Healthy Living Symposium Proceedings Toronto Sheraton Centre Hotel Toronto, Ontario June 16–17, 2003

Table of Contents

• Opening of the Symposium
  • The Honourable Anne McLellan, Minister of Health for Canada
  • The Honourable Jane Purves, Minister of Health for Nova Scotia
• Overview of the Healthy Living Strategy Framework and Review of the Consultation Findings.
  • Scott Broughton and Mary Kardos Burton
• Keynote Address
  • Dr. John Frank, Scientific Director, Institute for Population and Public Health, Canadian Institutes for Health Research
• Panel Presentation on Healthy Living
  • Dr. Elinor Wilson, Steering Committee Member for the Chronic Disease Prevention Alliance of Canada
  • Madeleine Dion Stout, Cree Speaker involved in Aboriginal health development, and nongovernment ACPHHS member
  • The Honourable Chester Gillan, Minister of Education and Environment for Prince Edward Island
  • Cathy Loblaw, President and COO, Concerned Children's Advertisers
  • Dr. Andrew Pipe, Chair, Health Strategy and Physical Activity Co-ordinating Committee of the College of Family Physicians of Canada
• Reception and Dinner Speakers
  • The Honourable Tony Clement, Minister of Health and Long-Term Care for Ontario
  • The Honourable Paul De Villers, Secretary of State (Amateur Sport)
  • Dr. David Katz, Associate Clinical Professor of Epidemiology and Public Health and Medicine, and Director of Medical Studies in Public Health, Yale University, School of Medicine
• Plenary Presentations on Proposed Action Plans by Working Groups
  • Public Information Working Group
  • Toward Integrated Strategies for Aboriginal Peoples
  • Community Development and Infrastructure
  • Leadership and Policy Development
  • Knowledge Development and Transfer
• Plenary Presentations on Additions to the Action Plans by Working Groups
  • Public Information Working Group
  • Toward Integrated Strategies for Aboriginal Peoples
  • Community Development and Infrastructure
  • Leadership and Policy Development
  • Knowledge Development and Transfer
• Next Steps
  • Mary Kardos Burton
  • Scott Broughton
  • Final Comments

The Honourable Anne McLellan, Minister of Health for Canada

Some important lessons are being learned from the recent SARS outbreaks in Toronto; most importantly, that good public health policy touches most areas of daily life, and that integrated approaches are needed to respond effectively to public health issues.

Similarly, it is important to address the challenges of healthy living through comprehensive integrated approaches. The shared risk factors that threaten health, such as physical inactivity, obesity, and tobacco use, are closely linked to income, education, and the safety of communities.

Leadership and effective policies are pivotal in creating the environments that inform and support healthier choices. The focus must be on creating stronger communities where healthy living is the norm.

Leadership – setting goals, defining objectives, and engaging and empowering people – is at the root of the Integrated Pan-Canadian Healthy Living Strategy umbrella framework, which will support the promotion of healthy behaviours; aim to reduce the rates of chronic disease, increase longevity, and improve quality of life; and, reduce the burden placed by chronic diseases on health care resources.

The Healthy Living Symposium is an opportunity to come together in collaboration and partnership to plan a course of action and clearly define the roles of different levels of government, health sector organizations, NGOs, NVOs, Aboriginal Peoples, the private sector, academia, consumer organizations, and ‘regular' Canadians – to find ways to work effectively together toward a shared objective. This is where federal, provincial, and territorial leadership is important.

The challenge is to create a concrete plan over the short-, medium-, and long-term, initially focussing on physical activity and healthy eating – a plan with milestones, timelines and measurable outcomes. It must build on existing grassroots experience and activities, and support existing alliances. The context of regional diversity must help guide the design of community interventions. By working together in partnership, it will be possible to develop and action plan that will help Canadians enjoy a healthier quality of life.

The Honourable Jane Purves, Minister of Health for Nova Scotia

As a Health Minister, the most desirable result this strategy can create is optimal physical health. But the strategy offers an opportunity to go beyond physical health to improve mental and emotional health as well. It is important to understand and acknowledge the complex interplay of factors - issues like childcare, education, and social services all play a role in healthy living.

The goal of the Healthy Living Strategy is to improve the health of all Canadians. Great improvements have been made in many areas of public health and health care provision, but the results of unhealthy living continue to be apparent every day in the health status of the elderly and the strain that preventable illness places on the health care system.

Canadians have already seen positive results from some dedicated efforts to improve lifestyles. These include a reduction in the number of young smokers, thanks to peer education programs like Active Kids/Healthy Kids that promote physical activity and healthy choices for children, and chronic disease prevention strategies.

Healthy Living is a priority in Nova Scotia, and an office of Health Promotion has just recently been established. It focuses on new approaches and will work closely with communities and organizations to enhance existing projects and develop new ones in partnership. At the same time, there is a commitment to alleviating the financial and geographic barriers to healthy living for all children.

Last September F/P/T governments agreed to work together to develop the Healthy Living Strategy. This symposium is an opportunity to share knowledge and expertise to help in that process. Ultimately the strategy will provide an innovative way to support wellness, instead of spending the bulk of health dollars on disease treatment. This will enable Canadians to live longer, happier, and more productive lives.

Scott Broughton and Mary Kardos Burton

Scott Broughton is Assistant Deputy Minister, Population and Public Health Branch, Health Canada, and Co-Chair of the Healthy Living Task Group of the Advisory Committee on Population Health and Health Security (ACPHHS). Mary Kardos Burton is Assistant Deputy Minister, Community Health Division, Ministry of Health and Long Term Care of Ontario, and Co-Chair of the Healthy Living Task Group of the ACPHHS.

Overview

In the current context of puzzling and demanding viral threats like SARS and the West Nile Virus, it is easy to lose sight of the fact that the greatest threats to individual health are related to everyday conditions. The social, physical, and economic environments create risks and challenges to health. However, not everyone experiences risks and opportunities in the same way and vulnerable groups experience significantly worse health than others.

The Healthy Living Symposium brings together representatives of various sectors and jurisdictions that share the unified goal of improving the health of all Canadians. That will necessitate addressing the underlying conditions that create health in a co-operative, collaborative, and integrated manner that promotes reduced duplication, shared knowledge, leveraging of resources, and the design of a common approach that can accommodate regional and population variations.

The Healthy Living Agenda

People's health choices and practices are strongly influenced by the environments in which they live, learn, work, and play. Healthy living requires

• Opportunity and access to health-supporting environments;
• Access to health information and services;
• Awareness, knowledge, and personal skills;
• Positive personal health practices.

Today, public health issues are at the forefront of concern for Canadians. Collectively, it is important to commit to investments in public health and take action on health promotion and healthy living. This will require a change in focus.

Globally, supportive international frameworks (such as the WHO's Global Strategy for the Prevention and Control of Non-communicable Disease) already exist. There is a good empirical base internationally, and the economic burden of chronic disease related to diet and physical inactivity has already been well established.

In Canada, there are many related healthy living strategies in every sector and jurisdiction, but co-ordination and collaboration are needed, as preventable diet and inactivity-related diseases continue to take a toll on human life, health, and productivity. Two of the most important pressing challenges to healthy living that the Healthy Living Strategy will address are the rapid rise in non-communicable diseases and disparities in health status among vulnerable groups.

The Framework

The Strategy Framework is an integrating umbrella under which strategies related by shared overall goals are linked and integrated. It is a starting point for sustained action that provides overall direction for the strategy. The strategy has three underlying guiding principles: integration, partnership and shared responsibility, and best practices.

The biggest barriers to healthy living right now are jurisdictional complexities, cultural and geographic diversity, and resistance to change. The Framework attempts to address these obstacles through the following strategic directions:

• Leadership and policy development;
• Knowledge development and transfer;
• Community development and infrastructure;
• Public information.

The integrated Pan-Canadian Healthy Living Strategy will strive to achieve short-, medium- and long-term health outcomes:

Short Term: Improved collaboration and integration of approaches, better access to health information and health promoting programs, increased knowledge and use of health information.

Medium Term: More Canadians engaging in healthy behaviours, health-promoting community environments, and improved access to health-supporting environments in rural, remote, and Northern communities.

Long Term: Reduction in health disparities, improved health outcomes, reduced human and economic burden of major disease groups, and improved quality of life.

Achieving these outcomes will only be possible through the creation of synergies among government sectors, the private sector, NGOs, researchers, and the Canadian public.

The Engagement Process

A series of dialogues on healthy living have taken place, including four pre-consultation meetings, nine roundtables in Canadian cities, and more than one thousand consultation workbooks. These consultations identified personal and systemic barriers to health, current challenges, and the conditions necessary for successful programs and initiatives.

Aboriginal stakeholders agreed on the need for approaches that are inclusive of mental, emotional, physical, and spiritual dimensions; culturally relevant and inclusive; and flexible enough to meet community needs and priorities.

Although many different perspectives were expressed, some common priorities arose, including overall agreement on the goals, broad outcomes, and strategic directions; the need for partnerships; a strong policy framework; and clear outcomes, targets, and measures.

During the discussions, over one hundred successful initiatives were identified. The next steps must build on work completed, and identify new ways to address gaps and ensure integration.

Ultimately, the symposium is the next step toward building a plan of action that

• Builds on established interest and momentum;
• Confirms the soundness of the framework;
• Moves from the conceptual level to the formulation of actions;
• Solidifies existing connections and networks.

Dr. John Frank, Scientific Director, Institute for Population and Public Health, Canadian Institutes for Health Research

Healthy living is much more than lifestyle choices-a number of issues are fundamental to a healthy living approach. There are determinants of health that change over people's lifetimes, including the biological environment, family, neighbourhoods, communities, nation states, and global influences that conspire to make people ill or well. In addition, determinants such as climate change, technological change, and social and cultural forces act in tandem with individual experiences and lifestyle practices to influence health. All of these elements must be taken into account when shaping healthy living policies.

Health disparities between different income levels, social classes, and ethnic groups must be reduced. To tackle this challenge, health care professionals must identify the causes of poor health. Canada focuses too much on helping the sick and not enough on maintaining health and preventing disease.

The development of a healthy living strategy must include a lifelong component because many lifestyle choices have been set by age 15 or 16, including the frequency of physical activity, food choices, and smoking habits. Even future income levels are influenced by academic achievement and work ethics that are formed during adolescence. “We must acknowledge openly that these decisions are being made by minors. We are too laid back about this. We need to make policies to help these young people.”

Good primary care is essential, but a mixture of strategies must be employed to change people's attitudes, feelings, and habits towards health. For example, a community may have a successful tobacco prevention program in its classrooms, but if the taxes on cigarettes are low (and Ontario has one of the lowest tax rates on tobacco in North America), the whole picture has not been targeted. And finally, healthy living should be seen as a lifelong concept – equally relevant through all the life stages, from pregnancy, to birthing, parenting, breastfeeding, growth and development, playing, learning, working, grand-parenting, and dying.

The discussion focused on integrated approaches to healthy living in each of the four strategic directions. Panellists presented the perspectives of the public and private sectors, NGOs, Aboriginal peoples, and academia.

Dr. Elinor Wilson, Steering Committee Member for the Chronic Disease

Prevention Alliance of Canada

The Chronic Disease Prevention Alliance of Canada (CDPAC) is an umbrella organization in which different groups can meet to share experiences, policy interventions, and programs. The focus is on leadership and team building. CDPAC's vision is to link systems and build upon existing initiatives in a co-ordinated and synergistic way. A broader focus that includes more than just the health sector is needed and an effort must be made to span the boundaries of different groups.

Horizontal and vertical co-ordination of government is needed, as well as the engagement of leaders (in terms of public health and primary care), involvement of the voluntary sector, and identification of the mechanisms for inter-sectoral engagement.

“History will be the driver… Success will be achieved by spanning gaps between sectors. We need to deliver a preventative dose in all communities.”

Madeleine Dion Stout, Cree Speaker involved in Aboriginal health development, and non-government ACPHHS member

The three major health determinants for Aboriginal peoples are healthy eating, healthy weight, and appropriate physical activity. Health disparities for vulnerable groups such as Aboriginal peoples are profound. The Pan-Canadian Strategy for Healthy Living will hopefully address this issue.

A re-integrated and re-aligned approach is needed to combine Western medicine practices with traditional medicine. The problems in Aboriginal communities are too large and too complex for each community to solve on its own. Economic and social reforms will bring the most significant changes.

Strategies specific to Aboriginal peoples are needed to embrace a population-based approach to healthy living that reflects their unique culture. In addition to formation of policies and identifying what the government can do for Aboriginal peoples, discussion should explore what Aboriginal peoples can do for themselves.

The Honourable Chester Gillan, Minister of Education and Environment for Prince Edward Island

The school system is an excellent conduit for the Healthy Living Strategy. Three strategies for successful school-based programs could be adopted. Firstly, regarding integration, focus on executing programs in permanent settings. Use community sites, such as schools, which will continue to function even if funding dries up. Schools are also great places to reach children and parents, both of whom are primary targets for healthy living strategies. Secondly, think globally while acting locally. For example, stress the need to plan for overall health while dealing with issues such as healthy body weights. Thirdly, for those who are operating within the school system, focus on the whole school—school, home, and community.

Prince Edward Island recently launched the first provincial healthy living strategy, based on healthy eating, exercise, and prevention of tobacco use. Later this year, an “active healthy school/community initiative” is planned, with a steering committee comprised of staff, students, parents, community members, and NGOs. Programs will be tailored to each community. Chief components of the initiative will be physical, environmental, emotional, and social well-being, healthy eating, reduction in tobacco use, and student leadership.

Cathy Loblaw, President and Chief Operating Officer (COO), Concerned Children's Advertisers

An integrated approach to healthy living is essential. Integration is all about working together, benefiting from each other's expertise, and sharing social responsibility. “No single person has created this issue and no one can solve it on their own.”

All those involved in the world of children—parents, educators, government, NGOs, and others—have a shared responsibility and a common goal of the well-being of Canadian children, although they may have different approaches and messages.

From the point of view of Concerned Children's Advertisers, it is important to review the media system and filter it through the eyes of healthy living. We live in a global media world and cannot always control what Canadian children see and hear, but if children have been taught media literacy and critical thinking skills, they can interpret what they see in a responsible manner.

Dr. Andrew Pipe, Chair, Health Strategy and Physical Activity Co-ordinating Committee of the College of Family Physicians of Canada

Academia plays an important role in the quality of education and academic research, and has much to contribute to the four strategic directions, namely leadership and policy development, knowledge development and transfer, community development and infrastructure, and public information. However, the perspective is often traditional and skewed. One reason is the issue of funding allocation and distribution. For example, there is a tremendous amount of money poured into researching the physiological causes of CVD, yet one of the primary factors leading to CVD is lack of physical activity. This type of external influence on health is not being satisfactorily addressed. “One hears that spending should be given to specific research, while all around us, there is a public health disaster going on that started as a whisper and has become a shout.”

Health professionals rely on academic institutions to provide fundamental epidemiological evidence in order to take action on public health challenges. Yet earlier in this session, comments were made that many of these types of studies have been under-funded or abandoned. There is a call for more relevance and for academics to demonstrate how their findings can be useful to public policy makers. Good policy starts with the facts. One of the ironies is that funding for the academic community often comes from a political body, creating some hesitancy within academia to advocate for public policy changes. A greater degree of collaboration, co- operation, and co-ordination between academic institutions, government bodies, and the private sector would be beneficial.

The Honourable Tony Clement, Minister of Health and Long-Term Care for Ontario

The importance of public health cannot be over-stressed; it is a day-in and day-out concern.

Public health, from its beginnings early last century, has always been tied to promotion of healthy living through physical activity, good hygiene, and healthy eating. In fact, public health was initially a grass roots movement designed to “save” people from less than ideal circumstances and environments.

In September 2002, the Ontario Ministry of Health and Long-Term Care and all other F/P/T Ministers, agreed on a number of short-, mid-, and long-term healthy living strategies with respect to nutrition and healthy activity. The Healthy Living Symposium is a milestone in the process of building a national Healthy Living Strategy for Canada. It aims to make a lasting impact in terms of improving overall health outcomes and reducing health disparities between population groups.

One of the challenges is to convince Canadians to adopt healthy behaviours; however, lasting change requires partnerships and collaboration to create environments where the healthy choices are the easier choices. For instance, the menus offered in school cafeterias influence what our children eat; the prices of healthy foods influence whether we buy them; the availability of bike paths and trails influence whether we use them.

The four strategic directions that form the basis of the Healthy Living Symposium are also the basis of the Healthy Living Strategy Framework. Collaboration between all stakeholders is needed. An effective strategy requires participation of all sectors, including education, food and agriculture, social and financial sectors, fitness and recreation, and others.

Symposium attendees and the groups they represent have the opportunity to develop recommendations for short-, mid-, and long-term strategies that will lead to healthy living for all Canadians.

The Honourable Paul De Villers, Secretary of State (Amateur Sport)

The Government of Canada is fully committed to ensuring that Canadians can maximize the health benefits of sport and physical activity. Sport and physical activity are important vehicles for promoting health and preventing disease, and play an important role in the Healthy Living Strategy, the success of which depends on partnerships like the one between Amateur Sport and Health Canada.

To reflect the Government's commitment to healthy living, the position of Secretary of State (Amateur Sport) will be changed to Secretary of State for Sport and Physical Activity. In addition, a new bill on the promotion of physical activity in sport is currently before the House. This new bill has four equal pillars: participation, excellence, capacity, and the interaction between sports and physical activity.

With these factors in mind, Sport Canada launched an unprecedented extensive cross-country consultation to identify ways to improve sport in Canada. These consultations led to the development of the Canadian Sport Policy, which has been endorsed by every provincial and territorial government. This policy reflects a new approach to co-operative leadership and collaboration between governments and sporting organizations. Specifically, it provides vision and direction for sport and commits all governments to set targets for increased participation and enhanced partnerships.

In March, the Act to Promote Physical Activity and Sport received Royal Assent. In its preamble, the law reinforces the Government's commitment to sport and physical activity and acknowledges those activities should be viewed as investments in the well-being of Canadians. The law also encourages increased participation of all Canadians, regardless of gender, ethnicity, age, or ability.

The Sport Policy allows for the funding of initiatives that promote participation and will expand the range of potential funding recipients to include provincial and territorial governments and other non-traditional partners. Rather than create new programs, the policy taps into existing ones to leverage funds and avoid squabbles over jurisdictional issues surrounding education and fitness.

The Ministers Responsible for Sport, Recreation and Fitness have expressed their support for the Healthy Living Strategy and have set a national target to increase levels of physical activity by 10 per cent in every province by 2010. The Ministers also agreed to aim programs at children and conduct research to establish benchmarks and reliable baseline data to help measure success.

Dr. David Katz, Associate Clinical Professor of Epidemiology and Public Health and Medicine, and Director of Medical Studies in Public Health, Yale University, School of Medicine

The impact of chronic diseases is much scarier than infectious diseases like SARS and West Nile. Chronic diseases exact an incredible toll on the population and have a monumental impact on public health. Research indicates that more than half of deaths are premature and attributable to modifiable factors. The combination of poor dietary choices and physical inactivity will soon be the number one cause of preventable death in the U.S. Everything that can be done pharmacologically is expelled to the margins if lifestyle issues are not addressed.

In Canada, the literature indicates that the prevalence of obesity is rising steadily in both adults and children, and there are unacceptable ethnic and cultural disparities. Statistical data indicates that between 1985 and the present, in both the U.S. and Canada, the prevalence of obesity has risen in every region. Nearly half of the Canadian population is overweight. And, there is a direct, scientifically established linear association between Body Mass Index (BMI) and all causes of mortality. It is an epidemic that is staggeringly out of control, and far beyond the realm of any other public health consideration. It will be expensive to confront and address the problem of obesity, but if that cost is weighed against the cost of treating problems arising from obesity, there are clear health care savings.

Obesity is so profoundly important to public health because of its link to diabetes. The prevalence of diabetes is rising in tandem with obesity. At the same time, Type II diabetes is linked with coronary disease and is increasingly becoming a health problem for children. It is only a matter of time before the associated heart disease begins to develop in younger overweight populations as well.

What a population eats affects mental health, its immune system, healthy bones and most of the other major systems in the body, but the focus cannot be on diet alone. Good nutrition and physical activity work together to promote better health.

The basic cause of obesity is an imbalance between calories taken in and calories expended. While it's true that there can be marked variations among individuals' ability to process calories due to basal metabolism, thermogenesis and physical activity, on a population level it has been clearly established that caloric intake/output imbalance is the principal cause of obesity.

Several factors are contributing to the inability to balance calories:

• The diameter of the average dinner plate has increased 30 per cent, encouraging larger portions;
• Physical activities and physical exertion through manual labour have decreased;
• Labour saving devices like cars have replaced physical activity;
• North Americans do not need to work as hard to obtain food as their ancestors.

It is important to develop sustainable approaches. The best way is to create straightforward messages that can be packaged and are easily understood by children. Healthier diets require

• Reduced trans-fats, saturated fats, and sodium;
• More fruits, vegetables, and whole grains;
• Fewer processed starches;
• Increased physical activity;
• Reduced portion sizes.

It is also important to bear in mind that humans are profoundly influenced by the environment in which they evolved—an environment that required a great deal of strenuous physical activity, where food was relatively scarce and difficult to procure. Public health specialists trying to address the obesity epidemic could benefit from reading the work of anthropologists. The healthiest diet for humans is the one that anthropologists report our ancestors ate.

Researchers already possess all the information needed about healthy eating. The challenge is to re-engineer the modern environment by adopting policies that promote activity and by empowering individuals to resist the toxicity of the modern food environment. That will require teaching people what a healthy diet is, motivating them, and promoting hands-on skills and strategies.

Public Information Working Group

Rapporteur: Gilles Lépine, Sport étudiant Québec

The group identified six key results:

• There is an awareness and understanding of nutrition, activity, and their relationship to chronic disease;
• Canadians are engaged in making healthy choices in a healthy environment;
• Healthy living is a cultural norm in Canada;
• More Canadian children and youth adopt healthy eating and physical activity habits;
• Accountability for healthy living issues is shared by public and private sectors;
• Long-term funding and resources are needed.

The promotion of awareness and understanding depends on forging meaningful and appropriate partnerships among players that are committed to the same healthy living goals. Research must be bridged to practice by ensuring that qualified practitioners are empowered to take action.

Physical education and health education should be mandatory for students from kindergarten to Grade 12. The existing Physical Activity Guide should be promoted, and individuals who can most effectively deliver messages should be identified. “High calibre” figures from sports and popular culture should be used to promote awareness and model their understanding of healthy living.

In order to engage Canadians in making healthy choices, stakeholders should be made aware of the 10 per cent target set by Ministers. “Setting targets is a good exercise, but their usefulness is limited if the public doesn't know about them.”

The direct link between social policies, poverty, and fitness, should not be underestimated.

Enabling people to make healthy choices requires the development of a national strategy to reduce poverty. In addition, an inter-ministerial communication plan should be implemented. To encourage the creation of healthy environments, “we need to press the alarm bell” and communicate a sense of urgency and educate the public about the multiple determinants of health. For healthy living to become a cultural norm, targeted, complementary messages must be developed, based on straightforward, and easily communicated, unambiguous messages. It is also important to learn from other environments and past experiences, and align initiatives with current points of cultural pride.

If more children and youth are to adopt healthy eating and physical activity habits, a multisectoral national strategy needs to be developed that extends beyond schools to the home and community, policies to increase physical education and health education in schools, messaging programs for pre-school children, and a national survey of health choice habits.

Effective, responsive, responsible mechanisms must be created to monitor and report on the actions of industry and government around the health status of Canadians. This must be a joint public/private sector responsibility that has built-in evaluation and assessment mechanisms.

Finally, creating cultural support for healthy life choices will ensure sustained political commitment and funding, and convince Canadians that healthy living is a worthwhile investment in the future.

Toward Integrated Strategies for Aboriginal Peoples

Rapporteur: Dr. Jeff Reading, Scientific Director, CIHR Institute of Aboriginal Peoples' Health

It is important to make a strong statement about the crisis in Aboriginal health, because no one seems to be paying attention and health determinants are not working.

Aboriginal peoples are the poorest of Canada's poor and their health outcomes are growing worse. The prevalence of Type II Diabetes indicates the extent of the crisis, he said. In the general population ten per cent of adults between the ages of 55 and 65 have diabetes. In the Aboriginal population its prevalence is six-fold. Not only is the incidence higher, there are earlier onsets and particularly alarming trends among the extremely young.

It is also important to acknowledge the hidden causes of disease and poor health in Aboriginal communities and to acknowledge that almost everyone is at extremely high risk of associated morbidity and mortality.

Any approach to Aboriginal health promotion must be based on the following set of principles:

• Dedicated needs and risk-based funding should be available to First Nations, Inuit, and Métis on and off reserve;
• Holistic approaches, encompassing spiritual elements, should be used;
• Actions must be based on culture and tradition and be flexible to address community needs;
• Programs must be community owned and directed;
• F/P/T partners must be accountable to Aboriginal peoples for funding;
• The needs of people with disabilities must be addressed.

Aboriginal programs cannot just be about exercise and obesity—they must promote mental wellness, adequate income, and access to safe, affordable foods and water. Programs should encourage communities to build healthier communities that support wellness and be funded based on needs and risks. They must balance physical, emotional, and spiritual components and provide access to culturally relevant services and lifestyles, while promoting changes in behaviour. They should also facilitate improved access to traditional foods and better understanding of the contributors to good health.

The group identified the following immediate actions that should be taken:

• Acknowledge that Aboriginal people suffer a large and growing burden of chronic disease and that this has “downstream” costs and effects for F/P/T governments;
• Recognize that solutions lie only partially within the nutrition and physical activity strategies;
• Recognize that a holistic approach emphasizing mental wellness is needed.

Short-term actions should focus on effective delivery of services. It is also important to note that “many health determinants are called, but few are chosen.”

In the medium term, it's imperative to recognize the need to solve the poverty issue first and to develop strategies that impact the determinants of health. It should also be acknowledged that the symposium does not constitute Aboriginal consultation. An appropriate National Strategy on Aboriginal Health Wellbeing must be developed, but only after more inclusive and exhaustive consultation has occurred.

Community Development and Infrastructure

Rapporteur: Judy Cutler, Congress of National Seniors Organizations

The group identified the following five key results:

• Development of community leadership;
• Sustained investment;
• Collaboration and partnerships;
• Equitable access and opportunity;
• Endorsement of all four initiatives from the roundtable summary.

The most important underlying issue is the need for a cultural shift from a bio-medical model to a disease prevention/health promotion model.

In order to develop community leadership, communities must actively lead and have a sense of ownership in the change process. A national steering committee should be established to develop and sustain local initiatives. There must be investment in community leadership development, with a focus on enlisting health professionals, teachers, and others as “Healthy Living Champions.”

Sustained investment in existing initiatives is important. Funding needs to be comprehensive, include all sectors, and be based on an integrated funding formula. Moreover, it is important to identify current strategies, best practices, policies, and curricula on healthy living and integrate them, instead of constantly “reinventing the wheel.”

To achieve working collaborations and partnerships, “we must stop working in silos” and start working together. It is also important to maximize existing community resources and encourage public-private partnerships to build healthy living facilities. It is critical to ensure that all practitioners promote healthy living.

Equitable access and opportunity require that all levels and departments of government view programs through a healthy living lens. National standards to make healthy living a right for all Canadians—regardless of age, socio-economic status or geography—must be developed. Services must be accessible in all settings and all communities. It is counterproductive to pit one sector against the other over funding and resource allocation or program promotion. Food security should be promoted through local agriculture, home, and community gardens and community kitchens.

Other key results included national healthy living policies and standards, a commitment to healthy school policy, supportive environments, and awareness of healthy living priorities. “The collaboration begins here, with all of us coming together to have input in terms of who should do what, but without clearly delineating roles and responsibilities, nothing is going to happen.”

Leadership and Policy Development

Rapporteur: Laurie Curry, Food and Consumer Products Manufacturers of Canada

The group identified seven key results:

• Policy coherence using a healthy living lens;
• New funding for the Healthy Living Strategy;
• An enhanced and more cohesive public health system;
• Improved healthy living practices in childhood and adolescence;
• Reduced social and economic inequities;
• Partnerships;
• Education.

To ensure coherent policy through a healthy living lens, it is important to develop “lens” criteria based on broad determinants of health and a review of existing policies. The group struggled with how to build appropriate infrastructure to support key functions. It agreed that programs should start now and not be delayed pending infrastructure design, but tools do need to be designed to provide direction and guidance for health policy.

An enhanced and more cohesive public health system must include public health functions in the Canada Health Act. It must also enhance public health capacity at all levels. Establishing a Health Council and a Commissioner of Health (similar to the U.S. Surgeon General), and a Centre for Disease Control North would also promote a more cohesive system.

Long-term core funding must be secured at all levels of government, and should be targeted at inter-sectoral and collaborative initiatives. There should be a moratorium on any funding cuts without comprehensive program evaluation. It is necessary to provide information to a broad range of diverse groups, therefore investment in appropriate and comprehensive information systems is required.

Knowledge Development and Transfer

Rapporteur: Cora Lynn Craig, Canadian Fitness and Lifestyle Research Institute

The group identified a number of common themes that crossed all areas of consideration. A foundation of the hierarchy of risks should be used, like the McKinley Framework to understand how lifestyle, poverty, obesity, social structure, and environmental issues affect chronic disease and overall health.

The group identified three key results:

• Bridge the gap between researchers, policy makers, practitioners, and end users;
• Improve data and surveillance systems;
• Establish a broad-based infrastructure for knowledge exchange.

In order to bridge the gap between research and policy, end users must be acknowledged as being an integral to the whole process. It is important to strengthen health promotion issues by learning from those who already have the education, so that current experience can be leveraged. A communication strategy for knowledge transfer should be developed, best practices in knowledge translation established, and pilot projects in knowledge dissemination instituted.

Improved data and surveillance systems require a comprehensive approach that spans the entire framework and includes social and environmental determinants as key indicators. It is necessary to identify gaps, especially for children and young adolescents. Existing data sharing and collecting mechanisms should be explored to establish best practices. This process must be sensitive when gathering data about Aboriginal people. Finally, commitment to long-term follow-up and the development of legislated shared-funding agreements is critical.

Public Information Working Group

Rapporteur: Gilles Lépine, Sport étudiant Québec

The group expressed concern about the relative weight of the various recommendations in the process. Actions were given equal weight regardless of whether they were supported by the broader group, or only by individuals.

There were also concerns raised about follow-up: who is going to carry it out, who will be the filter, and how will the final recommendations be drawn up?

Healthy eating and physical activity need to be presented in a more closely unified fashion.

Clear, quantifiable goals and a solid understanding of the relationships between relevant factors are required.

It will be necessary to have an overarching framework for approaching the subject if programs and policies are going to be truly integrated. Either the Canada Health Act must be changed to include public health, or a new Public Health Act must be created. Social marketing aspects require coherent approaches to communication, public information, and how to ensure the greatest impact on target audiences.

Accountability is also important. It must be clear who, exactly, is responsible for moving the process forward. There should be clear roles for government and competent, committed, welltrained leadership to co-ordinate actions on the ground.

Toward Integrated Strategies for Aboriginal Peoples

Rapporteur: Madeleine Dion Stout, Health Disparities Working Group

The Aboriginal group supported government-to-government discussions through an F/P/TAboriginal process aimed at setting up an advisory committee to the F/P/T Ministers of Health.

The group supported a request for distinct and adequate funding to permit appropriate consultation with First Nations, Inuit, and Métis. It also asserted the right of First Nations, Métis, and Inuit to control their own health systems.

The Aboriginal group recognized the input of kindred spirits who acknowledge problems with this process, and recognized the good work they produced during the workshop “carousel” and their valuable insights and inputs.

Community Development and Infrastructure

Rapporteur: Judy Cutler, Congress of National Seniors Organizations

Flexible, sustainable long-term funding to promote community development and create appropriate infrastructure is critical.

Local leadership is necessary, in conjunction with external support and expertise. More and better social marketing for health promotion is required. All programs and initiatives should be easy to access and understand and be as user-friendly as possible. Special efforts must be made to make funding requests less intimidating to create a more inclusive atmosphere for community and voluntary program participation.

The F/P/T process excludes many stakeholders and often fails to reflect the experiences of smaller communities. Cultural distinctiveness and diversity means that “mainstream” solutions and “one size fits all” approaches won't work for everyone.

Healthy living cannot exist in isolation; mental and spiritual wellness must be addressed first. This applies to all communities, not just Aboriginal ones.

There have been some remarkable successes like the Kamloops Food Security Program, which reduced food bank use by 30 per cent, with an initial investment of $15,000. The Vitality program was a great success and should be revitalized.

The best way to move the agenda forward is to focus on building community initiatives. While communities have wisdom, compassion, and motivation, they lack adequate funding and resources.

The strategy must be sensitive to local and regional realities.

Rhetoric must be grounded in reality. It is important to get the key results right and not to rush into the strategy. At the same time, healthy living is crucial and must be advanced as quickly as possible. It is important to work fast, but well.

Leadership and Policy Development

Rapporteur: Laurie Curry, Food and Consumer Products Manufacturers of Canada

The important areas discussed were funding, policy coherence, partnerships, education, and socio-economic factors. The most consistent theme was the importance of creating culture shifts. Participants noted that programs, actions, or initiatives already exist, which underscores the need for more and better information sharing, and good research and assessment of existing policies and programs.

Accountability for healthy living belongs to all, but must be grounded in a cohesive, comprehensive framework with clearly delineated roles and responsibilities. It is important to note that these workshops have produced a collection of information, not consensus.

Canadians expect everyone to work together towards the Healthy Living Strategy. This includes governments, F/P/T ministers, regional, and municipal governments, the public and private sectors, and inter-sectoral program deliverers.

Goals need to be focused and framed with good accountability mechanisms that permit ongoing consultation.

Education initiatives should focus on children from kindergarten to Grade 12. Education policies should be developed at the federal level, but possess good provincial and territorial synergies.

They should encourage the involvement of communities and the sport and recreation sectors.

Most importantly, programs and education must be fun.

Economic and social issues should be approached as issues of “equity” not “equality.” Healthy living requires safe environments and a paradigm shift from poverty alleviation to poverty reduction. Healthy living should be within every Canadian's reach.

Knowledge Development and Transfer

Rapporteur: Cora Lynn Craig, Canadian Fitness and Lifestyle Research Institute

It is clear that Canada is in a crisis situation that must be dealt with now. The key steps that need to be taken to achieve key results are known. Now it's a matter of putting politicians' “feet to the fire.”

The group is therefore making four specific recommendations that should be enacted within seven days:

1. Convene a meeting with Health Canada and provincial and territorial partners to assemble, date, and inventory existing surveys and research. Then using existing surveys regarding health data and behaviour, build a pan-Canadian system, sensitive to the needs of specific groups.
2. Identify specific recommendations and bring them forward to the First Ministers' conference.
3. Appoint a Health Commissioner (not an illness commissioner), modelled along the lines of the Auditor General to hold various departments and individuals responsible for their actions and commitments.
4. Create specific, measurable actions and a comprehensive measurable action plan that identifies key leaders who can act as content experts and represent vulnerable and under-serviced groups.

Mary Kardos Burton

High expectations were set for this symposium. Participants were asked to develop short-, medium-, and long-term actions and strategies. The response has been enthusiastic, intelligent, spirited, and passionate.

All sectors and all regions of the country have been heard. At every opportunity, efforts have been made to achieve multi-sectoral approaches.

Some of the messages expressed at the symposium included:

• This should not be the end of the opportunity for input.
• Target populations, programming, information and data, funding needs, and governance models must continue to be identified.
• Particular populations must be addressed because they have special needs or face significant challenges. These are identified by gender, developmental stage, and vulnerability.
• There must be a focus on children, but seniors and the rest of the population must not be ignored.
• The needs of people living in poverty, people with disabilities, and Aboriginal populations must be addressed.
• The Aboriginal population is at a different starting point and needs a different process.
• Programs should support what's working, and programming decisions need to be longterm and linked to evaluation.
• Baseline date must be collected, along with integrated surveillance data that goes beyond disease reporting.
• Goals must be linked to the ability to measure outcomes.
• The messages need to be better communicated.
• It is important to have all available resources contribute to actions, not just federal funds, but commitments from the F/P/T and municipal governments, NGOs and the private sector.
• Better information on what's available must be collected.
• The best form of governance is community leadership, but roles still need to be determined.
• All Canadians are accountable for healthy living.
• There is a need for mechanisms to bring people together among sectors and jurisdictions.
• The creation of a Health Council, Health Commissioner, and CDC-North, have been recommended, but in all cases they need to move beyond simple health issues to the broader spectrum of relevant factors.

There is commitment to moving forward. The messages from this symposium have been articulated loudly and clearly. The provinces will commit to improve communication to whoever needs to hear this message, so that everyone can move forward together.

Scott Broughton

Participants at the symposium share a common desire to make healthy living a reality for Canadians.

It is clear that these consultation processes have created expectations. An action plan will be taken forward to the Conference of Deputy Ministers of Health this summer, and the Conference of Ministers of Health this fall.

The reports to those conferences will contain the following elements:

• The Framework should be accepted and approved as the mechanism for moving forward.
• There is potential to create a forum for inter-disciplinary, inter-jurisdictional, intersectoral actions and consultations beyond the traditional F/P/T model.
• An enhanced surveillance agenda is necessary to acquire baseline data that can set and assess measurable goals and outcomes.
• The government needs to commit to funding, and proposals for how to resource this initiative must be included.
• Signals from events on communicable disease and clear messages about chronic disease scream that this is the time for action—a real focal point for public health.

There are also several mechanisms for feedback, follow-up, and ongoing input to this process:

• Reports will be available, containing specific details of the roundtables and symposium.
• The Government will work with F/P/T colleagues and Aboriginal communities to develop complementary, separate, or parallel processes to address Aboriginal needs.
• Since the strategy/game plan is still under construction, participants need to continue to provide feedback, including writing in, creating a Web site, or holding another smaller meeting.
• Representatives from Health Canada met with Sport, Recreation and Fitness Deputy Ministers from the provinces to work on a subset of programs that would mesh well with healthy living.
• There has been a commitment of Minister Gillan from P.E.I. to help move this process forward.
• The ACPHHS will be reporting to the Deputy Ministers in July.
• Between the Deputy Ministers and Ministers' meeting, there might be an opportunity for another meeting.
• When the Ministers meet in the fall, there will be an official communiqué; all participants will receive a copy.

By September or October, there should be a clearer picture of how the process will move forward.

Final Comments

Several participants expressed the need for stronger connections between the fundamental determinants of health and stronger commitments to population health. They cautioned against moving directly into a lifestyle approach without addressing underlying issues. Participants stressed the importance of being bold and not shying away from the importance of major determinants, like poverty, lack of housing, and unhealthy neighbourhoods. They also reiterated the inappropriateness of focusing healthy living for Aboriginal people on obesity and physical activity, when there are such significant fundamental issues that must be addressed first.