a lot of focus on nutrients. We are going to have a front-of-pack strategy for nutrients, labelling the saturated fats, the sugars, the sodium. For me, this is not a direct connection with a food-based or a food pattern approach; we're still focusing on nutrients, thereby perhaps contributing to confusion among the public.
    This is not easy, because over the last 20 to 30 years we have programmed the population to focus on nutrients. We have provided information on nutrients on the food labels. In the consultations with the public by Health Canada over the last couple of years, the population, the consumers, have been saying they want information about proteins, carbohydrates, lipids, and energy. This is really difficult, because we want to emphasize a whole diet approach, a whole food approach, yet we're going to still provide information on nutrients. This is a disconnect for me. I want to understand why we're going this way, because these two approaches are clearly different.


    There is, of course, in the U.S. and in Canada this recommendation for a substitution of saturated fat versus unsaturated fat. I think we have a lot of evidence to support this recommendation, but again, it's a highly nutrient-based recommendation. I would hope Health Canada, through the revised guidelines, will not emphasize this. It's putting too much emphasis on the nutrients, whereas we want them to focus on foods. We want people to focus on food substitution.
    Further, there is actually some controversy about this recommendation for substitution of saturated fat for PUFA; not from a cholesterol effect or health effect, but from a food-based effect, this is really hard to do. For example, if we say you have to substitute saturated fat for polyunsaturated fat, the bad fat for the good fat, how do you do that if you're consuming yogourt? You don't have yogourt high in unsaturated fat. Yogourt is going to be containing saturated fat as part of dairy fat. It's the same thing for cheese. This substitution is very difficult for the population to understand. Maybe we can address that in the question period. It's not as easy as it seems, and I think this is important to keep in mind.
    Of course, all guidelines right now around the world are trying to address this issue by using the totality of the scientific evidence. I'm just curious, and I don't understand why everybody is looking at the same evidence and not coming to the same conclusion. We're talking about a low saturated fat, high polyunsaturated fat paradigm, because in Canada and in the U.S. we say that's what the science says. Yet the Dutch health agency is saying they don't have the evidence to support that, and we're all looking at the same evidence. For example, in the Netherlands, they don't have the recommendations to consume lower-fat dairy products because they're saying they don't have the evidence for that. Personally, I've done a lot of research on this and I can't find evidence, for example, showing that consuming a low-fat yogourt is better for health than consuming a high-fat yogourt. This is a leap of faith mostly based on the fact that high-fat dairy contains more saturated fat. But there is evidence that the food matrix may modify the effect of the food on health. It's quite interesting, as a scientist, to look at this evolving work around the recommendations. We're all looking at the same evidence and we're not coming to similar conclusions.
    The whole issue on processed and prepared food I think is a great idea. Again, there is the risk of putting too much emphasis on some of these nutrients, and sugar is one of those. Just for your information, for sure, over-consumption of sugar is problematic; no one will argue against that, but I think we're putting a lot of weight on sugar. In some analyses around the world looking at nutrition factors contributing to the burden of disease, sugar, among all nutritional factors, comes in 10th place. It's just after fruit, nuts, sodium, processed meat, vegetables, trans fat, omega-3 fats, whole grains, and fibres—10th place for sugar. We are putting a lot of pressure on sugar. Maybe it's going to have an effect, but there are a lot of other areas in nutrition that could have a lot of effect on health.
    On the front-of-pack approach to sugar—and we've discussed that among our colleagues here in Quebec at our research institute—using the total sugar of the food is problematic. I'll give you some examples. Several products, cereals, for example, which are high in sugar, are below the cut-off for the front-of-pack label for sugar. Mini-Wheats, Honeycomb—you can name a lot of them—are just below the 15 grams per serving size, so they won't have a label for high-sugar content, but they may be just at 14 grams. That's a pretty high sugar content. The added sugar versus the total sugar for us is a key issue. There is a lot of challenge in looking at added sugar, of course, but from a public health perspective, I think this is something we need to consider as well.


    I'll say a word on juice. Of course, over-consumption of juice, over-consumption of sugary beverages, is not good for health, not good for obesity, and not good for cardiovascular disease. We feel, and I have discussed this with my colleague, again, avoiding wording related to juice intake is pretty strong. For me, I don't think we have evidence that zero millilitres of juice is any better than a little bit of juice. We have evidence that too much juice is not good, but there are nuances there, and from a public health messaging perspective, again from my scientist's perspective, we're lacking some evidence there.
    Doctor, could you come to a conclusion. We're out of time for your 10 minutes.
    Yes. I have nine minutes on my clock, so I'm finishing.
    I really appreciate the healthy eating strategy related to children. The banning of trans fats was a great initiative, and I'll speak more to that during the questions.
    I'll stop, and maybe I'll add more comments during the questions.


    Okay, thanks very much.
    We'll go to our seven-minute round of questions starting with Mr. Oliver.
    Thank you very much for your presentations today and for being here. I have to say it's tough studying this topic right before our holiday season. My office and house are full of candy and baked goods, and it's just a tough time to be talking about it, but thank you for being here.
    The first question is for Diabetes Canada and the Heart and Stroke Foundation.
    I was looking through the dietary approaches to stop hypertension, your DASH approach. Is what you presented today basically consistent with DASH, and is that consistent, as you understand it so far, with the guiding principles document?
    There are many overlapping recommendations between DASH, the Mediterranean, and some of the recommendations of the new Canada food guide.
    I will defer to our third speaker, who might know a little more with respect to the smaller nuances of the diets. But with respect to increased intake of fruits and vegetables, reduced intake of red meats, and so on, the DASH diet, because it was specifically formulated for hypertension, does look at specific nutrients such as magnesium and potassium, so dairy products play a big part of the DASH diet.
     I'll defer to the other speaker, if he has further comments.
    Thank you.
    I'll just add one comment, and I will defer to Dr. Lamarche, as well, if he wants to speak to the nuances of the DASH diet.
    For sure, we certainly have evidence through the U.S. National Academy of Medicine and many other international—
    I have only a minute, so if you're going to defer to the doctor, then—
    No problem, it's just that other international organizations have definitely recommended.... There is a relationship between low sodium consumption and health.
    Absolutely. Thank you.
    Dr. Lamarche.
    No, I don't think I have any other significant things to add. This is one pattern that is healthy for both diabetes and heart disease.
    Definitely I'm hearing messages around reducing sugar, reducing salt, swapping fats, and a swapping in the carbohydrate area for healthy carbs versus....
    Other countries have moved towards whether the distinction between saturated and unsaturated fats is really important versus lowering the carb intake. As I understand it, we're still recommending 300 grams of carbs in a 2,000 calorie diet. Some of the Scandinavian and Nordic countries—and there was a McMaster study—along with scientists from about eight other countries looked at 100,000-plus people, and their conclusion was that we need to start reducing our carb intake, and maybe allow some relaxing on the fat side.
    Dr. Lamarche, do you have any views on that? Your whole food, whole diet analysis, was capturing my attention.
    It's really hard to separate the effects of each of these nutrients, because they have to be interpreted in the context of each population. You're referring to The Lancet paper that I think was published in the summer. This was a multi-country study, and the context of carb consumption is very different among these countries, so we have to be careful how we interpret the data.
    For example, the Mediterranean diet is not a low-fat diet, but it's a healthy fat diet. According to that paradigm, we could shift towards a higher fat diet if you consume the higher quality types of fat. However, the risk with the higher fat diet is to accept the higher saturated fat diet from transformed products, which are not to be recommended. You have the Atkins diet that has been promoted quite a lot. This is a high saturated fat diet that had some effect on cholesterol, but we don't have any long-term study to support that.
    I don't think we need a recommendation on the amount of carbohydrates we should consume. This is variable from country to country, from population to population, even within Canada, but I think if you consume the right types of fat, then it's okay to consume a higher fat diet.
     Thank you.
    On processed and highly processed and refined foods, I know in my community there are lots of working families—both parents are working—and the kids have a thousand and one activities after school and on weekends. As far as the opportunity to cook from scratch and the cost for some families of cooking those diets are concerned—they have cost and time factors—are there reasonable substitutes?
    Some families I know in my neighbourhood are using those high-nutrition protein shakes, like Ensure and things like that, just to make sure something gets into their kids, because they don't always have time to put together a properly home-cooked meal, and some can't afford it.
    Are there products like that out there that should be considered in this, or is it just a straight no, you cook from scratch, you cook basic foods?


    If I could take the first crack at that question, certainly we would encourage innovation in the food manufacturing sector to try to reduce the harm from some of their products. Research in that respect, and more responsibility from the food and beverage industry as well, would be helpful to reduce that harm.
    However, it is definitely possible, with a bit of advance planning, to cook from scratch and plan your week ahead. It is very true that in this modern-day age of convenience—families are driving the kids to sports activities after work; you have two-parent families, both working, rushing home—it's more complicated. There is no doubt about it, and we're living in an age of convenience.
    What about single-parent families?
    We're living in an age of convenience, but with a little bit of planning and, as well, support from the government in terms of promoting a positive food environment, it can make it easier for these parents who are leading these hectic lifestyles to eat a little healthier.
    I would definitely underscore that advanced planning in terms of cooking from scratch before the start of the workweek could help.
    Are there any other answers? Do you both agree with that?
    Are products like Ensure—I don't want to name a brand—but those kinds of products, a substitute for a meal made from scratch, or are they all pretty unhealthy because they're processed and refined foods?
    I'll take that. Dr. Lamarche might want to add more later.
     As a dietitian, products like Ensure, Boost, and other similar products—Glucerna—have been pretty much reserved for people who are unable to eat whole foods. In the past, they were reserved for individuals who were just not well enough to consume whole foods on a regular basis. They were supplementary calories or a meal replacement for somebody who is elderly and unable to consume whole food. In recent years, they've taken on a whole new direction, with the understanding, or misunderstanding, that it's just as good as having a whole food breakfast or a whole food snack. I certainly would not suggest that it's a great alternative.
     I'm guilty as charged. Once in a while, if I don't have time to plan something for breakfast, I'll grab one and go. I think that's fine. It's when these things become the norm, that's absolutely not recommended.
    Certainly when you look at food, it is more than just a bunch of nutrients. It's a bunch of nutrients put together in some kind of cohesive format. When you isolate those nutrients and put them in a beverage—amino acids, various carbohydrates, whatever it is—you're losing something. If a whole food is healthy—the sum of its parts—and you take it out and you put into a liquid, is it still healthy? I don't think we have evidence to prove that it is as healthy.
    I think we've seen various scientific research that has showed us that when you pull something out of the food and you give it in a capsule.... Is it going to have the same health outcomes? No, because that something was part of a bigger something, and it's all those things working together that make it a healthy food.
    We have to move now to Mr. Berthold.


    Thank you, Mr. Chair.
    I want to thank the witnesses, whose testimony was rather eloquent.
    I am the critic and phantom minister for agriculture and agri-food. We can all agree that the agriculture and agri-food industry plays a major role in the Canadian diet. Unlike money, which doesn't grow on trees, food grows in fields. Agricultural products have to be looked after and processed.
    Mr. Arango, I liked one of your comments. You said you wished food manufacturers would innovate. You are sure that those people should have a say in the development of the new food guide. They can actually help contribute to improving the Canadian diet.
    Ms. Lewis, although I am getting a bit off topic, I want to thank you, as well as the other Diabetes Canada representatives, for the important work you have done with the opposition parties on the tax credits for people with type 1 diabetes. Together, we have managed to have the government listen to reason. Today, hundreds of people are very happy with the work we have done together.
    I want to thank the government for changing its position in this case. It is a good thing that the Liberals have recognized that a step in the wrong direction was made.
    Mr. Lamarche, I will give you an opportunity to speak a little French. I am sure it will be good for you. During your presentation, you mentioned science several times. I got the impression that, in your opinion, a number of other elements should be taken into account before the next food guide is developed and distributed. Am I wrong?


    No. I think that, in a number of cases, the claims being made are a bit premature. The general principles make sense, but some details are not specifically substantiated by research. I will again give the example of the recommendation on high-fat or low-fat products. I don't think it makes a difference whether Canadians consume low-fat or high-fat dairy products.
    As a researcher, my role is to check whether the recommendation that people consume low-fat dairy products is evidence-based. I combed through the literature and did not find any research claiming that it is preferable to consume low-fat yogourt over high-fat yogourt. Other people around the world—I gave the example of the Netherlands—have come to the same conclusion. The same could be said for cheese.
    Does science show that low-fat cheese is healthier than high-fat cheese? We don't have the answer, but a recommendation was made to that effect. I feel that the value of scientific data is being stretched in some cases.
    I completely agree with you, Mr. Lamarche. That is why I am here today.
    People have done a lot of work and research on nutrition, food and food processing. Those people are agri-food industry stakeholders and farmers. Institutes for research on agriculture have conducted clear research. There has been a tremendous amount of research on food. Unfortunately, from what I see, the Standing Committee on Health has planned two meetings to discuss Canada's Food Guide. However, there aren't any witnesses from the agri-food industry or the agricultural sector. To me, that's unbelievable.
    The Conservative Party of Canada is very close to the rural world, and it believes that food should come from Canada's regions. We think that those people have a say in this study. We would have really liked to hear their testimony and their explanations on how they process food and what the level of research on food processing is. We would have liked to know where we are headed. I think all those people want what is best for Canadians.
    For example, we talked about juice. Is it a matter of quantity or is juice itself bad? People could have come to explain what stage the research in this area is at. That is why, Mr. Chair, I will move the following motion:
That, pursuant to Standing Order 108(2), the Standing Committee on Health extend its study on Canada's Food Guide, and hear specifically from agriculture and agri-food stakeholders; and that the Committee report its findings to the House prior to the release of Part 1 of the new dietary guidance policy report.
    Mr. Chair, I will let you distribute the motion. If I may, I will explain why I have put it forward.
    I hope the witnesses understand that I have to make this extremely important presentation. It is not only for agriculture and agri-food sectors, but also for Canadians who expect the next food guide to contain all the information and take into account all the scientific data at their disposal, including data from the very sector that ensures that we have food to put on our plate and eat every week. Perhaps we could learn from those companies what efforts are being made in this direction.
    Mr. Chair, the Standing Committee on Agriculture and Agri-Food, of which I am a member, has studied the food policy. A report was tabled last week in the House of Commons. I would like to talk to you about an element of that report that seems very relevant to me. By the way, the report was adopted unanimously by the committee members. The Liberals, the New Democrats and the Conservatives agreed on the entire report and on some of the recommendations.
    The recommendation I want to discuss is about building bridges between producers and consumers. In food policy, it is important for people to know what they are eating, where it comes from and why they are eating it. In our study, witnesses pointed out that there was a great divide between producers and consumers because consumers are often unaware of how food is produced. We believe that public confidence is one of the priority principles of the agriculture and agri-food sector. In the report, we highlight the fact that farmers are proactive in this area. They organize visits to their farms and invite Canadians to meet with them to better understand how they produce food. The executive director of the Canadian Association of Fairs and Exhibits said that agricultural fairs are the ideal meeting place for the agricultural community and people from the city who want to know and understand where their food comes from. That is crucial.
    You were talking about the Mediterranean diet earlier. I have visited Mediterranean countries, where I saw that people eat a lot of cheese. If there is one place where people eat a lot of cheese, it is around the Mediterranean. However, I did not see many obesity problems in the places I visited over there.


    People don't have to go very far, since producers are close to markets. Consumers can talk to producers daily. That closeness to producers does not exist here, and I think it would be important to create it.
    According to a number of witnesses who have participated in our study, education is key in food policy to building those kinds of relationships between producers and consumers. According to some, the food policy can provide an opportunity to refute various myths on modern agriculture and promote the sector as a producer of food in a responsible and environmental friendly way that also focuses on animal welfare.
    I have actually been told that those concerns were taken into account when the food guide was developed. The guide is about the health Canadians, but it wants to take their impact on the environment into account. So it would be important for producers to come tell the committee members how hard they have been working, for years, to minimize the impact of their production on the environment.
    Allow me to read a quote:
If designed and implemented properly, Canada's food policy has an opportunity to bridge the gap between the Canadian public and modern Canadian agriculture. As an industry, we understand that building public trust is very important, and that we need to reconnect with consumers and the public. This initiative has the potential to bring the public and farmers and ranchers together to find shared values in Canada's food and agricultural systems.
    That statement was made by Dan Darling, President of the Canadian Cattlemen's Association.
    Why don't the members of this committee want Mr. Darling to come talk to them about the efforts those people are making to build bridges with Canadians and to understand their tendencies?
    Canadians want to eat better, and ranchers know that. If they want to continue to sell their products, they have to adapt. I would have liked for the committee members to take a few minutes to hear from the representatives of the Canadian Cattlemen's Association.
    The food guide also talks about labelling. That is causing a lot of concern in the industry among retailers and dairy producers because they don't know what will be put forward. However, Mr. Arango told us earlier that people wanted very specific facts and figures to know what they are eating. I think that all producers and other stakeholders from the agri-food sector agree on that. They want to avoid disincentives that may lead to people being just as afraid of consuming a food product as of buying a cleaning product. This is a source of concern. I believe that those people would have wanted to come share their position on labelling.
    Mr. Arango's foundation is working very hard with retailers to find a balance. That would make it possible to provide people with information on what they are eating and to prevent heart disease. Unfortunately, this committee does not seem to be interested in people from the agri-food industry explaining to them the consequences poor labelling may have on consumer choice. I would have liked those people to come explain to you that consumers' choices that are meant to be informed are not really informed
    Mr. Lamarche, who is a research chair in nutrition at the Université Laval, told us earlier that, if we were not careful, some products would not be labelled correctly and they could be more harmful to health than some labelled products because they contain natural sugar. So that is a major issue.
    I think it would be important for the committee and you, Mr. Chair, to give those people an opportunity to share their opinion on those issues.
    The recommendation of the Standing Committee on Agriculture and Agri-Food reads as follows:
The Committee recommends that the new food guide be informed by the food policy and include peer-reviewed, scientific evidence and that the Government work with the agriculture and agri-food sector to endure alignment and competitiveness for domestic industries.
    It's simple. Another House of Commons committee, made up of Liberals, Conservatives and New Democrats adopted this recommendation unanimously. No one was against it. All the Liberals accepted it. The report was tabled and has been well received.


    Since the food guide is related to health, I sincerely believe that its consideration is the responsibility of the Standing Committee on Health, which could follow up on that recommendation with the Standing Committee on Agriculture and Agri-Food.
    As I already said, I am moving this motion today to give producers, ranchers and dairy farmers an opportunity to be heard.


    Mr. Chair, on a point of order, the practice of this committee, of which my honourable colleague is not a permanent member, is that when we discuss witnesses for committee business, we go in camera. In his motion, he's now talking about specific witnesses and sectors that he wants to come before committee. Our practice is to have committee business discussed in public, except when we talk about specific witnesses. If he's going to continue this motion, I would move that we go in camera at this point.
    I ask the member if he's going to continue to talk about certain industries, organizations, or people.


    I won't talk about witnesses anymore, but I will still talk about producers' concerns. I actually think that, as a member of Parliament, I have the responsibility to communicate, where appropriate, comments we have heard in meetings of the Standing Committee on Agriculture and Agri-Food about Canada's Food Guide. So I will continue to talk about the recommendation of the Standing Committee on Agriculture and Agri-Food, whereby it is important for the new food guide to be informed by the food policy.
    The members of the Standing Committee on Health received a submission from the Dairy Farmers of Canada.


    I have a point of order, Mr. Chair.
    I move that the debate be now adjourned.


     Mr. Chair, I have the floor.
    You cannot do that. So I will continue what I was saying. Thank you very much.


    Mr. Chair, on a point of order, I believe there's a committee requirement that a motion be tabled 24 hours in advance before debate on it ensues. We've just received this motion now. We have our witnesses here, and they've come a long way. They are providing expert advice to us on a very important topic for all Canadians. I'm a bit disappointed that our member here has decided to make an issue out of one sector when we have very important nutrition and dietitian advice and issues that we need to be hearing from our witnesses.



    I have the floor, Mr. Chair.


    I think the reason we have a 24-hour requirement is to give us time to consider motions and be prepared to debate them. I believe this presentation right now is not consistent with the rules.
    We've discussed this, and the motion is on the topic we're discussing. He had the floor so he can move the motion.
    May I ask the clerk to confirm that, please?
    Yes. It's 48 hours' notice unless it deals with the matter under consideration.
    It is an exception, though, when somebody comes and tells us another committee is telling what this committee is supposed to study. We choose our own subjects here in this committee.
    Can I move that we go in camera for this discussion, then?
    If we're going to discuss any areas that he's already discussed or continues in that vein, I will go in camera.
    Yes, Mr. Davies.
    On the point of order, the motion itself deals with witnesses. The motion itself is, “That, pursuant to Standing Order 108(2), the Standing Committee on Health extend its study on Canada's Food Guide, and hear specifically from agriculture and agri-food stakeholders....”
    I don't see how we can be discussing this motion at all if not in camera. The motion itself deals with stakeholders and witnesses. I don't think it's appropriate to be having this discussion in public in which, once my honourable colleague cedes the floor, if he intends on doing that at the meeting, it invites us to comment favourably or unfavourably on the motion on particular witness groups, which should absolutely be in camera.
    I move that we go in camera immediately because the entire motion deals with that.
    I agree with that.
    I just want to ask the member, are you almost done?
    Two minutes.
    Two minutes. Will you...?
    I'm sorry, there's a motion.
    With respect, it doesn't matter to me if he takes two or 20 minutes. The motion is either in camera or it's not.
    Mr. Chair, I ask for the vote right now.


    If people don't want to vote now, I will take that as a refusal.


     We have a motion to go in camera.
    (Motion agreed to)


    Mr. Chair, a point of order.


You can't move a motion when I'm talking on a point of order. You can't do that.
    We just did.
    We're going to go in camera.
    [Proceedings continue in camera]



    [Public proceedings resume]
     All right. We're back in public.
    I apologize to our guests. Welcome to Ottawa.
    Now, for seven minutes, we go to Mr. Davies.
    Thank you, Mr. Chair.
    Thank you to the witnesses for being with us.
    Mr. Arango, a recent report by the Heart and Stroke Foundation found that 90% of online food and beverage ads viewed by youth are for unhealthy products high in fat, sugar, and salt, such as desserts, snacks, cereals, and sodas. The report noted that such advertising is a key factor in explaining why one-third of Canadian children are currently overweight or obese, and why, since 1979, the number of Canadian children with obesity has tripled.
    Since 1980 the province of Quebec, where childhood obesity rates are the lowest in the country, has banned advertisements for toys and fast food aimed at children under 13. In your view, should there be a national ban on junk food advertisements directed at young people?
     Absolutely. The Heart and Stroke Foundation's position is that we should have restrictions on unhealthy food and beverage marketing to kids. There should be a national ban. It should be as comprehensive as possible. It should use a very strong nutrient profiling mechanism. It should cover as many marketing media as possible. It's not sufficient, as was done in the U.K., to cover just TV, because then the industry just puts its resources and dollars into marketing in other media such as the Internet, fronts of packages, etc. It has to be very comprehensive.
    We're looking forward to continued debate on the issue, on legislation on restricting marketing to kids, which is going to be debated in the House later on this evening. It's very, very important for Canadians and for our kids that we institute such a ban.
    Thank you.
    Dr. Lamarche, I wonder if you, as the chair of nutrition and being from Quebec, have a view on a national ban on advertising of junk food to kids.
    I want to be transparent that this is not my area of expertise, but I think there is no reason to not introduce such a ban. You've demonstrated by the statistics you showed that this is a very impactful thing to advertise to children. It's low-hanging fruit.
    I believe Health Canada is leaning towards that, but it needs to be done. We're doing it in Quebec very well, so it's possible.


    Well, thank you for leading the way.
    The reason I bring that up is that we're dealing with the food guide, which is something that I think everybody around this table and in Parliament wants to promote as widely as possible as a source of information on healthy eating. It seems counterproductive to me if we counter that good work with very effective private sector advertising that is sending to children messages which are different or in fact the opposite from what we're trying to promote in the food guide.
    Ms. Lewis, the issue of a tax on sugar-sweetened beverages has come up. Would Diabetes Canada support a tax on sugar-sweetened beverages to help reduce consumption?
    Yes, absolutely. Diabetes Canada has been asking and advocating for a tax on sugar-sweetened beverages for the last year plus. It's well known that we are definitely in favour of that, and we're not alone.
    I'll turn back to you, Mr. Arango. You talked in your opening remarks about front-of-package labelling. I'm curious about your assessment of the current state of labelling. How are we doing in terms of telling consumers accurately and prominently about what's in the packages they're consuming?
    Certainly that's an issue. We have had an improvement in the nutrition facts table. It is going to be improved shortly. However, we also know, from a lot of research, that the nutrition facts table is not fully comprehensible to a lot of Canadians, especially folks who don't have high literacy levels and others, including children and so on. We need an easier system to communicate to Canadians what the healthfulness is of a particular food product.
    There's been a lot of research done through other international organizations that have demonstrated that highly visible, prominent, easy to understand, interpretive, intuitive symbols on the front of packages can have a huge impact in terms of changing the behaviour in terms of consumption patterns of consumers. We strongly support the current work being done by Health Canada to put warning labels on the front of packs that will indicate whether products are high in sodium, sugar, or fat.
     Dr. Lamarche, I'd like your view as a nutritionist on that as well. How are we doing right now? If I walked into a Loblaws or a Safeway, would I actually be getting the kind of information that you as a nutritionist would want me to be getting from the packages?
    I'll ask you another question, because I'll probably run out of time. I'm curious about the issue of the social determinants of health. According to Food Banks Canada:
Thirteen percent of Canadians live in a state of food insecurity, which means they do not have reliable access to adequate amounts of safe, good-quality, nutritious food. The root cause of hunger in Canada is low income, which consistently affects more than 4 million of us at any given time.
    Also, I'd like to know in your view to what degree a lack of access to affordable and nutritious food contributes to poor nutrition in Canada.
    How much time do I have?
    Voices: Oh, oh!
    Dr. Benoît Lamarche: I'll try to answer the first one quickly.
    I think the front-of-pack approach—it's been mentioned previously—is efficient. However, I've mentioned that we have some reservations regarding the sugar target, which is total sugar. Of course, this may change the behaviour of people, but it has an impact on industry as well. Industry will react to these labels and try to get below the target, of course, and not have the warning signs on their product.
     The question then becomes, is this the right number? Are we safe with 15 grams or 15% daily...? For me, the science is not that strong behind that actual number. We can debate that all day, but I have some concerns regarding the total sugar target, as opposed to the added sugar target.
    Regarding inequities in socio-economic status, I'm a strong proponent of getting access to healthy foods as a more efficient way to improve the health status of Canadians. Communication and education are going to work, but access is key. If we don't give people access to healthy food, it's going to have very little effect, irrespective of how we communicate.


    The time is up.
     Ms. Sidhu.
    Thank you, Chair.
    Thank you to all the witnesses for being here and for sharing their valuable information.
    My first question is for Diabetes Canada.
    There are 11 million Canadians who are living with diabetes or are prediabetes. In your statement, you said that there are going to be 13 million in 2027, with an expenditure of $4.6 billion on health care. It's a big burden.
     The Liberal government and our health minister are taking a big step and a good step in revising the food guide. Educating Canadians is an important part of embracing healthy eating. We are living in a diverse country, and we have many different languages from coast to coast to coast. What tools does your organization use to educate Canadians? How do you ensure this information relates to people from different cultures with different food habits?
    Diabetes Canada is very committed to getting the message out around how to manage and prevent diabetes. We publish the “Clinical Practice Guidelines” for health care providers to help them help their patients who are trying either to prevent or to manage their diabetes.
    With respect to nutrition, absolutely, every culture comes with their own specific cultural foods and eating habits and patterns. In order to ensure that for each of these cultures, particularly the ones who are at a higher risk of developing diabetes, there is some education that they can actually relate to, Diabetes Canada has created resources that are specific to South Asians, to indigenous peoples, to the Latin community—I'm forgetting one—and to the various cultures that are at a higher risk, in order to help them incorporate their own foods into the information we have in our guidelines.
    Thank you.
    This question is for the Heart and Stroke Foundation.
    In your strategic plan, you have indicated that the foundation has set a goal to the reduce risk factors for heart disease and stroke by 10% by 2020. As I said, our health minister has taken great steps to promote healthy eating by reducing saturated fat intake and making recommendations through the revised food guide. With this in mind and the future steps you would like to see in order to reach your goal by 2020, what steps do you think we should take?
     I certainly think a number of things that the government and Health Canada are proposing right now with the healthy eating strategy are going to help us achieve these targets.
     My colleague from Diabetes Canada did mention one thing, a levy on sugary drinks. That's not in the current strategy, but we think it should be in the future. That's definitely a key component. As well, the restricting of marketing of unhealthy foods and beverages to kids is a huge factor that is going to be very influential. The ban on trans fats is going to be very helpful as well to help us achieve these targets. Obviously, the revision of the food guide and front-of-package labelling are all key pieces that will help us achieve these risk-factor targets.
    In your view, in your 2020 target, do you think the government can take more steps? What is your suggestion on that?
    Similar to my colleague from Heart and Stroke, I think the multipronged approach is going to take more than just Canada's food guide being revised. It's going to take various policies, a lot of education, and as Dr. Lamarche mentioned, it's also going to be a policy that enables people to have the access they require. One tool or one tactic is not going to solve this issue. It really needs to be multipronged.
    The DASH diet is high in fibre, low in sodium, low in sugar, and low in saturated fats. This cardiovascular diet is recommended. The Diabetes Canada and Heart and Stroke websites both contain information about the DASH diet. While it is important to reduce sodium intake, are we not running the risk of replacing high sodium intake with a high potassium intake? When somebody who uses the DASH diet has CHF, a congestive heart failure condition, they have to monitor their potassium as well. Does the DASH diet increase the potassium level if we recommend the DASH diet?


     I know there are concerns with sodium levels in heart failure patients, so I think the recommendations are slightly different for heart failure patients. To your point, a different approach has to be taken for sure, but I think with the population at large, for folks not living with heart failure, it's very important to have low sodium for sure. Yes, a different approach has to be taken with heart failure patients.
    Thank you.
    As you know, the consequence of eating an unhealthy diet is that fatty deposits known as plaque block the arteries, which leads to heart attacks. We have talked about how healthy eating can reverse the risk of disease. How can healthy eating habits reduce artery blockage? How can the healthy eating strategy help to reduce unhealthy living?
    I won't talk to the actual mechanisms of how plaque is developed in the arteries, but I will say that there is a whole slew of very solid evidence to indicate that unhealthy diets and poor nutrition are related to the development of heart disease and stroke.
     Is a plant-based diet helpful?
    Plant-based, absolutely. If you look at the Mediterranean diets or other diets that focus on plant-based sources, there is an association with improved heart health. As I mentioned in my testimony, this is not necessarily at the exclusion of some animal proteins. We know you can get nutrients from lean meat, unsweetened milk, and other animal proteins, so it's not their exclusion, but we do support the food guide's overall proposal to focus mostly on plant-based foods.
    In our report on ultra-processed foods that was released last week, they looked at 13 different countries in Europe and Latin America, and those countries that had high rates of ultra-processed food consumption also had high rates of chronic disease, obesity, people being overweight. Once again, a major culprit is ultra-processed foods.
     The time is up. Sorry.
    That completes our seven-minute round of questions.
    Now we're going to five-minute rounds of questions, starting with Mr. Webber.
    Thank you, Mr. Chair.
    Thank you, witnesses, for being here today.
    I do want to echo Ms. Lewis's comment commending Ms. Sonia Sidhu for her work in diabetes and being an advocate for that. I do commend you as well. Thank you for what you do, Sonia.
    I've found these last few days talking about Canada's food guide to be rather depressing, really. Mr. Chair, I like yogourt. I like milk. I like red meats. I like cheese. I like sugar. I like saturated fats, for God's sake. I find that anything I enjoy, I can't eat, according to Canada's food guide. It is depressing, but I guess I should read the revised guide when it does come out.
    What I wanted to talk specifically about—and I did bring it up at the last meeting, but I do want to know what your thoughts are on it as well—is with respect to beverages. I'm quite surprised with your comment, Mr. Arango, regarding 100% fruit juice. You say that fruit juice has 33% more sugar than soda pop. Did I hear that correctly?
    Just to clarify, there are certain types of fruit juices, for example, 100% grape juice. There are some products of grape juice that have 33% more sugar than your regular Coca Cola product. Yes, there might be a small amount of minerals and vitamins in that fruit juice, but does it offset that significant increase in sugar? We think not. That's our concern with fruit juice, and we think Canadians should be aware of that. All sugary drinks are basically made equal, effectively.


    That is news to me. Can you tell me the difference between 100% fruit juice and fruit concentrate?
    I will explain. With respect to 100% fruit juice, how is it processed and how is it developed? They get the juice from a fruit; it's squeezed out of it. It's then heated at very high levels to kill bacteria and effectively all the vitamins and minerals are removed when they do this heating or processing. What's left is sugars known as free sugars. Then the juice is later fortified with vitamins and minerals, and that's how you end up with 100% fruit juice.
    The issue with this is that it's really no different from fortifying Coke. If you took Coke and you fortified it with vitamins and minerals, it's basically the same process as what's being done with fruit juice. The concern we have, once again, is that it has very high levels of sugars and we know that's associated with dental caries. That's why Health Canada is also quite concerned and trying to propose to remove 100% fruit juice as an alternative to fruits. We should not be recommending to Canadians that they drink fruit juice as an alternative to fruits. Canadians should eat their fruits, not drink them.
    So your beverage of choice—as Ms. Lewis said as well—is water.
    Plain water and milk are what we would advise. We understand that, on rare occasions, Canadians may want to consume a sugary drink. We're not saying if that ever happened it is the end of the world. I think we all know if we were to do that on rare occasions, it's not an issue. But at the population level, we cannot be promoting to Canadians the consumption of these products. The messages we deliver to the public will have an impact on their behaviour. We have to be careful in terms of how we message that.
    Can you support the message of sugar replacements such as artificial sweeteners, aspartame, for example, in fruit beverages or in soda pop? What are your thoughts on that?
    Our message at Heart and Stroke is to consume plain water and plain milk. We do understand that, if diet drinks with artificial sweeteners replaced all sugary drinks, there would be reduced harm to the population. That said, we don't promote diet drinks because we don't want to promote the societal craving for sugary drinks, for sweet-tasting drinks in the population. But we do acknowledge that there's quite a bit of evidence—I know it's emerging and it's changing—to indicate that diet drinks with artificial sweeteners are going to have much reduced harm compared to full-calorie sugary drinks.
    I'm not in the habit, usually, of giving thanks or kudos to the food and beverage industry, but we do think that the movement toward more bottled water and diet drinks is going to, at the population level, reduce harm for Canadians.
     Thanks very much.
    Ms. Sidhu, welcome back.
    I have read that for children, 10% of their daily calories come from sugar-sweetened drinks. This surely is contributing to the rate of childhood obesity. The obesity rate is growing very high. Do you think it will give more pace to growing diabetes, the sugary drinks, or, as Mr. Arango said, the 100% juice?
    I'm sorry, Sonia. Could you repeat the last part of your question?
    Do you think these sugar-sweetened...? How can we educate our kids to avoid those sugary drinks? I know that Bill S-228 is coming, and I'm speaking on that, too. Besides that, how can we give the correct message to our youth or other people to avoid that 100% sugar juice and to eat more food?
    At the risk of sounding redundant or repetitive, I think it's going to take a multipronged approach. My understanding is that the largest consumers of sugar-sweetened beverages are teenage youth, and the major purchaser of sugar-sweetened beverages to bring them in the home is the parents. It's going to take a combination of education modalities to reach the various target groups with respect to sugar-sweetened beverages, reducing the intake of that and increasing the intake of healthier foods.
    One thing I've learned in my practice is that everybody is motivated by something different, so there won't be a one-size-fits-all. People don't change behaviour all based on the exact same information or reason to change behaviour. I think it's up to the school system, the parents, the communities, or the Internet, wherever the various populations are, to get those messages out there.
    I have to give kudos to the SodaStream company. They have a commercial—you've probably seen it—where they're standing outside drinking sugar-sweetened soda as though it's the smoke break and everybody's outside smoking, and then they have to go in. One woman says, “I've been trying to kick the habit”, and the habit she's been trying to kick is drinking sugar-sweetened beverages. I really think that for that message to be strong enough, we almost have to treat it like smoking. To be caught with soda in your grocery cart.... You almost want to cover it with your other groceries so people don't know you're buying soda.
    I'm always amazed.... I'll tell you this secretly. I take secret pictures of people's shopping carts when soda is on sale, and the stacks of soda cans in a cart.... It's still very acceptable to buy it in large quantities, especially if it's on sale. The message isn't out there yet; this is still happening. I think the only way we're going to get that message out is to treat sugar-sweetened beverages, especially the regularly sweetened sodas, as though it's smoking, something you would be embarrassed to be doing.


    I would just add a few comments.
    I agree with my colleague. A multipronged approach is very important. With respect to public education and public awareness, I know that Health Canada is intent on developing a public awareness campaign. From what I understand, it will focus on parents of teenagers, advising them not to keep soda in the house. Not buying it and not having it in the house would help reduce consumption. That's a very interesting public awareness campaign.
    The other point I would add is with respect to a levy on sugary drinks. One interesting unintended positive outcome of a levy is that it will actually raise awareness in the population about the dangers of sugary drink consumption. If they know that a levy is being put on a sugary drink because it is not healthy, that would help increase the awareness. That's another way a levy would have a positive impact on health.
    Thank you.
    Thanks very much.
    Now we go to Mr. Van Kesteren.
     Thank you, Mr. Chair.
    Thank you all for being here.
    I'm going to go to you, Dr. Lamarche, and change channels a little. You're the doctor. I'm reading about how foods are broken down in our stomachs, the enzymes. It's just amazing how the body has been created. How important is what comes with the food? We've probably all seen or heard about the french fries—and I won't mention where they come from—that sit in the fridge for three months. They just don't deteriorate. They don't go mouldy. How important is it that the foods we eat have the bacteria to...? Is that part of the breakdown in our body as well? Is that something we need to look at as well?
    The bacteria?
    Well, whatever it is that breaks down the food. It's the bacteria that causes the moulds and all that. The processed foods apparently don't have any of these enzymes or whatever. Is there a coalition between our bodies and the food that's going in as well?
    Yes, there is. Of course, as much as we have diversity in our genes, we also have diversity in our gut capacity to digest and process food. This is of course the filter that will influence or modify the impact of a food on your health.
    At the end of the day, what we see from the literature is that if you consume a Mediterranean diet.... And that takes away the effect of the gut completely. If you consume that diet, irrespective of the genes you have in your gut, or the bacteria, you're going to have some benefits. There is a filter, but it's just a filter, and what we're seeing is the end product of that filter. At the end of the day, it's the whole diet that counts. There is an interaction between foods and how we process foods in the gut, but it's the whole diet that will count. This is just a filter.


    Maybe I'm not being clear but I guess I'm asking if there is a contribution from the food as well? The gut has the enzymes that the pancreas creates in the liver, and all the others. Do the foods also introduce a necessary bacteria or enzyme, or something, to break down the foods?
    Yes. For example, in some of the yogourts, you have a high bacteria count. Long term, this is going to influence your own flora of bacteria in your gut. The fibre that you consume might also influence your capacity to digest different foods. So, yes, the foods have an effect, but it depends on the content of that food. Some fats are better for the gut than others. The fibres are better. Some bacteria may be present in some foods. To answer, it's yes.
    Is that part of the problem with our processed foods, that they're, in essence, dead foods? They have nothing in them other than the starch contents.
    I was leading to another question. This is a personal curiosity.
    I love tomatoes. There are tomatoes that produce.... Again, I won't pinpoint where they come from. They're my absolute favourite, but they've been engineered genetically. At one point I noticed that they would sit on the shelf for weeks. Being a tomato lover, I know that tomatoes don't do that. Then I went to the location where this plant was first engineered. They told me that they took out the enzyme that breaks it down. Apparently they do this with apples too.
     Is this something we should possibly look at as well?
    This is something that we can do now. I have some colleagues here who did the same thing with strawberries. They actually crossed different types of strawberries, and they ended up with a strawberry that can stay on the shelf 20% or 25% longer without rotting.
    From a public health perspective, I don't think that's how we're going to solve the nutrition and health issue. This is—
    Sorry, I don't want to interrupt, but what I'm suggesting is that we're introducing foods into our bodies that aren't helping the body break it down. Are these foods possibly causing or triggering some reactions in our bodies? Has it been studied?
    I would say that we don't have any idea about this. The research is very thin on GMOs and on food modification. I would say that we don't know.
    You don't know at this point.
    We have to learn about this.
    Time is up.
     Thank you, Chair.
    We will move to Mr. McKinnon.
    Ms. Lewis, I believe you spoke earlier about the importance of food with a low glycemic index. Are you saying that we should focus on those kinds of foods, that kind of diet? To me, that is consistent with the common theme I'm hearing about reducing sugar and reducing refined carbohydrates.
    I'd like all of you to comment on that.
    In particular, Dr. Lamarche, I wonder if you can comment on any research out there that would support this.
    Please go ahead.
    Thank you for mentioning glycemic index.
    Diabetes Canada has been a supporter and proponent of the glycemic index for a number of years. The reason for that is when people consume a diet with a lower glycemic index.... For those of you who may not be aware, glycemic index measures or ranks foods according to how high blood sugar is raised after consuming those foods or beverages. Foods with a low glycemic index take a much longer time to raise blood sugar. Foods with a high glycemic index raise blood sugar levels immediately, so that would be the difference between having lentils, which are low glycemic index, versus pure sugar or glucose, which has a high glycemic index.
    The impact of consuming a more low glycemic index diet is that the outcomes of studies have shown that people have a much quicker sense of satiety, so they tend to eat less. It contributes to lower incidence of cardiovascular disease, and it can help people to lose weight. Much to our benefit at Diabetes Canada, it can help to prevent diabetes.
    We would love Canadians to have more foods with a low glycemic index. Right now, it's very difficult for Canadians to identify foods that are low glycemic index, because it's not written anywhere on the package, and it's very hard to find a list of which foods are low glycemic index.
    In a culture where we are demonizing carbohydrates, and people are talking about no carbs and low carbs, and “I don't eat carbs after 4 p.m.”, we need to look for alternatives that are what we call healthy carbs or quality carbs, because they are a great source of energy as well as fibre. Having more of the right carbs is really the direction we should be going in as opposed to telling people to eat no carbs or fewer carbs.


    Thank you.
    Mr. Arango, do you want to comment on this?
    I would just concur with my colleague that promoting the right carbs is definitely something we have to do.
    I would just point to an unfortunate situation from many, many years ago. Back in the late 1960s or 1970s, a researcher from Harvard University who received funding from the U.S. Sugar Association basically indicated that a lot of the sugar research that was out there was not credible, etc. He focused instead on saturated fats. That was something the U.S. Sugar Association wanted. The result of that was that we then had an ensuing focus on low-fat diets, and in these low-fat diets, the lower fat was replaced with higher levels of unhealthy carbs, refined sugars, etc. It is quite likely that this change in dietary patterns in the 1970s and 1980s was responsible for our overweight and obesity epidemic that we experience today.
    Just to the issue, yes, we want to eat the right carbs, but high carb consumption and low fat consumption is a problem. I know that Dr. Lamarche has also done some work in this particular area as well.
    Okay, over to you, Dr. Lamarche, and you can bring it home with the science.
    Yes, the glycemic index was invented in Canada, so we have to be proud of the Canadian researchers who invented it, David Jenkins and his team, and Tom Wolever.
    I think the issue in the field with the glycemic index, as good as it may be, is an issue of using it. As mentioned, this is hard, because we don't have this information. At the end of the day, if you consume whole-grain products, you're leaning towards low glycemic index products. If you consume vegetables, you're leaning towards low glycemic index products. If you look at the Mediterranean diet and at the DASH diet, they generally have a low glycemic index, so it's another way to look at a healthy diet.
     It's extremely useful, I think, for the management of type 2 diabetes, but from a practical perspective, since we don't have this information, it's really hard for the public to use it if we don't have the information on a product.
    We could argue whether it's a good strategy from a public health perspective. We understand a lot about food because of this discovery, but from a public health perspective, are we ready to change the whole landscape of labelling and so on to provide information on this? For me, that's a big question.
     Thanks very much. Time is up.
    Now we go to Mr. Davies for a three-minute round.
     Ms. Lewis, to what extent is diabetes linked to poverty?
    I guess the question is, to what extent is poverty linked to diabetes? We do see that there are a disproportionate number of people with diabetes who are in a lower socio-economic category. That could be for many reasons, and access to healthy food could be one of them. Knowledge and education levels could be another one, and there are various other social determinants of health of course. So, yes, that is something we know very well.


    Mr. Arango, you commented on meal planning. The statistic I have in front of me is that about 37% of Canadians currently plan their meals in advance. That actually strikes me as high, but let's assume that's the case. In your view, would a meal planning app based on the new food guide be a useful tool for Canadians?
    It would be one tool for sure. If Health Canada did contemplate that, it would be useful. There is certainly growth in nutrition-related eating apps. We have to be innovative in our approaches to addressing unhealthy diets and unhealthy lifestyles, so consideration of digital apps is certainly something that holds a lot of promise.
    Dr. Lamarche, I'll end with you.
    If there is one bit of advice you could give this committee about the food guide and what we should do with it, how it could be improved, and how it could be more effective, what would that be?
    Before I answer, there is another example where the science is not seen the same way by different groups. The group from Harvard, which is the mecca of research and nutrition, with regard to their drinking pyramid, say that it's okay to drink one small glass of juice every day. They look at the same evidence we do, and that's what they say. There you go. If it's small, it's okay.
    The main advice and the main concern I would have, and I've discussed this with many of my colleagues, has to do with all around communication. We have here an effort towards a whole food, whole dietary pattern approach, which I think is great, and yet we're focusing and several of the strategies are focused on nutrients. This is going to be very confusing to the population, because we're focusing on nutrients but we're telling them to worry about their whole diet.
     For me, this is really a communication issue, and the guide will have little effect if we create more confusion. I've listened to the previous meetings you've had, and judging just by the questions you have, everybody's confused. We have to find a way to reduce that confusion, to provide less information but key information, and to focus not too much on small details. That would be my recommendation.
    That's a great way to end.
     I want to thank all of our witnesses for great presentations and great information in language we can understand. We really do appreciate it.
    Dr. Lamarche, I think that by video conference it must be especially difficult to be there by yourself and to participate. Thank you very much.
    Thanks to our other witnesses as well.
    On committee business, I understand that our pharmacare study will be available to us on December 21, and we're planning to have our first meeting to look at the draft study on pharmacare on January 29.
    Mr. Oliver, you indicated that you wanted to make a motion.
    Yes, thank you, Mr. Chair.
    We've had a fair bit of discussion about the work agenda of the committee, and different proposals have been put forward. I thought I'd formalize it a bit. In the motion, I'm going to be recommending that we finish the work we already have on our plate, as you just referenced, on pharmacare. It's been almost two years since we identified a list of topics that we would like to work through. There are still some left—home care, palliative care, blood and organ donations—but I thought maybe the subcommittee should meet again to identify those projects and any others that have come up since it's been two years, really, since we did it, and then we would come back to the committee with a report from the subcommittee. My motion is consistent with that. I move:
That the Committee's work agenda be, in order, the following:
1. the consideration of a draft report and recommendations related to its study of the development of a national pharmacare program;
2. the consideration of a draft report and recommendations related to its study of antimicrobial resistance;
3. finishing the study and consideration of a draft report and recommendations related to its study of Canada’s Food Guide; and
4. the consideration of any legislation that is referred to it at that point of time; and
and that the Chair convene a meeting of the Subcommittee on Agenda and Procedure at the first available opportunity in 2018 during the regular Committee timeslot to discuss and plan other future work of the Committee with a report to be tabled at the following regular Committee meeting.


     Mr. Davies.
    Thanks, John.
    I'm just wondering, do you have a meeting in mind for that subcommittee meeting?
    It would be our first, unless it conflicts with the date you just proposed for pharmacare.
    The meeting on January 29.
    When's our first meeting after we come back? We're meeting on the Monday and Wednesday.
    Is January 29 our first day?
    That's why I ask, because there appears to be a conflict.
    We're going to be meeting on Mondays and Wednesdays when we come back.
    Is the 29th the first Monday we're back?
    It's the first day.
    Do you want the HESA subcommittee that day or do you want pharmacare that day?
    It would be nice to get a work plan sorted out, but it would be nice to get back to debating pharmacare as well, so maybe we should do pharmacare, but then the following meeting would be....
    I think we should get a crack at pharmacare first, but I do think this is important because we are directionless right now. So let's....
    At the first available opportunity as we work on the pharmacare study, we have a one committee break to do our work plan at subcommittee.
    Mr. Davies.
    May I make one suggestion while I still have the floor?
    The first Monday back is the first day we'll be back with our staff. I would suggest we have the subcommittee on the Monday and then let's get at the pharmacare report on the Wednesday. That would give us all a couple of days to work with our staff.
    An hon. member: What time are our meetings?
    Mr. Don Davies: Would that matter?
    That's why we propose the Monday, because we're all scrambling. Members are getting back.
    Yes, I'm in favour of that. Yes, let's do pharmacare on Wednesday.
    Do the subcommittee on the first Monday and start pharmacare on the Wednesday.
    All right, that's fine with me.
    Mr. Berthold.


    Mr. Chair, I will not try to request a study again, but I would like to get a copy of the motion in French, so that I can know what we are being asked to vote on.


    I think we're working on a translation.
    It's being translated by [Inaudible—Editor]
    This is not translated. This is not acceptable. If I have to vote, I have to vote on a motion with words, not on an interpretation of a motion.
    All right, well, it's the practice of this committee to do it this way, and so we're going to proceed with the vote on it.


    Mr. Chair, I remind you that documents from the Parliament of Canada and the government must be bilingual. By doing this, you are breaking the rules of the House of Commons.
    I really must point that out.


    Mr. McKinnon.
    This motion has not been distributed as a document. It has been read. Verbally it has been translated. That is sufficient for the business of this committee. It does not have to be tabled as a written document if it's given on an ad hoc basis.
    You know what? I'm not trying to be a stick in the mud but we don't even know what we're voting on in English.
    I can read it again if you'd like.
    Mr. Berthold is.... Well, you know, all right, fire.
    Would you like to read it again?
    Sure, absolutely, as many times as you need. I'll read it more slowly:
That the Committee's work agenda be, in order, the following:
1. the consideration of a draft report and recommendations related to its study of the development of a national pharmacare program;
2. the consideration of a draft report and recommendations related to its study of antimicrobial resistance;
3. finishing the study and consideration of a draft report and recommendations related to its study of Canada’s Food Guide; and
4. the consideration of any legislation that is referred to it at that point of time; and
and that the Chair convene a meeting of the Subcommittee on Agenda and Procedure at the first available opportunity in 2018 during the regular Committee timeslot to discuss and plan other future work of the Committee with a report to be tabled at the following regular Committee meeting.


     Mr. Van Kesteren.
    Mr. Chair, as I understand the member, he has given us the opportunity to introduce some other studies. I do know that some other studies that we have considered have been brought forward by this committee. Is the member suggesting that those suggestions not be part of the main motion?
    I am suggesting that, as is our past practice, the subcommittee on agenda and procedure take those priorities, already set, look at other ones, and come back with a report to be tabled at this committee, setting the priority for new studies.
    Mr. Chair, on a point of order, I'm conscious that the witnesses have not been discharged yet. It's perfectly fine if they want to stay and listen to this riveting discussion, but I'm wondering if we can formally thank them for their appearance so that they don't have to suffer any longer.
    Voices: Oh, oh!
    All right.
    Did you have a comment other than on the witnesses?
    No, not yet. I just think we should thank the witnesses and let them know that they can carry on with their lives.
    An hon. member: Let's call the vote.
    I'll delay the vote on this until we get it translated.
    On Monday, January 29, we will have a strategy meeting—
    With the subcommittee.
    —with the subcommittee.
    Mr. John Oliver: That's fine. That's all I want.
    The Chair: We'll have this motion translated and then we'll bring it back for a vote.
    The meeting is adjourned.
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