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Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
Food Health and Well Being in British Columbia
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Food Health and Well Being in British Columbia

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Food Health and Well Being in British Columbia

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  • 1. Copies of this report are available from:Office of the Provincial Health OfficerBC Ministry of Health4th Floor, 1515 Blanshard StreetVictoria, BC V8W 3C8Telephone: (250) 952-1330Facsimile: (250) 952-1362and electronically (in a .pdf file) from:http://www.healthservices.gov.bc.ca/pho/Suggested citation:British Columbia. Provincial Health Officer. (2006).Food, Health and Well-Being in British Columbia.Provincial Health Officer’s Annual Report 2005.Victoria, BCMinistry of Health.National Library of Canada Cataloguing in Publication DataMain entry under title:Provincial Health Officer’s annual report. – 1992–AnnualAt head of title: A report on the health of British Columbians.Some issues also have a distinctive title.None issued for 1993.ISSN 1195-308X = Provincial Health Officer’s annual report1. Health status indicators - British Columbia -Periodicals. 2. Public health - British Columbia –Statistics - Periodicals. I. British Columbia. Provincial Health Officer. II. Title: Report onthe health of British Columbians. RA407.5.C3B74 614.4’2711 C93-092297-2
  • 2. Food, Health and Well-Being in British ColumbiaProvincial Health Officer’s Annual Report 2005 Office of the Provincial Health Officer
  • 3. Ministry of HealthVictoria, BCSeptember 26, 2006The Honourable George AbbottMinister of HealthSir:I have the honour of submitting the Provincial Health Officer’s Annual Report for 2005.P.R.W. Kendall, MBBS, MSc, FRCPCProvincial Health Officer
  • 4. Table of ContentsAcknowledgements.......................................................................................................................................................................... xiiiHighlights .........................................................................................................................................................................................xvii Nutrition and Health .................................................................................................................................................................xvii Food Insecurity and Access to Nutritious Food .....................................................................................................................xviii Safety of the Food Supply......................................................................................................................................................... xix Food Security and Healthy Eating in the Aboriginal Population ........................................................................................... xix Working Towards Change ......................................................................................................................................................... xx Contents of this Report ............................................................................................................................................................. xxChapter 1: Nutrition and Health ........................................................................................................................................................ 1Why Do Food and Diet Matter? .......................................................................................................................................................... 1What is a Healthy Diet? ........................................................................................................................................................................ 1 Nutritional Confusion and Temptation ...................................................................................................................................... 1 Role of Food Guides .................................................................................................................................................................... 3 Canada’s Food Guide to Healthy Eating .................................................................................................................................... 3 The BC Nutrition Survey.............................................................................................................................................................. 4 Understanding the Determinants of Healthy Eating ................................................................................................................. 5Healthy Components: The Change in Understanding Fats, Proteins, and Carbohydrates ............................................................ 8 Fats ................................................................................................................................................................................................ 8 Carbohydrates .............................................................................................................................................................................. 9 Proteins ....................................................................................................................................................................................... 10 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia i
  • 5. Table of ContentsMicronutrients: Vitamins, Minerals, and Phytochemicals ............................................................................................................... 10Food Fortification to Improve Health .............................................................................................................................................. 12Dietary Needs at Specific Life Stages ................................................................................................................................................ 13 Pregnancy and Breastfeeding .................................................................................................................................................... 13 Low Birth Weight Rates ............................................................................................................................................................. 15 Infancy and the Toddler Years: The Need for Extended Breastfeeding................................................................................. 16 Dietary Needs During Senior Years .......................................................................................................................................... 17Food Allergies .................................................................................................................................................................................... 17Physical Activity .................................................................................................................................................................................. 19Summary............................................................................................................................................................................................. 20Chapter 2: The Agriculture and Food Processing Sector in British Columbia ............................................................................... 23Protecting BC Farmland and Supporting Farmers .......................................................................................................................... 24Food Imports: Pros and Cons ........................................................................................................................................................... 25 Food Miles .................................................................................................................................................................................. 25Summary............................................................................................................................................................................................. 26Chapter 3: Impact of Unhealthy Eating ........................................................................................................................................... 27Diet and Chronic Disease .................................................................................................................................................................. 27Cancer ................................................................................................................................................................................................. 29 High-Fat Diets and Cancer ........................................................................................................................................................ 29 Obesity and Cancer .................................................................................................................................................................... 30 Childhood Diet and The Risk of Cancer................................................................................................................................... 30Cardiovascular Disease ...................................................................................................................................................................... 30Diabetes .............................................................................................................................................................................................. 31 Type 1 Diabetes.......................................................................................................................................................................... 31 Type 2 Diabetes.......................................................................................................................................................................... 31 Gestational Diabetes .................................................................................................................................................................. 32Overweight and Obesity .................................................................................................................................................................... 33 What is Body Fat? ....................................................................................................................................................................... 33ii Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 6. Table of Contents Understanding Body Mass Index .............................................................................................................................................. 33 Body Mass Index Limitations..................................................................................................................................................... 34 Rising Obesity Rates in BC and Canada .................................................................................................................................... 36 Overweight and Obesity in Adults ............................................................................................................................................ 36 Overweight and Obesity in Children and Adolescents ............................................................................................................ 38 Overweight/Obesity, Inactivity, Smoking and their Associated Increased Health Care Costs in the BC Population .................................................................................................................................. 38The Obesogenic Environment .......................................................................................................................................................... 40 Changing Patterns of Food Consumption ................................................................................................................................ 41 Changing Patterns of Physical Activity ...................................................................................................................................... 43Eating Disorders................................................................................................................................................................................. 44 Anorexia and Bulimia ................................................................................................................................................................. 44 Obsessive Dieting....................................................................................................................................................................... 45 Fostering Healthy Relationships to Food ................................................................................................................................. 45Summary............................................................................................................................................................................................. 45Chapter 4: Food Security Among British Columbians..................................................................................................................... 47What is Food Security?....................................................................................................................................................................... 47 Food Insecurity in British Columbia ......................................................................................................................................... 49 Low-Income Cut-Offs ................................................................................................................................................................. 49The Impact of Food Insecurity on Vulnerable Populations ............................................................................................................ 50 Children ...................................................................................................................................................................................... 50 Seniors ........................................................................................................................................................................................ 52 Pregnant Women ....................................................................................................................................................................... 52How Much Does Healthy Food Cost?............................................................................................................................................... 52The Link Between Hungry Households and Poor Health .............................................................................................................. 55Food Distribution, Storage, and Preparation: Limited Choices for Low-Income People ............................................................. 56Measures to Reduce the Impact of Poverty ..................................................................................................................................... 57 Federal and Provincial Programs............................................................................................................................................... 57 Food Security: Public Health Core Function ........................................................................................................................... 58 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia iii
  • 7. Table of Contents Community Measures ................................................................................................................................................................ 59 Food Banks ................................................................................................................................................................................. 59 Capacity-Building Community Programs ................................................................................................................................. 59Food Policy Councils: Coordinating Efforts and Resources ........................................................................................................... 62 International Action ................................................................................................................................................................... 63Summary............................................................................................................................................................................................. 64Chapter 5: The Safety and Sustainability of Food and the Food Supply ...................................................................................... 65Foodborne Diseases .......................................................................................................................................................................... 65Risk from Food Pathogens in BC ...................................................................................................................................................... 66 Norovirus .................................................................................................................................................................................... 66 Bacillus cereus ............................................................................................................................................................................ 66 Enterohemorrhagic E.coli ......................................................................................................................................................... 67 Staphylococcus aureus .............................................................................................................................................................. 68 Salmonella .................................................................................................................................................................................. 69 Campylobacter ........................................................................................................................................................................... 69 Listeria monocytogenes ............................................................................................................................................................. 70 Clostridium botulinum .............................................................................................................................................................. 70 Clostridium perfringens............................................................................................................................................................. 70 Yersinia ....................................................................................................................................................................................... 71 Toxoplasma gondi...................................................................................................................................................................... 71 Marine-based Food Poisoning ................................................................................................................................................... 71 Vibrio parahaemolyticus ............................................................................................................................................................ 72Public Health Issues in Food Farming .............................................................................................................................................. 72 Changes in Farming ................................................................................................................................................................... 73 Intensive Livestock Operations ................................................................................................................................................. 73 Manure ........................................................................................................................................................................................ 74 Antibiotics ................................................................................................................................................................................... 76Growth-promoting Hormones in Beef ............................................................................................................................................. 78 Bovine Spongiform Encephalopathy – Mad Cow Disease ...................................................................................................... 79iv Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 8. Table of Contents Bovine-Spongiform Encephalopathy and Variant Creutzfeldt-Jacob Disease ........................................................................ 79 Bovine Spongiform Encephalopathy Record in Canada and Northwestern United States .................................................. 80Genetically Modified Organisms ....................................................................................................................................................... 81 Labelling of Genetically Modified Foods .................................................................................................................................. 83 The Way Forward on Genetically Modified Organisms ........................................................................................................... 83Public Health Issues in Seafood and Aquaculture ........................................................................................................................... 83 Industrial Contaminants ............................................................................................................................................................ 84Steps to Ensure the Safety of the Food Supply ............................................................................................................................... 85Summary ............................................................................................................................................................................................ 86Chapter 6: Food and the Aboriginal Population ............................................................................................................................. 89Terminology ....................................................................................................................................................................................... 89Availability of Data ............................................................................................................................................................................. 89Health Outcomes in the Aboriginal Population............................................................................................................................... 90Obesity and Diabetes in the Aboriginal Population ........................................................................................................................ 90Traditional Foods ............................................................................................................................................................................... 91 Change in Dietary Traditions .................................................................................................................................................... 92Health Significance of Dietary Change ............................................................................................................................................. 93Socio-Economic Status and Access to Food .................................................................................................................................... 94Food Safety and the Aboriginal Population ..................................................................................................................................... 95 Red Tides .................................................................................................................................................................................... 95 Industrial Pollutants ................................................................................................................................................................... 96 Botulism...................................................................................................................................................................................... 96 Micro-organisms in Game ......................................................................................................................................................... 97Impact of Chronic Disease ................................................................................................................................................................ 97Peri-natal Health Challenges ........................................................................................................................................................... 100 Infant Mortality Rates ............................................................................................................................................................... 100 Breastfeeding Rates.................................................................................................................................................................. 100 Infant Anemia ........................................................................................................................................................................... 100 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia v
  • 9. Table of ContentsChild and Youth Health Challenges ............................................................................................................................................... 101Addressing Food in the Aboriginal Context ................................................................................................................................... 101Summary........................................................................................................................................................................................... 101Chapter 7: Recommendations ........................................................................................................................................................ 103What We Know ................................................................................................................................................................................. 104What We Need to Know .................................................................................................................................................................. 104Steps to Make BC More Food Independent .................................................................................................................................. 104 What can individuals do? ........................................................................................................................................................ 104 What can communities do? ..................................................................................................................................................... 104 What can governments do? .................................................................................................................................................... 105Obesogenic Environment................................................................................................................................................................ 105 Health-Promoting School Environment ................................................................................................................................. 105 Public Education ...................................................................................................................................................................... 106 Monitoring and Regulation of the Marketing Approaches of the Food Industry ................................................................ 106 Urban Design and Transportation .......................................................................................................................................... 107 Data and Research ................................................................................................................................................................... 107Steps to Address the Obesogenic Environment ............................................................................................................................ 108 What can individuals do? ......................................................................................................................................................... 108 What can schools do? ............................................................................................................................................................... 108 What can communities do? ..................................................................................................................................................... 109 What can industry and businesses do? ................................................................................................................................... 109 What can physicians and health care professionals do? ........................................................................................................ 109 What can governments do? ..................................................................................................................................................... 110 Gaps in Data and Research ...................................................................................................................................................... 110Steps to Address Food Insecurity for Persons with Lower Socio-Economic Status .................................................................... 111 What can individuals do? ......................................................................................................................................................... 111 What can communities do? ..................................................................................................................................................... 111 What can governments do? ..................................................................................................................................................... 111vi Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 10. Table of ContentsSteps to Address Food Insecurity and Healthy Eating in the Aboriginal Population .................................................................. 111Steps to Address Food Safety .......................................................................................................................................................... 112 What can individuals do? ......................................................................................................................................................... 112 What can communities do? ..................................................................................................................................................... 113 What can industry, governments, and agencies do? .............................................................................................................. 113Working Towards Change ............................................................................................................................................................... 114AppendicesA: Technical Terms, Methods, and Statistical Computations ....................................................................................................... 115B: References.................................................................................................................................................................................... 119C: Health Authorities and Health Service Delivery Areas in BC .................................................................................................. 137Index ................................................................................................................................................................................................. 139Information boxes Provincial Health Officer’s Reports ........................................................................................................................................... xx What Do Healthy Diets Have in Common? ................................................................................................................................ 2 Mandatory Nutrition Labels ......................................................................................................................................................... 3 What is a Serving? ......................................................................................................................................................................... 4 Revision of Canada’s Food Guide to Healthy Eating ................................................................................................................. 5 Getting 5 to 10 a Day ................................................................................................................................................................... 8 Dietary Reference Intakes ........................................................................................................................................................... 9 Trans Fats.................................................................................................................................................................................... 10 The “Low-Carbohydrate, High-Protein” Diet ........................................................................................................................... 11 Glycemic Index (GI) .................................................................................................................................................................. 12 Benefits of Breakfast .................................................................................................................................................................. 13 Baby’s Best Chance .................................................................................................................................................................... 14 Canadian Journal of Public Health Supplement on Determinants of Healthy Eating ........................................................... 16 Keeping Well-Hydrated: Water is the Best Choice .................................................................................................................. 17 Sign Up for Allergy Alerts........................................................................................................................................................... 17 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia vii
  • 11. Table of Contents Grapefruit Juice: Food-Drug Interactions ................................................................................................................................ 18 Genetic Disorders and Food ..................................................................................................................................................... 19 Canada’s Physical Activity Guide .............................................................................................................................................. 20 Rx: 10,000 Steps ......................................................................................................................................................................... 21 Shapedown BC ........................................................................................................................................................................... 21 BC Farming Facts ....................................................................................................................................................................... 24 BC’s Greenhouse Boom ............................................................................................................................................................ 24 Making the Links ........................................................................................................................................................................ 25 Organic Farming in BC .............................................................................................................................................................. 26 Learning from Landmark Studies .............................................................................................................................................. 29 Chronic Disease Management and Healthy Eating.................................................................................................................. 30 Physical Activity’s Link to Health............................................................................................................................................... 31 Reducing Risks of Cancer and Heart Disease by Consuming Leafy Green Vegetables ......................................................... 32 Metabolic Syndrome .................................................................................................................................................................. 33 Cost of Obesity in British Columbia ......................................................................................................................................... 34 Self-Reported as Opposed to Measured ................................................................................................................................... 36 Guidelines for Food and Beverage Sales in BC Schools.......................................................................................................... 40 BC’s Healthy Living Alliance ...................................................................................................................................................... 41 Old Order Mennonite Children: Leaner, Fitter, Stronger ....................................................................................................... 42 Spotlight on McCreary Centre Society Survey ......................................................................................................................... 43 Dial-A-Dietician........................................................................................................................................................................... 46 Rates of Food Insecurity in Canada .......................................................................................................................................... 49 Regional Variations in Food Security in BC .............................................................................................................................. 50 Market Basket Measure.............................................................................................................................................................. 51 What is in the National Nutritious Food Basket? ..................................................................................................................... 52 Nourished Moms, Healthy Babes.............................................................................................................................................. 53 2005 Monthly Cost of Eating in BC ........................................................................................................................................... 54 Food Insecurity and Cigarettes ................................................................................................................................................. 55 Children Come First................................................................................................................................................................... 55 Relative Cost of Calories ............................................................................................................................................................ 55viii Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 12. Table of ContentsCore Functions in Public Health ............................................................................................................................................... 57Community Food Action Initiative............................................................................................................................................ 58The Cooking and Skill Building Project.................................................................................................................................... 58Seed of a Growing Movement ................................................................................................................................................... 60National Food Policy Framework .............................................................................................................................................. 61Nutrition and Food Policy in Norway ....................................................................................................................................... 62Golden Rules for Food Handling .............................................................................................................................................. 66Oysters and Norovirus in BC ..................................................................................................................................................... 67What is Good Handwashing?..................................................................................................................................................... 68Sprouts Risk ................................................................................................................................................................................ 68Emerging Foodborne Pathogens .............................................................................................................................................. 69Pork: Trichinellosis Disappearing ............................................................................................................................................. 70No Honey for Infants ................................................................................................................................................................. 71BC’s Worst Botulism Outbreak ................................................................................................................................................. 71Infections Passed by Unsafe Food Handling ............................................................................................................................ 72Manure-linked Deaths ............................................................................................................................................................... 73Ammonia Emissions in the Lower Fraser Valley ...................................................................................................................... 74“Extra Label” Drug Use .............................................................................................................................................................. 75Fighting Resistance .................................................................................................................................................................... 76The Codex Alimentarius Commission ...................................................................................................................................... 77Bovine Growth Hormone in Milk ............................................................................................................................................. 78TSEs – Fatal Brain Diseases ....................................................................................................................................................... 79What is Rendering? ..................................................................................................................................................................... 80Tracking Canadian Cattle........................................................................................................................................................... 80Genetically Modified Foods in Canada ..................................................................................................................................... 81Transfer of Brazil Nut Allergen via Genetically Modified Organisms...................................................................................... 81Cloned Cows? ............................................................................................................................................................................. 82Antibiotics on Salmon Farms..................................................................................................................................................... 83The Thrifty Gene Theory ........................................................................................................................................................... 90Provincial Health Officer’s Report: Diabetes in the First Nations Population ....................................................................... 91 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia ix
  • 13. Table of Contents Salmon and Crab ........................................................................................................................................................................ 93 Doctor Day, Food Boxes, and Community Kitchens in Aboriginal Communities ................................................................ 94 Botulism in BC ........................................................................................................................................................................... 96 Contaminated Foods ................................................................................................................................................................. 96 Studies in the Prevention of Obesity Among Children ......................................................................................................... 105 ActNow BC: Provincial Government Initiative for Healthy Living ........................................................................................ 106 BC School Initiatives on Promoting Healthy Eating and Increasing Physical Activity ......................................................... 107 Forum on Childhood Obesity, March 2005, Vancouver, British Columbia.......................................................................... 108 Obesity and Our Living Environment ..................................................................................................................................... 109 Assessing Fish Farms in BC ..................................................................................................................................................... 112 Royal Society of Canada Recommendations on Genetically Modified Foods (2001).......................................................... 113Figures 1.1 Percentage of BC Adult Population not Meeting the Suggested Five Servings of Grain Products Recommended by Canada’s Food Guide to Healthy Eating, BC, 2003 .................................................... 6 1.2 Percentage of BC Adult Population not Meeting the Suggested Five Servings of Vegetables and Fruits Recommended by Canada’s Food Guide to Healthy Eating, BC, 2003 ......................................... 6 1.3 Percentage of BC Adult Population not Meeting the Suggested Two Servings of Milk and Milk Products Recommended by Canada’s Food Guide to Healthy Eating, BC, 2003 ...................................... 7 1.4 Percentage of BC Adult Population not Meeting the Suggested Two Servings of Meat and Meat Products Recommended by Canada’s Food Guide to Healthy Eating, BC, 2003 .................................... 7 1.5 Neural Tube Defects, BC, 1983-2002 .................................................................................................................................. 13 1.6 Low Birth Weight Rates, Singleton and All Live Births, BC, 1986 to 2005 ........................................................................ 15 3.1 Twelve Leading Causes of Death, British Columbia, 2004 ................................................................................................ 28 3.2 Projected Health Services Costs for Persons with Diabetes With Implementation of Lifestyle Modification Program, BC, 2003/2004 to 2015/2016 ................................................. 32 3.3 Rates of Obesity, Adults 18 and Over, Canada and Provinces, 2004 ................................................................................. 35 3.4 Rates of Overweight, Adults 18 and Over, Canada and Provinces, 2004 .......................................................................... 35 3.5 Obesity Rates, Ages 2-17, Canada and Provinces, 2004 ..................................................................................................... 37 3.6 Overweight Rates, Ages 2-17, Canada and Provinces, 2004 .............................................................................................. 37x Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 14. Table of Contents 3.7 Proportion of Sample with Personal Health Numbers by Risk Cohort, Ages 25 and over, BC, 2003 ...................................................................................................................... 39 3.8 Proportion of Sample with Personal Health Numbers, by Number of Risk Factors, Ages 25 and over, BC, 2003 ................................................................................................... 39 3.9 A Preliminary Estimate of Average Annual Age-Adjusted Per Capita Costs (Hospital, MSP, PharmaCare) for Ages 25 and Over, by Risk Cohort, BC, 2001/2002 to 2003/2004.............................. 40 4.1 The Food System ................................................................................................................................................................. 48 4.2 Prevalence of Low Income After Tax (Selected Groups, BC, 1994 and 2003) ................................................................. 50 4.3 Child Poverty Rates, Canada and Provinces, 2003 ............................................................................................................. 51 4.4 Average Household Food Expenditures, Canada and Provinces, 2004 ............................................................................ 53 5.1 Organisms Causing Food Poisoning in BC, 2000 to 2004 ................................................................................................. 67 5.2 A Comparison of Reported Pathogens Associated with Foodborne Diseases in BC, 2000 and 2004................................................................................................................ 68 6.1 Age-Standardized Prevalence Rates for Diabetes, Status Indians and Other BC Residents, BC, 1992/1993 to 2003/2004 ..................................................................................................... 98 6.2 Age-Standardized Mortality Rates for All Cancers, Diabetes, and Circulatory System Diseases, Status Indians and other BC Residents, BC, 2002............................................................. 98 6.3 Potential Years of Life Lost (Age Under 75 Years) for All Cancers, Diabetes and Circulatory System Diseases, Status Indians and Other BC Residents, BC, 2002 ..................................... 99 6.4 Preventable Admissions to Hospital, BC, 2000/2001 ......................................................................................................... 99 6.5 Infant Mortality Rates, Status Indians and Other BC Residents, 1992 to 2002 .............................................................. 100Tables 4.1 2005 Monthly Cost of Eating in BC (based on living in a family of four) ......................................................................... 54 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia xi
  • 15. AcknowledgementsThe Provincial Health Officer gratefully acknowledges the Bob Fisk, MDfollowing individuals for their support and assistance. Director Population Health, Surveillance and EpidemiologyRosemary Armour Business Operations and SurveillanceMedical Advisor BC Ministry of HealthKnowledge, Management and TechnologyInformation Management Jan GottfredBC Ministry of Health Senior Advisor Aboriginal DirectorateAndrea Berkes BC Ministry of Aboriginal Relations and ReconciliationExecutive Administrative AssistantOffice of the Provincial Health Officer Roland Guasparini, MDBC Ministry of Health Chief Medical Health Officer Fraser Health AuthorityTom BradfieldRegional Director Trevor Hancock, MDAboriginal Health Medical ConsultantVancouver Island Health Authority Population Health, Surveillance and Epidemiology Business Operations and SurveillanceKaren Calderbank BC Ministry of HealthStatistics OfficerBC Stats Lance HillBC Ministry of Labour & Citizens Services Food Liaison Officer Health Products and Food BranchLarry Copeland Health CanadaDirectorFood Protection Services Joanne HoughtonBC Centre for Disease Control Regional Manager Healthy Communities andRay Copes, MD Community Food SecurityMedical Director Northern Health AuthorityEnvironmental HealthBC Centre for Disease Control Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia xiii
  • 16. Acknowledgements Deidre Kelly Lisa Nye Inspection Specialist Executive Director Canadian Food Inspection Agency Aboriginal Directorate BC Ministry of Aboriginal Relations and Reconciliation Jennifer Kitching Library Technician Alec Ostry Health and Human Services Library Associate Professor University of British Columbia Bruce Leslie Manager Veronic Ouellete, MD BC Ministry of Aboriginal Relations and Reconciliation Community Medicine Resident Fraser Health Authority Janice Linton Acting Director Enza Pattison BC HealthGuide Program Library Technician BC Ministry of Health Health and Human Services Library Janice Macdonald Kim Reimer Regional Executive Director Project Coordinator Dietitians of Canada, BC Region Population Health, Surveillance and Epidemiology Business Operations and Surveillance Chris Mackie, MD BC Ministry of Health Community Resident University of British Columbia Cathy Richards Community Nutritionist Lorraine McIntyre Interior Health Authority Food Safety Specialist Food Protection Services Fred Rockwell, MD BC Centre for Disease Control Medical Health Officer Vancouver Island Health Authority Lorna Medd, MD Medical Health Officer Deborah Schwartz Northern Health Authority Executive Director Aboriginal Health Richard Mercer BC Ministry of Health Research Officer Population Health, Surveillance and Epidemiology Daphne Sidaway-Wolf Business Operations and Surveillance Director, Trade and Intergovernmental Relations BC Ministry of Health BC Ministry of Agriculture and Lands Barb Miles Wendy Vander Kuyl Administrative Assistant Research Assistant Office of the Provincial Health Officer Population Health, Surveillance and Epidemiology BC Ministry of Health Business Operations and Surveillance BC Ministry of Health Mina Nia Senior Economist Parks and Protected Areas Branch BC Ministry of Environmentxiv Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 17. AcknowledgementsJay Wortman, MDRegional DirectorFirst Nations and Inuit Health BranchHealth CanadaMartin WrightExecutive DirectorStrategic Policy and PlanningBC Ministry of Children and Family DevelopmentMilt WrightDirector, Negotiations and Corporate MandatesBC Ministry of Aboriginal Relations and ReconciliationProject Team of the 2005 PHO Annual Report:Zhila Kashaninia – Project Manager, Managing EditorManagerProjects, Research and Reporting InitiativesOffice of the Provincial Health OfficerBC Ministry of HealthBarb Callander – Copy Editing, Proofreading and ReferencesManager, Projects and Strategic InitiativesBusiness Operations and SurveillancePopulation Health and WellnessBC Ministry of HealthLisa Forster-Coull – Content ExpertProvincial NutritionistPopulation Health and WellnessBC Ministry of HealthLorie Hrycuik – Content ExpertActNow NutritionistPopulation Health and WellnessBC Ministry of HealthAnne Mullens – First Draft WriterConsultant, Victoria, BCSarah Cox – First Draft WriterConsultant, Victoria, BCAnthony Alexander – Graphic DesignMercury Art & Design, Victoria, BC Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia xv
  • 18. HighlightsFood is a prerequisite and a determinant of health. The Nutrition and Healthconsumption and access to food is related to a complex food A substantial number of people in British Columbia, while notsystem that includes production, processing, distribution, food-insecure, are considered to be “malnourished”, eitheravailability, and affordability. All of these interrelated through overconsumption of foods that should be consumedcomponents can work to either support or interfere with in moderation, or through underconsumption of nutritiousthe access and affordability of healthy food choices for food, or both. The 1999 BC Nutrition Survey showed that 65populations. Any barrier, break, or weakness along the food per cent of those surveyed were not consuming the minimumsystem can undermine the ability of the population to access of 5 servings of vegetables and fruits per day, and that 25 persafe, nutritious food, which can then undermine their health cent of respondents consumed more than 35 per cent of theirand wellness. total calories from fat (Ministry of Health Planning [MOHP],In 1996, the World Food Summit defined food security as the 2003).following: Despite the complexities of food and nutrition, it is now clear Food security exists when all people, at all that poor food choices can be a significant risk factor for times, have physical and economic access to chronic disease. In 1988, the United States Surgeon General’s sufficient, safe and nutritious food to meet Report on Nutrition and Health estimated that two-thirds of their dietary needs and food preferences for all deaths in the United States were due to diseases that had an active and healthy lifestyle. some association to diet (United States Department of Health and Human Services, 1988). (Food and Agriculture Organization of the United Nations, 1996). In 2004, as with previous years, malignant neoplasms (cancer) and cardiovascular disease were the leading causes of deathAny food system is an economic and political creation. An in British Columbia (28 per cent and 23 per cent respectively)optimally nourished population depends on a healthy, (British Columbia Vital Statistics agency, 2005). There is solidsustainable food system that is influenced by the political evidence that over 50 per cent of different types of cancersand economic processes of policies, programs, markets, and a large proportion of cardiovascular disease could beand services. The influence of these processes impacts the prevented through behavioural and environmental changesproduction, processing, distribution, marketing, acquisition, (WHO, 2003b).and consumption of food. These in turn shape the individual,family and community, and the environment, agriculture, and Research has shown that one-third of all cancers could beeducation. avoided by eating more fruits and vegetables and whole Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia xvii
  • 19. Highlights grains, minimizing saturated fats and trans fats, maintaining Food Insecurity and Access to Nutritious Food a normal weight, and exercising regularly. Obesity itself is A healthy food system is essential to support healthy food strongly related to a large number of cancers, with estimates choices. In British Columbia, for the most part, the majority that 14 per cent of all deaths in men and 20 per cent of of the population has ready access to a wide variety of healthy all deaths in women from cancer could be attributed to food choices. However, certain groups, such as those on the current patterns of obesity in North America (Calle, low income, have challenges in affordability and accessibility Rodriguez, Walker-Thurmond, & Thun, 2003). to healthy foods. For those living in rural and remote In 2004, (based on Statistics Canada’s Community Health communities, the above issues are compounded by limited Survey) 23 per cent of adult Canadians were obese, with BMIs or expensive transportation of healthy foods to their rural of 30 or greater, compared to 14 per cent in 1978/1979. BC communities, as well as transportation barriers within the has the lowest rates of obesity in Canada; nevertheless 19 per community to local food sources. Overall, declining farmland, cent of the adult population in BC is considered obese, with reliance on imported food, and the inability for certain BMIs over 30. British Columbia had more people who were populations—most notably low-income British Columbians— overweight than all other provinces except Prince Edward to access safe, nutritious, and sufficient food, all contribute to Island. Both provinces had an overweight rate of 40 per cent. food insecurity in the province. The overall rate of overweight adults in Canada was 36 per The level of food insecurity in BC is above the national cent. average and is cause for concern. In 2001, about 17 per cent The obesogenic environment, which is defined as “the sum of BC’s population could not afford the quality or variety of of influences that the surroundings or conditions have on food they wanted, worried about not having enough to eat, promoting obesity in populations” (Swinburn, Egger, & or had not had enough to eat at some time in the previous Raza., 1999), has brought changes in eating patterns and 12 months. The national average was 15 per cent in the same physical activity that underlie the obesity epidemic. It is year. BC’s lower and lower-middle income households were through environmental modification that this epidemic can be most likely to have food insecurity, with 30 per cent of those reversed. households reporting at least one instance in the previous year of not having had enough food to eat (Ledrou & Gervais, In 1997, the World Health Organization Consultation on 2005). Obesity recommended the necessity for comprehensive public health approaches and strategies for the prevention Individuals in food-insecure households in Canada are more and management of overweight and obesity (World Health likely to report ailments such as heart disease, diabetes, Organization [WHO] 2000). These strategies aim to change and high blood pressure (Vozoris & Tarasuk, 2003). Once a the physical and social environments responsible for the chronic health problem appears, it is challenging for those increasing trends in overweight and obesity by intervention in on low incomes to follow dietary recommendations for their the following areas: illness, such as a low-sodium diet for high blood pressure, or a high-fibre, low-fat, low-added sugar diet for diabetes. Such • Health-promoting school environment special diets often cost more than the basic diet. For example, • Public education a diabetic diet costs about $60 more per month than the 2005 BC basic food basket (Anderson, McKellar, & Price, 2006). • Monitoring and regulation of the marketing approaches of the food industry Children in hungry households in Canada are reported to have significantly poorer health than other children • Urban design and transportation (McIntyre, Connor, & Warren, 1998). Almost 30 per cent of • Data and research children in food-insufficient households suffer from asthma, compared with 13.5 per cent of children in food-secure households (McIntyre, Walsh, & Connor, 2001). Insufficient nutrition during early childhood can cause permanentxviii Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 20. Highlightscognitive damage, affecting a child’s ability to learn and 30 people die (Canadian Food Inspection Agency, 2005c).function (Community Nutritionists Council of BC, 2004). For every foodborne disease that is reported, many are notAmerican studies have documented chronic minor health reported. The number of cases of foodborne disease wasproblems among children from food-insecure households that estimated to be over 650,000 in 2003, with an estimated costinclude fatigue, irritability, dizziness, recurring headaches, of $988 per individual per year (Ministry of Health, 2005b).frequent colds and infections, and difficulty concentrating According to the World Health Organization (WHO), a small(McIntyre et al., 2001). In adolescents, food insufficiency has number of factors related to food handling are responsiblebeen linked to low-level depression and suicide symptoms for a large proportion of foodborne diseases worldwide. The(Alaimo, Olson, & Frongillo, 2002). most common factors are:Factors affecting the ability to afford nutritious food in BC • Cross-contamination of food.include higher costs of a basic “market basket” of items,higher housing costs, inadequate social assistance rates, • People with poor personal hygiene handling food.increased levels of homelessness, and a minimum wage • Preparation of food several hours prior to consumption,level that can result in even full-time workers in some BC combined with improper storage at temperatures thatcommunities falling below the federal low-income cut-off. favour the growth of pathogenic bacteria and/or theA collaborative effort at the community, provincial, and formation of toxins.national level is needed to address the underlying cause • Insufficient cooking or reheating of food to reduce orof household food insecurity—poverty. Individuals, eliminate pathogens.communities, and governments need to support food securityinitiatives to ensure that access to healthy foods is available to In terms of genetically modified foods, Canada’s expertall people in British Columbia. panel on the future of food biotechnology recommended that Canada apply the “precautionary principle” to theSafety of the Food Supply introduction of genetically modified foods; this principle states that new technologies should not be presumed safeThe food we eat must not only be nutritious and be unless there is a reliable scientific basis to consider themconsumed in the right proportions to maintain health; it safe. As such, the panel called for more rigorous testing ofmust also be safe to eat. The potential public health impact genetically modified foods.of unsafe food is significant, capable of harming bothindividuals and large sectors of society. Food can be unsafe Food Security and Healthy Eating in the Aboriginal Populationfor consumption in many ways—through contaminationwith pathogens, toxins, or chemicals on the farm; during Most indigenous populations worldwide, including thedistribution, food processing, and retail operations through Canadian Aboriginal population, share a pattern of increasedimproper storage; or through unsafe food preparation in the illness and mortality compared to non Aboriginal populations.home. Ensuring the safety of the food supply requires a “farm- The key considerations are a long history of colonization,to-fork” risk management approach that guards against risks cultural deprivation, political impotence, and systematicor removes them at each point along the continuum that food discrimination, as well as genetics, lifestyle, socio-economictravels from being grown, raised, or harvested, to the time it is factors, poor quality housing and community environments,consumed. unemployment, and low levels of education.Most cases of foodborne illness are only recognized when In British Columbia, the First Nation populations haveat least two or more people become sick after eating a meal higher incidence and prevalence rates of chronic diseases,or food product in common. Symptoms can arise hours or such as Type 2 diabetes, compared to the rest of the BCeven days after the food is consumed. The Canadian Food population; these higher rates are directly linked to the issuesInspection Agency reports that each year about 10,000 cases of overweight and obesity. Traditionally, Aboriginal peopleof foodborne illness are reported from which approximately had access to their own nutritious foods and were much more Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia xix
  • 21. Highlights active. A combination of a change from the why some Aboriginal communities areProvincial Health Officer’s Reports traditional diet to one high in starch and “healthier” than others. sugar, and a change to a sedentary lifestyle,Since 1993, the Provincial Health Officer has • Support efforts by Aboriginal people coupled with a genetic propensity to storebeen required by the Health Act to report to achieve self-determination and a energy as fat (the “thrifty gene” hypothesis)annually to British Columbians on their collective sense of control over their may be responsible for the increase inhealth status and on the need for policies and futures, in both on-and off-reserveprograms that will improve their health. Some obesity rates and high prevalence of communities.of the reports produced to date have given a chronic diseases among the Aboriginalbroad overview of health status while others population. The following changes are • Encourage greater Aboriginalhave focused on particular topics such as air recommended to prevent obesity and participation in the governance, design,quality, drinking water quality, immunization, related chronic diseases: and delivery of culturally appropriateinjection drugs, First Nations health, injury health services. • Healthy and affordable foods shouldprevention, and school health. Reports by theProvincial Health Officer are one means for be available to Aboriginal communities Working Towards Change…reporting on progress toward the provincial (First Nations, Métis, and Inuit).health goals, which were adopted by the Health cannot be separated from • The possibilities of local foodprovince in 1997. environmental and societal influences production should be considered and surrounding the individual. FacingCopies of the Provincial Health Officer’s supported. epidemics of obesity and chronic illness,report are available free of charge from the • Government policies should support governments need to strive to createOffice of the Provincial Health Officer by communities interested in a re- environments that make the healthycalling (250) 952-1330 or at http://www.healthservices.gov.bc.ca/pho. introduction of traditional diets or their choice the easy choice. We cannot expect equivalent. people to make healthy choices when they live in unsupportive social and physical • Neighbourhoods should be safe for environments. It is therefore necessary families and children to be physically to work towards creating a positive and active. healthy social, nutritional, and physical The following recommendations from the environment where people can have access 2001 Provincial Health Officer’s Report, to healthy and safe food, and can take part The Health and Well-being of Aboriginal in physical activity that will allow them to People in British Columbia, are also live healthier lives. important in this context: • Improve housing conditions Contents of this Report and economic and educational The 2005 Provincial Health Officer’s report opportunities for Aboriginal people. intends to inform British Columbians of • Increase awareness of the health status the role of food and nutrition in the lives of Aboriginal people and the challenges of people in British Columbia. This report that Aboriginal people face. contains current research on nutrition and healthy eating, agriculture and food • Pay more attention to the non-medical, processing, the impact of unhealthy eating, cultural, and spiritual determinants of food insecurity, the safety of the food health. supply and food and Aboriginal population • Encourage participatory research to in British Columbia. The last chapter gain a clearer understanding as to focuses on recommendations for all the issues discussed in previous chapters. xx Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 22. Chapter 1: Nutrition and HealthWhy Do Food and Diet Matter? In British Columbia, for the most part, the majority of the population has ready access to a wide variety of healthyThe saying, “You are what you eat,” is true. The food we put food choices to support healthy eating patterns. We havein our mouths defines to a great extent our health, growth, an abundance of local and imported fruits and vegetables;and development, and ability to function well in a complex increasing diversity in cereal and whole grain products;world. Eating a variety of nutrient-rich, high quality foods a variety of milk, yogurt, and cheese choices; and a widewith the right proportions of fat, protein, carbohydrates, range of lean meats, poultry, seafood, eggs, nuts, seeds, andfibre, vitamins, minerals, and other dietary constituents, legumes.provides our body with what it needs for optimal growth anddevelopment. In addition, our increasing cultural diversity is exposing us to a rich and enticing variety of food choices and styles ofA healthy diet provides the ingredients we need to build and cuisine. While 50 years ago it would have been rare for therepair our bones and tissues and keep the complex workings majority of British Columbians to stray from a basic meat-of the human body functioning optimally. It gives us the and-potatoes diet, now both in our restaurant choices andmental and physical energy necessary for daily life—work, home cooking we can and do eat from an international arrayrecreation, relationships, and family life. of styles: Greek, Italian, Japanese, Chinese, Vietnamese, Thai,A healthy diet also protects us from infectious illnesses Indian, Mexican, and more. In short, many different dietaryand chronic diseases so that we may age with a minimum patterns can satisfy both hunger, nutrient, and lifestyle needsof ill health, pain, disability, and lost work days. Poor or and therefore confer lasting health benefits. The majority ofunbalanced diets are either the primary risk factor, or a major British Columbians are fortunate to have this smorgasbord ofcontributing factor, to a host of chronic diseases such as heart options.disease, stroke, cancer, diabetes, and high blood pressure(World Health Organization [WHO], 2003b). The health Nutritional Confusion and Temptationproblems that arise from unhealthy diets will be discussed in This abundance of choice, however, makes the public healthChapter 3 of this report. message about how to eat healthy much more complex. Unlike simple public health messages, such as “don’t smoke”What is a Healthy Diet? to reduce the impact of tobacco-related illness, informingIn our culturally diverse world, many traditional ways of eating people on what to eat to improve health and reduce disease ishave the right components to be considered “healthy”, i.e., more challenging.providing the nutrients required to support and promotehealth. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 1
  • 23. Chapter 1: Nutrition and Health Many people, regardless of education or to pick up prepared and prepackagedWhat Do Healthy Diets Have in level, become confused when faced with convenience foods. In 1970, AmericanCommon? the modern array of food choices now families spent one-third of their food available and are not sure how to choose dollars on meals outside the home. ThisMany healthy diets share similar features. the best diet for themselves and their has grown steadily so that by 2001, theRecent research has affirmed the traditional families. Complicating the picture are average family spent 47 per cent of foodMediterranean diet as one of the ideal styles individual factors such as taste preference dollars away from home (Sturm, 2005b).of eating to promote longevity and a range ofhealth benefits, particularly the prevention of and cultural patterns. On a larger scale, Prepackaged meals, and foods preparedheart disease and a decreased risk of a variety of food supply issues such as seasonal and in restaurants and fast-food outlets, tendcancers (Hu, 2003; Trichopoulou, Costacou, Bamia, geographical availability, agriculture and to have more calories, fats, sugars, and salt& Trichopoulos, 2003; Singh et al., 2002). food manufacturing infrastructure, and cost, (relative to nutrient content) than food all impact choice. prepared at home.The traditional Mediterranean diet features: Adding to the challenge of choosing Portion sizes in restaurants and fast-food• An abundance of unprocessed plant food (fruit, healthy food is the increasing availability outlets have also greatly increased over vegetables, whole grains, nuts, seeds, and legumes). of relatively cheap, often tasty, and usually the last two decades, inducing people to satisfying high-calorie, low-nutrient foods, consume more calories at a single sitting• Olive oil as the principal fat. such as fast food, snack foods, pop, candy, than they need. This “portion distortion”• Fish and poultry weekly. and other highly refined and processed and other factors contributing to excess foods. These foods typically contain calories calorie consumption are discussed in more• Red meat once or twice a month. in the form of fat or sugars and are often detail in Chapter 3.• Wine with meals but not to excess. high in salt and low in nutrients such as the A recent study found that too much choice vitamins and minerals needed for optimalThis diet—high in fibre, low in saturated itself can promote weight gain; both body function. These nutritionally poor(animal) fat and trans fats—is very similar to the humans and animals alike tend to overeat foods compete with and often displaceDietary Approaches to Stop Hypertension (DASH) when surrounded by many tempting tastesdiet, and to the recommendations of Canada’s healthy food choices in many people’s but reach satiation faster when eating justFood Guide to Healthy Eating. With a minimum diets, creating a paradox of being overfed one food (Raynor & Epstein, 2001).of processed foods and an abundance of grains, but undernourished. Obesity and nutrientvegetables, fruits, nuts, and seeds, these diets deficiencies can result in serious health Consumers can also be confused byprovide a healthy, well-balanced way of eating consequences. The 1999 BC Nutrition promotions and labels that seem toand are also satisfying to most palates. Survey (Ministry of Health Planning advertise a food as being healthier [MOHP], 2003) identified that 25 per cent than it actually appears. Labels such as of food in British Columbians’ diets came “cholesterol-free” on a bag of potato chips from the types of foods found in the “other” that are high in fat and salt, or “low-fat” food group from Canada’s Food Guide on cookies and baked goods that are to Healthy Eating. The intake of several high in sugar play into the widespread vitamins and minerals was also inadequate, consumer confusion around nutrition. In despite the use of supplements by the 2003, to combat the confusion in labelling, majority. Health Canada brought in new regulations making nutrition labels mandatory on most Other factors also contribute to the prepackaged food; however, the aggressive challenges of healthy eating. Eating styles marketing of food can still confuse some have changed over the last three decades consumers. and the modern family is more likely to eat meals away from home in restaurants, 2 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 24. Chapter 1: Nutrition and HealthRole of Food Guides of eating followed by the majority. Food guides in the past have come Mandatory Nutrition LabelsMany countries, including Canada, have under criticism, particularly from someadopted official food guides to help provide In 2003, Health Canada brought in nutritional advocates who charge that thedietary guidance. The guides promote regulations requiring most food labels to recommendations in most countries area pattern of eating for their citizens that carry a standardized nutrition facts table. The not forward thinking, and are sometimesreflects widely available food choices, regulations took effect in December 2005 for subject to intense lobbying from powerfulnutrient needs, and good health, and aim large manufacturers (smaller manufacturers sectors of the food industry, which then have until December 2007), although someto reduce the risk of nutrition-related influences the message and the pictures of companies began displaying the tables wellhealth problems and chronic disease. the food displayed (Nestle, 2002; Lang & before that date.The guides are based on a national Heasman, 2004).consensus of scientists; they identify the The facts table lists nutritional information such as the amount of calories, sugar, saturatednutritional requirements, and provide Canada’s Food Guide To Healthy Eating fat, trans fats, protein, sodium, and otherpictorial representations of the types of When Canada’s first food rules were vitamins and minerals, and the percentagefoods, in their varying proportions, that released in 1942, in the midst of the of daily requirements in the food. Thisare needed daily to promote health. The standardized information can help consumers Second World War, the primary aim was tographic depiction varies from country make more informed, healthy choices, prevent malnutrition during a time of foodto country. Some countries have food regardless of promotional claims on the front rationing. The federal government’s dietarypyramids, others food wheels or pie charts, of the package. recommendations have had six revisionsand some use food dinner plates. Canada over the last six decades to keep themuses a colourful food rainbow showing abreast of changing times. The most recentthe relative proportions of meat and revision occurred in 1992, and anotheralternatives, milk products, vegetables and revision is currently underway.fruits, and grain products that Canadiansshould eat to achieve optimal health. The 1992 revision changed the title, introduced the rainbow graphic, andWhile there are some differences between shifted philosophy from identifyingcountries in their food guides, the minimum daily requirements to preventrecommendations remain very similar deficiencies, to a total diet approach to(Painter, Rah, & Lee, 2002). The core prevent chronic diseases, by setting dailyrecommendations for most countries are: ranges based on the varying energy needs• Consume generous amounts of whole of different individuals (Health Canada, grains, vegetables, and fruits; and 2002).• Consume moderate amounts of meat, The 1992 guide provides both serving size milk, and dairy products. guidance and recommendations to make healthier choices in each food group:Although food guides are carefullydesigned, they have their limitations. • Grain Products: five to twelveFood guides need to convey complex, servings per day, choosing whole grainscientific information on nutrition in a breads and cereals more often oversimple, straightforward, easy-to-understand processed white flour products, pastas,manner. In addition, they need to reflect or rice.a country’s food supply and the patterns Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 3
  • 25. Chapter 1: Nutrition and Health • Vegetables and Fruit: five to ten • Emphasize cereals, breads, other grain servings a day, choosing dark green products, and vegetables and fruit. and orange vegetables and orange fruit • Choose lower-fat dairy products, leaner more often. meats, and food prepared with little or • Milk Products: Number of servings no fat. vary with age: • Achieve and maintain a healthy body - Children 4-9: two to three servings weight by enjoying regular physical daily. activity and healthy eating. - Youth 10-16: three to four servings • Limit salt, alcohol, and caffeine. daily. According to Health Canada, the Food - Adults: two to four servings daily. Guide is the most popular site on its website (Health Canada, 2002). The Food - Pregnant or breastfeeding Guide’s influence in institutional or public women: three to four servings daily. settings is widespread. Schools, hospitals,What is a Serving? Choices include 2% or lower fat milk, retirement homes, and other institutions evaporated milk, powdered milk,Canada’s Food Guide to Healthy Eating uses usually set their menus based on Canada’s various cheeses (including low fatthe term “servings” to describe how much of Food Guide to Healthy Eating. or skim milk varieties), and lower fata food to eat. The following are examples ofone serving: yogurt. The BC Nutrition Survey• 1 slice of whole grain bread, or 1/2 of a • Meat and Alternatives: two to three The 1999 BC Nutrition Survey was designed bagel or bun (30 g); servings per day. Choices include to obtain information on the eating habits• 1 cup of salad; various cuts of beef, pork, lamb, or of the adult population in British Columbia.• 1 medium banana, apple, or carrot, or 1/2 poultry; fresh or canned fish; eggs; The survey involved a total of 1,823 people cup of juice; beans and lentils; tofu; and nuts, with aged 18 to 84 throughout British Columbia• 1 cup of milk; the recommendation to choose leaner who were interviewed in their homes by• 3/4 cup yogurt; meats, poultry, fish, and dried beans specially trained public health nurses and• a meat portion the size of a deck of cards; and lentils more often. nutritionists.• 1/2 can of fish; The guide notes that the amount of food• 3 tbsp peanut butter; The 1999 BC Nutrition Survey has• 1/2 cup lentils/legumes. an individual requires each day from the created the first provincial database of four food groups depends on the person’sThere is evidence that people find the food consumption and nutrient intake age, body size, activity level, and sex. Youngterminology “serving” confusing and this is information, and can serve to monitor children and the elderly tend to needbeing examined in the new round of revisions future comparisons and trends in the lower number of servings while maleof the Food Guide (Health Canada, 2003c). nutritional and dietary choices (MOHP, teenagers or pregnant and lactating women 2003). need a higher number. Most people would require serving numbers in the mid-range. The survey results showed that the majority of men and women in BC (as high as 84 per In addition, the guide makes some other cent in some age groups) ate less than the general recommendations about healthy recommended amount of fruits, vegetables, eating: and milk products. In summary: • Enjoy a variety of foods each day. 4 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 26. Chapter 1: Nutrition and Health• 25 per cent of all calories consumed consumers’ perspectives on healthy eating came from high-calorie, low-nutrient (Health Canada, 2003c). The participants Revision of Canada’s Food Guide to food; primarily from foods and in general showed good knowledge of Healthy Eating beverages such as chips, pop, candy, what constitutes healthy eating, by naming In 2002, Health Canada announced that jams, alcohol, etc. whole grains, fruits and vegetables, fish Canada’s Food Guide to Healthy Eating would and lean protein, and low-fat milk products• 65 per cent of all participants were not be revised to take into account the changing as the healthier choices. However, the consuming the suggested five servings nature of Canadian society. The guide does not researchers noted a number of factors that need a wholesale change. Rather it needs to be of vegetables and fruits each day. could interfere with healthy eating: updated to include the changing nature of our• 77 per cent of participants were not food supply, the increasing ethnic influences • Time: Participants felt there was a consuming the suggested two servings on food choices, the growing problem lack of time in busy working lives to of milk products. of obesity, and the advances in scientific plan meals, shop for ingredients, and knowledge over the last decade.• Many were not getting the necessary prepare menus from scratch; as a result vitamins and minerals from their diets. they often chose to purchase and eat The revision process, which is still underway, The groups with the greatest nutrient pre-made convenience foods. has involved broad consultations including concerns were women and seniors. The focus groups with consumers, and input • Effort: The effort and energy it takes to from the food industry, health organizations, vast majority of participants were not eat healthy was identified as a barrier. governments, universities, consumer groups, consuming enough fibre. As well, good meal planning is required and other agencies. Working groups and• 25 per cent of participants were for timely use of fruits and vegetables advisory committees were established in 2004, consuming more than 35 per cent of and other fresh ingredients like fish and and have commissioned further research. their caloric intake from fat. meat before they spoil. Stakeholder consultations and consumer test groups are expected to continue, with the final• 55 per cent of participants were • Knowledge and skills: Participants revision of the Food Guide released sometime overweight or obese, based on actual cited a lack of ideas for creating a variety in 2006 or 2007. measurements of body mass index of healthy meals as a barrier. Others (BMI) and waist circumference. This were confused about contradictory food rate is higher than self-reported messages, particularly around proteins measurements and gives evidence that and carbohydrates. BC’s obesity problem may be worse • Taste: Some participants stated that than previously reported. The issues even though they knew some foods around increasing rates of obesity are were healthier, they did not like the discussed in Chapter 3. taste, particularly of vegetables, and instead had cravings for prepackagedUnderstanding the Determinants of Healthy and prepared foods.Eating • Cost: The cost of fruits, vegetables,Why do some British Columbians eat and other less processed food wasrelatively healthy and others do not? As a barrier to healthy eating. Thispart of the research activities around issue, along with others around foodthe revision of Canada’s Food Guide availability and food insecurity, isto Healthy Eating, Health Canada discussed in Chapter 4.commissioned a small study examining Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 5
  • 27. Chapter 1: Nutrition and Health Percentage of BC Adult Population not Meeting the Suggested Five Servings of Grain Products Figure 1.1 Recommended by Canada’s Food Guide to Healthy Eating, BC, 2003*• Based on the 1999 BC Nutrition Survey, 80 Males Females 70 71 overall, 41 per cent of all participants did 70 66 not meet the recommended servings of five 59 grain products per day. 60 53• Females were 3 times less likely to meet 50 42 the recommended servings of five grain Per cent products than males. 40 30• Over 65 per cent of females 50 years of 30 21 age and older did not meet the minimum 20 14 16 recommended servings of five grain products. 10 0 18-34 35-49 50--64 65-74 75-84 * The data adjusted for intra-individual variability and weighted by sample weights to provide population estimates. Source: Jenkins B. & Laffey, P., BC Nutrition Survey, Canada Food Guide Tables, E451313-011 CFG-V1, 2003. Health Canada Percentage of BC Adult Population not Meeting the Suggested Five Servings of Vegetables Figure 1.2 and Fruits Recommended by Canada’s Food Guide to Healthy Eating, BC, 2003* 90 84• Overall, 73 per cent of females and 78 56 per cent of males did not meet the 80 Males Females recommended servings of five vegetables 70 62 60 62 and fruits. 58 57 60 54• Approximately 62 per cent of males and 84 48 46 Per cent 50 per cent of females between 18 and 34 years of age did not meet the recommended five 40 servings of vegetables and fruits. 30• As with grain products, females were 20 much less likely than males to meet the 10 recommended servings of five vegetables and fruits. 0 18-34 35-49 50--64 65-74 75-84 * The data adjusted for intra-individual variability and weighted by sample weights to provide population estimates. Source: Jenkins B. & Laffey, P., BC Nutrition Survey, Canada Food Guide Tables, E451313-011 CFG-V1, 2003. Health Canada 6 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 28. Chapter 1: Nutrition and Health Percentage of BC Adult Population not Meeting the Suggested Two Servings of Milk and Milk Products Recommended by Canada’s Food Guide to Healthy Eating, BC, 2003* Figure 1.3 Males Females • Overall, approximately 77 per cent of those surveyed did not meet the recommended 100 90 91 87 87 minimum two servings of milk and milk 90 81 78 products. 75 75 80 69 • Over 80 per cent of females in every age 70 61 group (except those 75-84) did not meet the 60Per cent recommended minimum two servings of 50 milk and milk products. 40 30 20 10 0 18-34 35-49 50--64 65-74 75-84 * The data adjusted for intra-individual variability and weighted by sample weights to provide population estimates. Source: Jenkins B. & Laffey, P., BC Nutrition Survey, Canada Food Guide Tables, E451313-011 CFG-V1, 2003. Health Canada Percentage of BC Adult Population not Meeting the Suggested Two Servings of Meat and Meat Products Recommended by Canada’s Food Guide to Healthy Eating, BC, 2003* Figure 1.4 80 71 Males Females • Overall, approximately 26 per cent of 70 those surveyed did not meet the minimum recommended two servings of meat and 60 49 meat products. 50 • Over 70 per cent of females 75 years of agePer cent 40 33 32 and over did not consume the minimum 31 recommended two servings of meat and 30 meat products. 20 15 13 11 12 12 • Males were much more likely to meet their 10 minimum recommendations of two servings of meat and meat products than females. 0 18-34 35-49 50--64 65-74 75-84 * The data adjusted for intra-individual variability and weighted by sample weights to provide population estimates. Source: Jenkins B. & Laffey, P., BC Nutrition Survey, Canada Food Guide Tables, E451313-011 CFG-V1, 2003. Health Canada Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 7
  • 29. Chapter 1: Nutrition and Health Healthy Components: The nerve fibres throughout our entire body.Getting 5 to 10 a Day Change in Understanding Fats, Having enough of the right fat in the diet is particularly important to the growth andEating at least 5 to 10 servings of vegetables Proteins, and Carbohydrates development of young children, particularlyand fruits a day may be the single most Over the last ten years the science of brain development. A low-fat diet can beimportant food change most British nutrition has been expanding, in particular very harmful to young children.Columbians can make to improve their health. our understanding of the health-relatedSome simple ways to do this are: The recommendations for fat intake roles of fats, proteins, and carbohydrates.• Slicing fresh fruit on breakfast cereal. have changed over the years. In the The science behind nutrition research is 1960s, it was thought that diets high in• Making a yogurt smoothie with three or often very complex and full of controversy. fat were associated with higher rates of four fruits. The new Dietary Reference Intakes cardiovascular disease, heart attack, and recommend the following standards to• Drinking a low-sodium vegetable drink. stroke. The advice for two decades was to best prevent chronic diseases, and ensure eat a low-fat, low-cholesterol diet, choosing• Adding spinach to soups and salads. adequate intake of essential nutrients: lean animal food products as much as• Ordering vegetarian pizza with extra Fat: 20 to 35 % of calories possible. veggies. Carbohydrates: 45 to 65 % of calories In the 1980s, the advice was to reduce• Washing and preparing celery sticks, carrots, saturated fat (predominantly from animal peppers, and other vegetables and storing Protein: 10 to 35 % of calories sources) and increase polyunsaturated fat them in the refrigerator for easy snacking. Infants and young children have a greater (predominantly from plants.) In the 1990s,• Freezing 100 per cent juice as popsicles for a need for fat (particularly in the first 2 years a growing awareness of essential fatty acids frozen treat. of life) so their fat intake should be slightly called omega-3 led to more emphasis on higher at 50 per cent of calories for infants consuming healthy sources of fat such as• Having frozen vegetables on hand and (standard set by breast milk) and 25 to fish, walnuts, and flax. adding them to soups, omelettes, and stir- 40 per cent of calories for young children fries. Omega-3 and omega-6 fatty acids are not (Institute of Medicine [IOM], 2005). produced in our bodies and therefore must be consumed on a regular basis. Omega- Fats 3 fatty acids are best consumed from Why are fats so important? Most people food choices and not from supplements think that fat only clogs our arteries or (Covington, 2004). Generally, North contributes to obesity. But fats have Americans eat enough omega-6 in their an essential role to play in nutrition as diet, particularly through meat and eggs. they help with absorption of fat-soluble Research shows that these fats support vitamins A, D, E, and K, as well as other better pregnancy and breastfeeding nutrients, and provide flavour and satiety outcomes, may reduce the risk of at our meals. Fats become part of the cardiovascular disease or sudden death membrane of every cell in our body, from heart arrhythmias, and may also which dictates how well the cell functions reduce inflammation and blood clotting by enabling the passage of essential factors (Covington, 2004). compounds, like insulin, and preventing The healthier fats are beneficial because the transmission of harmful influences, they seem to increase the levels of such as potential carcinogens. Fat is also high-density lipoproteins (HDL) in the the main component in our brain, and blood, which are responsible for carrying plays a crucial role in protecting our cholesterol to the liver where it is 8 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 30. Chapter 1: Nutrition and Healtheliminated. These are often called “good Carbohydrates either break down intocholesterol”. The low-density lipoprotein glucose (also called blood sugar), or Dietary Reference Intakes(LDL) is responsible for the buildup of pass through mainly undigested as fibre. The Dietary Reference Intakes (DRIs) are acholesterol on the walls of blood vessels, Glucose is the fuel that the cells burn to comprehensive set of nutrient reference valuesand is often known as “bad cholesterol”. function. Insulin, released by the pancreas, for healthy populations that can be used is the vehicle that carries glucose to theThere is new research showing that many for assessing and planning diets. The DRIs cells and allows it to be transported acrosssaturated fats, traditionally seen as less replace previously published Recommended the cell membrane. Fibre is essential in Nutrient Intakes. These were established byhealthy, may actually be neutral or even our diets, too, for its role in preventing Canadian and American scientists through abeneficial to health. Milk fat, cocoa butter, constipation and helping promote healthy review process overseen by the United Statesand even some fats found in red meats digestive function. National Academies, an independent, non-have shown a positive impact on weight governmental body (IOM, 2005).and heart disease risk (Hu, Manson, & Carbohydrates have been primarilyWillett, 2001). Clarifying the role of fats in classified as simple or complex The DRIs reflect the current state of scientifichealthy diets will be the source of much carbohydrates depending on the length of knowledge with respect to nutrientresearch in the next decades. the molecular chain. Simple carbohydrates requirements. The Health Canada’s Office of are short chain sugars such as fruit sugar Nutrition Policy and Promotion will be usingHealthy Fats the DRIs to ensure that dietary guidance to (fructose), corn sugar (dextrose), and table Canadians, such as Canada’s Food Guide to• Plant oils, such as olive oil, canola oil sugar (sucrose). Complex carbohydrates Healthy Eating, is scientifically sound. The DRIs• Fish oils from fatty fish such as tuna and are the longer chain sugars most often will also be used to assess the nutrient intakes salmon found in vegetables, grains, and starches. of Canadians. The functional indicators used• Flaxseed and walnuts Now a new classification system, called to establish the DRIs will be considered when glycemic index, is emerging based not interpreting the dietary assessment.Less Healthy Fats on chain length but instead on how fast• Animal fats, such as butter, high-fat carbohydrates are broken down into The DRIs are published as a series of reports by cheeses, beef tallow, and high-fat red glucose in the digestive process. the National Academy Press. The reports can be meat viewed online and ordered from the National The widespread dietary advice in the 1980s Academy Press at:Fats to avoid and 1990s was to reduce the consumption http://search.nap.edu/nap-cgi/naptitle. of simple carbohydrates and increase the cgi?Search=dietary+reference+intakes.• Trans fats found in processed foods consumption of complex carbohydrates. such as cookies, crackers, and snack Between 1991 and 2001, the consumption food of all carbohydrates, both simple andHowever, it should be noted that all fats complex, increased by 15 per centare high in calories; therefore, even when (Statistics Canada, 2002). The increase inconsuming healthier fats, if more calories carbohydrate consumption in the form ofare consumed than are burned off, weight sugar consumption and its relation to ill-gain will result, leading to potential health health and obesity is discussed in greaterrisks. detail in Chapter 3. Despite the complex science surroundingCarbohydrates carbohydrates, there is fairly simple adviceCarbohydrates are a group of compounds that has remained remarkably consistentderived from plants, which include simple over the years: Eat plenty of wholeand complex sugars, starches, and fibre. grains, fruits, and vegetables, and reduce processed food. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 9
  • 31. Chapter 1: Nutrition and Health Proteins positive results (Yancy, Olsen, Guyton,Trans Fats Bakst, & Westman, 2004; Dansinger, Protein is important for the building, Gleason, Griffith, Selker, & Schaefer, 2005).Trans fats are artificially created by heating maintaining, and repair of body tissues.liquid vegetable oils with hydrogen. They It is the building block of our structural One salient fact has been illuminatedusually appear as “hydrogenated vegetable elements such as bones, muscles, and by the popularity of high-protein, low-oils” on food labels. Over the last 30 years, cells, and is important in the body’s natural carbohydrate eating: protein and fat tendthis man-made fat has become ubiquitous defense system against disease. Over to be more satiating than carbohydratesin processed food such as cookies, crackers, the last decade, an increasing scientific (Yancy et al., 2004). Therefore, eating apotato chips, french fries, and other snack focus has been on the role proteins and balanced diet that includes some healthyfoods such as microwave popcorn and frozen their relative proportions play in healthy fat and lean protein at each meal combinedpizza. Some trans fats naturally occur in the eating. This scientific interest has been with fruits, vegetables, and whole grainsmeat or milk of ruminant animals, such as beef fuelled by the popularity of high-protein, will be more satiating and sustaining, andand lamb, and research is starting to show that low-carbohydrate diets, specifically the can reduce the need to snack betweenthese natural trans fats do not have the same Atkins Diet. One major concern is that meals.harmful properties as commercially produced a high-protein, low-carbohydrate diettrans fats. deliberately puts people into a metabolic Micronutrients: Vitamins,Since trans fats have been linked to heart state called ketosis. In ketosis, fat isdisease, Canadian consumption of them is now Minerals, and Phytochemicals burned, creating harmful residues calledrecognized as a significant public health issue. ketones that can accumulate in the body, The intake of a wide range ofResearch over the last decade has found that micronutrients, including vitamins, potentially damaging the kidneys and othercommercially produced trans fats increase LDL organs (Duggirala & Mundell, 2003). A minerals, and phytochemicals (orand decrease HDL cholesterol (Hu, Manson, second concern is the limited amount of antioxidants) is essential to healthy& Willett, 2001). It is becoming increasingly vegetables, fruits, and whole grains on the growth and development. Deficiencies inclear that Canadians should drastically reduce,or eliminate, all trans fats. In November diets, and the long-term impact this may various vitamins and minerals can lead to2004, the federal government created a have on the risk of chronic disease and significant health problems, such as scurvymulti-stakeholder task force to develop cancers. (vitamin C), rickets (vitamin D), blindnessrecommendations and strategies to reduce (vitamin A), anemia (iron), weak bones Over the last four years, a number oftrans fats in Canadian foods to the lowest (calcium), or spina bifida (insufficient folic randomized controlled trials have shownlevels possible. The total trans fat content acid in pregnancy). that while initial weight loss is generallyfor all vegetable oils and soft, spreadablemargarines sold to consumers or used as an more rapid on the high-protein diets, after In recent years, research has shown thatingredient in the preparation of foods on site a year, there was no difference between the phytochemicals may also be equallyby retailers or food service establishments amount of weight lost or blood lipid levels essential to good health. Found inshould be limited to 2 per cent of total fat. The compared to a low-fat, high-carbohydrate plants, these compounds include beta-total trans fat content of all other foods should diet (Samaha, et al., 2003; Foster, Wyatt, & carotene (found in carrots and otherbe limited to 5 per cent of total fat content Hill, 2003; Stern et al., 2004). Limitations of orange fruits and dark green vegetables),(Health Canada, 2006). Due to new nutrition studies were high dropout rates (greater lycopene (found primarily in tomatoes),labelling and public awareness, manufacturers than 34 per cent for both diets) and and flavonoids (found primarily in soyhave started to eliminate unnecessary trans low compliance to both diets by study products). By eating a wide array offats from their products. participants (Ware, 2003). In more recent colourful fruits and vegetables—orange, studies, similar results were found, and it yellow, red, green, blue, and purple— was concluded that it is not the individual people will be exposed to the unique components of the diets, but overall caloric array of phytochemicals, as well as restriction leading to weight loss that was essential vitamins, minerals, and fibre probably the major factor leading to some that each colour has to offer alone and 10 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 32. Chapter 1: Nutrition and Healthin combination. There is evidence that is common. In a separate analysis of the BCphytochemicals, particularly beta-carotene, Nutrition Survey data (Barr, 2004) it was The “Low-Carbohydrate,lycopene, and minerals and vitamins found that: High-Protein” Dietsuch as vitamin E, may be more effective • 46 per cent of the population had The low-carbohydrate, high-protein diet waswhen consumed in foods than taken taken one or more supplements on promoted as early as the 1960s as a way toas a supplement (Willett & Stampfer, the previous day and 64 per cent in the rapidly lose weight and improve cardiovascular2001). These phytochemicals may be one previous month. disease (Atkins, 1998). The diet gainedreason why the consumption of fruits popularity in the 1980s, but after some relatedand vegetables is so beneficial to health • Of those who took supplements, the deaths it dropped out of favour until it wasand seems to ward off cancer and other majority were taking only one or two reinvented and promoted as the New Atkinsdiseases. See Chapter 3 for more discussion supplements, but almost 25 per cent Diet.about dietary links to specific diseases. had taken four or more supplements on The Atkins Diet, which heavily restricts the previous day.For decades, the nutritional advice for the carbohydrates and promotes the consumptiongeneral population has been that if you are • Supplement use was more common in of unlimited protein and fat, has been highlyeating from the four food groups according women than men and in adults over the controversial among health professionals,to Canada’s Food Guide to Healthy Eating age of 50 compared to younger adults. some of whom charge that the diets areyou do not need extra vitamins or minerals dangerously high in saturated fat, compromise • Daily multivitamins were the most vitamin and mineral intake, and risk causingin the form of supplements to get enough common supplements consumed cardiac, renal, and liver abnormalities if peopleof these beneficial micronutrients. The but many people reported taking follow them for longer than a few months (St.results of the 1999 BC Nutrition Survey non-vitamin supplements such as Jeor et al., 2001). One of the most controversialfound that the majority of diets in BC are glucosamine and/or chondroitin recommendations of the Atkins diet states thatlow in the recommended dietary intakes of during the induction phase of the diet, one can sulphate, garlic, various oils, echinacea,many essential micronutrients: eat all the bacon, eggs, steak, and other high- and gingko biloba.• Many adults have inadequate dietary fat, high-protein foods one wants, but must • Supplement use was contributing to the not eat fruits, grains, or vegetables. intakes of folate, vitamins B6, B12, and nutritional inadequacy of the diets but C, magnesium, and zinc. Despite the more than 30 years of public in some cases (such as seniors) more popularity—and the lasting, vociferous• Intake of calcium and fibre was below supplements such as vitamin B12 might scientific opposition against it—there is little recommended levels for all adults. be needed for seniors. scientific evidence about the health impacts,• 10 to 14 per cent of pre-menopausal The BC Nutrition Survey authors concluded whether positive or negative (Ware, 2003). women had inadequate iron intake. that due to the degree of supplement use, recommendations for supplement use in• Almost half of BC seniors who future dietary guidance, such as Canada’s completed the survey reported that Food Guide to Healthy Eating, should be they did not obtain enough folate and included. Education regarding effective 16 per cent had low levels of vitamin use of supplements and potential adverse B6. effects from excessive supplements should• Between 10 to 21 per cent of BC seniors also be addressed. did not receive enough vitamin B12. We know that the same health benefits ofPerhaps because many people believe they eating a variety of healthy foods varied inare not getting adequate nutrition in their colour and nutrients cannot be achieveddaily food choices, supplement use in BC by taking a vitamin or mineral supplement. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 11
  • 33. Chapter 1: Nutrition and Health For most British Columbians, taking a daily The incidence of rickets began to fall byGlycemic Index (GI) multivitamin/multimineral compound is the early 1970s and soon after was virtually safe and probably helpful to their overall eliminated (NAS, 2003).The glycemic index was conceived in the early health, particularly if diets remain poor.1980s by Dr. David Jenkins from the University Canada, the United States, Chile, and Others such as pregnant women andof Toronto. The index measures how fast a Australia began adding folic acid to flour seniors, as described later in this chapter,carbohydrate is converted to glucose through in the late 1990s (Honein, Paulozzi, need extra micronutrients. The best advicethe digestive process. Some carbohydrates Mathews, Erickson, & Wong, 2001). Withinbreak down into glucose very quickly and are is still to get the majority of your vitamin a few years, neural tube defects such assaid to have high glycemic indexes. Others and mineral needs from a well-balanced spina bifida in newborns had dramaticallybreak down more slowly, produce more gentle diet; however, it should be noted that decreased, by at least 20 per cent and upincreases, and require less insulin to transport supplements do decrease the level of to 54 per cent in some locales (Gucciardi,the glucose into cells. The overall glycemic nutritional inadequacies in the population. Pietrusiak, Reynolds, & Rouleau, 2002;response (or glycemic load) is how much sugar Persad, Van den Hof, Dubé, & Zimmer,is released into the bloodstream at once. It can Food Fortification to Improve 2002). As was noted in the 2002 Provincialbe influenced by how much carbohydrate is inthe food, how much you eat, what foods are Health Health Officer’s Annual Report on thepaired together, and how the food is cooked. Health and Well-being of People in British Adding vitamins and minerals to commonThe following are the glycemic index levels of Columbia, folic acid fortification also food staples is a proven public healthsome common foods: appears to be good for adult health, as it technique to correct identified nutritional has been linked to a decrease in vascularLow glycemic index: deficiencies at a population level and disease (blood clots and hardening of the promote better health. Food fortification• skim milk, plain yogurt, apple, orange, arteries) as well as a decrease in cancer, has a long history in Canada and is plums, pinto beans, lentils, chickpeas, particularly colorectal cancer (Bailey, generally a public health success story. peanuts, peaches, pumpernickel bread, all- Rampersaud, & Kauwell, 2003). bran cereal. Canada began its food fortification history The benefits of folic acid fortificationMedium glycemic index: with the voluntary addition of iodine in salt have led some public health experts to in 1949 (the United States had done this• banana, pineapple, new potatoes, popcorn, advocate for an increase in folate levels in 1924). This addition was responsible brown rice, whole wheat bread, shredded (Oakley, 2002). However, authors of a for virtually eliminating goiter, a common wheat cereal. recent Canadian study note that more thyroid disorder (National Academy of population-based studies are needed toHigh Glycemic Index: Sciences [NAS], 2003). In 1944, following further assess the effects of fortification of studies that found a high percentage of the• white rice, baked white potatoes, flour, to determine whether fortification population were suffering from nutritional cornflakes, rice crispies, white bagel, most levels should be increased, and to rule out crackers, french fries, table sugar. deficiencies, Newfoundland introduced whether or not it would mask pernicious the mandatory fortification of flourFor more information, please contact the anemia (vitamin B12 deficiency) in older with calcium, iron, and B vitamins, andCanadian Diabetes Association at: adults (Persad, 2002). fortification of margarine with vitamin A.http:// www.diabetes.ca/Section_About/ Soon after, this practice was adopted across In 1998, Canada began allowingglycemic.asp . Canada. manufacturers of soy and other vegetable “milk” products to voluntarily fortify To try and reduce the high incidence the drinks with between 6 and 15 of rickets, vitamin D was added to milk micronutrients. This voluntary fortification products beginning in the 1950s—first offers more options for consumers to gain dried, then evaporated, and then fluid milk. nutritional benefits from milk alternatives. 12 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 34. Chapter 1: Nutrition and HealthDietary Needs at Specific Life affects how the baby grows in uterus, asStages well as during breastfeeding. There is Benefits of Breakfast some indication that appropriate fetal andAt certain times in our life we have greater infant nutrition and growth is essential for For decades, the common wisdom has beenor lesser needs for calories and nutrients: helping to prevent chronic diseases later in that eating breakfast is better than goingduring pregnancy and lactation, infancy, without, but few studies actually examined life—many researchers use the phrase “fetaland advancing age, for example. This can the impact on weight and nutritional status. origins of adult disease.”alter the concept of what is considered a The 1999 BC Nutrition Survey examined thehealthy diet for any specific life stage. The Canada’s Food Guide to Healthy Eating relationship of eating breakfast with body forms the basis of a healthy diet for women mass index (BMI) and nutritional status ofdietary needs of children and adolescents, during pregnancy and breastfeeding; survey subjects.particularly the relationship between dietand the growing concern over obesity rates, the guide recommends that this group It found that 85 per cent of participantsare discussed in more detail in Chapter 3. consume additional servings from the consumed breakfast, with women slightly grain, vegetable/fruit, and milk products outnumbering men (87.5 per cent to 81.8 perPregnancy and Breastfeeding food groups. Typically, pregnant and cent). There was no difference in BMI between breastfeeding women need to eat three breakfast eaters and non-eaters; however,An increase in both calories and nutrients regular meals a day and at least three breakfast eaters consumed more fibre andare needed to meet the physiological snacks to meet their nutritional needs. more nutrients, particularly more of vitaminsdemands of both mother and child Women should pay particular attention to C, B6, and A, and iron, magnesium, calcium,to support a healthy pregnancy and the following key nutrients that support phosporus, thiamin, riboflavin, and potassiumbreastfeeding. The mother’s nutrition (Barr, 2006). healthy moms and babies. Figure 1.5 Neural Tube Defects, BC, 1983-2002 Number of Cases Although there are limitations to BC’s data 1.8 collection on neural tube defects, it appears400 Number of Cases Rate per 1,000 births that the BC rate has declined significantly since350 1.6 the mid-1990s, an indication of the results of the fortification of flour with folate and the 1.4300 inclusion of an appropriate amount of folic acid Rate per 1,000 total births 1.2 in multivitamins (Figure 1.5).250 1200 0.8150 0.6100 0.450 0.2 0 0 1983-1987 1988-1992 1993-1997 1998-2002 Source: BC Vital Statistics Agency, Ministry of Health, Health Status Registry Report, 2002. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 13
  • 35. Chapter 1: Nutrition and Health • Folate (folic acid): Found in leafy arising from the release of the DietaryBaby’s Best Chance green vegetables, as well as in dried Reference Intakes is that calcium peas, beans and lentils, whole grain absorption adapts during pregnancy toTo ensure the best outcomes for mom and help meet fetal needs, so that women cereals, nuts, and orange juice, folicbaby, the BC Ministry of Health produces acid is an essential nutrient that has need only to meet the minimumBaby’s Best Chance, a handbook given to been linked to a reduction in birth requirements for calcium for theirall expectant mothers in BC. Now in its defects, particularly neural tube specific age group. Many women dosixth edition, it provides a host of valuable defects (spinal cord, spina bifida, brain not meet these requirements and needadvice on pregnancy and birth, includingrecommendations on what to eat for a healthy development) (Wharton & Booth, to increase their intake by increasingpregnancy and while breastfeeding. For more 2001). Inadequate folic acid intake has consumption of milk products, calcium-information, please refer to http://www. also been associated with congenital fortified soy beverages, dark green leafyhealthservices.gov.bc.ca/cpa/publications/ heart malformation, cleft palate, limb vegetables, and/or taking a calciumbabybestchance.pdf. malformations, and digestive and supplement if it is not possible to get urinary tract malformations (Czeizel, enough calcium through foods and 1996; Shaw, O’Malley, Wasserman, beverages. Tolarova, & Lammer, 1995). While it is • Iron: Many women start out their possible for a very careful eater to meet pregnancies with iron deficiency nutrient requirements through eating because of iron loss during folate-rich foods, it is recommended menstruation combined with diets that all women of childbearing age typically low in iron. Women’s iron (teenage years through to menopause) needs then increase during pregnancy, take a 0.4 mg folic acid supplement particularly in the second and third daily, generally through a multivitamin. trimester, when both mother and fetus The recommendations include all need iron for the development of blood women of childbearing age because supplies. A developing baby also stores it is critical that folic acid be taken iron for use after birth. A pregnant prior to conception and in the first woman is advised to take an extra 5 mg weeks of pregnancy. Even if a woman of iron in the second trimester and 10 is not trying to conceive, a pregnancy mg in the third trimester. It is difficult is possible, and so it is critical that the to consume that much iron through supplement be taken by all women food; therefore it is recommended that of childbearing age, not just those pregnant women take iron supplements trying to conceive. The recommended during pregnancy. supplement is 0.4 mg or more of folic • Essential Fatty Acids: Derived acid daily at least one month prior to primarily from vegetable oils, fatty fish, conception and throughout the first fish oils, and nuts and seeds, essential trimester. fatty acids are divided into two main • Calcium: Calcium is necessary to build groups: omega-3 and omega-6. They strong bones and tissues in the fetus are essential for the healthy neural and and to maintain the mother’s bone retinal development of the baby. An health. The previous recommendation amount of 1.4 grams per day of omega- of medical professionals was to 3 and 13 grams per day of omega-6 substantially increase calcium intake is recommended for women during during pregnancy. The new thinking pregnancy (IOM, 2005). 14 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 36. Chapter 1: Nutrition and Health Low Birth Weight Rates, Singleton and All Live Births, BC, 1986 to 2005 Figure 1.6 6% p = 0.004* Infants with low birth weight are more likely 5% to have increased risk of illnesses, and/or poor health throughout childhood. Low birth 4% p = 0.099* weight is often associated with a higherPer cent 3% chance of death within the first year of life. All Live Births In British Columbia, the number of live births 2% Singleton Live Births with low birth weight has increased in the Exponential last two decades. However, at the same time 1% the number of multiple births, particularly 0% for mothers over the age of 35, has increased significantly since the late 1980s. When we 92 00 01 90 94 96 03 89 93 99 02 88 91 04 05 86 87 95 97 98 19 20 20 19 19 19 20 19 19 19 20 19 19 20 20 19 19 19 19 19 Year consider singleton babies, which constitute the majority of births, the rate of low birth weight Source: BC Vital Statistics Agency babies has remained relatively stable since the Prepared by: Population Health Surveillance and Epidemiology late 1980s (Figure 1.6). * Log Linear Regression: All Live Births Slope = 0.005 (0.002 to 0.008 95% CI). Singleton Live Births Slope = -0.003 (-0.006 to 0.001 95% CI).• Adequate Fluids: Pregnant and pregnancy body mass index level. For nursing women need to take in at least more information, please refer to: 1.5 litres of fluid daily, primarily from http://www.healthservices.gov.bc.ca/ water and healthy beverages. Alcohol cpa/publications/babybestchance.pdf. should be avoided completely. Along with eating a healthy diet, pregnant• Food Safety: Food needs to be women should get adequate sleep and handled, stored, and cooked safely. regular, low-impact physical activity. Pregnant women should avoid raw or Smoking cessation and complete avoidance undercooked fish/meats, pâtés, soft or of all recreational drugs is essential. All unpasteurized cheeses, many herbs, prescription and over-the-counter drugs and unwashed fruits and vegetables, should only be taken under a doctor’s to avoid the common causes of food supervision. poisoning. Pregnant women, women of childbearing years, and young children Low Birth Weight Rates should limit their consumption of Infant weight at birth can tell us about predator fish such as shark, swordfish, the current and future health of the or fresh [not canned] tuna to once per child, as well as the general health of the month, as there is concern over the mother. Low birth weight is considered levels of mercury in these fish (Health to be a weight below 2,500 g (5.5 lbs) Canada, 1999). for a newborn, and is often associated• Overall Weight Gain: The with premature birth (before 37 weeks recommended amount of weight gain gestation). Many complex, inter-related varies according to the mother’s pre- factors have a bearing on the birth weight Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 15
  • 37. Chapter 1: Nutrition and Health of an infant, including overall nutritional Recently both the World HealthCanadian Journal of Public Health and general health of the mother as well Organization and Health Canada releasedSupplement on Determinants of as prenatal care, age, economic status, position papers recommending thatHealthy Eating ethnicity, partner abuse, fertility drug use, women exclusively breastfeed until six and smoking. Teenage mothers and first- months, and continue breastfeeding withIn 2005, a series of articles were commissioned time mothers over the age of 35 tend to complementary foods to two years of ageby Health Canada’s Office of NutritionPolicy and Promotion to further look at the have lower birth weight babies. and beyond. This recommended durationdeterminants of healthy eating across Canada. of exclusive breastfeeding represents While the proportion of low birth weightThe articles were published in a special an increase of two months from prior babies born each year has remained stablesupplement to the Canadian Journal of Public recommendations (WHO, 2004; Health for two decades, improvement can beHealth entitled Understanding the Forces that Canada, 2004c). made, particularly in some sub-populationsInfluence Our Eating Habits: What We Know and such as Aboriginal families, and in specific The vast majority of babies in BritishNeed to Know (2005). The papers highlightedthe need for more research into the individual regions of BC. For example, for the Columbia are now breastfed for at least aand collective determinants of healthy eating. period of 1986 to 2002, the Vancouver few weeks of life. The National LongitudinalSome of the many issues documented by the Health Service Delivery Area had a greater Survey of Children and Youth (Statisticssupplement and also identified as challenges prevalence of low birth weight infants Canada, 1999b) found that 93.1 per centto healthy eating in British Columbia are: than the provincial average for all years, of children aged 0 to 3 years in BC were except 2001. As data for low birth weight is breastfed for at least some portion of life,• The impact of advertising and mass media recorded by the mother’s usual residence, compared to the Canadian average of 79.9 on choice. this higher prevalence is not a by-product per cent.• The relationship between socio-economic of high-risk mothers coming to Vancouver’s status and diet. The benefits of breastfeeding include: tertiary hospitals to give birth. Instead,• Issues around aging and its impact on the it may be related to socio-economic • Reduction in gastrointestinal ability to eat well. factors, including low income, smoking infections: Formula-fed infants and by the mother during pregnancy, poor toddlers experience more frequent and• Barriers to healthy eating among Aboriginal diet, pregnancy-induced hypertension, severe stomach upsets and infections people. and multiple births. The trend of women (Kramer et al., 2003).• The relationship of self-esteem and body postponing pregnancy until age 35 or older • Improved cognitive and motor image to food selection. can also be a factor as these women are development: Preliminary researchThese important synthesis papers, combined more likely to have pregnancy-induced shows that children who are formula-with the results of the BC Nutrition Survey, hypertension and gestational diabetes. fed do not perform as well on cognitiveoffer a point from which to build and and motor development tests at 18implement a broader strategy to enhance, Infancy and the Toddler Years: The Need for months (Morley & Lucas, 1997).promote, and support healthy eating in British Extended BreastfeedingColumbia and Canada. For more information, • Appropriate growth, and potential Breastfeeding provides the essentialplease refer to the website at: http://www. reduction in obesity in future nutrients for healthy growth andhc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/ years: Formula-fed children’s growth development and provides antibodies topdf/nutrition/volume_96-S3-e.pdf patterns vary from breastfed children. protect against infection and allergies. An increasing body of research is Experts agree that human breast milk showing a strong likelihood that contains the optimal balance of nutrients breastfeeding may provide protection needed for brain and body growth of young against obesity in childhood, children (McCain & Mustard, 1999). adolescence, and adulthood (Dewey, 2003; Fewtrell, 2004). 16 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 38. Chapter 1: Nutrition and Health• Improved jaw and dental • Adequate hydration: Since thirst, development: Formula-fed infants along with appetite, can decrease with Keeping Well-Hydrated: Water is have more problems with crowded age, the elderly often do not get the the Best Choice teeth and typically experience more cues to tell them they are becoming An essential part of a healthy diet is dental decay in childhood. dehydrated. The daily recommendation consuming enough fluids to keep the body is for seniors to drink eight or moreWhile the health benefits of breastfeeding well-hydrated, particularly during physical glasses of fluid from water, milk, juice, activity or when temperatures are hot. Youngare increasingly clear, the barriers or and soups, even if they do not feel children and seniors are most susceptible tochallenges to continued breastfeeding thirsty. Fluids are also important in dehydration, particularly through illness orneed to be examined in order to support preventing constipation, particularly if high temperatures. Each person has differentlonger duration rates. A return to work fibre intake is increased. fluid needs, but the United States Institute ofand unsupportive environments for Medicine suggests 3 litres a day for a man andbreastfeeding are reasons women stop • Vitamins D and B12: The ability 2 litres a day for a woman (IOM, 2004).breastfeeding. In some cases, untrained to convert sunlight to vitamin Dor unsupportive health professionals may diminishes with age. The daily Fluids can come from many sources, includingencourage a mother to stop. As noted recommendation from the Dietary milk, soups, coffee, tea, and juices inin the 2002 Provincial Health Officer’s Reference Intake Standards is 800 IU. moderation. Sugary pops should be reduced orAnnual Report, more women might The ability to absorb vitamin B12 from avoided completely. The best source of fluids is plain water.continue breastfeeding after six months if food through the digestive process alsoemployment policies were more flexible diminishes with age. All individuals over You will know if you are consuming the rightor if a special room was set aside to enable the age of 50 are recommended to take amount of water if your urine is typically anursing mothers to express milk at work a synthetic form of vitamin B12. The BC very light yellow, of normal quantity, and you(Provincial Health Officer [PHO], 2003). Nutrition Survey found that more than feel well. Darker urine and less urinary output 50 per cent of all those 50 years of age suggests you need to drink more water (MayoDietary Needs During Senior Years and older did not take B12 supplements Clinic, 2006). a month before the survey.As we age, our body processes slowdown, reducing our need for calories Social isolation and a decreasing ability or Sign Up for Allergy Alertsand reducing our appetite. This can be desire to prepare meals can be a barriera challenge for seniors, who often have to healthy eating in seniors. This can be Families and individuals with severe foodincreased needs for nutrients, but are often addressed by eating meals in groups, allergies can sign up with the Canadian Foodeating less calories. Individuals who are 70 and other initiatives to ensure nutritious Inspection Agency (CFIA) to receive recall notices when allergens unexpectedly appearyears of age or older should ensure they meals for seniors are easily accessible and in foods.have the following elements in their diet. enjoyable for all aging citizens. All food manufacturers must list ingredients• Nutritionally-dense food: Due to a reduction in appetite, choices should Food Allergies in their foods but sometimes during manufacturing, allergens such as peanuts may include lean meats, whole grain foods, An estimated 4 to 8 per cent of children and contaminate a product that is usually peanut- a wide range of dark green and orange 1 to 2 per cent of adults have one or more free. Through the CFIA, a recall is issued to vegetables, and milk products. food allergies. Food allergies occur most immediately take the product off the store often in families with a history of other shelves. To subscribe to the free alerts, please• Increased fibre: The elderly often allergic disease, such as asthma, eczema, visit: http://www.inspection.gc.ca. suffer from constipation, so increasing fibre intake can improve digestive and nasal allergies (Al-Muhsen, Clarke, & function. Kagen, 2003). A list of eight foods account for 90 per cent of all food allergies: cow’s Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 17
  • 39. Chapter 1: Nutrition and Health milk, eggs, soy, wheat, peanuts, tree nuts to be quite rare, (1 in 3,000 individuals)Grapefruit Juice: Food-Drug (walnuts, almonds, etc.), fish, and shellfish but the introduction of a range of newInteractions (Al-Muhsen et al., 2003). Symptoms of food blood tests has shown that the disorder allergies involve a variety of systems in the is much more common, affecting atGrapefruits are healthy food choices, packing body. While the majority of food allergies least 1 in 250 North Americans (Sandera lot of vitamin C, but research has found that are not life threatening, anaphylaxis is the et al., 2001; Farrell & Kelly, 2002) andthey should not be consumed with a growing most serious systemic reaction; it includes perhaps as many as 1 in every 111list of drugs, including heart and cholesterolmedications, Viagra, some antihistamines, and breathing difficulties, severe swelling of the people in the United States (Fasano,antidepressants and anti-anxiety drugs. throat, face, and appendages, and heart 2003; Israel, Levitsky, Anupindi, & stoppage (Ellis & Day, 2003). Deaths from Pitman, 2005). Many of these peopleA compound in grapefruit called food anaphylaxis most often occur away may have very vague symptoms thatfuranocoumarin inhibits an enzyme in the from home when the individual consumes bring them repeatedly to the doctorsmall intestine, which can lead to a dangerous a food unknowingly and then delays or with complaints such as irritable bowelbuild-up of drug concentrations. Patients does not use an epinephrine injection disease, infertility, patchy hair loss,should consult with their pharmacist aboutpossible grapefruit juice/drug interactions. (Sampson, Medelson, & Rosen, 1992). anemia, depression, delayed puberty, and itchy skin blisters called dermatitis All individuals with potentially fatal food herpetiformes (Fasano, 2003). In allergies should carry an Epi-pen® (an absence of the typical symptom of auto-injector of epinephrine), read food diarrhea, it can take years for the labels very carefully, and strictly avoid disease to be properly diagnosed the allergen. In the case of children with (Farrell & Kelly, 2002; Israel et al., severe allergies, suspect foods such as 2005). Within two weeks of eating a peanuts may be restricted in the school gluten-free diet, and strictly avoiding setting, particularly in the youngest grades; food products that contain any wheat, however, researchers note that while this barley, and rye or their derivatives, an can reduce the chance of exposure, it does individual with celiac disease will begin not eliminate it. Therefore, when children to show improvement (Farrell & Kelly, with severe food allergies attend a school, 2002). all staff must know how to identify and manage an anaphylactic reaction and have • Lactose Intolerance: Lactose a wide range of other precautions in place intolerance is an inability to digest (Canadian Society of Allergy and Clinical the sugar lactose, which is a major Immunology, 2005). component of milk and milk products. It arises in individuals with a deficiency Other conditions such as celiac disease and in an enzyme called lactase, which lactose intolerance also affect between 1 breaks down lactose into glucose in the and 5 per cent of the BC population. small intestine so it can be absorbed • Celiac Disease: An autoimmune in the bloodstream. The individual condition triggered in genetically has bloating, pain, gas, diarrhea, and susceptible individuals by eating the intestinal discomfort, usually about 30 gluten in wheat, barley, and rye, celiac minutes after drinking milk or dairy disease causes damage to the lining of products. Canadians of First Nations, the small intestine, typically causing African, or Asian descent have a higher diarrhea, bloating, and malnutrition. Up prevalence for lactose intolerance than until about 10 years ago, it was thought those of European descent. Those with 18 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 40. Chapter 1: Nutrition and Health mild sensitivities can generally consume milk products, especially fermented ones such as yogurt and cheese, Genetic Disorders and Food in small amounts with meals. For those with a stronger sensitivity, there are products available that contain an Favism: For people with a genetic mutation for an enzyme called G6PD (glucose-6-phosphate dehydrogenase), a simple dish of broad beans (fava enzyme that breaks down lactose, making milk products beans) may provoke sudden destruction of red blood cells and lead to hemolytic accessible to all but milk-allergic individuals. Some people anemia and jaundice and possible death. It is the most common enzyme prefer to use calcium and vitamin D supplements to disorder in the world, affecting primarily people in Africa, the Mediterranean, replace the key nutrients they are missing from their daily and Asia, and is thought to confer protection from malaria (WHO, 1989). People food intake. Given that osteoporosis is very common with the genetic mutation must be careful of certain drugs, particularly sulfa and the incidence is growing, it is crucial that British drugs and anti-inflammatories. For more information, please refer to the G6PD Columbians ensure they are getting adequate calcium and Deficiency Favism Association at http://www.g6pd.org. vitamin D. Hemochromatosis: An inherited genetic disorder most common in people ofWhenever a genetic disorder or food intolerance requires a Northern European descent, it causes too much iron to be absorbed from food,person to limit a food group, a Registered Dietitian should be leading to iron build-up in organs, joints, and tissues, leading to debilitating andconsulted to ensure that nutrient deficiencies are prevented. potentially fatal conditions such as diabetes, arthritis, liver and kidney damage,Dial-A-Dietitian is an excellent first contact for any questions and even organ failure. It is the most common inherited disorder in Canada butabout food intolerance or allergies. You can reach Dial-A- is often undiagnosed. Treatment comes from limiting iron in the diet, removingDietitian at: 1-800-667-3438, or 1-604-732-9191 for Vancouver. blood in a series of sessions until blood iron is at normal levels, and then regular removal of a pint of blood every few months for life. People with the condition oppose the fortification of iron in common foods, such as cereals and bread. ForPhysical Activity more information, please refer to the Canadian Hemochromatosis Society atRegular physical activity plays an essential role in http://www.cdnhemochromatosis.ca.complementing healthy eating and ensuring maximum health Phenylketonuria: Phenylketonuria is a genetic disorder found in about 1 inbenefits. Eating healthy food goes hand-in-hand with moving every 15,000 births in BC. It creates a deficiency in an enzyme needed to breakour bodies, stretching our muscles, and increasing our heart down a common amino acid, phenylalanine, found in almost all proteins. Arates on a daily basis. screening blood test was created in 1964 and now every baby in North America is tested after birth. Those with the deficiency can lead a normal life if theyRegular physical activity not only burns calories, thus eat a very low-protein diet, avoid aspartame, and take a specific amino acidpreventing weight gain, but can also help delay or prevent supplement.many serious illnesses and chronic conditions. Physical activityimproves sleep, increases energy levels, and helps reduce Galactosemia: This rare disorder (1 in 80,000 births) is a recessive genetic condition that leads to a deficiency in an essential enzyme that breaks downstress, anxiety, and depression. The health risks of inactivity galactose, a milk sugar. All newborns are tested in BC and an infant who hasinclude premature death, heart disease, obesity, high blood inherited a gene from parents must be placed on a strict diet avoiding all lactosepressure, Type 2 diabetes, osteoporosis, stroke, depression, and galactose, mostly from dairy products. Although the child may lead aand colon cancer. relatively normal life, long-term complications are still possible.Although British Columbians are the most active in Canada,the majority are not active enough to benefit their health.The 1999 BC Nutrition Survey found that 61 per cent ofparticipants did no strenuous activity, and 36 per cent did nomoderate exercise during their leisure time. However, 80 percent believed they were getting enough activity. This falsebelief creates a barrier to encouraging British Columbians tobecome more active (MOHP, 2003). Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 19
  • 41. Chapter 1: Nutrition and Health Statistics Canada’s National Population • Strength: Two to four days a week,Canada’s Physical Activity Guide Health Survey and its Canadian Community adults should do resistance activities Health Survey reported similar results; such as weightlifting or resistanceHealth Canada, through the Public Health these surveys found that two-thirds of training to strengthen muscle and boneAgency of Canada (PHAC) and the Canadian Canadians and 50 per cent of British and improve posture.Society for Exercise Physiology, has created an Columbians are inactive. Among the mosteasy-to-use physical activity guide, similar in British Columbia has set the goal for 2010 concerning finding is that 50 per centlook to Canada’s Food Guide to Healthy Eating. of being one of the healthiest jurisdictionsFeaturing a similar colourful rainbow, the of BC children are not active enough to to ever host an Olympic Games. With ourguide gives a pictorial representation of the obtain health benefits. Societal changes beautiful, natural physical environment, ourtypes of endurance, flexibility, and strength have meant that most children spend more relatively mild and inviting climate, and theactivities Canadians should do on a regular time watching television and playing video huge range of physical activity available tobasis. games than playing outdoors. us in the province, we should all make theThe two-page guide, which is designed to be Any physical activity is better than none effort to engage in some form of physicalposted on a refrigerator, can be downloaded at all and even 10 minutes of walking, 3 activity.from the Physical Activity Unit of the PHAC times a day, or taking the stairs instead ofwebsite. Guides specifically aimed at children, the elevator, can start sedentary people in Summaryyouth, and seniors have also been created. For the right direction. However, for adults, itmore information, please refer to: http://www. is recommended that for maximum health • Despite a host of different styles ofphac-aspc.gc.ca/pau-uap/paguide/. healthy eating, the components of a benefits they should build up to 60 minutes of moderate, daily physical activity. If the healthy diet are very similar: lots of activity is vigorous, 30 minutes, 4 times a whole grains, fruits, and vegetables, week, can confer health benefits. Children with moderate amounts of healthy fats should have 90 minutes of moderate to and lean protein, such as from milk strenuous activity each day. products, nuts, seeds, fish, chicken, eggs, beef, beans, tofu, or other Adults should have a mix of the following vegetarian protein sources. physical activities: • For more than 50 years, Canada’s • Endurance (or aerobic) activities: Food Guide to Healthy Eating has been Four to seven days a week, adults helping Canadians make healthy food should engage in continuous activities choices based on the best scientific that raise the heart rate and condition knowledge of the day. The current the heart, lungs, and circulatory system revision of the Food Guide, now such as climbing stairs, brisk walking, underway, will continue this tradition biking, swimming, dancing, jogging, or and attempt to reflect the changing cross-country skiing. nature of Canadian society. • Flexibility: Four to seven days a • The determinants of healthy eating— week, adults should engage in gentle why some British Columbians eat stretching, bending, and reaching to a more healthy diet than others—is keep muscles and joints flexible and highly complex and linked to a number limber. of inter-related factors. Time, effort, knowledge, skills, education, age, socio- 20 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 42. Chapter 1: Nutrition and Health economic level, family patterns, culture, • The fortification of food supplies with and many other factors all link together micronutrients, such as iron, vitamin Rx: 10,000 Steps to influence healthy eating. D, B vitamins, and folic acid, over the last 40 years has been a public health The journey to physical health could start with• The three “macro” components of a journey of 10,000 steps every day. Walking success story that has reduced disease healthy eating—fats, carbohydrates, 10,000 steps—about 8 kilometres—every and improved health. Health Canada and proteins—have been the focus day is becoming a popular fitness slogan is making revisions to fortification of extensive nutritional research in in North America. All it takes is a good pair policies, which will give manufacturers of walking shoes, a pedometer to measure the past few decades. Now there is a more leeway to fortify foods (Health steps, and the commitment to get out and growing understanding that some fats Canada, 2005a). walk. A number of research programs are are healthy and an essential part of a now looking at the benefits (see http://www. healthy diet, particularly the essential • At various stages in life, particularly canadaonthemove.ca), but already studies in fatty acids found in plant oils, fish, and pregnancy, breastfeeding, infancy, and both North America and Britain are finding nuts. senior years, individuals require specific that a pedometer may be a very effective nutritional advice. More calories and motivational tool to show people their relative• Eating a small amount of lean protein nutrients are needed to produce and level of activity in a day and boost their activity at each meal can be more satiating and feed healthy babies. Infants should be to achieve greater health benefits (Dinger, prevent rapid changes in blood sugar, exclusively breastfed until 6 months Heesch, & McClary, 2005; Heecsh, Dinger, which in turn can lead to the decreased of age and then breastfeeding should McClary, & Rice, 2005). consumption of calories. continue as part of the diet until at least• While common nutritional advice for 2 years. Seniors need more vitamin B, Shapedown BC decades has advocated that adequate D, and calcium, and often need to use micronutrients—vitamins, minerals, supplements to get their nutritional Shapedown BC is a comprehensive program and phyotchemicals—can be consumed needs as their appetite declines. for the assessment and treatment of by eating a healthy diet, 50 per cent of childhood and adolescent obesity. Initiated • A diet that is healthy for most British by BC Children’s Hospital in Vancouver, BC, British Columbians take a multivitamin Columbians can be unhealthy for some Shapedown BC involves a team of health or other supplement each day. The British Columbians, particularly those professionals – physicians, dietitians, mental taking of supplements is important if with allergies and conditions. To avoid health professionals and exercise specialists individuals are consuming nutritionally nutritional deficiencies, registered – who offer counselling and group sessions. inferior diets. Research is showing dieticians should be consulted The components of the program include that a number of phytochemicals medical assessments, 10–week program whenever a specific health condition found in fruits and vegetables—such of one-on-one counseling, and education restricts a specific food group, such as as beta-carotene and lycopene and materials and resources on nutrition provided milk or wheat products. other antioxidants—are beneficial to by counselling professionals. health and are best consumed not by • Physical activity—about 60 minutes of Shapedown BC helps children, adolescents, supplements but by eating a diet rich in moderate activity for adults each day—is and their families develop healthier attitudes fruit and vegetables. an essential complement to healthy towards nutrition and physical activity eating. with the goal of achieving healthy weights. Shapedown BC has achieved positive results and is intended for implementation in all regional health authorities in the near future. For more information, please contact www. actnowbc.gov.bc.ca. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 21
  • 43. Chapter 2: The Agriculture and Food Processing Sector in British ColumbiaOnly three per cent of BC’s landmass is arable farmland. discussion about food production in relation to food security.Nevertheless, that small proportion supports more than 200 Commercial fisheries are the fourth largest primary industrydifferent crop commodities. According to Smart Growth in the province—after forestry, mining, and agriculture—andBC, a provincial non-governmental organization devoted to generate about $364 million annually. Seafood processing offiscally, socially, and environmentally responsible land use both wild and farmed fish accounts for almost 20 per cent ofand development, BC’s agricultural products meet more than the value of BC’s food manufacturing industry (MAL, 2004b).50 per cent of provincial food needs and offer many options The province’s aquaculture industry is steadily growing infor a nutritious, locally grown diet (Smart Growth BC, 2004). importance, producing everything from farmed AtlanticIn 2001, there were 20,290 farms in BC covering 2.6 million salmon to Manila clams and Japanese scallops. Salmon, bothhectares (Ministry of Agriculture and Lands [MAL], 2005). wild and farmed, is by far the most dominant commodity inAgriculture is not just about producing food, however, as BC’s seafood industry, accounting for 44 per cent of the totalBC’s agricultural sector also produces thousands of jobs and value of all of BC’s seafood products. The annual total valuesupports the BC economy. In 2004, total farm cash receipts of BC’s seafood harvest, both farmed and wild, is almost $640reached $2.4 billion, and more than 297,000 people were million, and processed seafood products fetch about $1.1employed in agricultural-related services (MAL, 2005). billion wholesale (MAL, 2004b).BC’s livestock sector, which includes dairy, cattle, hogs, Despite the abundance of food produced in BC, the provincepoultry, eggs, honey, and fur and game-farm animals, imports $3.5 billion worth of farm and food productsaccounts for 42 per cent of BC farm cash receipts. Distinct (including fish) from other countries, and an additional $3.4areas of the province are home to different types of livestock billion from other provinces. If food security were measuredproduction. Hog, poultry, and egg production are primarily like trade deficits and surpluses, there would be an annualfound in the Lower Mainland, while beef cattle ranches are food security deficit of $1.9 billion with other provinces andconcentrated in the Cariboo and north Thompson-Okanagan countries (MAL, 2005). Importing large amounts of foodregions. Large dairy herds are mainly located in the Lower affects food security by:Mainland, southeastern Vancouver Island, and the Okanagan-Shuswap area. BC’s dairy industry generates more revenue • weakening the local food-producing economy;than any other component of the agricultural industry (MAL, • removing support for BC farmers, and secondary2005). producers and distributors;While not considered part of the agricultural sector per • increasing the amount of “food miles” for each food itemse, BC’s seafood industry occupies a key place in the BC which adds to the environmental impact of the food; andfood industry and economy and is rightfully part of any Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 23
  • 44. Chapter 2: Agriculture and Food Processing Sector in British Columbia • making the population more vulnerable The economics of farming in BC isBC Farming Facts to disruptions in food supply particularly relevant to food security and distribution. puts the issue of ALR land in context.• Of BC’s 94.78 million hectares of land and Protected agricultural land has little fresh water mass, only 3 per cent is suitable for agricultural use (MAL, 2004b). Protecting BC Farmland and meaning if local farmers cannot make a living wage from farming it. Farmers are• In 2001, BC had 20,290 farms covering 2.6 Supporting Farmers aging and it is difficult to find people to million hectares. Of this total, 618,000 Since only three per cent of BC’s total work in the fields, due to the low wages hectares is in crops (MAL, 2005). land base is suitable for agriculture, it that farmers must pay in order to make a• About 61,000 British Columbians live on is important to make the best use of it profit. In addition, property taxes and the farms (1.5 per cent of the population) (MAL, to produce food and other agricultural cost of water for irrigation can be high. 2005). products. The Agricultural Land Reserve The cost of farmland, especially near urban (ALR) was established by the provincial centres, is so high that new farmers cannot• More than 225 different agricultural government in the early 1970s, to ensure afford to get into the business. commodities are produced in BC (MAL, that land suited to agriculture was not 2005). Idle ALR lands adjacent to fast-growing developed or used for other purposes.• Agriculture produces about $22 billion in urban areas are especially vulnerable to Prior to the ALR’s creation, BC lost 6,000 consumer sales (MAL, 2005). development. At the time of this report, hectares of its best agricultural land each almost 4,000 acres of some of BC’s best year to development (Smart Growth BC, farmland were being considered for 2005). The ALR currently includes aboutBC’s Greenhouse Boom removal from the ALR for subdivisions 4.7 million hectares of the best classes ofBC has the third largest greenhouse production and business parks (Smart Growth BC, arable soil on both Crown and private landin Canada, after Ontario and Quebec. n.d.). While cheap, imported foodstuffs (Provincial Agricultural Land Commission, are obviously desirable from a consumerIn 2004, a total area of 2,310,844 m2 was n.d.). Boundaries have changed since the perspective, there are other issues to bedevoted to greenhouse production in BC. ALR’s inception, but the size of the reserve considered, including the benefits of localNinety-five per cent of the greenhouse has remained almost the same. production, the loss of local jobs, and theproduction is located on the Lower Mainland, From the point of view of increasing BC’s environmental costs of “food miles.”with the remaining on Vancouver Islandand the Interior. In 2004, 85 commercial food security, it is noteworthy that not all To support a local food supply and providegreenhouses were in operation in BC. The land within the ALR is farmed. Farming is healthy, nutritious food for the population,principal crops grown include tomatoes, bell encouraged, and non-farm use is restricted, there must be an infrastructure in placepeppers, cucumbers, and lettuce. Different but significant tracts of ALR lands are idle that supports local farmers and foodvarieties of plants and flowers are also grown due to a variety of factors. These include producers. Innovative programs suchin BC greenhouses (Ministry of Agriculture, the economic challenges of farming, as the Linking Land and Future FarmersFood and Fisheries, 2003). especially small-scale farming, and the group and the Small Scale Food Processors rising price of real estate in many parts ofIn 2005, total greenhouse sales were over $583 Association help to foster this initiative.million—a significant increase from $403 BC, particularly in farming areas adjacent tomillion in sales in 2000 (Statistics Canada, fast-growing urban centres in southwestern The public also needs to be better informed2000, 2005a). BC and the Okanagan. On Vancouver about food production and why it matters Island, for instance, only about one-half of to the economy, food security, and public ALR land is currently used for agriculture health. The BC program, Agriculture in the (Vancouver Island Agri-Food Action Plan Classroom, is an initiative designed to bring and Trust Strategy, as cited in MacNair, BC agriculture to students, and help young 2004). children understand the food system. 24 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 45. Chapter 2: Agriculture and Food Processing Sector in British ColumbiaThese types of initiatives will help protect evoke not just the distance food hasfarmland and make farming and food been transported, but also the underlying Making the Linksproducing a viable form of employment in environmental, economic, and social costsBC. of moving food ever greater distances from In 1994, a local organic farming community the farm gate to the dinner plate. in Victoria started a non-profit organization called Linking Land and Future FarmersFood Imports: Pros and Cons The seemingly limitless food choices (LLAFF), which helps match small-scaleA century ago, most of the food consumed come with a high environmental price organic farmers with landowners who wouldin BC was produced in the province; today, tag. As the food transportation industry like their land to be farmed.almost 50 per cent comes from outside expands to keep up with global demand, Although members must make their ownthe province. On Vancouver Island, the the food supply chain consumes an ever- matches, LLAFF offers other assistance todifference is even more pronounced. Just greater portion of non-renewable energy new farmers including a tool lending library,50 years ago, 90 per cent of Vancouver resources. The further food travels, the farming and education grants, sample leases,Island’s food was grown and processed by more it contributes to increased carbon and partnership planning information.local farmers; today, only 10 per cent of the dioxide emissions and global warming. Information is available at (250) 361-1747food eaten on Vancouver Island originates One study of food consumption in Iowa (mailbox 1).there (Haddow, 2001, as cited in MacNair, found a significant transportation savings Another new, innovative organization is the2004). and a corresponding reduction of up to 7.9 Small Scale Food Processors Association, a million pounds in carbon dioxide emissions province-wide group that aims to help createToday, BC consumers can choose from if just 10 per cent more of the produce value-added food products out of local fooda wide variety of foods for healthy meals. consumed in Iowa originated in an Iowa- sources, such as specialty cheese out of localRather than relying on canned, preserved, based regional or local food system (Pirog, dairy products. One of its programs, calledor frozen food during the winter months Van Pelt, Enshayan, & Cook, 2001). When the living inventory, links producers withas previous generations did, most British food travels long distances, extra packaging suppliers, such as a pumpkin pie maker withColumbians can choose fresh, flavourful, is often required, which uses fossil fuels for a local pumpkin grower. The organizationand nutritious foods year-round, regardless manufacturing and burdens waste disposal not only supports regionally based, small-of season. Indeed, consumers have come and recycling systems. A study in the scale food processing systems, but advocatesto expect that most types of fresh food will United Kingdom found that the real cost for supportive policies to foster the growthbe available year-round, and think little of of small-scale food producers. For more of a market basket of food would be 11.8buying New Zealand apples, Chilean sea information on the Association, please refer to per cent higher per week if the true cost ofbass, and Peruvian asparagus. Imported their website at http://www.ssfpa.net. food miles in environmental and societalfoods often have larger scale production, factors was included in the price (Pretty,lower labour costs, and longer growing Ball, Lang, & Morison, 2005).seasons, which makes them cheaper thanlocally produced fare (MacNair, 2004). Eating local food in season is the best wayPackaged foods from across the globe are to minimize the environmental impactalso available in BC in large quantities and of food and increase food security. Localvarieties. The average supermarket in BC food, in season, is fresh, flavourful, andstocks 25,000 different items, and that nutritious. Spinach and asparagus, fornumber keeps growing. instance, lose 50 per cent of their vitamin C content within 24 hours after pickingFood Miles (MacNair, 2004). Buying locally produced food also makes it easier for consumersThe concept of food miles is used to to trace exactly where their food comesmeasure how far food travels from from and how it is produced, improvingproducers to consumers. Food miles Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 25
  • 46. Chapter 2: Agriculture and Food Processing Sector in British Columbia confidence in the safety of the food SummaryOrganic Farming in BC system. With the burgeoning greenhouse • BC has a relatively thriving and production of fruits and vegetables in BC,BC leads Canada in organic farming. The successful agricultural, food processing, buying local means fresh produce can beprovince has an estimated 175 organic fruit and fisheries sector, but there are available out of the typical summer growingfarms, and 135 organic vegetable farms. vulnerabilities such as idle, productiveApples are, by far, the largest organic fruit season. Moreover, consumer support of farmland, urban pressures oncrop in BC, with an estimated 719 acres under local and regional foodstuffs helps BC productive farmland, and an increasingproduction; broccoli is BC’s largest organic farmers stay in business, ensuring that difficulty for BC farmers to make avegetable crop, with 124 acres devoted to its healthy and abundant food will be available decent living working the land.cultivation. BC has 12 non-organic fruit farms for future generations.for every organic farm, and 14 non-organic • BC’s Agricultural Land Reserve, Consumers can help increase food securityvegetable farms for every organic one. That administered by the Provincial and minimize environmental impacts incompares with a 62 to 1 ratio for fruit farms Agricultural Land Commission, hasand 82 to 1 ratio for vegetable farms in Ontario BC by using their purchasing power to been preserving BC’s best farmland(MAL, 2005). support BC farmers and fishers. The BUY for more than two decades. The BC program, launched in 1993 by the Agricultural Land Commission Act provincial government and private industry, must continue to reflect its purpose aims to increase consumer recognition of to preserve agricultural land despite BC products. More than 5,000 products existing pressures. with the BUY BC logo are now available at major grocery stores throughout the • BC imports more than 50 per cent province. Surveys show that three-quarters of its food, which means that British of BC consumers recognize the logo. Columbians have access to a wide Various farming organizations and coalitions range of fresh, nutritious foods at are creating logos or marketing strategies relatively cheap prices year-round. This targeted at consumers throughout the reliance on imports, however, leaves province. Promoting products that are the province vulnerable to potential grown and processed in BC creates more disruption in the food supply by job opportunities for British Columbians, physical, economic, or political factors reduces food miles, and strengthens the in other regions. economy. For more information on Buy BC, • Importing food also increases please refer to their website at http://www. “food miles”—the distance food bcac.bc.ca/buybc/. has travelled— which increases the environmental impact of that food, particularly through the use of non-renewable energy resources, excess packaging, and an increased contribution of carbon dioxide emissions. • BC’s food security can be strengthened by consumers using their purchasing power to buy BC-produced food products as often as possible. 26 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 47. Chapter 3: Impact of Unhealthy EatingDiet and Chronic Disease and regular physical activity will be insufficient in reducing one’s overall risk of cardiovascular disease or cancer ifDuring the 20th century, a profound shift occurred in the tobacco products are used. Obesity on its own is a significantpredominant pattern of diseases that affected populations, risk factor for many diseases and arises when the amountespecially in developed nations like Canada, the United States of calories consumed is greater than the calories expended,and some European countries. Infectious communicable no matter the source of those calories. The quality and notdiseases no longer represented the prime burden of disease, just the quantity of the fuel we put in our body matters toin a large part due to public health advances such as better our overall health; one can be of normal weight, exercisesanitation, improved nutrition, immunizations, and the regularly, avoid smoking, and still be unhealthy or at risk ofavailability of antibiotics. Instead, non-communicable disease, chronic diseases because of eating nutritionally poor foodspecifically chronic diseases like cancer, cardiovascular (WHO, 2003b).disease, and respiratory disease, rose in prominence and nowmake up about 80 per cent of the disease burden in North Chronic diseases—many with diet as aAmerica and about 50 per cent worldwide (World Health prominent risk factor—now make up 80 perOrganization [WHO], 2003b). cent of the disease burden in North AmericaSometimes, (and inaccurately) called “lifestyle diseases”, many (WHO, 2003b).of the most prevalent chronic diseases have a limited number The area of diet and chronic disease is an evolving science,of risk factors, behaviours and conditions that contribute to which has many complexities. Unhealthy diets may taketheir prevalence. Some of the risk factors, such as advancing 30 or 40 years, or longer, to increase the risk of cancer,age, genetic heritage, or gender, are not modifiable. But cardiovascular disease, or other chronic diseases, a time lagother risk factors—such as tobacco use, alcohol consumption, that makes studying the correlations highly complex. Whilephysical inactivity, diet, and the conditions and environments tobacco-related cancers also tend to take decades to develop,in which people live—can be changed. There is increasing the correlation is relatively simple and can be evoked by ascientific evidence that nutrition, physical activity, and other simple question: Did you smoke? Diets, however, can beenvironmental factors may influence gene expression and highly diverse and feature potentially hundreds of differenttherefore influence susceptibility (WHO, 2003b). food combinations. Studying the relationships betweenWhile this chapter focuses on the relationship between food food and health relies on the recall of individuals or onchoices and health, it is important to stress that from a public responses in self-reported questionnaires, both of which canhealth perspective one must consider the interplay of all risk be unreliable (Willett, 2005). It is not surprising, therefore,factors for diseases in context. For example, healthy eating that the medical and scientific literature is full of apparent contradictions. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 27
  • 48. Chapter 3: Impact of Unhealthy Eating Twelve Leading Causes of Death, British Columbia, 2004 Figure 3.1 Cause of DeathIn 2004, as with previous years, malignant Malignant neoplasms 8,401neoplasms (cancer) and cardiovasculardisease were the leading causes of death in Cardiovascular disease 6,697the province (Figure 3.1). More than 1 in 4deaths (28 per cent) were due to malignantneoplasms, with the age-standardized Cerebrovascular diseases 2,280mortality rate of 15.77 deaths per 10,000standard population. Cardiovascular Unintentional injuries 1,112disease was the second leading cause ofdeath, responsible for more than one-fifth Chronic pulmonary disease 1,227of all deaths (23 per cent), with the age-standardized mortality rate of 11.38 per Pneumonia/Influenza 1,24210,000 standard population (British ColumbiaVital Statistics Agency, 2005). There is a Diabetes melitus 1,001solid evidential basis to believe that over 50per cent of different types of cancers and a Other circulatory system 842large proportion of cardiovascular disease diseasescould be prevented through behavioural and Other diseases of the 767environmental changes (Who, 2003b). digestive system Other disorders of the 583 nervous system Certain infectious and 568 parasitic diseases Urinary system diseases 607 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 Number of Deaths Source: British Columbia Vital Statistics Agency, 2005 Since chronic disease tends to appear later factor for chronic disease. In 1988, the in life, and dietary patterns change over a United States Surgeon General’s Report lifetime, it is also not clear whether certain on Nutrition and Health estimated that time periods are more important than two-thirds of all deaths in the United others for establishing risks for chronic States were due to diseases that had some disease. How significant are various eating association to diet. The Surgeon General patterns during infancy, early childhood, also noted that for individuals who did adolescence, and adulthood relative to each not smoke and who drank responsibly, other? At this stage of our understanding the single most important personal choice we simply do not know (Frazão, 1999). influencing long-term health was what they ate (United States Department of Health Despite these complexities, it is clear that and Human Services, 1988). poor food choices can be a significant risk 28 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 49. Chapter 3: Impact of Unhealthy EatingCancer In 1997, the American Institute for Cancer Research and the World Cancer Research Learning From Landmark StudiesIn 2004, cancer was the leading cause of Fund released a comprehensive reviewdeath in British Columbia, claiming 8,401 Two large, long-term studies of specific of scientific evidence on what is knownlives (British Columbia Vital Statistics populations—one following residents of about diet, nutrition, and cancer (WorldAgency, 2005). In 2003, there were 17,828 a Massachusetts town and the other some Cancer Research Fund [WCRF] & American 240,000 nurses in 11 American states—havenew cases of cancer, predominantly lung Institute for Cancer Research [AICR], 1997). done much to illuminate the relationship ofcancer and prostate cancer in men and This report estimated that changes in diet diet and lifestyle choices to health. The twolung cancer and breast cancer in women could prevent 50 per cent of breast cancers, longitudinal observational studies are among(Statistics Canada, 2005d). 75 per cent of stomach cancers, and 75 per the most important epidemiological studiesIt is estimated that more than 50 per cent cent of colorectal cancers. A second edition in the world and together have spurred someof cancers could be prevented through of the report is being prepared for release 1,200 seminal research papers.lifestyle change. The largest preventable sometime in 2006. The Framingham Heart Study began in 1948,cause of cancer is tobacco use; however, following 5,209 healthy men and women It is estimated that dietary factors accountit is estimated that one-third of cancers every 2 years; they were given comprehensive for approximately 30 per cent of cancers inin industrialized nations are diet-related, health exams, blood tests, and lifestyle western countries (Key, Allen, Spencer, &making diet the second most important questionnaires to elucidate the risk factors for Travis, 2002); this link suggests that eatingcause of cancer (WHO, 2003b). Regular cardiovascular disease. In 1971, 5,124 children more fruits, vegetables, and whole grains,physical activity, even at moderate or of the original cohort were recruited for the minimizing saturated fats and trans fats,recreational levels, is associated with lower “offspring” study. Now overseen by researchers maintaining normal weight, and exercising at Boston University, the Framingham studyrates of some cancers, particularly colon regularly throughout the entire lifespan has revealed a wealth of information aboutcancer (Chao et al., 2004). Lack of adequate could help reduce the risk of cancer. A diet the impact of smoking, exercise, obesity,physical activity may account for 12 to 14 rich in fruits and vegetables (especially high blood lipids, high blood pressure, and dietper cent of colon cancer (Slattery, 2004). in folate) is key to preventing the formation on cardiovascular disease and other chronicThe role of diet in cancer has been of many cancers, particularly colorectal diseases (National Library of Medicine, 2005a).suspected for decades, especially in light cancers (Strohle, Wolters, & Hahn, 2005). The Nurses Health Study began in 1976,of the differing rates of specific cancers recruiting 122,000 married registeredbetween countries. These epidemiological High-Fat Diets and Cancer nurses between the ages of 30 and 55 todifferences disappear when individuals of For a long time it was thought that high- investigate the long-term consequences ofone heritage move to another country. For fat diets were linked to cancer, especially oral contraceptives. The study was expandedexample, Asian women who lived in Asia breast cancer, but a number of prospective to include a wide range of lifestyle issues onwere five times less likely to develop breast studies have failed to demonstrate this health.cancer than North American or European link (Willett, 2005). This may be because Over the last three decades, the responsewomen (Muir, Waterhouse, Mack, Powell, & “high-fat” is too general a label, as we now has been greater than 90 per cent and inWhelan, 1987; Doll & Peto, 1981). However, know that some fats (most plant fats) are 1989 a second cohort of 116,686 youngerAsian immigrants to North America have beneficial and others are harmful (some nurses was added. Run by the Harvard Schoolbeen shown to lose this advantage within saturated animal fats and all man-made of Public Health, the study has producedone to two generations after relocation. trans fats). Recent research indicates that more than 260 research papers about theIt has been assumed that one of the key it may not be the fat itself, but rather that relationships between diet, exercise, smoking,determining factors may be the difference people who are eating high-fat food are and hormonal factors to the risk of cancer,in diet, although with so many variables in cardiovascular disease, heart attacks, stroke, not eating enough fruits and vegetablesdiets, confirming the specifics is difficult diabetes, and other health problems in women (Frazão, 1999; Willett, 2005). It could alsoto study and remains contentious (Willett, (National Library of Medicine, 2005b). be that high-fat diets tend to be high-calorie2005). Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 29
  • 50. Chapter 3: Impact of Unhealthy Eating diets, leading to obesity, which is linked to 2005). The increasing rates of obesity inChronic Disease Management increased cancer risk (WCRF/AICR, 1997; children also raises concerns about theand Healthy Eating Willett, 2005). potential for an increase in cancer rates in future years, since obese children tendChronic diseases cannot be cured, but Obesity and Cancer to remain obese into adulthood andsymptoms and complications can be therefore will be exposed for a longergreatly improved with good chronic disease Over the last few decades, studies havemanagement, including attention to diet. duration to potentially toxic compounds consistently linked obesity with a wideChronic disease management promotes pro- called adipokines that are secreted by fat. range of cancers. In one of the largestactive, evidence-based treatment by a team A high-calorie intake in childhood has prospective studies of more than 900,000of health professionals, such as dietitians been associated with an increased risk of American adults over 16 years of age,and therapists. An essential element is cancer in later life even if the child obtains increased body weight was associatedempowering patients to manage their disease a normal weight as an adult (Frankel, with increased death rates from allthemselves; for example, learning how to eat Gunnell, Peters, Maynard, & Davey, 1998). cancers combined and from cancers athealthy for their condition. multiple specific sites. In both sexes,For the last three years BC has been leading being overweight or obese significantly Cardiovascular DiseaseCanada in developing chronic disease increased the risk of death from cancer Deaths from cardiovascular disease remainmanagement programs, including holding of the esophagus, colon, rectum, liver,special patient self-management workshops the second leading cause of death in British gallbladder, and kidney, as well as from Columbia. In 2004, 6,697 people died ofthroughout the province. The goal of patient non-Hodgkin’s lymphoma and multiple cardiovascular disease, accounting for one-self-management is to give the patient greater myeloma. Overweight or obese women fifth of all deaths in the province (Britishconfidence in his or her ability to make alife-improving change. The process is taught had a higher risk of death from cancer of Columbia Vital Statistics Agency, 2005).through a free course, called “Living a Healthy the breast, cervix, uterus, and ovary, while overweight and obese men had a higher Cardiovascular disease includes a wideLife with Chronic Conditions”, which takes risk of death from stomach and prostate range of disorders of the heart and bloodplace in groups of about ten people withchronic disease, and is led by two people from cancer. The authors estimated that the vessels, such as coronary heart disease,the community, also with chronic disease, current patterns of obesity in the United which includes myocardial infarction (heartwho have been specially trained to deliver the States could account for 14 and 20 per attacks), angina, atherosclerosis (hardeningprogram. Patients attend for a total of fifteen cent of all deaths from cancer in men and of the arteries), stroke, transient ischemichours over six weeks. Gradually they develop women respectively (Calle, Rodriguez, attacks (mini strokes), hypertension (highthe skills to become informed, active patients Walker-Thurmond, & Thun, 2003). blood pressure), and congestive heartwho are able to manage the impacts of their failure.illness on their functioning, emotions, and Childhood Diet and The Risk of Cancer Hypertension and diabetes increaserelationships. It is not yet clear how dietary choices in the risk of coronary heart disease andThe provincial government has funded the stroke and are associated with dietary childhood and adolescence may influenceprogram until 2006 with $60,000 for each habits, particularly the high consumption the risk of cancer in later life. Largehealth authority. A toll-free number, 1-866- prospective studies that have followed of saturated fats, salt, and refined902-3767, can provide information about adults have been unable to collect reliable carbohydrates, and the low consumption ofthe locations and dates of the next round of data on eating patterns during childhood; fruits and vegetables (WHO, 2003b).courses. In-depth information is also availablethrough the University of Victoria Centre on however, the theory remains that anAging, Chronic Disease Self Management unhealthy diet in the formative years maywebsite at http://www.coag.uvic.ca/cdsmp. promote DNA damage that may emerge as cancerous mutations later in life (Willett, 30 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 51. Chapter 3: Impact of Unhealthy EatingSummarizing two decades of research, the Diabetes2003 World Health Organization report, Physical Activity’s Link to Health Diabetes is a chronic condition that resultsDiet, Nutrition, and the Prevention of from the body’s inability to sufficiently Why are people who are more active usuallyChronic Disease, noted that there was produce or use insulin, a hormone healthier than those who are sedentary? It isgood scientific evidence for the following in produced by the cells in the pancreas that not simply because they burn more caloriesrelation to cardiovascular disease: and prevent obesity, but rather that regular regulates the storage and use of glucose• Increased Risk of Cardiovascular in the body. The three main types of exertion, like tuning an engine, has many Disease physiological benefits, from the smallest diabetes are Type 1, Type 2, and gestational Smoking remains one of the highest micro-cellular level to large macro systems. diabetes. risk factors for cardiovascular disease. Although the process is not well understood, Consumption of trans fats (especially Type 1 Diabetes physical activity seems to prevent the deep fried and baked goods), palmitic following chronic diseases and illnesses: Type 1 diabetes, sometimes described as acid (a saturated fatty acid found in insulin-dependant diabetes, occurs mostly • Cancer: increasing immunity and butter, cheese, meat, and coconut and metabolism, increasing gut motility, in children or adolescents. In Type 1 palm oil), and myristic acid (another regulating hormones, decreasing obesity. diabetes, the immune system attacks the saturated fatty acid found in most dairy insulin-producing cells in the pancreas • Cardiovascular disease: strengthening products), refined sugars, as well as and destroys them. As a result, little or no heart and lung function, increasing oxygen high salt foods, are all risk factors. Being insulin is produced in the body. Individuals exchange, improving blood lipids, and overweight or obese, physically inactive, with Type 1 diabetes need daily injections increasing elasticity of arteries leading to and having a high alcohol intake also of insulin to control their blood glucose. lower blood pressure. increases the risk of cardiovascular Scientists still do not know why the • Diabetes: increasing metabolic rate, disease (WHO, 2003a). body’s immune system attacks the cells decreasing body fat, moderating insulin, and• Prevention of Cardiovascular in the pancreas; however, they believe improving glucose disposal and cell insulin Disease genetic factors or viruses may be involved. sensitivity, potentially reducing diabetes by Consumption of fruits and vegetables, Symptoms of Type 1 diabetes include thirst, up to 60 per cent. fish and fish oils, and foods high in frequent urination, constant hunger, weight • Osteoporosis: strengthening muscles, omega-3 oils and potassium, along loss, blurred vision, and fatigue. If this enhancing bone density, improving with regular physical activity and low to condition is not diagnosed and treated with flexibility, balance, and coordination, moderate alcohol intake, can prevent insulin, patients could lapse into coma and leading to fewer falls or injuries. heart disease. As noted in Chapter 1, could die (Health Canada, CCDPC, 2002). consumption of polyunsaturated and • Mental health: endorphins reduce monounsaturated plant oils that lower Type 2 Diabetes stress, and relieve depression and anxiety (Bauman, 2004). low density lipoprotein (LDL) and Type 2 diabetes is the most common type increase high-density lipoprotein (HDL) of diabetes and accounts for more than 90 lower the risk of cardiovascular disease. per cent of the diagnosed diabetes cases. There is reasonable evidence to believe Type 2 diabetes typically occurs in people that high-fibre diets (e.g., containing over 40 who are overweight or obese. Most unsalted nuts, seeds, whole grains, etc.) individuals with Type 2 diabetes are insulin can lower LDL cholesterol levels. resistant1 ; however, by losing weight,1 Although insulin can attach normally to receptors on liver and muscle cells, certain mechanisms prevent insulinfrom moving glucose into these cells where it can be used. This is known as insulin resistance (Health Canada,CCDPC, 2002, p.20-21). Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 31
  • 52. Chapter 3: Impact of Unhealthy Eating exercising, and taking oral medication, it older. Gestational diabetes should beReducing Risks of Cancer and is possible to overcome this resistance. treated with diet and/or insulin since theHeart Disease by Consuming Leafy The general symptoms of Type 2 diabetes condition might adversely affect bothGreen Vegetables include feeling tired and sick, frequent the baby and the mother. Management urination, excessive thirst, excessive includes screening, patient education,Spinach, kale, romaine lettuce, swiss chard, hunger, and weight loss. Type 2 diabetes control of blood sugar, and perinataland collard greens have been shown toprovide fibre, folate (a B vitamin essential for can also lead to a number of diseases such monitoring (Health Canada, CCDPC, 2002).formation of DNA, the genetic material of the as cardiovascular disease (heart diseases) It is estimated that approximately 2 millioncells), and many different phytochemicals and microvascular diseases (kidney failure, Canadians have diabetes, and around(plant chemicals protective against diseases), blindness, etc.) (Health Canada, CCDPC, 40 per cent of these cases will developincluding carotenoids and flavonoids. 2002). complications. Factors that can lead toStudies in the United Kingdom and the obesity, such as lack of physical activity Gestational DiabetesUnited States have found that a diet rich in and unhealthy eating habits, play a majorleafy green vegetables is associated with Gestational diabetes occurs in some role in the onset of Type 2 diabetes. Type 2significant reductions in the risk of developing pregnant women and in most cases diabetes rates are 3 to 5 times higher in thecolon cancer and heart disease.(University ends after birth. More than 40 per cent Aboriginal population than in the generalof Liverpool, 2002; Harvard School of Public of women with gestational diabetes may population in Canada (Health Canada,Health, 2004). develop Type 2 diabetes when they get 2003b). Figure 3.2 Projected Health Services Costs for Persons With Diabetes With Implementation of Lifestyle Modification Program, BC, 2003/2004 to 2015/2016The direct costs for diabetes to the health 2,000,000,000care system in BC, including hospitalization, 1,900,000,000 Projected Cost No Reduction Incidence > $200 millionmedical services plan and PharmaCare were Projected Cost Based On 25% Incidence Reduction 1,800,000,000about $1.04 billion in 2003/04. These costs By Lifestyle Modification Program Projected Costs ($)** > $400 million 1,700,000,000 Projected Cost Based On 50% Incidence Reductioncould rise to $1.90 billion by 2015/2016 if the 1,600,000,000 By Lifestyle Modification Programprevalence rate continues to rise at the currentrate. However, if prevention initiatives can 1,500,000,000reduce the incidence of diabetes by just 25 per 1,400,000,000cent, an annual savings of over $200 million 1,300,000,000could be realized within 10 years. A 50 per cent 1,200,000,000reduction would result in an annual savings of Lifestyle Modification starting in 2006/2007over $400 million. 1,100,000,000 1,000,000,000 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 14/15 15/16 Year Note: For the purpose of this analysis, the resulting estimates were modelled from a widely reported study involving a nutritional and physical activity intervention for non-diabetics at risk of developing diabetes (Diabetes Prevention Program). It must be acknowledged that the results of a specific clinical trial are not necessarily attainable at the population level, but can assist in the development of goals for a population prevention strategy. Source: Population Health Surveillance and Epidemiology, Ministry of Health, 2005. 32 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 53. Chapter 3: Impact of Unhealthy EatingThe prevalence and incidence of diabetes Unfortunately, research shows that onceis increasing in British Columbia. In an individual is overweight or obese, the Metabolic Syndrome2004, in British Columbia, approximately tendency is to gain even more weight Research over the last decade has found that a220,000 individuals—5.2 per cent of the rather than lose it (Le Petit & Berthelot, cluster of disorders of the body’s metabolismpopulation—were living with diabetes. 2005). is a warning of heightened risk of developingEach year, approximately 20,000 British In 1997, the World Health Organization, cardiovascular disease, stroke, or diabetes. TheColumbians are newly diagnosed with clustering of metabolic symptoms are: in its seminal report Obesity: Preventingdiabetes and it is estimated that 4 out and Managing a Global Epidemic, called • Obesity, particularly around the abdomen;of 10 people with diabetes will develop obesity “the greatest neglected publiccomplications such as blindness, • High blood pressure; health problem of our time.” It definedkidney disease, cardiovascular disease, obesity as “a condition of abnormal • Abnormal cholesterol levels (high totalamputations, and reduced life expectancy or excess fat accumulation in adipose cholesterol or triglycerides, or low HDL, the(McParland, 2002). In BC, Status Indians tissue to the extent that health could be “good” cholesterol);have 1.4 times the prevalence rate of impaired” and blamed the rising rates on andiabetes compared to other BC residents. • Insulin resistance, in which certain increasingly sedentary lifestyle combinedThe mortality rate among people with mechanisms prevent insulin from moving with overconsumption of high-fat, high- glucose into liver and muscle cells wherediabetes is more than twice as high as calorie foods. it can be used (Health Canada, Centre forthe rate among people who do not havediabetes. Over 6,000 individuals with Chronic Disease Prevention and Control What is Body Fat? [CCDPC], 2002).previously diagnosed diabetes died in2003/2004, accounting for over 20 per cent Fat (adipose) tissue is a metabolically active While each of these disorders itself is a riskof all deaths in the province. The majority endocrine organ that secretes numerous factor for disease, having one or more of themof these deaths are caused by diseases hormones and cytokines—compounds in combination dramatically increases theof the circulatory system and malignant used in cell-to-cell communications. risk of developing a serious, life-threateningneoplasms (cancers), which occur as a Adipokines (the proteins produced by fat disease. It is concerning that the incidenceresult of diabetes complications. Effective tissue) have been the subject of intense of metabolic syndrome in obese children and research in recent years and are being adolescents is increasing (Weiss et al., 2004;management of diabetes has been shown Engelmann, Lenhartz, & Grulich-Henn, 2004).to result in the reductions in complications. cited as important factors in inflammatory processes, insulin resistance, blood More research is needed about howFor more information on diabetes, please pressure regulation, immune system aggressively metabolic syndrome should berefer to the 2004 Provincial Health Officer’s regulation, and other processes (Wisse, managed medically. Currently, according toAnnual Report, The Impact of Diabetes the American Heart Association, the preferred 2004; Rudin & Barzilai, 2005; Trayhurn &on the Health and Well-being of People method of control is to lose weight and Wood, 2004). It is now clear that adiposein British Columbia at http://www. increase physical activity (Mayo Clinic Staff, tissue is very complex and is involved inhealthservices.gov.bc.ca/pho/. 2004; American Heart Association, 2004). moderating appetite, metabolism, and other physiological processes. VariousOverweight and Obesity adipokines secreted by fat may be theOver the last 25 years, rates of overweight reason that obesity itself is linked to soand obesity have increased dramatically many disease processes (Trayhurn & Wood,worldwide, including Canada and British 2004).Columbia. The impact of this epidemic,which affects both adults and children, Understanding Body Mass Indexis profound in terms of its potential Body mass index (BMI) is the standardhealth and psychosocial consequences. measure used to categorize overweight Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 33
  • 54. Chapter 3: Impact of Unhealthy Eating and obesity both at the individual and their BMI changes and their ratesCost of Obesity in British Columbia population level. Body mass index is of overweight and obesity do not calculated by taking a person’s weight correspond to the adult categories.The annual cost of obesity to the health in kilograms divided by height in metres Canada has adopted the US Centerscare system in British Columbia in 2000 was squared. Individuals with a BMI of 25-29.9 for Disease Control growth charts,estimated to be $380 million per year (Colman, are considered overweight, and those recently updated and released in 2000.2001). This figure includes the amountspent on doctors’ fees, hospitals days, and with a BMI of 30 and above are considered The revised growth charts provide anpharmacare costs. obese. improved tool for evaluating the growth of children based on the growth ofThe analysis noted the total cost to BC is Underweight <18.5 both breastfed and formula-fed babiesmuch higher when indirect costs of missed Normal 18.5 - 24.9 in the US. BMI is the most commonlydays of work, poor quality of life, disability, Overweight 25 - 29.9 used approach to determine if adultsdecreased productivity, and premature death Obese >30 are overweight or obese and is also theare included. The study estimated the total Individuals with BMIs of 25 or greater recommended measure to determine ifcost could be as high as $830 million per year,second only to tobacco. generally have a higher risk of metabolic children are overweight. The new CDC syndrome, diabetes, coronary heart BMI growth charts can be used clinicallyHowever, the analysis probably underestimates disease, stroke, cancer, gall bladder disease, beginning at two years of age, when anthe true cost of obesity for a number of arthritis, and other health problems; the accurate stature and date of birth canreasons. The analysis used old rankings of body higher the BMI, the greater the risk of be obtained.mass index (BMI), which puts the threshold health problems. Statistics Canada hasfor overweight and obesity at BMI 27 or higher • Ethnic groups: The BMI rate can categorized obesity risks into three classes:as opposed to 25. It also based the estimates misjudge the risk of obesity-relatedon self-reported data rather than directly Class I (BMI 30-34.9), Class II (BMI 35-39.9), health complications in non-Europeanmeasured BMIs. As a result it tallied the cost and Class III (BMI >40). Those with a BMI populations. Studies have shownof obesity based on the estimate that 29 per of 40 or above have extremely high rates of people of Asian, South Asian, andcent of British Columbians were overweight or health problems and in the past were called Aboriginal heritage may have a higherobese—rather than the 55 or 60 per cent from morbidly obese. risk of health problems at lower BMIthe latest BC Nutrition Survey and Statistics measures, while individuals of AfricanCanada findings respectively (Tjepkema, n.d.). Body Mass Index Limitations descent may not see health problems Given that BMI is based on a calculation of until a BMI surpasses 26 (Razak body measure, it is not recommended for et al., 2005). Some have called for use in certain populations, as it may not be BMI rankings to be revised for non- a true reflection of their health risks. Some Europeans, setting thresholds of BMI of the inaccuracies include: 23 (overweight) and BMI 26 (obese) for Asian populations, and BMI 26 • Certain body types: Athletic, (overweight) and BMI 32 (obese) for muscular individuals will weigh more those of African descent (Razak et al., and have a higher BMI that does not 2005). reflect their true health risk. Individuals who are very lean, very tall, or very • Elderly: As people age they lose short may also have inaccurate BMIs muscle mass, making them lighter (Tjepkema, n.d.). but not necessarily leaner. BMI can misclassify them as being in a healthy • Growing children and adolescents: range when their actual fat levels put As children grow and develop, them at risk of health problems. 34 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 55. Chapter 3: Impact of Unhealthy Eating Rates of Obesity, Adults 18 and Over, Canada and Provinces, 2004 Figure 3.3 40 Canada 23 Per cent 35 34 British Columbia had the lowest rates of 31 obesity in Canada; nevertheless, 19 per cent 30 29 of those 18 and older were obese, with BMI 28 26 25 of 30 or greater. Newfoundland had the 25 25 22 23 highest rate of obesity at 34 per cent.Per cent 19 The overall rate of obesity for Canada was 23 20 per cent. (Figure 3.3) 15 10 5 0 NF PE NS NB QC ON MN SK AB BC Source: Statistics Canada. 2004 Canadian Community Health Survey. Rates of Overweight, Adults 18 and Over, Canada and Provinces, 2004 Figure 3.4 41 Canada 36 Per cent 40 40 British Columbia had more people who were 40 overweight than all other provinces except 39 Prince Edward Island. Both provinces had an 38 overweight rate of 40 per cent. The overall rate 37 37 of overweight adults in Canada was 36 per 37 cent. (Figure 3.4)Per cent 36 36 36 35 35 35 35 34 34 33 32 31 NF PE NS NB QC ON MN SK AB BC Source: Statistics Canada. 2004 Canadian Community Health Survey. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 35
  • 56. Chapter 3: Impact of Unhealthy Eating Despite the limitations of BMI, it is the results were released in two separateSelf-Reported as Opposed to most convenient and efficient method Statistics Canada reports in July 2005, oneMeasured available to screen populations for reporting the results for adults and the overweight and obesity trends and to other for children. A comparison of theseMost people overestimate their height and/or compare Canadian population rates two surveys is provided in the followingunderestimate their weight when filling historically, currently, and to other section.out questionnaires or answering telephonesurveys. Women tend to underestimate their countries. However, due to its weaknesses,weight, while men tend to overestimate BMI should not be used as the sole method Overweight and Obesity in Adultstheir height (Tjepkema, n.d.). This natural to screen individuals in terms of obesity- • In 2004, 23 per cent of adult Canadianstendency leads to the reporting of lower BMI related health problems. Other important were obese, with BMIs of 30 or greater,numbers and underestimates the prevalence elements should also be considered, compared to 14 per cent in 1978/1979.of overweight and obesity in the population. including the following:When health professionals directly measure • In 2004, 36 per cent of adult Canadians • Waist size: in women, waists largerand weigh survey populations, the reporting were overweight (BMI 25 +), comparederrors are removed. than 76.2 cm (30 inches) generally to 35 per cent in 1978/1979. correspond to being overweightIn Canada, most surveys of obesity since and waists over 88 cm (35 inches) • The combined rates of overweight and1978 have been self-reported. However, the correspond to being obese. For men, obesity mean that almost two-thirds (591999 BC Nutrition Survey directly measured the measures are 88 cm (35 inches) per cent) of Canadians had a BMI of 25and weighed its 1,823 participants, finding for overweight and 100 cm (39.5 or greater in 2004. In 1978/1979, 49 perthat 55 per cent were overweight or obese, inches) for obese. This tool is currently cent of Canadians had a BMI greatersignificantly higher than previous estimates. recommended for use in conjunction than 25.In 2004, for the first time in 26 years, the with BMI.Canadian Community Health Survey nationally • The most striking increases in obesitymeasured and weighed respondents. The • Medical tests where warranted: For for adult Canadians were in the 25-34results showed that almost 60 per cent individuals with risky BMIs or high waist age group and 75 and older age group,of Canadians were overweight or obese circumference, tests for high blood where obesity rates doubled to 21 per(Tjepkema, n.d.). pressure, blood lipid levels, and blood cent and 24 per cent respectively. sugar levels can confirm elevated health • Obesity rates peaked among individuals risks such as metabolic syndrome and age 45 to 64, with 30 per cent having a diabetes. BMI of 30 or greater. Obesity rates were lowest at 11 per cent for adults of both Rising Obesity Rates in BC and Canada sexes between the ages of 18 and 24. In July 2005, Statistics Canada released a • Diet was a factor in obesity rates. report confirming that obesity rates are Men and women who ate fruits and at an all-time high in Canada. The results vegetables less than three times a day were obtained from the 2004 Canadian were more likely to be obese than Community Health Survey (CCHS) that those who consumed those foods five directly measured the heights and weights or more times a day. This association of 8,661 Canadian children aged 2 to 17 persisted even when age and socio- and 12,428 Canadian adults 18 and older. economic status was taken into The last time a national survey measured account. heights and weights was in 1978/1979. The 2004 results revealed that obesity is more prevalent than predicted. The CCHS survey 36 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 57. Chapter 3: Impact of Unhealthy Eating Obesity Rates, Ages 2-17, Canada and Provinces, 2004 18 Figure 3.5 17* Canada 8 Per cent 16 BC had the lowest obesity rates for 14 13* children and adolescents at 7 per cent and Newfoundland had the highest at 17 per 12 cent. Canada’s overall rate was 8 per cent 10 10 9* 9 (Figure 3.5). 9Per cent 8* 7 8* 7* 8 6 4 2 0 NF PE NS NB QC ON MN SK AB BC *Coefficient of variation between 16.6% and 33.3% (interpret with caution) Source: Statistics Canada. 2004 Canadian Community Health Survey. Overweight Rates, Ages 2-17, Canada and Provinces, 2004 Figure 3.6 25 Canada 18 Per cent 23 22 22* In 2004, 20 per cent of children and 21 20 adolescents were overweight in BC. 20 19 19 19 The province with the highest rate was 16* Nova Scotia (23 per cent). Canada’s overall overweight rate was 18 per cent 15 14* (Figure 3.6).Per cent 10 5 0 NF PE NS NB QC ON MN SK AB BC *Coefficient of variation between 16.6% and 33.3% (interpret with caution) Source: Statistics Canada. 2004 Canadian Community Health Survey. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 37
  • 58. Chapter 3: Impact of Unhealthy Eating• The level of physical activity was also a factor in obesity; 27 • Physical activity and sedentary pursuits were also related per cent of both males and females who were sedentary to rates of overweight and obesity. The more hours of were obese and 39 per cent were overweight. “screen time” youth spent watching television, playing video games, or using the computer, the more likely they• New immigrants to Canada tended to be the least obese, would be overweight or obese. but that “healthy immigrant” effect was lost within one or two generations. Overweight/Obesity, Inactivity, Smoking and• Being overweight or obese was a risk factor for a number their Associated Increased Health Care Costs in of chronic conditions. As BMI increased, so did the likelihood of having high blood pressure, diabetes, and the BC Population heart disease. A preliminary analysis of a sample of 7,694 BC residents, 25 years of age and older,1 assessed the risk factors ofOverweight and Obesity in Children and Adolescents overweight/obesity, physical inactivity, and smoking,2 as well• The obesity rates for children and adolescents (2 to17) as their associated health care costs. Only 18.6 per cent of increased from 3 per cent in 1978/1979 to 8 per cent in the individuals had no risk factors, 37.9 per cent had one risk 2004. factor, 32.1 per cent had two risk factors, and 11.4 per cent had all three risk factors. Furthermore, a substantial majority• 18 per cent of children and adolescents were overweight (68.6 per cent) had physical inactivity and/or overweight/ in 2004, compared to just 12 per cent in 1978/1979. obesity as risk factors (Figures 3.7 and 3.8).• Combining the rates of overweight and obesity showed In this preliminary analysis, the average annual age-adjusted that in 2004, 26 per cent of Canadian youth were per capita health care cost for those with no risk factors was overweight or obese, compared to just 15 per cent in $1,003, increasing to $2,086 per capita3 for individuals with 1978/1979 —a 70 per cent increase. all risk factors (smoking, overweight/obese, and physically• Over the past 25 years, the rate of obesity for adolescents inactive). In general, the cost data show a consistent pattern aged 12 to 17 has tripled from 3 per cent to 9 per cent. of increasing costs from one to two risk factors with the The combined overweight/obesity rate for this age group greatest costs associated with all three risk factors. It is increased from 14 per cent to 29 per cent. notable that the inactive individuals had similar costs to the overweight/obese smoker individuals. The final bar on Figure• Diet was a factor in obesity rates as youth who ate 3.9 shows the relative costs for those who have one or more fruits and vegetables more than five times a day were risk factors. substantially less likely to be obese.1 The 7,694 sample was from the 2003 Canadian Community Health Survey (CCHS) and included those individuals 25 years of age and older who responded tothree risk factor questions (smoking, body mass index, activity level), who had a valid Personal Health Number (PHN), and who also gave permission for theirhealth records to be linked with other databases for research purposes, in an aggregated manner to protect personal privacy. The analysis used the CCHS ShareFile with Bootstrap Weights for PHNs as provided by Statistics Canada. Excluded from Figures 3.7 and 3.8 were another 428 persons who did not respond to atleast one of the risk factor questions, or who were underweight (BMI < 18.5), or who were in certain inapplicable other categories.2 Smokers included those who were current or former daily smokers. Overweight/obese persons included those who had a Body Mass Index (BMI) of 25 or greater.Persons categorized as inactive were those whose responses indicated that regular physical activity was not currently part of their lifestyle.3 For each person, costs for three years (2001/2002 to 2003/2004) were aggregated from the three sources (hospital, Medical Services Plan, and PharmaCare).The Medical Services Plan and PharmaCare costs are actual amounts paid for medical services and prescriptions. Hospital costs are estimated using averagecost per weighted case figures for BC in each of the three years. The annual average total cost is the total costs for the three years divided by three.38 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 59. Chapter 3: Impact of Unhealthy Eating Figure 3.7 Proportion of Sample with Personal Health Numbers by Risk Cohort, Ages 25 and over, BC, 2003 Out of 7,694 BC population sample size, 18.6 per cent had no risk factors. About 48 Inactive Smoker per cent were overweight/obese, about 9.1% No Risk 47 per cent were current or former daily Inactive 18.6% smokers and about 41 per cent were Overweight/Obese inactive (Note: these categories overlap). 9.5% Inactive Overweight/Obese 11.4% 13.7% Inactive Overweight/Obese Smoker Overweight/Obese 11.4% Smoker Smoker 13.5% 12.9%Source: Population Health Surveillance and Epidemiology, Population Health and Wellness, BC Ministry of Health, 2006. Figure 3.8 Proportion of Sample with Personal Health Numbers, by Number of Risk Factors, Ages 25 and over, BC, 2003 In assessing the risk factors of overweight/ obese, inactivity, and smoking, only 18.6 Three Risk Factors No Risk Factors per cent had none of the risk factors. Close 11.4% 18.6% to 38 per cent had only one risk factor. Two Risk Factors One Risk Factor 32.1% 37.9%Source: Population Health Surveillance and Epidemiology, Population Health and Wellness, BC Ministry of Health, 2006. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 39
  • 60. Chapter 3: Impact of Unhealthy Eating Figure 3.9 A Preliminary Estimate of Average Annual Age-Adjusted Per Capita Costs (Hospital,Based on the BC sample population of MSP, PharmaCare) for Ages 25 and over, by Risk Cohort, BC, 2001/2002 to 2003/20047,694, approximately $1.8 billion in healthcare costs can be attributed to overweight/ Risk Cohort*obesity, physical inactivity, and smoking. No Risks** Basic Costs for Overweight/Obese No Risk Individuals Smoker Additional Costs for Overweight/Obese Smoker Individuals with Risk Factors Inactive Inactive Overweight/Obese Inactive Smoker Inactive Overweight/Obese Smoker One or More Risk Factors*** Costs per Person $500 $1,000 $1,500 $2,000 $2,500 *Based on CCHS 2003 sample for BC who provided a valid Personal Health Number and permission for data linkage. **Never Daily Smoker, BMI 18.5-24.9, Physically Active or Moderately Active. ***Includes 428 individuals who were non-responders for one or more risk factors, underweight persons, and certain inapplicable other categories. Source: Population Health Surveillance and Epidemiology, Population Health and Wellness, BC Ministry of Health, 2006. In summary, persons with one or more approximately $1.8 billion in health careGuidelines for Food and Beverage of the risk factors (overweight/obesity, costs can be attributed to overweight/Sales in BC Schools physical inactivity, and smoking) comprised obesity, physical inactivity, and smokingBritish Columbia has recently introduced 81.4 per cent of the sample population (of in the BC population (Figure 3.9). Further“Guidelines for Food and Beverage Sales in BC whom 68.6 per cent were overweight/obese research is planned to incorporate the dataSchools” to help eliminate junk food and improve and/or physically inactive). Age-adjusted from the 2000/2001 and 2005 Canadianstudent health. These voluntary guidelines will health care costs for persons with one or Community Health Survey samples intohelp schools to divide food and beverages into more of these risk factors were 69 per cent the analysis, to allow a more detailedfour categories: choose most, choose sometimes, higher than for persons with none of the assessment of individual risk factors andchoose least, and not recommended. The aim risk factors. Cumulatively, if the experience costs by age, gender, and region.of this program is to discontinue sales of “notrecommended” items, and move toward selling of the individuals in the sample is projected“choose most” and “choose sometimes” items. onto the provincial population, 36 per cent The Obesogenic Environment of health care program costs (hospitals, MSP, and PharmaCare) are attributable to On the surface, the cause of obesity these risk factors. is straightforward: more calories are consumed than are burned off through Therefore, based on this preliminary physical exertion. Maintaining a steady analysis and 2004/2005 costs of $4.9 weight is an equation in which the billion,4 incurred for the population number of calories eaten in the form of aged 25+ years, it is estimated that food or drink must be equal to that used 4 Cost estimates based on hospital programs ($2.7 billion), Medical Services Plan ($1.5 billion), and Pharmacare ($0.7 billion), incurred by BC residents aged 25+ years. 40 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 61. Chapter 3: Impact of Unhealthy Eatingas fuel during physical movement and body processes. Anyimbalance in the equation will result in either weight gain BC’s Healthy Living Allianceor weight loss. To lose weight, people must consume fewer In 2003, a coalition of more than 20 different health-related organizations, suchcalories or expend more energy. as the BC chapters of the Canadian Diabetes Association, Cancer Society, andWe know that the growing rates of obesity cannot be placed the Heart and Stroke Foundation, and regional health authorities joined forcesonly on the shoulders of individuals. Obesity is highly with provincial and municipal governments to help improve preventive healthcomplex and has elements of genetics, cultural behaviour, in BC. Recognizing that behind most chronic diseases are four common riskand psychology. In addition, certain environments or social factors—poor diet, inactivity, obesity, and tobacco use—the Alliance’s missiontrends can make it more likely that obesity will result. Some is to improve the health of British Columbians through leadership that enhances collaborative action to promote physical activity, healthy eating, and livinghave identified these environments as the “obesogenic” smoke-free.environment. The obesogenic environment has been definedas an environment with a sum of influences that promote The primary focus of the Alliance is to address not only the common risk factors,obesity in a population (Swinburn, Egger, & Raza, 1999). but to begin to address the underlying determinants, such as socio-economic status and education, that contribute significantly to cancer, cardiovascularIt is clear that a number of profound changes to human disease, chronic respiratory disease, and diabetes. The Alliance has set theculture, in relationship to food and physical exertion, have following targets for 2010:occurred over the last three decades. Since genetic change • 9 out of 10 British Columbians will be non-smokers.does not occur in such a short time frame, it is reasonable toconclude that changes in environment underlie the obesity • 7 out of 10 British Columbians will consume five or more fruits and vegetablesepidemic and it is through environmental modification that each day.this epidemic will be reversed. • 7 out of 10 British Columbians will be physically active.Changing Patterns of Food Consumption • 7 out of 10 British Columbians will be at a normal weight.What we eat and the way we eat has changed over the last The coalition emphasizes that government policies need to make healthy choicesthree decades. These changes include: the easy choices for British Columbians. The collaboration brings together a number of BC ministries, health organizations, and a wide array of community• More convenience, restaurant, and prepackaged participants and organizations to create a network that will link more than food: With many families consisting of two working 25,000 volunteers throughout the province to help change the lifestyle-related parents, or single parents, the prevalence of home-cooked behaviours that are making us ill. meals made from scratch is diminishing. More families In March 2006, the BC Ministry of Health announced an additional investment choose prepackaged or convenience foods to help get a of $25.2 million to the BC Healthy Living Alliance. For more information on the meal on the table when they come home. Takeout meals Alliance, please refer to their website at: http://www.bchealthyliving.ca/. like pizza have also increased, as have meals outside the home (Sturm, 2005a).• More high-calorie drinks: Soft drink consumption has doubled in North America since the mid-1970s (Enns, Mickle, & Goldman, 2002; Murray, Frankowski, & Taras, 2005; Sutherland, 2004). A 355 ml serving of pop may contain between 10 to 12 teaspoons of sugar and between 140 to 160 calories. Children in particular are drinking more sugary drinks than ever and this replaces other more nutritious drinks such as milk, fruit and vegetable juice, and water. One of the many findings of the Harvard School of Public Health Nurses Health Study was that Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 41
  • 62. Chapter 3: Impact of Unhealthy Eating women who drank one sugary beverage then translated into more caloriesOld Order Mennonite Children: a day had an 80 per cent higher risk of consumed from carbohydrates (Taubes,Leaner, Fitter, Stronger gaining weight and developing Type 2 2002; Ludwig, 2003). diabetes than women who consumedA recent Canadian study gives credence to • More food choices: As noted in less than one sugary drink a monththe theory that our contemporary lifestyle is Chapter 1, too much choice, even iffuelling the obesity epidemic. (Schulze et al., 2004). it is healthy, can promote weight gainResearch by obesity expert Dr. Mark • Larger portions: Since the 1970s, because both humans and animalsTremblay and a team from the University of standard portion sizes have increased alike tend to overeat when surroundedSaskatchewan and the University of Lethbridge in almost all food groups in both by many tempting tastes, but reachcompared children raised in Old Order restaurants and home (Nielsen & satiation faster when eating just oneMennonite communities, who live much as Popkin, 2003; Young & Nestle, 2002; food (Raynor & Epstein, 2001).our grandparents did, to children in urban and Nestle, 2003). Research in the United • More snack food: Eating a meal as arural communities of Saskatchewan. The study States which looked at portion sizesfound: primary family activity has declined over sold as single servings in convenience the last three decades, but snacking has• Mennonite children had no physical stores, fast-food establishments, and increased (Sturm, 2005b). Consumption education class and did no organized chain restaurants showed that the of snack food such as chips, crackers, sports but had leaner triceps, stronger grip portion size of many common foods popcorn, and pretzels has tripled since strength, and greater aerobic fitness than including soft drinks, hamburgers, the 1970s (Enns et al., 2002). Snack children raised in a more contemporary and hot dogs began to grow in the food is often high in calories and low environment. 1970s, rose sharply in the 1980s, and in nutrients, and since it is often not• Mennonite children did 18 minutes more has continued to rise in parallel with satiating nor feels like a real meal, physical activity each day through walking increasing body weights. Some current people may still consume regular meals and traditional farm and household chores. portion sizes are more than twice the on top of snacks, adding to extra calorie size of portion sizes from the 1970s.• The researchers estimated the difference consumption. in activity levels would account for 15,000 • More carbohydrates in relation to • Nutritious food is more expensive: fewer calories, or about 4 fewer pounds fats and proteins: Some public health The prices of various food products a year and 40 fewer pounds between the officials have noted that the beginning have shifted over the last three decades. decade from childhood to adolescence of the obesity epidemic coincides (Canadian Institute for Health Information, The cost of fresh fruits and vegetables with the beginning of the message 2005). has increased at a greater rate than from public health, the American the cost of soft drinks, snacks, and Heart Association, and others to eat convenience food (Sturm, 2005b). a lower fat diet. This generally sound This can skew food choices away from advice may have had the negative healthy foods to the cheaper, higher side effect of encouraging people to calorie food, particularly for families eat proportionally more calories from on limited incomes. For example, an simple carbohydrates. Trends show apple (44 calories), a chocolate bar (200 that fat consumption for children fell calories) and a bag of potato chips (40 by about 100 kcal, but at the same time chips, 300 calories) all cost about $1, carbohydrate consumption increased by however, when people are on limited about 150 to 200 kcal (Enns et al., 2002; income, their choice may be based on Sturm, 2005b). Since protein and fat are what is more satiating and costs less. more satisfying, some speculate that avoiding fats made us hungrier, which 42 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 63. Chapter 3: Impact of Unhealthy EatingWhen combined, impact of our foodenvironment results in many North Spotlight on McCreary Centre Society SurveyAmerican adults and children routinely Since 1992, the McCreary Centre Society, a small non-profit BC organization, has conducted three surveysconsuming an extra 200 to 300 calories on BC adolescents. Each survey consisted of a sample of 30,000 adolescents from grades 7 to 12. The 1998a day. In the United States, for example, Adolescent Health Survey looked specifically at weight issues and weight practices.surveys show that the average caloric In each survey, BC youth were asked a wide variety of questions, including whether they have dinner withintake for men has increased from 2,450 their family regularly, whether they eat breakfast in the morning, and how much time they spend watchingcalories a day to 2,618, and for women television, playing video games, or engaging in physical activity. The surveys collected self-reported data onfrom 1,542 calories a day to 1,877 (Wright, height and weight, which was then used to calculate body mass index (BMI). Youth in British Columbia haveKennedy-Stephenson, Wang, McDowell, self-reported an increase in BMI over the last decade.& Johnson, 2004). One pound is equal to Over the three surveys, the self-reported results have shown the following:3,500 calories; an extra 200 calories a daytranslates to 73,000 extra calories a year, or • In 2003, 18 per cent of boys were overweight, compared with 15 per cent in 1992. Obesity in boys during the same time period went from 2 per cent to 5 per cent. For girls, the difference was relatively minor; 9a weight gain of over 20 pounds each year. per cent of girls were overweight in 1992, compared to 10 per cent in 2003, while obesity rose from 1 per cent to 2 per cent during the same time period. As a result of the inherent weaknesses in self-reportedChanging Patterns of Physical Activity data, these findings are likely undercounting the levels of overweight and obesity.The extra calories consumed over the last • For boys, the highest prevalence of overweight was found in the Northwest, Kootenay-Boundary, andthree decades might not have translated Central Vancouver Island regions. The lowest prevalence of overweight was found in Richmond, theinto excess weight if the levels of physical Okanagan, and North Vancouver Island. For obesity, the highest prevalence was found in the Northernactivity had not dramatically decreased Interior and Northwest, while the lowest was in the Kootenay-Boundary and North Shore/Coast Garibaldi regions.at the same time. BC has the highest rateof physical activity in Canada yet even • The Northwest region was also the highest for both overweight and obesity in girls, with East Kootenayhere daily physical activity has declined. and the Okanagan close behind. The lowest prevalence of overweight and obesity for girls was found inFactors influencing reduced movement and Vancouver, Richmond, and North Shore/Coast Garibaldi.physical activity include: • Adolescents in BC compare favourably to the rest of Canada in being physically active. Among those in grades 7-12, 75 per cent exercise at least 3 days a week. A smaller number of obese youths say they• Supremacy of the automobile: exercise 3 or more days a week. Society has increased its reliance on automobiles. Many families have two • As youths age, the level of physical activity declines. The vast majority of 13 and 14 year-olds were very active, but by the time the youth reach age 17, their activity levels dropped significantly. Fifty per cent of cars, and most errands and trips are adolescent girls of that age did no exercise at all. done by car even if it is only a few blocks to the grocery store. In addition, • The surveys showed that overweight or obese adolescents used the computer and watched television instead of riding bikes or walking, most more than adolescents who were normal weight. About 26 per cent of obese adolescents watched more than 6 hours of television a week. children are now driven to school. The majority of working adults drive all or • The surveys asked questions of teens regarding attempts to lose or gain weight, and about methods to part of the way to work. Finally, the lose weight. A total of 60 per cent of overweight teens and 71 per cent of obese teens were currently trying to lose weight. increasing availability of “drive-through” services such as fast food, coffee, • Purging behaviour—vomiting as an attempt to lose weight—has declined since 1992, with just 7 per banking, or video drop-off means cent of girls and 3 per cent of boys reporting that they used vomiting at least once a month as a strategy people are becoming even less active. for losing weight. In 1992, the numbers were 9 per cent of girls and 5 per cent of boys. • Teens who were obese were far more likely to report that they had been discriminated against because• Neighbourhood design: of their appearance in the last year. They were also less likely to be involved in some group and social Neighbourhoods and cities are now activities; this could contribute to an increase in sedentary pursuits among this group (McCreary Centre designed around the automobile. Two Society, 2003). Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 43
  • 64. Chapter 3: Impact of Unhealthy Eating recent studies found that suburban sprawl is associated “Back-to-basics” movements and an increased focus on with higher BMIs and more chronic disease, while people academics have diminished the perceived value of physical who live in dense urban centres are more likely to walk activity. By Grade 11, the majority of Canadian students no (Sturm & Cohen, 2004; Ewing, Schmid, Killingsworth, longer take physical education classes at school. Zlot, & Raudenbush, 2003). Lack of walking or bike paths, • Adult exercise: BC has the highest rate of physically heavy traffic, and poor lighting can make walking or active adults in Canada; nevertheless, the BC Nutrition cycling unsafe or unpleasant. Survey found that 61 per cent of adults do no strenuous• Labour-saving devices: Devices such as ride-on activity and 36 per cent are sedentary, doing no moderate lawnmowers, snow blowers and leaf blowers, robotic nor vigorous activity. The primary reason cited was lack of vacuums, dishwashers, sound-activated lights, remote time due to work and family commitments. Research has controls, irrigation systems, automatic garage door found, however, that productivity increases when workers openers, and many others mean that even those small take time to exercise. Depression and anxiety decrease movements associated with household chores and daily with regular exercise. living are no longer part of our lives.• Increasing “screen time”: Television, computer games, Eating Disorders internet surfing, video games, video, and DVD make it Although often overshadowed by the focus on obesity, eating possible for people to spend hours in front of a screen disorders represent the other side of what is essentially the with no physical activity. The amount of time spent in same fundamental problem: a disordered and unhealthy front of a television or computer screen is directly related relationship to food. Obsessive dieting, anorexia, and bulimia, to increased BMI rates in both children and adults. The while different in their particular behaviours, share the 2003 McCreary Centre Society Adolescent Health Survey common feature that the individuals who suffer from these found that overweight and obese adolescents watched six disorders have lost the ability to eat a normal, healthy diet. more hours of television per week than those of normal weight. In North America, eating disorders are the third most common chronic health condition for females between the• Changes to children’s play: Children are much less ages of 15 and 19. The disorders carry with them a high risk likely to be sent outdoors for unstructured play. This of serious health problems such as cardiac irregularities, may be due to issues such as parents’ safety concerns, electrolyte imbalances, weakened bones, permanently more children being in after-school programs away from damaged dental enamel, and other complications, including home, fewer stay-at-home parents, and more structured, death. Experts note that eating disorders usually begin as organized play. As Dr. Mark Tremblay told the BC Forum an attempt to control weight gain or because of a fear of on Childhood Obesity in March 2005, unorganized becoming obese. Most eating disorders originate in early- to play is more strongly related to decreased obesity than mid-adolescence, in individuals with a fragile sense of self who participation in organized sport, in which children may see body weight as the one area they think they can control only get 20 minutes of vigorous activity once or twice a (Johnston, 2004). week, rather than daily play outside (Childhood Obesity Foundation, 2005). Anorexia and Bulimia• School activities: While there have been encouraging Anorexia involves restricting food to the point of extreme initiatives in BC to integrate more physical activity starvation and weight loss; it effects about 1 per cent of the into the daily life of the school through the innovative population, predominantly females. Bulimia involves binging ActionSchools! BC Program, schools are still not being on food followed by purging by vomiting, laxative abuse, used to their full capacity to encourage physical activity. or diuretic misuse; it is estimated to effect about 6 per cent44 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 65. Chapter 3: Impact of Unhealthy Eatingof the population. Studies have shown that anxiety and Fostering Healthy Relationships to Fooddepression are both common co-morbidities in anorexia and This chapter illustrates the multitude of health problemsbulimia. Treatment with antidepressants and anti-anxiety that can arise through unhealthy patterns of eating. Whilemedications has shown some effectiveness. However, the weight loss will be beneficial for overweight/obese adultsmost promising treatment is cognitive behavioural therapy, and for children who have gained far beyond healthy growthwhich can address the underlying belief of self-worth being recommendations, the public health focus must be ontied to appearance (Mehler, 2003). promoting healthy eating in balance with regular physical activity, rather than focusing on weight loss. The mostObsessive Dieting important aspect is that a person is fit and healthy for theirThe results from the 2003 McCreary Centre Society particular body shape.Adolescent Health Survey show that dieting behaviour is The goal of public health interventions in BC around food andcommon among adolescent girls, even if they are of normal exercise must be to create a society that fosters, for all Britishweight. More than 50 per cent of girls of normal weight in the Columbians, a healthy relationship to food, as well as enablingMcCreary study said they were on a diet. Dieting behaviour everyone to experience the benefits of being fit and to feelis even being found in younger and younger Canadians, even the joy and fun that comes from regular physical activity.those of normal weight (McVey, Tweed, & Blackmore, 2004;Jones, Bennett, Olmstead, Lawson, & Rodin, 2001). Onelongitudinal study that involved almost 15,000 adolescent Summarymales and females found that not only was dieting ineffective • Non-communicable chronic diseases such as cancer, heartto control weight but it actually led to weight gain, primarily disease, diabetes, and respiratory disease now representas a result of restrictive eating following by bouts of binge 80 per cent of the disease burden in North America. Theseeating (Field et al., 2003). diseases have inter-related risk factors, some that cannotOne of the concerns about focusing on obesity as a public be modified, such as age, genetics, or gender; and othershealth challenge is that it may contribute to an increase in that can be modified, like smoking, diet, and exercise.eating disorders and an unhealthy focus on weight loss as Poor food choice is a significant risk factor for chronica solution to obesity, rather than focusing on promoting disease.healthy, active lifestyles that combine eating good food with • In 2004, cancer was the leading cause of death in BCregular physical activity. (8,401 deaths). Smoking remains the most commonObesity is a symptom of profound changes in our society and preventable cause of cancer, but diet is likely to bethe corresponding disruption to our relationship with food the second most common cause. In 1997 a landmarkand movement. A focus on weight loss alone can promote international report estimated that changes in diet couldunhealthy dieting behaviour in vulnerable individuals such as prevent 50 per cent of all breast cancers, 75 per cent ofadolescent girls and women. One of the underlying factors stomach cancer, and 75 per cent of colorectal cancer.in all eating disorders is the belief that physical appearance • Research has shown that one-third of all cancers coulddictates one’s value as a person (Mehler, 2003). This thinking be avoided by eating more fruits and vegetables,is prominent in our media-saturated, celebrity-obsessed whole grains, minimizing saturated fats and trans fats,world, and we must be careful that in our zeal to reduce maintaining a normal weight, and exercising regularly.the health impacts of the obesity epidemic we do not fuel a Obesity itself is strongly related to a large number ofcontinued obsession about appearance and increase eating cancers, with estimates that 14 per cent of all deathsdisorders as a result. from cancer in men and 20 per cent of deaths in women could be attributed to current patterns of obesity in North America. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 45
  • 66. Chapter 3: Impact of Unhealthy Eating • Cardiovascular disease was the second 1978/1979 to 18 per cent in 2004. BCDial-A-Dietitian leading cause of death in BC in 2004 had the lowest obesity rates for children (6,697 deaths). Research has shown and adolescents at 7 per cent andDial-A-Dietitian is an organization dedicated that the consumption of fruits and Newfoundland had the highest at 17to providing “readily accessible quality vegetables, fish, and omega-3 fatty acids per cent. Canada’s overall rate was 8nutrition information to the public andhealth information providers throughout and potassium, combined with regular per cent. Combining the rates, 26 perBritish Columbia” (Dial-A –Dietitian Nutrition physical activity and moderate alcohol cent of BC children were overweightInformation Society, 2004). Dial-A-Dietitian consumption, is protective. Eating trans or obese, up from 15 per cent inhelps consumers by offering free nutritional fats, deep fried foods, and baked goods, 1978/1979.information and raises consumer awareness as well as being overweight, increases • Obesity is highly complex andof other related health services in British the risk of cardiovascular disease. has elements of genetics, culturalColumbia. Registered dietitians answer • An epidemic of Type 2 diabetes is now behaviour, and psychology. Certainquestions in 130 languages from the public,health educators, and the media by phone, occurring in BC. In 2004, approximately environments or social trends canmail or the web. This service complements 220,000 British Columbians were living also make it more likely for obesitythe nutrition services provided by health with diabetes. The major risk factors to result. Some have identified suchauthorities. In response to demand for are obesity, physical inactivity, and poor environments as the “obesogenic”information, the Allergy Nutrition Service diet. environment, which is defined as anopened to health professionals in November environment with a sum of influences • In July 2005, Statistics Canada released2004, and the public in March 2005. Provincial that promotes obesity in a populationhealth ministry guidelines, and a new tool a report confirming that obesity rates (Swinburn et al., 1999).called “Practice Based Evidence in Nutrition” are at an all-time high in Canada. The(PEN) help to answer consumers’ questions. results were obtained from the 2004 • The obesogenic environment hasPEN provides the dietitians answering Canadian Community Health Survey brought changes in eating patternsquestions with the most current healthy eating (CCHS) that directly measured the and physical activity that underlie theevidence-based recommendations, with links heights and weights of 8,661 Canadian obesity epidemic and it is throughto supporting references, and resources. children aged 2 to 17 and 9,488 environmental modification that this Canadian adults 18 and older. epidemic can be reversed.In 2005/06, 20,509 calls were answered bythe Dial-A-Dietitian service and there were • In 2004, 23 per cent of adult Canadians • Anorexia, bulimia, and obsessive dietingmore than 440,000 visits on the website. were obese, with BMIs of 30 or greater, are flip sides to the same fundamentalAreas of concern for callers were diabetes, compared to 14 per cent in 1978/1979. problem of obesity. About 7 per centcardiovascular conditions, infant feeding to BC has the lowest rates of obesity in of individuals, usually adolescent girls,manage or prevent allergies, and digestion Canada; nevertheless 19 per cent of the suffer from anorexia or bulimia.(ulcer, diverticulosis, constipation, post adult population in BC are consideredsurgery). • The goal of public health interventions obese with BMIs over 30. BritishDial a Dietitian works in partnership with around food and physical activity Columbia had more people who werethe BC Nurseline to help British Columbians must be to create a society that overweight than all other provincesmake informed decisions about their helps children, adults, families, and except Prince Edward Island. Bothhealth. Dial a Dietitian hours of operation are communities to develop healthy provinces had an overweight rate of 40Monday to Friday, 9 am to 5 pm. For more relationships to food and to experience per cent. The overall rate of overweightinformation, please contact Dial-A-Dietitian the energy and invigoration that comes adults in Canada was 36 per cent.at 604-732-9191, 1-800-667-3438 or visit the from being physically fit.website at www.dialadietitian.org. • In 1978/1979 only 3 per cent of children were obese, compared to 8 per cent in 2004; the percentage of overweight children rose from 12 per cent in 46 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 67. Chapter 4: Food Security Among British Columbians Chapter 4: Food Security Among British ColumbiansWhat is Food Security? transportation barriers within the community to local food sources. It is important to note that those involved inAs stated in earlier chapters, food is a determinant of health production, processing, and distribution of foods should beand the food that is available to people will determine their able to make a living wage while using safe farming practicesnutritional choices. This simple statement, in fact, is related to that do not compromise the air, land, and water for now anda complex food system that includes production, processing, for future generations (Hamm & Bellows, 2003).distribution, availability, affordability, and consumption offood. All of these interrelated components can work to either Food security is defined by a situation insupport or interfere with available and affordable healthy which all community residents can obtainfood choices at the community level. Any barrier, break, or a safe, culturally acceptable, nutritionallyweakness along the food system can undermine the ability of adequate diet through a sustainable foodthe population to access safe, nutritious food, which can then system that maximizes self-reliance andundermine the health and wellness of the population. social justice.” (Hamm and Bellows, 2004) “Food security exists when all people, at all times, have physical and economic access to Food scarcity and deprivation represents a significant and sufficient, safe and nutritious food to meet growing problem for the poor in many western nations, their dietary needs and food preferences for including Canada. If individuals lack the physical or economic an active and healthy lifestyle.” access to the foods they need in order to live productive, (Food and Agriculture Organization of the United Nations healthy, and active lives, they are considered to be food- [FAO], 1996) insecure. People may be food-insecure because they live in geographically isolated communities with limited availabilityA healthy food system is required to support healthy food of nutritionally adequate and safe foods, or they may lackchoices. Some special groups in our population may have sufficient funds to purchase foods that constitute a healthyadditional challenges accessing healthy foods. For those on diet. Individuals or families who are anxious about their abilitylow-income, affordability and accessibility to healthy food to acquire personally acceptable food through normal foodcan be challenging. For immigrants, religious groups, or channels, without having to rely on emergency food programsAboriginal population, there may be additional challenges like food banks, are also considered to be food-insecurein accessing foods that are culturally acceptable. For those (Davis & Tarasuk, 1994; Travers, 1996).living in rural and remote communities, the above issuesare compounded by limited or expensive transportation Food insecurity re-emerged as a concern in Canada duringof healthy foods to their rural communities, as well as the 1980s and 1990s, as a result of recessions and the erosion Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 47
  • 68. Chapter 4: Food Security Among British Columbians Figure 4.1 The Food System ion O p ti l at a ll pu m yN o urishe d Po em He th al st yS y u st a dS in a b l e Foo Policies Services Programs Economy Production Consumption Education and Trade Processing Acquisition Science and Distribution Marketing Agriculture Technology (Fisheries and Food) Society Environment and Culture Health Individual Family (Nutrition and Community and Food Safety) CapacityAny food system is an economic and political creation. The interdependence of economic and political elements of the food system is illustrated in Figure 4.1. Anoptimally nourished population depends on a healthy sustainable food system that is influenced by the political process of policies, programs, and services. Theinfluence of this process is present on economic factors such as production, processing, distribution, marketing, acquisition and consumption of food. These factorswill then shape elements such as economy and trade, science and technology, society and culture, health, individual family and community capacity, environment,agriculture, and education.Adapted from: Making the Connection – Food Security and Public Health, The Food Security Standing Committee of the Community Nutritionists Council of BC, March 2004.of the social safety net through government spending cuts Some types of Canadian households—such as single parents,aimed at debt reduction (Tarasuk & Davis, 1996). The number recipients of social assistance, and the Aboriginal populationof food banks increased significantly during these decades, living off-reserve—are more likely to experience foodand children’s school-based feeding programs were expanded insecurity. About 31 per cent of the Aboriginal population(McIntyre, 2003). In 2000/2001, the number of Canadians living off-reserve report food insecurity, more than doubleconsidered to be living in food-insecure households was the rate for the non-Aboriginal population (Ledrou & Gervais,almost 15 per cent—an estimated 3.7 million people (Ledrou 2005). Chapter 6 of this report will discuss in detail the& Gervais, 2005). relationship between food and health as it relates to BC’s Aboriginal population.48 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 69. Chapter 4: Food Security Among British ColumbiansFood Insecurity in British Columbia of about $13,778. The incomes of BC families (with children) receiving social Rates of Food Insecurity in CanadaThe level of food insecurity in BC is above assistance were approximately 17 to 18the national average and is cause for In 2000/2001, Statistics Canada posed per cent lower in 2004 than they wereconcern. In 2001, about 17 per cent of BC’s questions about food access and consumption in 1994 (First Call, BC Child and Youthpopulation could not afford the quality on the Canadian Community Health Survey. Advocacy Coalition [First Call], 2005).or variety of food they wanted, worried Respondents were considered to be food-about having enough to eat, or had not had • More people are homeless and lack insecure if, in the previous 12 months, dueenough to eat at some time in the previous access to even basic cooking and food to a lack of income, they, or someone in their12 months. The national average was 15 storage facilities. In Greater Vancouver, household, met at least one of the followingper cent in the same year. BC’s lower and the number of homeless people criteria:lower-middle income households were increased by more than 100 per cent • worried that there would not be enough tomost likely to have food insecurity, with from 2002 to 2005, to more than 2,100 eat;30 per cent of those households reporting people. An additional 126,000 people • did not eat the variety or quality of food thatat least one instance of not having had in about 56,000 Greater Vancouver they wanted, or;enough food to eat in the previous year households are at risk of becoming(Ledrou & Gervais, 2005). homeless (Greater Vancouver Regional • did not have enough to eat. Steering Committee on Homelessness, Using this definition, 15 per cent of theSome examples of the higher costs of living 2005). In Victoria, where the homeless population, aged 12 or older, had been food-and reduced purchasing power in BC that were counted for the first time in 2005, insecure. Over 40 per cent of people in low- ormay be behind the higher rates of food about 700 people were dependent lower-middle-income households reportedinsecurity include the following: on emergency shelter or lived on the food insecurity, and almost 25 per cent of• The cost of housing has risen in BC’s streets, and a majority of those reported middle-income households did as well. major urban centres, which makes health problems (Victoria Cool Aid Younger people were more likely to report food it more difficult to obtain affordable Society, 2005). insecurity. About 18 per cent of people aged housing. The waiting list in BC rose 12 to 44 had experienced some component of • The provincial minimum wage of $8 an from 2001 to 2003, after declining from food insecurity. Rates were also high among hour1 means that an individual working 1996’s high of 11,250 applicants. In Aboriginal people living off-reserve, at 31 per 40 hours a week for 52 weeks in a year 2001, about 10,000 people were on cent. earns $16,640, considerably below the the list for social housing; by 2003, federal government’s Low Income It should be noted that the survey does not that number had risen to 10,450. Most Cut-Off (LICO) (Ministry of Labour and cover the homeless or Aboriginal people of the applicants were in the Greater Citizens’ Services, 2003). living on-reserve, which may mean that the Vancouver region, and the majority of prevalence of food insecurity in Canada is those were families (Irwin, 2004). higher than reported (Ledrou & Gervais, 2005). Low-Income Cut-Offs• Based on 2004 income assistance Established by Statistics Canada, Low payments, BC’s amount of assistance Income Cut-Offs (LICOs) are a measure for two parents with two children of income below which a family would be was the second lowest in the country substantially worse-off compared to the (National Council of Welfare, 2005). average population. Such families would A single parent in BC with one child likely spend a larger proportion of their would only have a total annual income1 This applies to people who have worked a total of 500 hours with one or more employers. If the person has no paidwork experience or had less than 500 hours prior to November 15, 2001, their minimum wage would be $6 per hour(Ministry of Labour and Citizens’ Services, 2003). Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 49
  • 70. Chapter 4: Food Security Among British Columbians income (approximately 20 per cent more) income populations. For example, two orRegional Variations in Food on food, shelter, and other necessities three decades ago, the elderly populationSecurity in BC (Statistics Canada, 2006). were the largest group in the “low-income” category, while more recently, lone-parentSome areas of BC are more likely to have food- LICOs were first introduced in 1968 and families—particularly those headed byinsecure households than others. People living were based on 1961 Census income data women—occupy the larger proportionin upper Vancouver Island, the Central Coast, and 1959 family expenditure patterns. (Figure 4.2) (Fellegi, 1997; Statisticsthe Cariboo, East Kootenays, and the Fraser Subsequent LICOs were revised basedValley are more likely to have experienced Canada, 2006 & 2005b).* on national family expenditure data fromfood insecurity. More than 14 per cent of the 1969 to 1992. The latest LICO figures werepeople surveyed in these regions reported calculated for seven categories of family The Impact of Food Insecurity on“sometimes” or “often” worrying that their size from one person to seven or more in Vulnerable Populationshousehold would not have enough to eat due a family for rural areas and urban centresto lack of money. In Vancouver and the Capital (Statistics Canada, 2006 & 2005b). ChildrenRegional District, more than 11 per cent ofpeople surveyed said they had experienced Statistics Canada has clearly maintained Adequate nutrition in childhood supportsfood insecurity at some point in the previous that LICOs are not a measure of poverty healthy growth and development andyear. Residents of the North Shore were the and are intended to only identify those increases opportunities for a long andleast likely to have been food insufficient who are substantially worse-off compared productive life. The disproportionate(Statistics Canada, 2001). number of children living in hungry to the average population. However, in the absence of a nationally recognized households is a matter of grave concern. and accepted measure of poverty, LICOs Across Canada, children are, in general, have made it possible to study important the age group most likely to live in hungry trends and changing composition of lower- households (Che & Chen, 2001). Figure 4.2In 2003, over 50 per cent of female headedfamilies with children under 18 had incomes Prevalence of Low Income After Taxbelow the LICO. (Selected Groups, BC, 1994 and 2003)* LICO income thresholds are typically used Persons < 18 years in female lone-parent 56.0for large urban areas over 500,000. Low families 51.4income thresholds for smaller communitysizes are substantially lower. The Ministry of Persons 65 years 10.3Employment and Income Assistance states and over 10.2that the majority of income assistance clients Persons < 18 yearsreceive significantly higher allowances than the 18.5 in all types of 18.0 families 1994 2003basic rates for Expected to Work clients that areusually cited. A single person with a disability Females, 65 years 11.6receives basic monthly income assistance of and over 15.5$856, and a person with multiple barriers(PPMB) case receives $608 compared to $510 15.1 All persons 15.0for expected to work clients. Nearly 70 per centof cases are Persons with a Disability or PPMBs.The average assistance payment to all single 0 10 20 30 40 50 60 70cases across the caseload, including other Per cent low incomesupplements was $716 in August 2006. (DonVan Wart, personal communication, 2006). Source: Statistics Canada. (2003). Income in Canada, 2003 [Catalogue No. 75-202-XIE; CANSIM Table 202 - 0802]. Ottawa, ON: Statistics Canada. 50 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 71. Chapter 4: Food Security Among British ColumbiansStudies show that children living in single • About 10 per cent of children living inparent households are more likely to poverty had at least one parent working Market Basket Measureexperience food insecurity. The 2000/2001 in a year-round, full-time job. Some doCanadian Community Health Survey found not receive enough work hours to earn Introduced by the federal government in 2003, this measure tabulates what it costs a familythat one-third of lone female parents a sufficient living, while others are in of four, with two adults and two children, toreported food insecurity (Ledrou & Gervais, minimum-wage jobs that do not allow purchase a basket of basic goods and services2005). Significantly, more than one-half of them to climb above Statistics Canada’s in 48 different parts of the country. People arethe children in Canada who experienced Low Income Cut-Offs (First Call, 2005). considered to be relatively impoverished whenhunger in 1996 lived in households their income—after taxes, child support, • Almost one out of every five BCreceiving a main income from employment payroll deductions, and out-of-pocket medical children live in poverty, based onand not from social assistance (McIntyre, expenses—falls short of covering the cost of Statistics Canada’s Low IncomeWalsh, & Connor, 2001). the prescribed “basket” of goods. The survey Cut-Offs. found that one in five British ColumbiansIn BC, child poverty2 diminished slightly in For BC’s low-income households, and does not have enough money to afford itemsthe late 1990s, and then rose significantly that are considered to be the components of individuals or families receiving incomein 2002 and has remained stable in 2003 a reasonable standard of living in Canada. assistance, putting healthy food on theand 2004. These items include basic necessities such table is a daunting task. Food expenses,• About 160,000 BC children lived in unlike housing costs, are one of the as nutritious food, shelter, clothing, and transportation, as well as sundries such as poverty in 2003. more elastic components of household stamps and video rentals (Human Resource budgets, and can be compressed to• Overall, the poverty rate for BC children Development Canada, 2003). accommodate other urgent expenses in two-parent families was 15 per cent such as transportation, utilities, and in 2003, while the rate for children personal hygiene items. Juggling living in single-parent families was 65 household expenses to afford food is per cent (First Call, 2005). 2 The measure of poverty is based on Statistics Canada’s Low Income Cut-Offs. Figure 4.3 Child Poverty Rates,* Canada and Provinces, 2003 In 2003, BC had the highest rate of child 30 Canada Canada Before Tax After Tax poverty in Canada. (Before Tax) (After Tax) 25 24 13 Per cent 18 Per cent 22 22 21 20 19 17 18 17 17 16 16 16Per cent 15 14 13 11 11 11 11 11 10 5 5 0 BC MN NF NS SK NB QC ON AB PEI * Poverty rates are based on Low-Income Cut-Offs for 2003 from Statistics Canada Source: Income Trends in Canada, 1980-2004, Statistics Canada, 2004. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 51
  • 72. Chapter 4: Food Security Among British Columbians a constant and stressful battle in low- Pregnant WomenWhat is in the National Nutritious income households (Vozoris, Davis, & Women in food-insecure households riskFood Basket? Tarasuk, 2002; McIntyre, 2003). having an inadequate intake of essentialTo determine the cost of buying nutritious food nutrients, such as folate, found in leafy Seniorsin Canada, Health Canada uses a standardized green vegetables and fresh fruit. Formethod called the National Nutritious Food Seniors over the age of 65 who are on fixed pregnant women, this can put their unbornBasket. The basket, also referred to as the incomes are another vulnerable population child at higher risk of neural tube defects,healthy food basket, is consistent with the in BC. In 2004, 13.7 per cent of the BC and can compromise nutrition duringfood purchases of ordinary Canadians, and population was over the age of 65, and this breastfeeding.meets basic nutrient and caloric requirements. per centage will increase to 23.5 per centThe food in the basket requires preparation, Inadequate nutrition during pregnancy by 2031.3necessitating time and cooking skills, and does can lead to low birth weight infants, whichnot account for any food purchases at food As noted in the 2002 Provincial Health significantly increases the neonatal healthservice outlets. Officer’s report, The Health and Well- T care costs to meet the immediate health being of People in British Columbia (PHO, needs of the child, and puts them at riskThe National Nutritious Food Basket consists of66 foods that reflect nutrient requirements and 2003), the majority of seniors in BC are of permanent disability such as learningfood purchase patterns. It includes products doing well. Nationally 70 per cent of seniors disabilities, respiratory problems, poorfrom the four food groups in Canada’s Food are homeowners, with 64 per cent being eyesight, and other long-term physicalGuide to Healthy Eating, including: mortgage-free. While most BC seniors are disabilities. healthy and relatively well-off, some seniors• dairy products such as 2% milk, fruit- flavoured yogurt, and cheddar cheese; are isolated and alone, with insufficient How Much Does Healthy Food income or social support. These are most Cost?• protein sources such as stewing beef, often elderly women who have outlived chicken legs, cooked ham, frozen fish fillets, their partner. In 2002, 10.2 per cent of The cost of food in BC varies from dried navy beans, and peanut butter; BC’s female seniors were living below neighbourhood to neighbourhood, and• grains like white and whole wheat bread, the LICO levels set by Statistics Canada, from community to community. People dry spaghetti, long grain white rice, cooking meaning they spent a larger proportion of living in rural and remote communities, oatmeal, and all-purpose flour; their income on food, shelter, and other as well as lower income communities, can necessities (PHO, 2003). expect to pay more for food than those• fruit and vegetables such as oranges, canned living in urban areas with a wide range of tomatoes, apples, romaine lettuce, frozen Elderly people who lack sufficient food are grocery stores easily accessible by foot, mixed vegetables, cabbage, and carrots; more susceptible to depression, reductions bicycle, public transportation, or private• condiments like butter, margarine, white in taste and smell sensations, poor health, vehicle. sugar, and jam. and poor dentition (Wolfe, Olson, Kendall, & Frongillo, 1998). Inadequate diets Notably, food prices in BC rose 38 per centThis tool can be used to compare the relative among the elderly may also contribute to from 1989 to 2003 (Dietitians of Canada,cost of food in Canadian communities 2003), a time period also characterized or worsen disease, increase disability, spur(Dietitians of Canada, 2004). by rising housing costs, lower real social the advance of age-related degenerative diseases, decrease resistance to infection, assistance rates, and reductions in federal and extend hospital stays (Wolfe, et al., employment insurance benefits. 1998). Every year, registered dietitians working in public health for regional health 3 Population estimates (1986-2004) and projections (2005-2031) by BC STATS (P.E.O.P.L.E.30), Service BC, BC Ministry of Labour and Citizens’ Services. 52 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 73. Chapter 4: Food Security Among British Columbiansauthorities, price the nutritious food Published annually since 2000, The Cost ofbasket to determine the monthly cost Eating in BC reports have all concluded Nourished Moms, Healthy Babesof purchasing the basket for a BC family that BC residents living on low incomesof four (two parents and two children), cannot afford a healthy diet after paying for BC’s Pregnancy Outreach Program (POP) is a nutrition program that provides prenatal andby surveying grocery stores across the average shelter expenses. For example, the postnatal services and resources throughoutprovince. An economies of scale factor for report notes: the province to support women who are at riska family size smaller or larger than four is • A single woman living alone on income of having a low birth weight baby.then applied to determine food costs for assistance would not be able to afforda variety of age and gender groups. This POPs began as a way to reach out to women reasonable shelter or healthy food. She who do not access typical prenatal services.information is used to prepare The Cost would receive a total of $510 per month There are now over 46 programs in BCof Eating in BC report by the Dietitians of on assistance. Shelter (a bachelor (Burglehaus, 2004). The programs have beenCanada, BC Region, and the Community apartment at the 25th percentile for beneficial in reducing the chance of mothersNutritionists Council of BC. In 2005, based rent) alone would cost about $580 per having a low birth weight baby. In 2004,on a study of 109 grocery stores across 5 month. After paying rent, she would approximately 6,500 women were seenregional health authorities, they found that not be able to afford any food, or any through the POPs in BC (Ministry of Health,the monthly cost of feeding an average BC 2005a). other necessities (Dietitians of Canada,family of four was $654.46, which was 3.5 2005b);per cent higher than in 2004 (Dietitians ofCanada, 2005b). Figure 4.4 Average Household Food Expenditures, Canada and Provinces, 2004 Overall, BC residents spend more for food$8,000 than all other provinces except Alberta. The Canada $6,910 $7,110 $7,130 $7,120 average food expenditure in Canada in the$7,000 $6,870 $6,410 same year was $6,910 (Figure 4.4). $6,180 $6,070 $6,190 $6,060$6,000 $5,670$5,000$4,000$3,000$2,000$1,000 $0 NF PEI NS NB QC ON MN SK AB BC Source: Statistics Canada. (2005c). Survey of household spending [CANSIM Table 203-0001]. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 53
  • 74. Chapter 4: Food Security Among British Columbians 2005 Monthly Cost Of Eating in BC Table 4.1 (based on living in a family of four)2005 Monthly Cost of Eating in BC Age/Gender Groups Total Monthly Cost Family Of Four $654.46To determine the cost of healthy eating in BC, Family Of Three $477.34in June 2005, registered dietitians across the Childprovince priced a food basket using Health 1 Year $74.62Canada’s National Nutritious Food Basket 2–3 Years $80.43measure, in 109 grocery stores in all health 4–6 Years $107.86regions. The food basket is neither an ideal diet Boynor the least expensive diet but it is consistent 7–9 Years $130.48with the food purchases of ordinary Canadian 10–12 Years $160.20households, based on a family of four. The food 13–15 Years $186.68costs do not include take-out or restauranteating and do not consider the potential 16–18 Years $218.53availability of emergency food programs. The Girleconomies of scale factor for a family size 7–9 Years $123.80smaller or larger than four was applied to 10–12 Years $145.55determine total food costs. The food costing 13–15 Years $156.13tool was used in this report to determine 16–18 Years $149.24the affordability of food for a low-income Manfamily and various family scenarios living on 19–24 Years $207.64income assistance compared to the average 25–49 Years $199.85Canadian family. This has been reported as 50–74 Years $179.53an appropriate use of this costing tool. The 75+ Years $161.67proportion of disposable income (take home Womanearnings plus child and family benefits) spent 19–24 Years $152.49on food for the low-income family, including 25–49 Years $144.13the family on assistance, was compared to 50–74 Years $140.96the average family. The money available after 75+ Years $136.85shelter and provincial health care plan costs Pregnancy and Breastfeedingwould need to be used to purchase food and 13–15 Trimester 1 $169.35all other necessities including transportation, 13–15 Trimester 2 $178.79clothing, child care, personal hygiene items, 13–15 Trimester 3 $178.79laundry and cleaning supplies, school supplies 13–15 Breastfeeding $185.12and fees, and medical, dental, and optical 16–18 Trimester 1 $169.30costs. The potential costs of these other 16–18 Trimester 2 $181.74necessities was determined using 2005 costing $181.74 16–18 Trimester 3data from the Social Planning and Research $187.20 16–18 BreastfeedingCouncil of BC (SPARC). 19–24 Trimester 1 $165.36Source: Dietitians of Canada, 2005b. 19–24 Trimester 2 $176.97 19–24 Trimester 3 $176.97 19–24 Breastfeeding $181.87 25–49 Trimester 1 $157.86 25–49 Trimester 2 $167.79 25–49 Trimester 3 $167.79 25–49 Breastfeeding $171.77 54 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 75. Chapter 4: Food Security Among British Columbians• A single-parent family with two children The Link Between Hungry receiving income assistance plus their Households and Poor Health Food Insecurity and Cigarettes Child and Family Tax Benefit would be $26 short after paying for shelter Earlier in this report, the impact that Food insecurity contributes to costly health unhealthy diets have on health was problems in many ways. Lower income groups, and food. They would have nothing outlined. Low-income British Columbians for instance, exhibit higher smoking rates. left for all other expenses, including face challenges in affording healthy foods Cigarette smoking among lower income transportation, clothing, laundry women is reported to reduce stress, and supplies, and other items (Dietitians of and that may well contribute to their higher also act as an appetite suppressant. One Canada, 2005b); rates of chronic diseases and nutritional study showed that primary caregivers in problems, including micronutrient• Low-income families in BC also “hungry households” were 1.7 times more deficiency (Health Canada, 1996). likely to smoke than other primary caregivers struggle to balance food costs with Studies consistently show that people in (McIntyre, Connor, & Warren, 2000). other necessary expenditures. A low- income family of four, with one earner hungry households have poorer nutrition in a full time job at $11/hour, has a than those in food-secure homes. The daily Children Come First disposable monthly income of $2,218, diet of low-income households generally Research shows that parents in food-insecure including child and family benefits. This does not include many fruits, vegetables, households will deprive themselves of family has $587 remaining, after average or whole grains. It is also lower in essential nutritious food in order to feed their children. shelter and food expenses, to pay for nutrients than typical diets in food-secure One study of food-insecure women in Atlantic all other costs of daily living, including households, including calcium, iron, Canada found that mothers compromised their clothing, transportation, toiletries, magnesium, folate, and vitamin C (James, own nutritional intake to ensure their children Nelson, Ralph, & Leather, 1997). Canadian had optimal nourishment. The mothers’ diets school supplies, etc. In comparison, women in food-insecure households eat far lacked adequate intakes of most nutrients a BC family of four with an average fewer fruits and vegetables and consume examined. Nutrients in their children’s diets income (disposable monthly income of appeared to be sufficient, with the notable $4,307) still has $2,333 to spend each far less than the recommended dietary exception of folate and zinc (McIntyre et al., month after housing and food costs. allowance of vitamin C, potassium, and 2003). While the average-income family of other key vitamins and minerals, compared four would spend about 15 per cent of to women in food-secure households. Relative Cost of Calories their income on the food basket, the The frequency of fruit and vegetable low-income family would need to spend consumption among these women Healthy, nutritious food costs more per calorie about 30 per cent of their income to declined significantly as food insecurity than unhealthy junk food. The following items buy the same food basket. A family of status increased (Statistics Canada, 2001). all cost about $1 in BC: four on income assistance would need Individuals in food-insecure households in • One apple – 44 calories. to spend 44 per cent of their income on Canada are more likely to report ailments • One chocolate bar – 200 calories. the food basket (Dietitians of Canada, such as heart disease, diabetes, and high 2005b). blood pressure (Vozoris & Tarasuk, 2003). • One bag of potato chips (40 chips) – 300 calories.• A single, pregnant woman living alone Once a chronic health problem appears, it on income assistance in BC would is challenging for those on low incomes to When people are poor, they will often choose most likely be unable to feed herself follow dietary recommendations for their to eat cheaper, unhealthy food because it gives adequately or nourish her developing illness, such as a low-sodium diet for high them a higher caloric intake. Diets replete with blood pressure or a high-fibre, low-fat, low- added sugars and fats are far more affordable baby. She would receive $555 a added sugar diet for diabetes. Such special than healthy diets comprised of lean meats, month in assistance, which would not diets often cost more than the basic diet. whole grains, and fresh vegetables and fruits cover the average cost of a bachelor (Drewnowski & Darmon, 2005). apartment at $580 a month (Dietitians For example, a diabetic diet costs about of Canada, 2005b). Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 55
  • 76. Chapter 4: Food Security Among British Columbians$60 more per month than the 2005 BC basic food basket determines what type of food is bought, which, in turn,(Anderson, McKellar, & Price, 2006). influences health-related behaviours (Toronto Food Policy Council, 1996).Children in hungry households in Canada are reported tohave significantly poorer health than other children (McIntyre, A comparison of food retail outlets in Toronto’s twoConnor, & Warren, 1998). Almost 30 per cent of children in poorest neighbourhoods indicates that, the poorer thefood-insufficient households suffer from asthma, compared neighbourhood, the more convenience outlets it has andwith 13.5 per cent of children in food-secure households the fewer full-service grocery stores. Twenty-four-hour(McIntyre et al., 2001). Insufficient nutrition during early convenience stores stock items like chips, pop, packagedchildhood can cause permanent cognitive damage, affecting a baked goods, candy, chocolate bars, magazines, cigarettes,child’s ability to learn and function (Community Nutritionists lottery tickets, and higher-priced milk products. There areCouncil of BC, 2004). American studies have documented few (if any) fresh fruit and vegetables. In Toronto’s Regent-chronic minor health problems among children from food- Moss Park neighbourhood, 57 per cent of families and singleinsecure households that include fatigue, irritability, dizziness, persons live below the low-income cut-off. In Toronto’s Southrecurring headaches, frequent colds and infections, and Parkdale neighbourhood, one-third of families and 43 per centdifficulty concentrating (McIntyre et al., 2001). In adolescents, of single persons live below the low-income cutoff line. Infood insufficiency has been linked to low-level depression and Regent-Moss Park, the poorer of the two neighbourhoods, 62suicide symptoms (Alaimo, Olson, & Frongillo, 2002). per cent of all food stores are convenience outlets. In South Parkdale, 33 per cent are convenience stores (Toronto FoodParadoxically, as food insecurity increases, so does the Policy Council, 1996). No similar data exists for BC but thistendency for women to be overweight or obese, increasing would be an important area of future research.the potential for obesity-related chronic diseases such asdiabetes (Townsend, Peerson, Love, Achterberg, & Murphy, Studies in the United States show that the poorer sections2001; Drewnowki & Specter, 2004). A study of obese Canadian of many American cities have been abandoned altogether bychildren found that 6.4 per cent of children in the wealthiest food retail outlets. Studies from the United States and thequarter of the population were obese, compared with 12.8 United Kingdom show that people without automobiles payper cent in the poorest quarter (Community Nutritionists more in money, time, and energy for access to quality foodCouncil of BC, 2004). stores (Toronto Food Policy Council, 1996). For seniors and the disabled, limited access to shopping canFood Distribution, Storage, and Preparation: pose a major barrier to obtaining food. Poor mobility canLimited Choices for Low-Income People make nutritious food inaccessible even to those who can afford it. Functional impairments can also have an impact onAside from cost, other factors also limit and prevent low- the ability to prepare and consume food.income British Columbians from accessing healthy foods.In order to have food security, BC residents must also have People living in single rooms or other basic accommodationready physical access to quality grocery stores and food also face barriers to the nutritious and economical preparationsources, kitchens to cook in, and places to safely store food. of foods. They may only have access to a hot plate, lack aLow-income individuals often have fewer choices to address refrigerator, and have limited room for storage of bulk foodthese factors. that is often available at lower prices. The homeless have no access to cooking or food storage facilities.For those on low incomes, lack of easy access to grocerystores can pose an additional obstacle to the attainment of Northern aboriginal communities also face unique challengesfood security. Vulnerable people may live in areas that are not in attaining food security. Food sold in northern aboriginalwell served by quality food outlets. The range of food available communities is more expensive, frequently poor in quality,in stores accessible to low-income families and individuals and lower in nutritional value than traditional foods grown56 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 77. Chapter 4: Food Security Among British Columbianslocally (Dietitians of Canada, 2005a). Low financial hardship for families with incomesincomes are a major contributing factor of $35,000 or less (National Council of Core Functions in Public Healthto the prevalence of food insecurity in Welfare, 2005). Provinces and territoriesthese communities, but so are quality were allowed to adjust social assistance For the last few years, BC’s Ministry of Health has been involved in an extensiveproblems associated with inappropriate or child benefit payments by an amount process to define a set of core functionsshipping, handling, and home preparation equivalent to the NCB supplement. These in public health—key preventive andof commercial foods. Shorter growing adjustments would allow provinces and protective services that have good evidenceseasons in the north pose a challenge for territories to reinvest in benefits and of effectiveness and whose impact can belocal growers. Chapter 6 provides a detailed services for low-income families with measured.explanation of diet and health among BC’s children (National Child Benefit, n.d.).Aboriginal population. Through extensive consultations and research, In BC, the BC Family Bonus was reduced a core functions framework has been by the full value of the federal supplement, established and 21 core programs, includingMeasures to Reduce the Impact meaning that families on social assistance food security have been identified. Now,of Poverty were no further ahead. The National in the second phase, evidence papers for Council of Welfare advocated an immediate each program are being written, model coreSince it is now recognized that the main end to these types of “clawbacks” by BC program papers and performance measuressolution to individual and household food are being developed, and an extensive website and other provinces (National Councilinsecurity is to eliminate poverty, the final is being created by the ministry. The third of Welfare, 2005). From the beginning,section of this chapter looks at the various phase will be a three-year, rolling process of Newfoundland and Labrador and Newactions by the federal and provincial implementation that will continue (7 programs Brunswick did not reduce social assistancegovernments, and by communities, schools, at a time) until 2009/2010. payments. More recently, the governmentsand municipalities to address the impact of of Nova Scotia, Quebec, Manitoba, Alberta, For each core program, health authorities willpoverty on food security. and Ontario decided to limit their clawback develop program components and measures, (National Council of Welfare, 2005). identify their gaps, and develop performanceFederal and Provincial Programs improvement plans and targets. In the thirdIn operation for the last three decades, The BC government provides social year, it is hoped that they will be able tounemployment insurance (now called assistance for those who have no other report on their progress in a system that isEmployment Insurance) is a fund to source of income but this assistance has transparent and accountable to the public.assist people who are temporarily jobless. not kept pace with inflation and falls short For more information on Core Functions in of covering the cost of shelter and food. Public Health, please refer to the Ministry ofFollowing the restructuring of the fund in Health website at http://www.health.gov.1995, eligibility for benefits was restricted, In BC, the Provincial Health Officer bc.ca/prevent/.levels of benefits were lowered, and shorter has stated that evidence suggests thatbenefit periods were instituted, which government programs that reduce socialresulted in fewer people receiving funds inequities, and mitigate the impacts ofand greater economic hardship. Low- low socio-economic status, will have moreincome families and individuals do receive impact on the health of the population thana quarterly Goods and Services Tax credit simply providing more and more healthfrom the federal government. services to treat preventable disease (PHO,Since 1998, low-income families with 2003). Placing a priority on ensuring thatchildren have been eligible for the federal low-income families can afford to purchasegovernment’s monthly National Child nutritious food would be an important stepBenefit (NCB), a supplement to the Canada towards reducing food insecurity in BC andChild Tax Benefit intended to help relieve fostering a healthier population. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 57
  • 78. Chapter 4: Food Security Among British Columbians As an example, the BC government introduced the SchoolCommunity Food Action Initiative Meal Program in 1991 to provide hungry children with the nutrition they need to be able to concentrate and learn atThe Community Food Action Initiative is a joint project between the Ministry of school. The costs of this program were shared by schoolHealth, the BC Public Health Alliance on Food Security, and the Provincial Health districts, community agencies, and the provincial government,Services Authority. The objectives of this initiative are to: and by 1996, meals were offered at 300 schools in BC. While• Increase awareness of food security. this program is a great help, it appears it may not be enough. The organization Breakfast for Learning reports that at least 35• Increase access to local, healthy foods. new school meal programs are needed in BC and 67 existing• Increase food knowledge and skills. programs should be expanded (Directorate of Agencies for• Increase community capacity to address local food security. School Health, BC, 2002).• Increase development and use of policy that supports community food security. Food Security: Public Health Core FunctionThis initiative is a part of the healthy eating component of ActNow BC and will Over the past decade, food insecurity has become a seminalprovide support for the planning and implementation of community, regional, concern, not just in BC, but across Canada and around theand provincial initiatives for increased access to safe, culturally acceptable, world. In 1996 the United Nations’ Food and Agriculturenutritionally adequate diets through a sustainable food system. Organization organized a World Food Summit that launched aA number of agreed-upon principles have been applied to the Community concerted campaign to achieve global food security, bringingFood Action Initiative which include: respect for autonomy, dignity, and together governments, international organizations, and alldiversity; universal access, targeted focus; fairness and openness; flexibility; sectors of society. The right of all people to have access tocomprehensiveness; evidence-based; and accountability. safe and nutritious food was affirmed by 187 countries at theMore information about the Community Food Action Initiative will be available summit, including Canada.on the ActNow BC website (BC Public Health Alliance on Food Security, 2005; In BC, the importance of food security to public health wasProvincial Health Services Authority, 2006). recognized in 2005, when food security was designated a core public health function. Core functions are a set of publicThe Cooking and Skill Building Project health services and activities that have the following criteria:The Ministry of Employment and Income Assistance is working collaboratively • A primary or early secondary prevention intervention.with the Ministry of Health to identify options for a $250,000 fund made available • Reasonable scientific or “best practice” evidence exists forfor fiscal year 2006/2007 by the Ministry of Employment and Income Assistance. both its effectiveness and cost-effectiveness.The money will be used to support activities to increase food security in localcommunities related to cooking and skill building for low-income families. • Performance indicators exist or can be developed that can measure its impact (Hancock, T., personal communication). By establishing food security as a public health core function, it is recognized that access to sufficient, safe, and nutritious food is a core need that BC’s health authorities, the provincial government, and society itself must address. Better nutrition in turn will help to reduce the overall burden of acute and chronic disease and disability and improve the health and wellness of the people in British Columbia. 58 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 79. Chapter 4: Food Security Among British ColumbiansCommunity Measures • Almost 8 per cent of BC food bank recipients are employed, and 10 per cent receive disability support.The community response to food insecurity includes foodbanks, community gardens, community kitchens, and other Food banks were created as an emergency response andprograms such as good food boxes. Food banks are not a were never intended to provide a nutritious diet. As theysolution to food insecurity and were meant to be temporary are dependent on donations, the type of food availableemergency measures. Capacity-building initiatives such as varies widely from week to week, and month to month. Thecommunity gardens, farmers’ markets, and fruit-picking majority of food is processed or packaged since vegetablesprojects all help to improve access to healthy food, as well and fruit are less likely to be donated than other types ofas to support local growers and producers. Community food (Wilson & Tsoa, 2002). Many food banks simply do notfood policy councils have been key in many communities in have the capacity to store refrigerated products or produce.supporting and advancing such capacity-building initiatives. Nor can food banks accommodate people with medical conditions requiring special diets, such as low-sodium foodsFood Banks for hypertension or low-sugar foods for diabetes.The first food bank in Canada opened in Edmonton in 1981. In order to assist as many people as possible, most BC foodLike subsequent food banks that opened across the country banks also limit the number of times each month that anduring the 1980s and 1990s, it was originally intended as a individual or family can access emergency supplies. Six outtemporary measure to address an emergency need for food. of ten BC food banks restrict visits to once a month, and theTwo decades later, as a result of escalating demand, food average food bank provides only about four days worth ofbanks have become a permanent fixture in Canada. Today, food in its hampers. Across Canada, 40 per cent of food banksthere are 95 food banks in BC and 550 nationwide (Canadian had difficulty keeping shelves stocked in 2003; the followingAssociation of Food Banks, 2004). year, that number had risen to almost 48 per cent (Canadian Association of Food Banks, 2003, 2004).The number of people who use BC’s food banks continues torise. In 1997, approximately 1.5 per cent of BC’s population Food banks fill a gap by providing emergency food to peoplerelied on food banks; by 2004, the number of people using facing hunger, but they are not a dignified means to accessfood banks had climbed to 2 per cent (Canadian Association food, are nutritionally inadequate, are limited in quantityof Food Banks, 2004). Each March, the Canadian Association and quality, and do not build capacity towards increasedof Food Banks conducts the only national survey of Canada’s food security for all. As such, although they are—at present—emergency food programs. In March 2004, the association’s indispensable, food banks do not constitute a viable solutionHungerCount survey found that: to food insecurity in BC.• More than 84,000 British Columbians—or over 32,000 Capacity-Building Community Programs BC households—used food banks during that month, an increase of 16 per cent over 2003. The following are some examples of initiatives that help those in the community, including those with a low income,• More than 26,000 BC food bank recipients during that access healthy foods. Many of these initiatives are operated month were children. by volunteers with short-term grants that are under constant• Almost 8,000 more BC children needed emergency food threat of elimination. in March 2004 compared with 2003. • Urban Agriculture and Community Gardens: Some• Seniors represented almost 7 per cent of BC food bank British Columbians now grow some of their own food users in 2004. in community plots, in rooftop or balcony gardens, or in their backyards. For those who do not have access• A majority of BC food bank users are on social assistance. to a plot of land, for a small annual fee, they can have Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 59
  • 80. Chapter 4: Food Security Among British Columbians their plots in a community garden, or remaining one-third is made into juiceSeed of a Growing Movement they can share a plot and its harvest that Lifecycles sells to support programs with others. Fifteen gardens exist focusing on the issues of health, food,In 1977, a University of Tennessee professor, in the Capital Regional District. On and urban sustainability.Robert Wilson, asked the question: If food Vancouver’s east side, the 3.5 acreis as essential as water, housing, and health • Good Food Boxes: The idea for Strathcona Community Gardenservices, why don’t cities have a Department of the Good Food Box started in BeloFood? His work with graduate students showed has been operating on public land Horizonte, Brazil in 1993 to address thethat cities do not plan comprehensively for for 20 years, providing low-income malnutrition of 20 per cent of the childfood security as they do for other necessities, families with fresh produce they population. The municipal governmentand this in fact can lead to fragmentation, might otherwise not be able to afford. began bulk buying of local fruits andcounterproductive efforts, and few lasting Kamloops has four community gardens, vegetables to increase access to healthysolutions to a community’s food problems. including one specially designed for food. Today, communities all over BC, disabled people. Nanaimo FoodShareOut of this research and fueled by concerns both urban and rural, have introduced operates a popular community gardenof feeding visitors to the Knoxville World Good Food Box programs. Mainly runFair, Knoxville, Tennessee, became the first with communal plots. Gardeners by volunteers, the program provides acommunity to create a food policy council in donate fruit and vegetables to charity weekly or bi-weekly box of fresh fruits1982. A group of multidisciplinary stakeholders or share it among themselves (Kalina, and vegetables for an average price ofadvise the city or regional government 2001). Municipalities are working on $10. The box is available to anyone,about policies related to agriculture, food garden policies to support community but the majority of customers aredistribution, food access, and nutrition; work gardens. low-income. Produce is purchased astogether to coordinate efforts; and providecomprehensive solutions to local or regional • Fruit Tree Projects: Each summer much as possible from local farmers,food issues. and fall, large quantities of fruit rot with a commitment to carry in-season on the ground in BC because tree food. A typical BC winter box mightSince 1982, similar policy councils have been owners cannot pick, or have no use include broccoli, pears, apples, carrots,adopted across North America to address the for, an overabundance of apples, and potatoes, while a summer boxunderlying factors impacting food security. The cherries, pears, and plums. Across might contain cantaloupe, cauliflower,councils don’t meet Wilson’s original vision of the province, volunteer fruit picking and cucumbers. The Good Food Boxa “Department of Food” as they have limited occurs in communities like Nelson, builds food security in a number ofdecision-making power, but they do influencepolicy. Kamloops, Nanaimo, and Vancouver to ways. It increases the amount of fruits make use of surplus fruit. Volunteers and vegetables available to those onIn Canada, Toronto’s Food Policy Council, harvest the fruit, keep a portion for low incomes, making a healthier dietcreated in 1991, has produced some of themselves, and distribute the rest to more affordable. It also helps build athe country’s seminal documents on food community agencies that help hungry strong, sustainable local food systemsecurity issues and solutions. See Food people. In Victoria each year, the non- by supporting local farmers and usingSecurity Learning Centre (http://www. profit group Lifecycles picks about organic produce wherever possibleworldhungeryear.org) and Toronto Food PolicyCouncil (http://www.toronto.ca/health/tfpc_ 31,000 pounds of apples, cherries, (Kneen, 2004). In the South Okanaganindex.htm) for more information. pears, plums, grapes, and quince from and Similkameen, the Healthy Harvest backyards and divides it into 3 equal Box, organized by a not-for-profit, portions. One-third is shared between food-buying club, is sold to 350 families volunteer pickers and tree owners, each week, and the goal for 2005 was one-third goes to community agencies to increase that number to 800 or 1,000 such as AIDS Vancouver Island, and the (Interior Health, n.d.). 60 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 81. Chapter 4: Food Security Among British Columbians• Community Kitchens: Like the that community kitchen programs good food box, modern community in Canada have a limited potential to National Food Policy Framework kitchens have roots in South America, resolve food security issues related where they were established almost to chronic poverty, because they do Federal/Provincial/Territorial (FPT) officials in both health and agriculture have developed 20 years ago in Brazil, Chile, and Peru. not substantially alter a household’s a number of important documents linked The aim of community kitchens is to economic circumstances (Tarasuk & to food policy, such as Canada’s Action Plan bring together low-income men and Reynolds, 1999). for Food Security, the healthy eating and women to share the cost and work nutrition components of the Pan-Canadian • Community Farmers’ Markets: of cooking. The kitchens are not a Healthy Living Strategy, and the Canadian Years ago, when most of BC’s charity, although in many communities, Food Inspection System Blueprint. However, population lived in rural areas, many they are sponsored by churches, there have been challenges in implementation people relied on farmers’ markets government agencies, service clubs, of the various initiatives, and in this context, to buy food they did not grow or community groups, who often the discussions on a National Food Policy themselves. Today, community markets donate cooking space. Groups using Framework began (Advisory Committee on are undergoing a revival. Currently, community kitchens reduce the cost Population Health and Health Security, 2004). about 60 markets exist around the of food by buying in bulk, and make In April 2004, the FPT Ministers of Agriculture province. That number is increasing nutritious soups and casseroles using directed agriculture officials to improve the steadily; in 2000 alone, about 10 new lentils, beans, and other low-cost coordination of food policy across Canada and markets were established in BC (BC ingredients. In addition to providing to develop a vision for a strong food sector. Association of Farmers’ Markets, n.d.). opportunities to share culinary skills, They asked that agriculture officials work with Each community market is unique; the kitchens help increase support counterparts in the health sector, to ensure some might sell only certified organic and self-esteem for those on low that a national food initiative took into account produce, others sell both organic and health, social, and economic benefits. incomes, and offer a friendly place to non-organic fruits and vegetables, make new friends. Different kitchens The FPT initiative would provide national while many also offer other fresh cater to diverse needs. In Kamloops, policy direction for health and agricultural food, including baked goods, eggs, many kitchen participants are single issues in the entire food continuum (farm- cheese, fish, chicken, and beef. The mothers. Single males who rely on to-fork), and would support action on food markets provide an opportunity for Kamloops food banks have formed safety, industry viability and innovation, small-scale producers to sell their other collective kitchens. Another and healthy eating. Benefits would include wares at a price reflecting the real cost Kamloops community kitchen caters better coordination on food safety, decreased of production, and give consumers incidence of foodborne illness and diet-related to college students living in residence, access to fresh, local foods. A growing disease, increased profitability and innovation who may only have access to a hot trend in urban centres across North in the food sector, and improved consumer plate or microwave. One Nanaimo America is to have markets set up one confidence in the entire food system (Health community kitchen matches teenage day in lower-income neighbourhoods Canada, 2004b). single mothers with elderly widows. to support better access to healthy When Kamloops’ Community Kitchens In the October 2004 meeting of the FPT foods, helping address the fact that were evaluated, they demonstrated Ministers of Health, Ministers committed to lower-income neighbourhoods often continued work on the framework, and stated positive outcomes, including greater do not have grocery stores nor good that further discussions on the development food security through increased access access to transportation. These farmers’ of a framework would take place in the to nutritious food, higher levels of markets bring local, nutritious foods ensuing months (Canadian Intergovernmental personal skill development, improved close to home, provide support Conference Secretariat, 2004). However, self-esteem, and enhanced social for local farmers, and benefit the no progress on the development of the support among participants (Kalina, neighbourhood socially. Framework has been made to date. 2001). Another study, however, found Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 61
  • 82. Chapter 4: Food Security Among British Columbians Food Policy Councils: Coordinating Efforts andNutrition and Food Policy in Norway ResourcesNutrition and food policy has a long history in Norway, beginning in the early With such a complex continuum from farm-to-fork underlying1930s with the debate over the interrelation between income, nutrition, and food security, piece-meal efforts, such as food banks andhealth. In 1937, a National Nutrition Council (NNC) was formed to create a community kitchens, can only make a small dint in thenutrition and food policy. underlying factors that make physical and economic access toBeginning in the 1950s, the proliferation of energy-rich foods into the food so difficult for some people.marketplace led to changes in food habits and lifestyles, resulting in a Some communities are mobilizing to create moresubstantial increase in mortality from coronary heart disease. It became clear coordinated, comprehensive approaches so that the wholethat changes in nutrition and agriculture policy were needed to improve thehealth of the population. population of a community, regardless of income or individual resources, has better access to healthy foods. Food policyIn 1974, a White Paper was developed that emphasized the need to align councils that advise governments can provide an effectivethe food supply with policy. This paper supported the development of a forum for all stakeholders to work together to examine thecoherent food policy that required collaboration across the public sectors, issues. The establishment of a food policy council signals thatorganizations, and industry. The 1974 policy supported implementation of a community is moving from short-term relief of hunger andregulatory, financial, and education measures to achieve dietary change. malnutrition (e.g., establishing food banks and soup kitchens)A variety of national strategies were implemented to support the policy. Anational nutrition campaign was undertaken, higher education at the university to a more long-range, coordinated planning process to helplevel for nutritionists was implemented, medical education changed, and the address food insecurity.agriculture sector was supported to make significant changes in the production The effectiveness of food policies has been demonstratedand distribution of foods. Agriculture and food policy were also integrated with in many countries. For example, in 1975, Norway adoptedother economic measures. The policy underwent further development and a food policy to promote healthy diets, increase local foodrevision in 1975, 1982, and 1993. production and agricultural development, and contribute toThe impact of the Norwegian nutrition and food policy has been significant. world food security. By the 1990s, consumption of fats hadPublic surveys have repeatedly shown that the population is more decreased by 6 per cent (from 40 to 34 per cent) and theknowledgeable about the link between diet and health since the inception of death rate from heart disease had also decreased.the first food policy. Substantial dietary changes have been reported througha variety of sources such as wholesale food figures and household food In Canada, food policy councils, such as in Toronto,consumption surveys undertaken by the National Bureau of Statistics. The Vancouver, and Kamloops, have promoted policiesagriculture landscape has changed over the years to support the food policy. and programs aimed at improving food security in theWith regard to the health impact, there has been a 50 per cent and 25 per cent community. Toronto’s Food Policy Council promotes areduction in mortality from coronary heart disease among middle-aged men variety of community food security programs designed toand women. provide community access to an affordable, healthy diet,The next step in the Norwegian policy is to shift from focusing on a single including: community shared agriculture, farmers’ markets,disease into a broader health strategy (Norum, Johansson, Botten, Bjorneboe, & good food box programs, community kitchens, communityOshaug, 1997). restaurants, community gardens, rooftop gardens, and school food programs. Evaluations of these programs have shown a decrease in social isolation, an increase in fruits and vegetables consumption, an increase in community food self- sufficiency, and an increase in sustainable food production (Community Nutritionists Council of BC, 2004). In BC, the cities of Vancouver and Kamloops have formed food policy councils. The Kamloops Food Policy Council 62 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 83. Chapter 4: Food Security Among British Columbianswas established in the mid-1990s when the need for food policy councils or coalitions that work to support localbanks and community gardens began to grow to address action for a healthier food system. This is fertile future workthe emerging food needs of the city of 85,000 people. The for organizations such as the Union of British Columbiacouncil develops and promotes policies so that everyone has Municipalities. However, a similar coordinated effort isaccess to a stable supply of nutritious food. It also provides needed on a provincial level. It would be highly beneficiala framework to support local and regional sustainable to have a coordinated, comprehensive approach for a safe,agriculture and food production (Lobe, 2005). secure, and sustainable food policy for BC adopted by all the provincial ministries with mandates along the food securityIn Vancouver, the creation of a food policy council was part continuum. Such a policy could support:of a City Food Action Plan devised in 2003. The action planwas established in response to concerns about the current • Local farming, food processing, and distribution.food system, and to help Vancouver become a leader in the • Better education on where food comes from, and betterdevelopment of sustainable food policies and practices (City knowledge and skills in healthy eating.of Vancouver, 2004b). Vancouver’s food policy council iscomprised of individuals from widely different backgrounds, • The creation of local access in neighbourhoods to farmers’and encompasses all sectors of the food system, including markets, gardens, and other resources.production, processing, access, distribution, consumption, • Adequate income assistance rates and initiatives toand waste management (City of Vancouver, 2004a). support healthier food choices.The Vancouver Food Policy Council will examine every aspect Since the impacts and origins of food insecurity are multi-of the food system from field to meals, focusing on where and dimensional, policy responsibility rests with many ministrieshow food is grown, transported, and distributed. One of the and sectors. Dietitian organizations such as the Communitycouncil’s major objectives is to inform the public about food Nutritionists Council of BC and the Dietitians of Canada havesecurity issues, and to improve the health and sustainability of called for increased inter-ministerial coordination to addresslocal food systems through initiatives such as farmer’s markets food insecurity in BC.and encouraging institutional buyers to purchase locallyproduced food (City of Vancouver, 2004a). International ActionIn Victoria’s Capital Regional District, a major initiative is At the November 1996 World Food Summit, the internationalunderway to create a Food Charter that will encourage community, including Canada, made the commitment toresidents to think about where their food comes from and reduce by half the number of hungry and undernourishedhow it is produced. The Charter will also outline steps to people no later than the year 2015. In response to the Worldcreate a sustainable and secure local food and agriculture Food Summit, Canada developed an Action Plan for Foodsystem, and to improve access to nutritious and sufficient Security containing plans and steps Canada could take tofood (Capital Region Food & Agriculture Initiatives improve food security both domestically and internationallyRoundtable, n.d.). A broad range of organizations are involved (Agriculture and Agri-Food Canada, 1998). This plan wasin forging the Charter. They include the Canadian Cancer launched on October 16, 1998, and a Food Security BureauSociety, the Vancouver Island Health Authority, Small Scale was established in February 1999 under the auspices of theFood Processors Association, and environmental non-profit federal Agriculture and Agri-Food Canada.groups such as the Land Conservancy of BC (Weizel, 2005). Unfortunately, apart from two progress reports in 1999 andThe growing movement towards a coordinated, 2002, little has been done to truly implement the plan andcomprehensive approach at the community level is an to date there are few tangible results. More federal attentionimportant step in addressing food insecurity, and more needs to be placed on food security as a determining factorBC communities should be supported to establish food underlying the health of Canadians. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 63
  • 84. Chapter 4: Food Security Among British ColumbiansSummary • Families and individuals on social assistance in BC have little or no money after paying for shelter to purchase• Food security exists when all people at all times have food and other necessities. physical and economic access to sufficient, safe, and nutritious food to meet their dietary needs and food • Along with the inability to purchase healthy food, preferences for an active and healthy lifestyle (FAO, 1996). individuals with inadequate income experience other barriers to eating and preparing healthy food, including• The inability to access healthy food, termed food reduced access to grocery stores or fresh produce in their insecurity, affects a number of British Columbians either low-income neighborhood, and a lack of transportation because they lack the economic means to purchase to food outlets. Homeless individuals usually have no healthy foods and/or because they live in remote BC cooking or food storage facilities, forcing them to live locations. from hand to mouth for every meal.• In 2001, 17 per cent of BC’s population could not afford • A number of initiatives are available in some communities, the quality or variety of food they wanted, worried such as school meal programs, food banks, community about having enough to eat, or even went hungry in the gardens and fruit tree programs, community kitchens, previous 12 months. This was higher than the national and good food boxes, but these initiatives are often not average of 15 per cent. accessible to all in need, are piece-meal at best, and are• Factors affecting the ability to afford nutritious food in BC not funded in a sustainable manner. include higher costs of living for a basic “market basket” of • The growth of community food policy councils, which items, higher housing costs, inadequate social assistance bring a diversity of stakeholders together, is helping to rates, increased levels of homelessness, and a minimum create a more coordinated and comprehensive approach wage level that can result in even full-time workers in to address food insecurity at the community level. some BC communities falling below the federal poverty line. • More work needs to be done at the community, provincial, and national level to address the underlying• Hunger and malnutrition are physically damaging to all cause of household food insecurity—poverty. people, but some populations are particularly vulnerable. Children, seniors, and pregnant women are at increased risk of disability, poor health, and even death from insufficient caloric and nutritional intake. The fetuses of pregnant women can be permanently damaged from malnutrition.64 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 85. Chapter 5: The Safety and Sustainability of Food and the Food SupplyThe food we eat must not only be nutritious and be In BC and Canada, foodborne illness is estimated to occurconsumed in the right proportions to maintain health; it far more frequently than actually reported. Individuals canmust also be safe to eat. The potential public health impact experience episodes of gastrointestinal upset, diarrhea, orof unsafe food is significant, capable of harming both what many term “stomach flu,” and be unwell for a day orindividuals and large sectors of society. Food can be unsafe two. An unknown but substantial proportion of these arefor consumption in many ways—through contamination thought to be due to contaminated food. Such individualwith pathogens, toxins, or chemicals on the farm; during cases are usually short-lived and rarely lead to a confirmeddistribution, food processing, and retail operations through diagnosis.improper storage; or through unsafe food preparation in the Most cases of foodborne illness are only recognized when athome. Ensuring the safety of the food supply requires a “farm- least two or more people become sick after eating a meal orto-fork” risk management approach that guards against risks food product in common. Symptoms can arise hours or evenor removes them at each point along the continuum that food days after the food is consumed. Every year a provincial ortravels from being grown, raised, or harvested to the time it is national outbreak occurs in which a group of individuals getconsumed. sick from a certain foodborne pathogen. The Canadian Food Inspection Agency reports that each year about 10,000 casesFoodborne Diseases of foodborne illness are reported from which approximatelyFood has long been recognized as a possible source of illness. 30 people die (Canadian Food Inspection Agency, [CFIA],Although we know a great deal about food poisoning and 2005c).how to prevent it in the 21st century, foodborne illness and According to the World Health Organization (WHO), a smallfood contamination still create widespread illness and death number of factors related to food handling are responsiblein the world. The most common causes of foodborne disease for a large proportion of foodborne diseases worldwide. Theare: most common factors are:• Bacterial, viral, or parasitic infections; • Preparation of food several hours prior to consumption,• Toxins in food created by bacterial growth, such as in the combined with improper storage at temperatures which case of botulism or E.coli 0157:H7, or toxins created by favour the growth of pathogenic bacteria and/or the harmful algae species, mostly in seafood and shellfish or formation of toxins; mycotoxins created by certain molds; and • Insufficient cooking or reheating of food to reduce or• Chemical contaminants. eliminate pathogens; Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-being in British Columbia 65
  • 86. Chapter 5: The Safety and Sustainability of Food and the Food Supply • Cross-contamination of food; and 2000 to 2004 (Figure 5.1). The Centers forGolden Rules for Food Handling Disease Control and Prevention in Atlanta, • People with poor personal hygiene Georgia, estimate that Norovirus causes 50The World Health Organization has developed handling food. per cent of all foodborne outbreaks in theten rules for safe food preparation that, if These food safety risks can be avoided with United States (Widdowson et al., 2005).followed, greatly reduce the chance of anyone safe food handling. This estimate appears to be consistent withbecoming sick from foodborne illness: British Columbia’s experience.1. Choose foods processed for safety, i.e. Risk from Food Pathogens in BC pasteurized products over unpasteurized. Bacillus cereus The World Health Organization has2. Cook foods thoroughly. Bacillus cereus is a gram-positive, rod- identified more than 45 pathogens that are3. Eat cooked foods immediately. linked with foodborne illness and disease. shaped bacterium that, after Norovirus, Not all of these are health risks in BC or is the leading cause of bacterial food4. Store food promptly and carefully. poisoning in BC. From 2000 to 2004, Canada. In general, the symptoms and Perishable foods should be kept at below Bacillus cereus was traced to 20 incidents dangers of all food poisonings are much 40 C until ready to cook or eat. Bacteria can more severe in infants, young children, of food poisoning, and was also associated grow and spoil food left in temperature 40C the elderly, and immune-compromised with a further 5 incidents, causing over to 600C. For more information, visit Canadian individuals. The most common food 200 illnesses. Chinese food, which was Food Inspection agency at http//www. inspection.gc.ca. pathogens1 in BC are: predominately purchased as take-out and from restaurants, was involved in 60 per5. Reheat cooked foods thoroughly. cent of these illnesses. Norovirus6. Do not allow any contact between raw food Bacillus cereus bacteria are commonly Norovirus is a very small virus that can or its traces and cooked food. found in soil and many foods, particularly cause food poisoning illness when present7. Wash hands repeatedly. in food or water. After ingesting as few grains like rice that can become as 5 to 10 viral particles of this tiny virus, contaminated with the organism. If the8. Keep all kitchen surfaces meticulously clean. most people will develop symptoms of food is stored in a warm, wet environment,9. Protect food from insects, rodents, and other severe vomiting and diarrhea within 12 to the spores can germinate and the animals. 60 hours. This illness often causes severe vegetative cells of the bacteria grow,10. Use safe water. dehydration and may become serious in resulting in high numbers of the bacteria. young children and the elderly. Norovirus When the bacteria are in high enough inThe BC HealthFile’s tips on safe food handling numbers, they produce toxins, which can has often been called the Norwalk-likegenerally follow the above list but add a few cause diarrhea and vomiting. Sometimes virus. While the usual transmission of theother cautions: virus is person-to-person, the virus can heating can destroy the toxins, but since• Do not let anyone with diarrhea or infected also be present in foods contaminated by some toxins are resistant to the heat, even sores prepare food. someone who is sick with the virus. Some cooking food thoroughly may not help. foods eaten raw, like oysters, can become That is why it is so important to make• Wash all fruits and vegetables before eating. contaminated with the virus, and cause sure that cooked food is rapidly cooled• If in doubt, throw it out! (Ministry of Health large outbreaks. Other foods that have to 40 C (recommended “cold-holding” Services [MOHS], 2001) temperature). been involved in transmission of the virus include salads, sushi, and catered meals Two other types of common food of sandwiches and wraps. Norovirus was poisoning, Staphylococcus aureus and identified in food or ill persons in 50 per Clostridium perfringens, also share the cent of all foodborne illnesses in BC from same characteristics of Bacillus cereus. 3 In most cases, the information provided is from Canadian Food Inspection Agency’s factsheets. 66 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 87. Chapter 5: The Safety and Sustainability of Food and the Food Supply Organisms Causing Food Poisoning in BC, 2000 to 2004 Aeromonas spp. Figure 5.1 Yersinia enterolytica Amanita pantherina Vibrio Bacillus cereus From 2000 to 2004, Norovirus was Staphylococcus aureus responsible for 50 per cent of all foodborne Botulism Torovirus diseases in BC. Shigella sonnei Campylobacter Salmonella Ciguetara toxin Rotavirus Clostridium perfringensPleisomonas shigelloides Cyclospora cayetanensis Paralytic Shellfish Poisoning E coli 0157: H7 Listeria monocytogenes Norovirus Source: BC Centre for Disease Control, 2004.Together, these three organisms were One particularly virulent EHEC strain, Oysters and Norovirus in BCresponsible for 38 confirmed incidents of E.coli 0157:H7, first identified in 1982,food poisoning in BC, causing 290 illnesses has become a major public health threat From January to March 2004, oysterbetween 2000 and 2004. This figure likely worldwide. It lives harmlessly in the gut consumption was associated with clinicalunderestimates the actual amount of of cattle and deer, but can contaminate illness in 79 individuals from 68 separate incidents in BC. Oysters were eaten raw (73disease these organisms cause by at least food or water supplies through contact per cent of cases), pan fried (10 per cent),10-fold, as illnesses can only be confirmed with infected intestinal contents or and deep-fried with batter (8 per cent).when leftover foods or clinical samples are manure. Raw or undercooked hamburger, Norovirus was found in leftover oysters stillsubmitted to the food poisoning reference unpasteurized milk or juice, unwashed in the shell and those previously shuckedlaboratory at the BC Centre for Disease fruits and vegetables that have been sold in plastic tubs. The oysters were tracedControl. fertilized with infected cow manure, or back to at least 14 different harvest sites, 18 poor handwashing are the most common suppliers/producers, and 45 different points ofEnterohemorrhagic E.coli sources of infection. The presence of just purchase. This outbreak suggests that oysters 10 bacteria can cause infection. In 2 to 7 were contaminated with Norovirus over aOf the more than 50 different strains of the per cent of infected individuals, particularly geographically dispersed area in the Pacificbacteria Escherichia coli, only a few are the elderly and children under the age of Northwest by an unknown source (David etharmful. The sub-strain enterohemorrhagic 5, the infection progresses to hemolytic al., 2006).E.coli (EHEC), also called verotoxic E.coli, uremic syndrome, characterized by acuteproduces a toxin that can cause vomiting, kidney failure and the risk of death. Indiarrhea, and fever and, in severe cases, recent years, BC has had cases linked tobloody diarrhea, kidney failure, and undercooked hamburger, unpasteurizedpotential death from hemolytic uremicsyndrome. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 67
  • 88. Chapter 5: The Safety and Sustainability of Food and the Food Supply apple juice, unpasteurized goat milk, and and up to 30 to 50 per cent of the humanWhat is Good Handwashing? tainted salami. Although the Canadian population are carriers. Contamination Food Inspection Agency routinely tests of food from poor hygiene, coupled withUse soap and warm water and create a good hamburger meat and issues recalls when improper temperature storage of foods,lather, and wash your hands for about 20seconds (the time it takes to sing the “happy E.coli are found, there is no guarantee can create conditions that allow S. aureusbirthday” tune). You should wash your hands that all hamburgers meat is bacteria free. bacteria to multiply to levels that allowthis way particularly after using the toilet, or The dangers of E.coli can be removed by SEs to be released from the bacteria intowhen you touch potentially contaminated thorough cooking (for example, internal food. So far, 14 different types of SEs havesurfaces. temperature of hamburger patties should been identified (Le Loir, Baron, & Gautier, reach 710 C), pasteurizing, and careful 2003). Symptoms usually have a violentSprouts Risk handling of food products. onset—usually about 2 to 4 hours after eating the food, but onset may be as shortIn recent years, raw sprouted seeds and beans Staphylococcus aureus as 30 minutes or up to 8 hours later. Thehave been linked to outbreaks of foodborne symptoms are severe nausea, vomiting,illness, caused by Salmonella and E.coli 0157: Causing an estimated 25 per cent of allH7 in North America, Europe, and Japan. The cramps, and prostration, often with food poisonings, Staphylococcus aureusbacteria can become lodged in tiny cracks diarrhea and sometimes lowered blood (S. aureus) bacterial strains that causeof the seeds and then multiply in the warm, pressure and lower body temperature. food poisonings are characterized by onehumid conditions needed to sprout the seeds. Symptoms are short-lived—usually about 24 virulence factor—the ability to produceManufacturers are working with the Canadian hours—but the intensity can be extreme. staphylococcal enterotoxins (SEs). Other S.Food Inspection Agency to remove the risk, aureus bacterial strains (not related to food The foods most likely to becomebut the safest course of action is to thoroughlycook sprouts in stir fries or soups (CFIA, 2000). poisoning) can cause conditions from skin contaminated are those that come in infections to toxic shock syndrome, and are contact with food handler’s hands without important pathogens in the community and further cooking: pastries, custards, dips and hospitals. S. aureus is found in the nostrils, dressings, sandwiches, cheese, and sliced skin, and hair of warm-blooded animals, meats. The source can be a food handler A Comparison of Reported Pathogens Associated with Figure 5.2 Foodborne Diseases in BC, 2000 and 2004The BC Centre for Disease Control 4 3.5 2000 2004investigates outbreaks of food poisoning log adjusted case ratein collaboration with the regional health 3authorities. Reportable communicable 2.5diseases associated with food poisoning, 2and investigations into outbreaks, reveal 1.5that in general, rates for some foodborne 1diseases have dropped since 2000 while 0.5others have increased (Figure 5.2). 0 lla s lla s s sA es sis r oli reu reu en cte io ne ige en ria E.c ti ing r ce au ba ati Vib o tog spo Sh lm nic rfr lo B. p S. ocy He py Sa lo ge pe Cyc m in on C. Ca tox L. m o ver Source: BC Centre for Disease Control, 2004. 68 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 89. Chapter 5: The Safety and Sustainability of Food and the Food Supplywho carries the organism, or an infected most common sources of infection are rawcow, which contaminates milk or cheese. It or undercooked eggs, unpasteurized milk Emerging Foodborne Pathogensis important not to leave risky foods sitting and other dairy products, undercooked In recent years, organisms previouslyunrefrigerated for more than two hours. or contaminated poultry or raw poultry unrecognized as foodborne are emerging as juices, or contaminated meat products. potential risks in the food chain, including:Salmonella Fruits and vegetables, particularly melons and cantaloupes, which have been • Helicobacter pylori – Prior to 1982,Salmonella bacteria cause a sudden contaminated by infected manure and dirty stomach ulcers were thought to be createdinflammation of the intestine (enterocolitis) by stress, spicy food, excess stomach acid, utensils and cutting boards, can also becombined with a sudden onset of and lifestyle. Now it is known that spiral- sources of infection.headache, abdominal pain, fever, diarrhea, shaped helicobacter bacteria create 90 pernausea, and sometimes vomiting. In severe cent of duodenal ulcers and 80 per cent Campylobactercases, the infection, called salmonellosis, of gastric ulcers. Treatment is typically 2can cause septicemia or can localize into More than 20 different strains of the weeks of antibiotics and a drug to suppressa tissue of the body causing inflammation bacteria Campylobacter exist; they are stomach acid to allow the ulcer to heal.of the joints, heart, lungs, brain, or most commonly carried by cattle and Although its transmission routes are notkidneys. Deaths are rare, but the very old, chicken, but are also found in puppies, clear, there may be a significant foodbornevery young, or immunocompromised kittens, pigs, and some wildlife. The component, particularly from infected adult food handlers to children.individuals are at risk of death, especially microbe is thought to be responsible forfrom rapid dehydration. Healthy individuals 5 to 14 per cent of all cases of diarrhea • Arcobacter butzleri – This organism, foundcan be weakened and experience diarrhea worldwide. Two strains—C. jejuni and C. primarily in cattle and poultry, is related tofor days. coli—are the most common. It is estimated the Campylobacter family; it grows at cooler that close to 100 per cent of poultry carry temperatures, causing similar disease.Health Canada reports more than 6,000 C. jejuni. Modes of transmission include • Cyclospora – This is a one-cell protozoancases of Salmonella in Canada each year. eating undercooked meat, particularly parasite previously found only in tropicalMore than 2,400 recognized serotypes poultry, cross-contamination from cutting settings. Cyclospora outbreaks have occurredof the bacteria Salmonella exist and are boards and cooking implements, as well as in recent years in Canada and the Unitedcarried by a wide range of domestic and poor handwashing after handling infected States, and are linked to raspberries,wild animals including poultry, swine, animals or meat. Transmission through mesclun lettuce, cilantro, and perhaps basil.and cattle, and pets such as dogs, cats, contaminated water also occurs. The Symptoms are primarily severe diarrhea, lossturtles, iguanas, and rodents. The United of appetite, and stomach cramps. resulting human illness, campylobacteriosis,States Centers for Disease Control and is characterized by diarrhea, abdominal • Cryptosporidium parvum – LongPrevention have recently simplified the pain, malaise, fever, nausea, and vomiting. associated with waterborne outbreaks, thiscategorization of Salmonella into two A rare paralysing neurological condition, protozoan parasite lives in the intestinesmajor species, S. bongori2 and S. enterica, Guillain-Barre Syndrome (GBS), in which of cows and forms a durable cyst thatwith the latter the most common source the immune system attacks the myelin may contaminate food, through manureof human infection. Infections from these sheath around peripheral nerves, has been fertilization of fruit and vegetables, orspecies generally arise from contact with shown to occur in about 1 to 2 of every infected food handlers.food from infected animals or with food 2,000 cases of Campylobacter infection. Infection from these emerging foodbornethat has been contaminated by the infected There are about 80 GBS cases a year in BC, pathogens is likely prevented by goodfeces of an animal or person. Adequate of which about 30 per cent (about 24 cases handwashing and safe food preparation (Mengcooking and proper washing of hands and a year) may have had a Campylobacter & Doyle, 1997; Lehner, Tasara, & Stephan, 2005).surfaces can eliminate the bacteria. The infection as a precursor. As a general2 S.bongori is most often found in cold-blooded animals, such as lizards, but has been isolated from pigeons and inrare cases can be cultured from infants less than 13 months old. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 69
  • 90. Chapter 5: The Safety and Sustainability of Food and the Food Supply rule, all chicken and hamburger should months—until the toxin is cleared. Long-Pork: Trichinellosis Disappearing be cooked until the internal temperature term disability can occur as a result. reaches 710 C (1600 F) for ground beef andFor centuries, the roundworm trichinella C.botulinum spores are ubiquitous in meat and 740 C (1650 F) for poultry (Britishwas an endemic public health threat, carried the soil worldwide and they thrive in a Columbia Centre for Disease Controlby pigs and infecting humans through moist, oxygen-free, low pH environment. [BCCDC], n.d.).undercooked pork. Larva from the worm would Improper food processing, particularlymigrate through tissue, forming cysts in the home canning of low acid foods (e.g.,muscle of both the pig host and humans who Listeria monocytogenes asparagus, corn, beans, mushrooms), orate infected pork meat. The infected human Listeria is a rod-shaped bacteria commonly alkaline conditions promote the growthwould experience pain, swelling, fever, and found in soil, mud, water, and the forage of this bacteria. Foods suspended in oil,fatigue. The infection, called trichinellosis, food of ruminants like cows and sheep. such as garlic, chili peppers, sun-driedcould even cause death if enough cysts were It most often causes foodborne illness tomatoes, and herbs should be dried,consumed. outbreaks through unpasteurized soft acidified, or refrigerated to prevent theThe rule “don’t eat pink pork” became dogma. cheese. Unlike other bacteria, its growth development of toxins. Baked potatoesIn the last few decades, largely by a change is not inhibited by refrigeration. Infection cooked in foil should be served hot orin farming practices so that pigs are no longer can cause headache, muscle-aches, fever, refrigerated. Home-canned and fermentedfed meat and table scraps, trichinella has and gastrointestinal upset. More severe fish have also been linked to outbreaks.essentially disappeared from modern pork infections can lead to meningitis and/or The toxin is very powerful—1 teaspoonproduction. There has not been a confirmed septicemia. It is particularly dangerous to could kill 100,000 people (MOHS, 2002).case of trichinellosis from eating infected pork pregnant women, often causing miscarriage Damaged or bulging cans may be a signin Canada for more than 15 years (Canadian or stillbirth, or can infect the newborn, that the contents harbour the toxin. HighPork Council, 2005). causing meningitis or septicemia for the temperatures destroy the toxin, so peopleHowever, trichinellosis has not disappeared infant, often with fatal consequences. In using home-canned foods should boil themcompletely, and it is now linked to eating 2002, BC had two serious outbreaks of for 10 minutes before use.undercooked wild meats, particularly bear, listeriosis, both linked to small cheesewolf, and artic marine mammals in Canada. In producers on Vancouver Island (BCCDC, Clostridium perfringensBC, there were no cases of trichinosis in 2004; 2002).however, in 2005, 27 cases were traced to the Another spore-forming, toxin-producingconsumption of bear meat (McIntyre et al., bacteria, C.perfringens is found in soil, Clostridium botulinum2006). dust, sewage, and the intestinal tracts of This bacteria, which is responsible for animals and humans. The organism is botulism, produces a potent toxin when most often a problem in leftovers that it multiplies. Botulism is a severe and life- have been left to stand unrefrigerated for threatening food poisoning marked by more than two hours, most commonly nerve impairment and paralysis, including cooked beans and meat gravies. Generally respiratory paralysis. Up to 10 per cent of a mild disease of short duration, the food affected people die. The first symptoms poisoning is marked by stomach pain, can be double or blurred vision, difficulty nausea, and diarrhea. It is most commonly swallowing, and dry mouth. Vomiting and associated with catering companies, diarrhea may also be present initially. Some schools, and other institutions that do not victims of the poisoning may need to be have adequate refrigerated storage space. supported by a respirator—sometimes for Along with B. cereus and S. aureus, this organism causes illness through improper temperature storage of food. 70 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 91. Chapter 5: The Safety and Sustainability of Food and the Food SupplyYersinia primarily through contact with infected cats, but eating undercooked meat from an No Honey for InfantsTwo species of this bacteria cause food infected grazing animal—particularly pork,poisoning: Y. enterocolitica and, less C.botulinum can exist in honey. The bacteria goat, lamb, and mutton, and, more rarely,commonly, Y. pseudotuberculosis3. Both or its spores do not grow in the honey, but if beef—is a possible route of transmission.types are found most commonly in under- given to infants under the age of one, they can Cysts in the meat can remain infective forcooked pork, unpasteurized dairy products, grow in the baby’s intestine. years, perhaps for as long as the life of theand contaminated water. Outbreaks have animal. Infection at the tachyzooite stage C. botulinum spores from other sources, suchalso been linked to contaminated tofu. of the lifecycle can occur through drinking as soil, can also begin dividing in an infant’sThe infection, called yersiniosis, usually intestine. The illness usually begins with unpasteurized milk from an infectedarises three to seven days after eating constipation followed by lethargy, listlessness, animal, such as unpasteurized goat’s milk.contaminated food. Symptoms vary loss of appetite, poor head control, anddepending on the age of the infected Infection is marked by swollen lymph weakness (floppy baby). Infant botulism isperson. Children are the most commonly nodes (lymphadenopathy) and flu-like now the most common form of botulism inaffected and have symptoms of abdominal illness with fever and malaise. Some people North America. Some studies estimate 5 perpain and diarrhea, which is often bloody. who are infected show no symptoms at all. cent of all sudden infant death syndrome mayOlder children and adults can have right- The parasite can migrate through tissue in be intestinal (infant) botulism (Chin, 2000).sided abdominal pain and fever, which the body and lodge in places such as themay be confused with appendicitis. In rare brain, retina of the eye (causing blindness), BC’s Worst Botulism Outbreakcases, it may cause arthritis-like joint pain, or the heart (causing inflammation of In 1985, a botulism outbreak was linkedrash, and sometimes blood poisoning. It the heart muscle). The infection can to chopped garlic in soybean oil used inusually resolves on its own but in more remain dormant for years and reactivate two popular sandwiches at a well-knownsevere cases it may need to be treated only if the person’s immune system is downtown Vancouver restaurant. In error,by antibiotics. BC had two outbreaks of suppressed. It is particularly dangerous the product had been left unrefrigerated foryersiniosis, one in 1998, which affected 74 to immunocompromised individuals and months before being opened. The outbreakpeople, and one in 1999, which affected to a developing fetus (the infection can occurred in two clusters, separated by about 347 people. Although in both cases the cause severe brain damage to the fetus). weeks, and a total of 34 people were affected,contaminated food was never definitively Infection through meat consumption is 7 of whom needed life support. What wasconfirmed, in the first outbreak, there was more common in Europe than in Canada, unusual about the outbreak was the slowa strong association with homogenized particularly in France; as a result, all onset of symptoms, some arising more thanmilk, and in the second, dry fermented pregnant women in France are screened 10 days after eating the sandwich. Some ofsalami (Public Health Agency of Canada, for the organism. BC’s largest outbreak of those affected were tourists who only came1999,2000). toxoplasmosis was in 1995 in Victoria, and down with symptoms once they had returned home to the Netherlands and the United States was associated with drinking water, notToxoplasma gondi (Centers for Disease Control and Prevention, food. 1985).Another protozoan parasite rarely linked Marine-based Food Poisoningto foodborne illness is Toxoplasmagondi, which infects a wide range of birds, A number of marine organisms exist thatmammals, and humans but only reproduces can cause food poisoning in humans. Inin the intestines of domestic and wild cats BC, the one that has the most harmfulor other felines. This parasite produces a potential is paralytic shellfish poisoningvery durable cyst that is shed in cat feces; (red tide), which is described in more detailthe cyst can exist in the environment in Chapter 6 for its impact on Aboriginalfor a year or more. Human infection is population. Blooms of the dinoflagellate3 The bubonic plague is caused by another species, Y. pestis. and is transmitted by food. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 71
  • 92. Chapter 5: The Safety and Sustainability of Food and the Food Supply algae Alexandrium create a toxin that is Vibrio parahaemolyticusInfections Passed by Unsafe Food absorbed by filter-feeding shellfish and In the summer of 1997, over 100 peopleHandling bivalves, contaminating them and making became ill with gastroenteritis caused them potentially fatal to humans who eatWhile not essentially foodborne illnesses, by a naturally occurring environmental them.many common human diseases can be passed bacterium, Vibrio parahaemolyticus.from one person to another through unsafe A second toxin is ASP (amnesic shellfish Self-harvested oysters were traced tofood handling, particularly poor personal poisoning). This is caused by blooms of approximately 50 per cent of the cases,hygiene. Cholera and typhoid fever can be the diatom Pseudonitzia producing a toxin and the oysters were harvested frompassed by food contaminated with the feces called domoic acid. ASP symptoms include several different coastal BC areas. After thisor urine of infected food handlers. In BC, the nausea and vomiting as well as neurological outbreak, surveillance and other controlmost significant public health risks for disease measures for shellfish harvesting were effects, and has been linked to memorytransmission from infected food handlers are disorder. This toxin was first described implemented by Environment Canada,Hepatitis A and shigella. during an outbreak in eastern Canada in the Canadian Food Inspection Agency,Hepatitis A 1987, which caused 100 illnesses and 3 Fisheries & Oceans Canada (DFO), and the deaths. Province of BC.Hepatitis A is caused by an RNA virus thatattacks the liver, and is sometimes spread Another toxin-based poisoning is ciguatera In 2005, only 6 of the 10 Vibrio illnessesby infected food handlers as a result of poor poisoning, which occurs in tropical fish that were traced to local BC shellfishhandwashing. The infection can be acquired have eaten toxin-producing algae. British consumption, 50 per cent of which werewhen people travel to countries with poor traced to self-harvesting oysters. To Columbians are usually only affected whenhygiene practices. Once infected, a person can travelling to hotter climates; the last case of minimize the risk of consuming unsafepass the virus on to others for two weeks or ciguatera food poisoning in BC was due to oysters, consumers should only harvestmore before they know they are infected, and a BC resident bringing back red cod from shellfish in approved open areas at thecan be infective up to one week after gettingsick. Onset of symptoms is rapid, including Fiji. water’s edge after a receding tide, usefever, dark urine, and abdominal discomfort, treated drinking water to rinse shellfish, Another form of fish and seafood-relatedand jaundice a few days later. Hepatitis can and wash hands after handling raw seafood. food poisoning is Scombroid, also calledalso be passed by sewage-contaminated Cooking oysters to an internal temperature histamine poisoning; it most often occurswater, or shellfish exposed to sewage. of 60ºC (140ºF) for at least 5 minutes when fish of the Scombridae family (tuna, will destroy the Vibrio bacteria (Fyfe etShigella mackerel) are spoiling or decomposing. al., 1997). To check if an area is open for Fish in this family contain high levels ofShigella is a bacterium found in the intestinal shellfish harvesting, call toll free attracts of humans. It causes shigellosis, a flu- histidine, and at temperatures above 40C, 1-866-431-3474, or visit the DFO website atlike illness that usually appears about three spoilage bacteria release enzymes that http://www.pac.dfo-mpo.gc.ca.to seven days after eating contaminated food. convert the histidine to histamine. WhenCooking will destroy the organism, so the most eaten, it creates an allergic-like histaminecommon contaminated foods are cold salads reaction in the individual, creating hives, Public Health Issues in Food(pasta, potato, tuna, shrimp, turkey, fruit, etc.) itching, flushed face, swelling, stomach Farming(CFIA, 2006). pain, and even nausea and vomiting. The way we raise and grow our food can Symptoms may have to be treated by have a direct bearing on the quality of an antihistamine. The best way to avoid the food and the likelihood that it may Scombroid is to keep fish well-refrigerated harbour or transmit foodborne illness. and to eat it promptly before any Over the last four or five decades dramatic decomposition can take place. changes have taken place in Canada and the world in the way food is produced. 72 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 93. Chapter 5: The Safety and Sustainability of Food and the Food SupplyFood globalization has also introduced concerns. Running a small family farmconsumption of food from a much larger is a hard life with demanding physical Manure-linked Deathsgrowing circle than in the past. Some of labour and economic hardships. Many Highly publicized disease outbreaks in recentthese changes have improved the quality of the health concerns that derive from years in North America have been linked toof the food we eat, reduced foodborne large-scale factory farming (for example, manure contamination of water supplies andpathogens, and increased efficiency and bacterial contamination and concerns over juice.productivity. But these changes have also antibiotics and hormonal residues) alsohad their downside, with adverse impacts exist, albeit usually on much smaller scale In May 2000, heavy rains washed cattleon the environment, the introduction of family farms. For example, poorly handled manure into a shallow well in Walkertonnew contaminants to the food supply, or manure infected with E.coli 0157:H7 can Ontario, contaminating the town’s aquifer. Approximately 2,700 people were infectedan increase in the prevalence of microbial cause an outbreak of disease whether it with hemorraghic E.coli, 65 were hospitalized,contamination of herds or crops. comes from a small or large farm. In fact, and 7 died (PHO, 2000b). The farmer was the E.coli that contaminated the aquifer found to have followed safe manure handlingChanges in Farming in Walkerton, Ontario in 2000, killing 7 practices and was deemed not at fault; rather people and infecting thousands, came from the unsafe operation of the water system wasOver the last few decades, the small family a small family farm of less than 100 cattle found to be at fault (O’Connor, 2002).farm has been quickly disappearing, (O’Connor, 2002).to be replaced with fewer, larger, and In 1993, 400,000 people in Milwaukee weremore industrialized farms. This trend to Being able to feed more people, at a lower infected with the parasite Cryptosporidium andfewer, larger farms has taken place in all cost, on less land, with more systematic an estimated 100 people died, most of themagricultural commodities. According to processes, in general, is a positive step elderly or immunocompromised. The source ofStatistics Canada, the number of farms forward for human health; nutritious the Milwaukee outbreak was attributed to thein Canada declined from 318,361 in 1981 food is more readily available at a more manure-laced run-off from nearby cattle farmsto 246,923 in 2001, albeit, with increased competitive price and farmers can contaminating the water supply at one of theproductivity (Statistics Canada, 2004). In generally make a better living. However, city’s two water treatment facilities (Hoxie,1935, an average Canadian farm produced Davis, Vergeront, Nashold, & Blair, 1997). the increasing industrialization of farmingenough food for 11 people; by 1994, it over the last half century, while increasing Manure residues with E.coli have also taintedproduced enough for 123 people (Statistics the productivity and economic viability unpasteurized juices and fruits and vegetables,Canada, 1999a). of farming, has created some new types leading to outbreaks of disease and deaths. of public health concerns, both through In 1996, three outbreaks of E.coli 0157:H7Poultry farming is a good example of made 86 people sick and killed 1 child after the concentration of large numbers ofthe trend to fewer, larger farms, with they consumed unpasteurized apple juice. animals on small plots of land and in themore animals on smaller plots of land. It is believed the apples were contaminated increasingly industrialized nature of raisingThe number of poultry farms in Canada after falling to the ground (Ministry of Health, crops.declined from 8,700 in 1981 to 4,900 in 2000).2001, but the number of birds on the farms Intensive Livestock Operationsrose from 89 million to 124 million in thesame period. That translates into 39 per The industrialization of the raising of farmcent more birds on 43 per cent fewer farms animals poses some public health risks.(Mwansa, 2004). This farming approach to raising meat has a number of different names. In CanadaMany people idealize the life of the it is most often called intensive livestocksmall family farm and decry the growing operations (ILOs) or confined feedingindustrialization of farming. Both small operations (CFOs). In the United States it isand large farms have strengths and most often called Confined Animal Feedingweaknesses, and their own public health Operations (CAFOs.) Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 73
  • 94. Chapter 5: The Safety and Sustainability of Food and the Food Supply Hog, cattle, poultry, and dairy farming health risks are adequately protected. TheAmmonia Emissions in the Lower are all experiencing an ILO approach. Canadian Medical Association has calledFraser Valley According to the United States for a moratorium on large hog farms until Environmental Protection Agency, an more studies have been conducted toIn 2000, it was estimated that 75 per cent of all ILO or CAFO is a farm operation that has assess the risks. Potential public health risksammonia emissions in the Lower Fraser Valley more than 1,000 beef cattle, 2,500 hogs, are described in the following sections.were due to cattle, pig, and poultry housing;manure spreading and storage; and inorganic or 100,000 hens. In the United States, anfertilizer application. Environment Canada is estimated 54 per cent of all livestock are Manureworking with agricultural producers and other concentrated on 5 per cent of the farms Farms with large concentrations of animalsstakeholders to find solutions to the ammonia (Gollehon, Caswell, Ribaudo, Kellogg, produce huge amounts of manure everyemissions. Some options being considered Lander, & Letson, 2001, as cited in single day. In 1996 (the most recent figuresincluded transporting manure to areas that American Public Health Association, 2003). available), Statistics Canada estimated thathave lower levels of nitrogen, and changing Exact figures are not available for Canada, Canadian livestock produced 361 millionpoultry diets to reduce the nitrogen content ofmanure. Airshed plans and stricter control of but it is estimated that similar trends are kilograms of manure daily, or some 132nitrogen and sulphur oxide emissions in this taking place here. In the case of hogs, billion kilograms a year. No doubt thisregion are also recommended (Environment the animals are raised entirely in closed amount has increased in the last decadeCanada, Manure Causing White Haze, n.d. as buildings from birth to slaughter. In cattle, (Hofmann & Kemp, 2001). Americancited in PHO, 2004). the animals are raised on pasture and studies estimate that 575 billion tonnes of then usually shipped to more confined animal manure are produced annually on “feedlots” for final feeding six months prior American ILOs/CAFOs. to slaughter. British Columbia does not have as many The public health concerns of these ILOs as Alberta, Ontario, and the Prairies, intensive livestock operations include so the concern over the creation of large manure production and handling; the use amounts of manure is not as acute here as of antibiotics and hormones to promote in other provinces. According to Statistics rapid growth and to stem the spread of Canada, only the Fraser Valley has locations disease from so many animals in close where manure concentration are at the quarters; the potential for infectious highest level of more than 2,000 kilograms disease to take hold; and the creation of air of manure per hectare of land. While even pollution. small amounts of manure improperly handled can spread disease, huge The Canadian Public Health Association concentrations may exceed the capacity of (CPHA) and American Public Health the land to absorb the nutrients or create Association (APHA) have both passed problems in its safe and effective disposal. resolutions regarding ILOs/CAFOs. The CPHA in 2000 called for a national approach Refuse from animals includes not only to ILO regulation, in particular because fecal matter but straw and bedding soaked regions with the least environmental in urine and other waste. While manure controls or regulations may be the most does contain valuable nutrients that can be economically attractive to producers. The used to replenish soils, too much manure APHA in 2003 called for a precautionary or improper handling of manure can pose moratorium on new CAFOs because risks to public health for the following there is insufficient data whether public reasons: 74 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 95. Chapter 5: The Safety and Sustainability of Food and the Food Supply• Pathogens: Manure contains potential antibiotic-resistant strains of microbes disease-causing bacteria, viruses, (Chee-Sanford, Aminov, Krupuc, “Extra Label” Drug Use and parasites including E.coli 0157: Garigues-Jean, & Mackie, 2001). Using a drug in animals in a way that is not H7, a number of Camplylobacter • Dust, moulds, and noxious gases: generally recognized or approved by the label and Salmonella species, Listeria Manure, when dry, can release irritating or by Health Canada is called “Extra Label” Drug monocytogenes, Helicobacter pylori, dust and mould spores into the air that Use (ELDU), or off-label use. Veterinary doctors and the protozoa Cryptosporidium. and others acknowledge they have used are an irritant to airways, exacerbating Improper handling of manure from over-the-counter or prescription drugs meant bronchitis and asthma. Poultry farming ILOs may increase the potential for humans for decades as a way to save sick contributes to poor air quality in the transmission of disease. It is important animals. In 2000, a European Union delegation Fraser Valley. Volatile compounds to note that even proper handling audited Canada’s control of veterinary drug from manures, such as ammonia and of manure may still cause disease. In use in the food supply and raised concerns hydrogen sulfide, and other noxious Walkerton, Ontario, the farmer who had about potential ELDU misuse, noting varying odours can pollute the air and cause spread manure on his field in the weeks provincial standards and a lack of a national headaches and other health complaints. approach to the issue. prior to heavy rainfall in 2000 was found Hydrogen sulfide (noted by the rotten to have completely complied with safe The public health concerns of ELDU are: egg smell) produced by liquid manure manure-handling practices (O’Connor, can be a potent neurotoxin that causes • Possible drug residues in food products that 2002). This incident reflects the risk of persistent brain damage and can be are not tested for nor regulated. improper water treatment where land deadly at higher levels, but there is applications of manure occur in close • Possible antimicrobial resistance. controversy over the potential health proximity to water sources. effects at low levels (United States Health Canada has initiated a steering• Nitrogen and phosphorous: Excess Environmental Protection Agency, 2003; committee to identify the gaps in ELDU nitrogen and phosphorous from Woodall, Smith, & Granville, 2005). controls and the impact on public health, and manure leeching into the soil or water The uncertainty over the impact of to examine and develop policy options. Initial can cause eutrophication and algae hydrogen sulfide produced by large- issue identification reports are available at the Veterinary Drug Directorate at: http://www. overgrowth of surface water. The scale hog farms is part of the reason hc-sc.gc.ca/vetdrugs-medsvet/eldu_e.html. blooms degrade water quality, and various health groups, such as the some algaes, such a cyanobacteria Canadian Medical Association, Canadian (blue-green algae), can create toxins Public Health Association, and American harmful to human health (PHO, 2000b) Public Health Association, have called and kill aquatic life. for moratoriums on large-scale farms until more scientific study can be• Antibiotics and metal compounds: conducted. Antibiotics and metal compounds, such as iron, arsenic, manganese, zinc, In BC, the Code of Agricultural Practice and other trace minerals are routinely for Waste Management is part of the added to animal feeds to promote Agricultural Waste Control Regulation, growth and improve overall health. which in turn is part of the Waste About 25 per cent to 75 per cent of the Management Act. The Code prescribes antibiotics in animal feed can pass into specifications for manure storage, handling, the manure unchanged where they can and application as fertilizer. The Code affect soil, water, and air quality, and applies to all agricultural operations and potentially help foster the creation of has no specific references to intensive Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 75
  • 96. Chapter 5: The Safety and Sustainability of Food and the Food Supply livestock operations. Key elements of the States found that of the 20 per cent thatFighting Resistance Code include establishing the required contained Salmonella, 84 per cent were setback of manure storage and feeding resistant to at least one antibiotic and 53Resistant strains of bacteria cannot be blamed operations from water courses or water per cent were resistant to three antibiotics.solely on the use of antibiotics in animals. supplies, the amount of time manure can The authors concluded that resistant strainsInappropriate use in humans is equally be stored, and the conditions under which are common in retail ground meats andproblematic. The general public should do the manure can be spread on fields. Livestock called for the adoption of guidelines forfollowing: farmers who conform to the Code do not more prudent use of antibiotics in food• Use antibiotics wisely—finish all require a Waste Management Permit. animals (White et al., 2001). This study, prescriptions, do not demand antibiotics to along with others showing the relationship treat viruses, and do not share prescriptions. Antibiotics between animal use and growing Try watchful waiting for ear infections and resistance, led to a New England Journal other illnesses that could be viral. Today, it is estimated that more than half of of Medicine editorial calling for the ban of all antibiotics produced in North America• Do not use antibacterial soaps or cleaning all non-therapeutic use of antimicrobials in are used in animals, not only to treat and products. In general, the use of antibacterial animal feed (Gorbach, 2001). prevent sickness, but also to promote soaps or products offers no benefit when compared to plain soaps, and their use likely growth. This practice of giving antibiotics In 1999, Health Canada established the contributes to the emergence of antibiotic to animals in absence of disease, common Advisory Committee on Animal Uses of resistance. for more than 50 years, is considered a Antimicrobials and Impact on Resistance significant factor fuelling the growing drug- and Human Health. The advisory• Avoid flushing antibacterial cleaning resistant strains of pathogens around the committee issued a final report in 2002 products or unused drugs down toilets world. which reviewed the literature and made or sinks where they can contaminate the 38 recommendations, including restricting environment. In June 2000, the World Health all animal use of antimicrobials to a• Wash hands regularly with plain soap. Organization warned that the growing prescription, improving surveillance of drug resistance of microbes threatened to• Follow safe food handling practices. resistant strains, setting thresholds and reverse medical progress worldwide. In benchmarks to measure resistance, as well• To exert lobbying pressure on agriculture, 2003, an international expert consultation as improving the evaluation of antimicrobial consider supporting producers who avoid convened by the Food and Agricultural efficacy as growth promoters. Health antibiotics or who are certified organic Organization, Organization of International Canada formulated a policy response to the producers. Epizootics, and the World Health report in 2003 through its Veterinary Drugs Organization concluded that “there is Directorate. clear evidence of adverse human health consequences due to resistant organisms Progress in dealing with this issue in resulting from non-human usage of Canada has been slow, largely because of antimicrobials” in Europe (Food and its controversial nature. In general, public Agricultural Organization of the United health officials support much tighter Nations, Organization of International restrictions and regulations, even bans, on Epizootics, World Health Organization, the use of antimicrobials in animals. Many 2003). note that a greater focus on good hygiene and more space for animals could reduce Studies are finding that resistant bacteria the need for antibiotic use. The veterinary in meats can be transferred to humans. A and agricultural sectors counter that the 2001 study that sampled for Salmonella growing problem of resistance cannot in ground beef, chicken, turkey, and pork be blamed solely on animal use and that purchased from retail stores in the United 76 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 97. Chapter 5: The Safety and Sustainability of Food and the Food Supplyrestricting the use in animals will lead to human exposure to resistance arising frommore animal disease, poorer quality meat, the consumption of animal products. The Codex Alimentariusand higher costs for food. They claim it is Commission The 2005 report found the following keybetter to prevent outbreaks by small doses results: For more than 40 years, a joint body of theof antibiotics than to have to treat animals World Health Organization and the Unitedwith much larger doses once an infection • Isolates of generic E.coli showed Nations Food and Agriculture Organizationhas taken hold. resistance to one or more has been setting international standards antimicrobials in 88 per cent of swine, through the Codex Alimentarius Commission.Gaps in information and scientific data have 84 per cent of chicken, and 34 per cent The Commission has two main purposes:also hampered progress. One of the key of cattle in abattoirs across Canada. protecting consumer safety and establishingrecommendations in the Provincial Health fair and standard practices to promoteOfficer’s report entitled Antimicrobial • With Salmonella, 41 per cent of isolates international food trade. Formed in 1963, theresistance. A recommended action from chicken and 49 per cent from Commission’s guidelines now cover all foodsplan for British Columbia (2000a) was swine collected in abattoirs across whether processed, semi-processed, or raw.to implement monitoring mechanisms Canada were resistant to one or more The Commission provides approval standardsfor antimicrobial use in animals and antimicrobials. for anything that might be in food, from howhumans, and to survey the prevalence and many bits of peel are tolerated in a tin of • A sample of 3056 clinical isolates fromsusceptibility of resistant organisms in “whole peeled tomatoes”, to the acceptable human Salmonella showed that a largeagricultural settings and health care. daily intakes for growth-promoting hormones number of strains were resistant to one in beef cattle.In 2003, the Canadian Integrated Program or more of 16 antimicrobials.for Antimicrobial Resistance Surveillance In 1995, in a controversial decision, the • In retail samples, resistance was lower Commission established Maximum Residue(CIPARS) was created in collaboration than in abattoirs; however, resistance to Limits (MRLs) for growth-promotingwith Health Canada, the Canadian Food the drug ceftiofur in E.coli was found in hormones—a decision that later became theInspection Agency, and provincial partners. 18 per cent of isolates from chickens in basis for a complaint brought to the WorldThe surveillance program has been Ontario and 33 per cent of isolates from Trade Organization by Canada and the Unitedmodeled after international surveillance chickens in Quebec. States regarding a European Union ban onprograms, such as one in Denmark and beef treated with hormones. Canada andone in the United States. Now under the • For campylobacter in retail chicken, 72 the United States successfully argued thatauspices of the Public Health Agency of per cent of isolates in Ontario and 79 the Commission’s decision to set maximumCanada, CIPARS is monitoring the trends per cent of isolates from Quebec were residue limits signaled that the hormones werein the development of antimicrobial resistant to one or more antimicrobials. scientifically proven safe (Kimbrell, 2000).resistance in the food chain. One of the key Of most concern was that around 4 In 2003, the Codex established 50 newgoals of CIPARS is to build a solid evidence per cent of isolates in both provinces standards, which included geneticallybase for developing overarching policies on were resistant to ciprofloxacin, one of modified organisms and irradiated food. Theantimicrobial use. the most important antibiotics in the guidelines establish broad general principles current drug arsenal for treatment of to make the analysis and management ofCIPARS has now released two reports, one human infections. risks related to foods uniform across all of thein 2004 (reporting on 2002 trends), andthe latest in March of 2005 (reporting on The 2005 report concluded that the findings Codex’s 173 member countries. Provisions include pre-market safety evaluations, tests2003 trends). Surveillance activities include create an important baseline, and that future on potential allergies, and product tracing forcollecting samples from the intestinal results, including expanding retail samples recall purposes. For more information on thecontents of animals at slaughter and testing to other provinces, will help inform future Codex, please refer to the Food and Agriculturesamples of retail meat in Ontario and risk management decisions (Canadian Organization’s website at http://www.fao.org.Quebec as an indirect measure of potential Integrated Program for Antimicrobial Resistance Surveillance, 2005). Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 77
  • 98. Chapter 5: The Safety and Sustainability of Food and the Food Supply In October 2005, a National Conference hormones at a slow but constant rateBovine Growth Hormone in Milk was held on Agriculture’s Role in Managing (Health Canada, 2005b; United States Food Antimicrobial Resistance. The conference and Drug Administration, 2002).Recombinant bovine somatotropin, also known brought together federal, provincial,as rBST, is a synthetic version of a naturally The scientific and public health industry, and academic organizations fromoccurring growth hormone. Developed by communities in North America generally across Canada to review the surveillancea United States company, Monsanto, and accept the use of HGPs in beef on the basis data and progress to date, debate regulatoryapproved for use in the United States in 1993, that existing scientific evidence does notthe hormone is given to cows by injection to initiatives, and formulate actions in Canada show its residues pose an undue risk tostimulate increased milk production when towards prudent use of antimicrobials over human health. The Codex Alimentarius haslactation cycles are in decline. It boosts milk the next five years. established a maximum residue limit (MRL)production in the average cow by 10 to 15 for HGPs in beef, which is followed byper cent. In 1999, Health Canada rejected use Growth-promoting Hormones Health Canada. The European Commissionof the product in Canada not for any concern in Beef and European scientists, however, claimover risks to human health but because rBST hormone-treated beef is potentially toxicis harmful to the health and wellness of dairy Growth-promoting hormones havecows; it significantly increases the risk of and unsafe for human consumption. been used by Canada’s beef industrymastitis, infertility, and lameness in cows. for more than three decades. Hormonal A 1989 European Union ban on beefHuman health is seen to be unaffected as up growth promoters (HGPs) increase lean raised with hormones has been theto 80 per cent of all rBST and BST (naturally tissue growth and reduce fat deposition, focus of a protracted trade dispute that,produced in the pituitary glands of all cattle) enhancing food conversion efficiency at the time this report was written, wasis destroyed by pasteurization (Dohoo et al., because fat is so energy dense. HGPs can still not resolved. Despite a World Trade2003; Health Canada, 2005b; rbstfacts.org, boost beef production by as much as 15 Organization (WTO) ruling in favour ofn.d.). per cent, resulting in cheaper meat for the position that hormone-treated beef consumers. Although many people believe is safe for human consumption, and that hormones are widely used in other WTO-sanctioned retaliatory trade actions meat and egg production, in Canada the use taken by Canada and the United States, of growth hormones is permitted only in the European Union maintains its ban on beef cattle. The use of growth hormones is beef treated with hormones. At the centre currently prohibited in Canada’s veal, pork, of the European Union’s concern is the poultry, and egg industries (Health Canada, natural hormone estradiol-17ß, and the 2005b; Canadian Pork Council, 2005; debate whether it is a complete carcinogen Stephany, 2001). that exerts both tumour-initiating and tumour-promoting effects. Some European Health Canada has approved six hormones scientists are concerned about the impact for use in beef cattle. Three are naturally of estradiol-17ß on pre-pubertal children, occurring hormones: progesterone, who they believe may be particularly testosterone, and estradiol-17ß. The other sensitive even to low doses (Andersson three are synthetic hormones: trenbolone & Skakkebaek, 1999). The European acetate, zeranol, and melengestrol acetate. Union also says there is inadequate data All of the hormones are administered as for a quantitative assessment of potential subcutaneous implants (a pellet behind the health hazards of the five other growth ear) with the exception of melengestrol promoters, but maintains that pre-pubertal acetate, which is given as a feed additive. children are at the greatest risk from The implants are designed to deliver the estradiol-17ß (European Union Food 78 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 99. Chapter 5: The Safety and Sustainability of Food and the Food Supplyand Feed Safety, 2005). Health Canada’s Bovine Spongiform Encephalopathy firstVeterinary Drug Directorate reviewed the became a public health concern when TSEs – Fatal Brain Diseases17 studies commissioned by the European the disease emerged among cattle in theUnion and concluded that residues in meat southern part of Britain in late-1986. An Transmissable spongiform encephalopathies (TSEs) are all characterized by spongyfrom animals treated with HGP, when epidemic of BSE rapidly ensued, with deterioration of the brain. They are unusual inadministered according to good veterinary a peak of more than 37,000 confirmed that they can be infectious and hereditary andpractices, do not pose undue risks (Health cases in the United Kingdom in 1992 and also arise sporadically. They are all incurableCanada, 2005b; International Trade Canada, a total of more than 170,000 cases of BSE and fatal. The TSEs include:2005). diagnosed by 1998. The source of the epidemic is believed to be cattle feed that • Scrapie – known for more than 200 yearsBovine Spongiform Encephalopathy – Mad included the rendered protein from sheep to affect sheep and goats.Cow Disease infected with a TSE called scrapie. Once • Chronic Wasting Disease (CWD) – affects the disease had been transmitted to cows, deer and elk.The rise of Bovine Spongiform its spread was augmented by the additionEncephalopathy (BSE), or mad cow disease, • Kuru – is a rare and fatal brain disease of the dead carcasses of BSE-infected cowscan be linked to the huge expansion in among the cannibalistic Fore tribe of Papua back into the rendering process.the scale of livestock farming. Before the New Guinea, who, in a funeral ritual, eat theadvent of industrial farming, cattle raised Cows with BSE exhibit a number of brain tissue of the deceased.for meat were fed on a diet of grass and different symptoms, including lack of • Creutzfeldt-Jakob Disease (CJD) – ahay. As farm operations grew larger, it coordination or difficulty standing up, dementia affecting humans that arisesbecame more efficient to move cattle to nervous or aggressive behaviour, abnormal sporadically with about 0.5 to 1.5 casesfeedlots. BSE is thought to have emerged posture, decreased milk production, and per million population annually, mostbecause farmers, who were looking for weight loss. Milk, muscle, and blood from arising spontaneously and up to 15 per centa cheap source of protein and a way of cattle infected with BSE have never been hereditary. Cases of CJD have been spread asdisposing of unmarketable cattle remains, found to be infectious. Infectivity has been a result of contaminated medical proceduresused cattle feed augmented with protein limited to the brain, spinal cord, and retina. and growth hormone. Eighty per cent ofrendered from the carcasses of other cattle The incubation period for BSE is about four infected patients die within a year.(CFIA, 2005a). In essence, it was a form to five years (Johnson & Gibbs, 1998; CFIA,of bovine cannibalism in which ruminant 2005a).herbivores were fed meat proteins fromtheir own species. This practice has now Bovine Spongiform Encephalopathy andbeen banned. Variant Creutzfeldt-Jakob DiseaseBovine Spongiform Encephalopathy is a Creutzfeldt-Jakob Disease (CJD), a TSETransmissible Spongiform Encephalopathy that affects humans, is not linked to(TSE), a group of rare fatal diseases food consumption. In the past decade,linked to an infectious protein particle however, a new form of CJD called variantcalled a prion, short for “proteinaceous Creutzfeldt-Jakob Disease (vCJD) has beeninfectious particle.” The prions attack the diagnosed. Scientists believe it is linked tobrain tissue and central nervous system of the consumption of meat products fromanimals, including humans, forming spongy cattle infected with Bovine Spongiformmisshapen tissue. Prions and TSEs are Encephalopathy (BSE). Overall, 149 peopleemerging as potentially significant public in the United Kingdom and France havehealth risks (Belay & Schonburger, 2005). died from vCJD. The only cases of vCJD Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 79
  • 100. Chapter 5: The Safety and Sustainability of Food and the Food Supply reported in Canada and the United States, • Canada’s fourth case was discovered inWhat is Rendering? along with one case in Japan, have been January 2006, and its fifth in April 2006. in people thought to have eaten infected Since April 2006, three additional casesRendering, which dates back to Egyptian beef during extended stays in the United have been confirmed.times, converts animal carcasses into fats and Kingdom (FAO, 2005; CFIA, 2005b). Noproteins for other industrial uses. Bones, fat, The existence of BSE cannot be confirmed human cases of vCJD have originated ingristle, tough membranes, hooves, hides, in live animals. Symptoms of BSE can only Canada or the United States from infectedand horns comprise about 40 per cent of an be confirmed through testing of an animal’saverage steer’s weight and can quickly putrefy North American beef. brain after death (CFIA, 2005a).following slaughter. Renderers mince rawanimal materials and boil them in vessels Bovine Spongiform Encephalopathy Record Canada has a number of safeguards in placesealed under pressure. The mixture separates in Canada and Northwestern United States to eliminate BSE and to ensure that anyinto fats on top and protein below and animals that contracted the disease before Inspection agencies in both countries haveboth find uses in a huge array of industrial safeguards were in place do not enter the detected BSE in a small number of cows,products, including soap, cosmetics, gelatin, food or animal feed systems: none of which entered the food or animalpet food, asphalt, and tires. Cattle feed began feed systems: • Canada banned the importation ofincorporating rendered fats in the 1960s andthen, in the 1990s, rendered proteins were cattle from the United Kingdom • The first case of BSE in Canada wasadded to boost animal growth rates (Rampton and Ireland in 1990 and instituted a found in 1993, in a beef cow imported& Stauber, 1997). BSE researchers believe monitoring system for the remaining from Britain.this may be the origin of BSE in beef cattle, animals in Canada that had beenparticularly in Britain. • A second Canadian case of BSE was imported from the United Kingdom confirmed in May 2003. A Canadian since 1982. Food Inspection Agency investigationTracking Canadian Cattle • In 1990, Canada made BSE a reportable determined that the infected animalThe Canadian Cattle Identification Program disease, meaning that any suspect BSE consumed feed containing ruminantfor cattle and bison was created in 2001 to case must be reported to a federal meat and bone meal that was producedtrace individual animal movements from birth veterinarian. before a 1997 feed ban, whichto slaughter. Farmers and ranchers apply ear introduced restrictions eliminating the • In 1991, Canada banned beef productstags to any cattle or bison leaving their farm or use of rendered meat and bone meal from other European countries withranch. The information on the tags is registered from ruminants. Canada, unlike the BSE cases.in the CFIA’s database. If a slaughtered cowtests positive for BSE, the inspection agency United States, also bans the feeding • Canada’s BSE surveillance program wascan trace its origins and try to uncover the of poultry litter and plate waste to created in 1992. The program tests thesource of the problem (CFIA, 2003a). ruminants. brains of high-risk cattle for BSE. • Canada’s third case of BSE was • In 1997, Canada banned the use of confirmed in January 2005. Results of rendered protein products from a feed component investigation were ruminant animals (cattle, sheep, goats, pending at the time this report was bison, elk, and deer) in feed for other written. ruminants. A ban on materials from • Two BSE cows have been found in ruminant in all initial feed is under Washington State: one in December active consideration by the Canadian 2003 and the second in June 2005. The Food Inspection Agency and should be first cow was born on an Alberta farm. supported. 80 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 101. Chapter 5: The Safety and Sustainability of Food and the Food Supply• Canada only allows the importation of Genetic engineering is a promising field. live ruminants and their meat and meat In the food industry, it has the potential Genetically Modified Foods in products from countries considered to make available products such as high- Canada to be free of BSE, and has additional protein rice, high-iron milk, and high- Genetically modified squash, tomatoes, import controls for animal products and vitamin A rice, all of which may contribute potatoes, corn, soy, cotton, flax, canola, and by-products from countries where BSE to solving global nutritional deficiencies. wheat have all been approved for sale in has been confirmed. Genetic engineering may also help increase Canada. Canola grown in Canada has been food security by making food production genetically modified for increased nutrition• At-risk parts of slaughtered animals, more efficient and reducing prices if and pollination control, while the genetic including the brain and other central genetically modified seeds result in larger make-up of corn, potatoes, and cotton nervous system tissue, must be yields per cultivated area. Innovations has been altered to build insect or disease removed from cows slaughtered for such as allowing cold tolerance to be bred resistance. Corn, canola, soy, and cotton human consumption in Canada (CFIA, into plants could increase food security have all been changed to increase herbicide 2005a). by allowing people living in northern resistance. Three traits have been tinkered with communities to grow more foods and in tomatoes to delay ripening. Health CanadaGenetically Modified Organisms therefore enjoy more fresh and less approved the sale of the genetically modified expensive produce with much greater Flavr SavrTM tomato in 1997 (CommunityGenetically modified organisms are Nutritionists Council of BC, 2001; Healthorganisms whose genetic material (DNA) nutrients (WHO, n.d). Canada, 1997).has been altered by scientists as a way Given the relative infancy of biotechnology,to introduce a potential advantage to there is still much that we do not knoweither the consumer or the producer, Transfer of Brazil Nut Allergen via about potential long-term impacts ofor to both. Also known as genetic Genetically Modified Organisms genetically modified food on human health.engineering or modern biotechnology, The World Health Organization, while The potential transfer of genes from foods thatgenetic modification of organisms involves endorsing biotechnology as a means of are common allergens is one of the areas ofmanipulating their genes to incorporate a improving human health and food security, concern around genetically modified foods.new trait, or to alter or silence an existing points to a number of health issues of When scientists conducted research aimedtrait. For example, by introducing into to improve the quality of soybean meal as an potential concern. In 2001, the Royalcorn the gene of a natural bacterium that animal feed, they transferred genetic material Society of Canada Expert Panel on theattacks crop pests, corn crops can be coding for a storage protein from a Brazil nut Future of Food Biotechnology, convened at to a soybean. Since the Brazil nut is knownraised without using an external pesticide. the request of Health Canada, the Canadian to cause anaphylaxis in some individuals, theSoybeans that are genetically modified Food Inspection Agency, and Environment soybeans were tested to see if the allergenicto tolerate applications of the herbicide Canada, also outlines issues of potential protein had been transferred. Research wasRoundup offer producers a new tool for public health concern. These include: discontinued when tests determined that theweed control. Dismantling a tomato gene allergenic protein had been transferred to therelated to ripening, in order to prolong • Allergenicity: The potential exists soybean (CFIA, 2001).shelf life, means that genetically modified for food biotechnology to create newtomatoes can ripen on the vine and obtain allergens or to transfer allergenictheir full flavour without quickly spoiling proteins into non-host foods. Foron store shelves. Otherwise, tomatoes are some consumers, such as thoseoften harvested while green and exposed allergic to peanuts, even trace amountsto ethylene, a ripening hormone, during of an allergenic food may cause adelivery (WHO, n.d; CFIA, 2001; Falk et al., severe reaction and potentially fatal2002). anaphylactic shock. Genetically modified foods currently available to Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 81
  • 102. Chapter 5: The Safety and Sustainability of Food and the Food Supply BC consumers do not appear to have a of these antibiotic-resistant genes fromCloned Cows? significant potential for causing allergic genetically modified foods to cells in reactions, but the risk for allergic the body or bacteria in the intestinalIt is now possible to clone cows and other reactions will increase as the volume tract, particularly given the rise infood animals. Cloning uses DNA from a single and scope of genetically modified foods drug-resistant bacteria and declininganimal parent to create an offspring that is in the marketplace grows. For food- effectiveness of many antibiotics.genetically identical to the parent. In the allergic individuals, genetically modified Although the probability of suchUnited States, although cloned cows exist, theUS Food and Drug Administration has not yet foods introduce another variable transfer is low, expert panels struck byapproved the sale of milk or meat from cloned in deciding which foods are safe to the Food and Agriculture Organizationanimals in the marketplace. consume (CFIA, 1998; WHO, n.d.; of the World Health Organization, Community Nutritionists Council of BC, and three federal departments of theIn Canada, foods produced from animals 2001). Canadian government, have bothcloned using embryonic cells, such as embryo recommended the use of geneticsplitting and embryonic cell nuclear transfer, • Toxicity: Much remains to be learned modification technology withoutare not considered to pose food safety concerns about changes in natural toxicants inand face no restrictions on marketing. antibiotic-resistant genes. To keep genetically modified foods, such as this recommendation in perspective,A new cloning method, however, does raise oxalic acid in green potatoes and other the expert panel convened bysome food safety concerns. Some animals vegetables. Potential adverse health Canada’s three federal departmentsproduced through somatic cell nuclear transfer effects could arise as a result of the points out that the widespread use of(SCNT), the type of cloning that produced over-expression of a toxicologically antibiotics in animal feed, along withthe famous sheep Dolly, have had significant active constituent in genetically the indiscriminate use of antibiotics inhealth problems. According to Health Canada, modified foods, such as an existing human medicine, likely constitutes afurther investigation is needed to determine protein, meaning that humansthe safety of food products from these animals far greater risk factor for the increase in could have greater exposure to theand their offspring. Livestock cloned using antibiotic-resistant bacteria than genetic constituent than previously found inSCNT are not permitted to enter Canada’s modification technology (WHO, n.d.; their diet. Genetically modified foodsfood supply due to insufficient data to guide Royal Society of Canada, 2001). could also lead to a potential excessrequired pre-market safety assessments of intake of nutrients, as iron-fortified milk • Outcrossing: If conventional crops orfood from these animals and their progeny could cause iron overload or exacerbate related species in the wild are exposed(Health Canada, 2003a; Dairy industry looksaskance, 2005). undiagnosed hemochromatosis, and a to genes from genetically modified surfeit of vitamin A could increase the plants, or conventional and genetically risk of birth defects (Royal Society of modified seeds are mixed, there could Canada, 2001; Community Nutritionists be an indirect effect on food safety Council of BC, 2001). and security. One example is when traces of a genetically modified maize • Gene Transfer: Antibiotic-resistant strain approved only for feed use genes are commonly used to create appeared in maize products for human genetically modified foods. The consumption in the United States. antibiotic-resistant genes are used as One solution to thwart outcrossing marker genes that are introduced along is for countries to adopt strategies with DNA coding for the desired trait to minimize mixing, such as clearly to allow confirmation that the transfer separating fields between genetically of genes has been successful. Health modified crops and conventional crops concerns relate to the potential transfer (WHO, n.d). 82 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 103. Chapter 5: The Safety and Sustainability of Food and the Food SupplyLabelling of Genetically Modified Foods The Way Forward on Genetically Modified Organisms Antibiotics on Salmon FarmsLabelling of genetically modified foodsremains controversial, and different It is clear that food biotechnology has BC salmon farms, unlike many on-land factorycountries have adopted different rules. potential advantages to food production farms, only use antibiotics therapeutically—toEuropean Union countries require and public health, yet at the same time treat disease—and not as a preventiveall prepackaged products containing concerns exist on its proper use and measure.genetically modified organisms to state on potential unintentional ramifications. Four antibiotics are approved for use onthe label: “This product contains genetically To overcome this dichotomy, Canada’s Canadian salmon farms. In BC, the antibioticsmodified organisms.” Non-prepackaged expert panel on the future of food must be prescribed by a veterinarian and aregenetically modified products displayed for biotechnology has made a number of administered in fish meal. The total amountsale in the European Union must contain recommendations related to public health. of antibiotics used on BC salmon farms fellthe same statement either on the product The panel recommended that Canada to its lowest level in a decade in 2001, whenor in connection with its display. apply the “precautionary principle” to approximately 175 grams of antibiotics were the introduction of genetically modified used for every ton of production. By 2003, dueIn Canada, as in the United States, foods. According to the precautionary to increased disease outbreaks, that numbermandatory labelling of genetically modified principle, new technologies should not be had climbed to almost 350 grams of antibioticsfoods is not required if there is no for every ton of production, or a total of presumed safe unless there is a reliabledocumented safety risk to the product. about 25 metric tons of antibiotics used on scientific basis to consider them safe. AsCanadian consumers currently do not know all BC salmon farms that year. The Canadian such, the panel called for more rigorousif the tomato, corn, squash, or other food Food Inspection Agency regularly samples BC testing of genetically modified foods andthey eat has been genetically modified, salmon to ensure that antibiotic residues fall independent review of the test results, withor if the prepackaged crackers and other within legal limits (Ministry of Agriculture and increased public access to the test resultsfood they buy have been manufactured Lands, 2004c). (Royal Society of Canada, 2001).with genetically modified canola oil orother genetically modified ingredients.In 2004, the Standards Council of Canada Public Health Issues in Seafoodadopted a voluntary standard for labelling and Aquacultureof genetically modified foods that could Consumers are bombarded withlead to more labels on food ingredients confusing information about the safetyand food items. Health Canada requires of both farmed and wild fish. Althoughlabelling of genetically modified foods only the health advantages of eating fish areif there is a health or safety risk such as well established, it can be difficult to siftthe presence of a common allergen (CFIA, through what are often contradictory2004; European Union Food and Feed messages about the benefits and risks ofSafety, n.d.) eating fish and other seafood. OngoingLabelling is an area of controversy. Those publicity regarding the high levels ofin favour of genetically modified organisms mercury present in tuna and swordfish,say labels might deter uninformed people and persistent organic pollutants (POPs)from buying healthy and safe food, while found in both farmed and wild salmon,those in favour of the labels say consumers might prompt some people to choose tohave the right to know what they are eliminate fish from their diet altogether.buying. The worrisome decline in wild fish stocks, and heated public debate surrounding BC’s Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 83
  • 104. Chapter 5: The Safety and Sustainability of Food and the Food Supplyquick-growing salmon farming industry, make it even more Aquaculture has a tremendous potential to provide largechallenging for consumers to select options that are healthy numbers of people with protein. Species such as tilapia andboth for themselves and for the environment. catfish as well as salmon are widely considered to be healthy food choices.As with other public health issues, the risks and benefitsof consuming fish must be considered in context. Experts The main concerns about farmed salmon parallel thegenerally agree that the beneficial health aspects of eating experience with intensive livestock operations discussedone or more servings of fish a week outweigh any potential earlier in this chapter. The same conditions vis-à-vis waste,health risks from exposure to contaminants. The Canadian antibiotic use, overcrowding, and disease transmissionHeart and Stroke Foundation, for its part, recommends that can exist for improperly managed fish farm operations. Inconsumers eat two to three servings of fish each week as part addition, large numbers of fish confined in open net oceanof a nutritious diet. There is indirect evidence to support pens may be endangering wild stock by facilitating the rapidclaims that the regular consumption of fish, particularly the spread of sea lice and other diseases, or may harm otheromega-3 polyunsaturated fatty acids found in fish oils, play marine species when medications are added to salmon feedan integral role in cell membrane function and development to combat sea lice and other health problems.of the brain and eyes (Ruxton, 2004; Harris, 2004). Omega-3 Other concerns include a fear that if Atlantic salmon escapefatty acids are a member of the alpha-linolenic acid family. from the pens, they could compromise the genetic integrityThey are believed to prevent blood platelets from clotting and of Pacific salmon. There has been a significant drop in theattaching to artery walls, reducing the risk of stroke and heart number of escapes of Atlantic salmon in BC in recent years.disease. Omega-3s are also thought to reduce levels of serum Other concerns are that farming uses a high ratio of threetriglycerides that, along with cholesterol, increase the risk of kilograms of fish in salmon feed to produce one kilogram ofheart disease. Some studies suggest that consuming at least farmed salmon, as well as the increase in use of new vaccinesone serving of omega-3-rich fish per week can reduce the risk and medicines aimed at reducing disease in farmed salmon.of death from heart disease by 44 per cent (Heart and StrokeFoundation, 2004; Harris, 2004). Critics of open pens say closed containment systems would remove the risk of transferring disease to wild stock, eliminateAs many wild fish stocks decline, aquaculture is promoted as the potential for escapes, and ensure that other marinea viable means of supplying protein for balanced diets that species are not affected by medications fed to farmed salmonpromote good health. In BC, the aquaculture industry has or by fish waste discharged from open net pens. Thereexpanded significantly during the past several decades. BC’s is, however, a significant increase in energy requirementsaquaculture enterprises produce everything from scallops associated with land-based pens and waste still needs to beto geoducks, but salmon farming dominates the industry. disposed of in an appropriate fashion.Although aquaculture has been practiced in some countriesfor centuries, many of today’s aquaculture operations are Industrial Contaminantshighly intensive and farms can contain up to one million fish.The vast majority of BC farmed salmon are Atlantic because One cause for concern, from a public health perspective,they have better growth and survival rates than Pacific salmon, is the potential level of some contaminants that mayare more docile, and provide more flesh to meet market be concentrated in both wild and farmed fish. Somedemand. Chinook salmon, native to the West Coast, are being contaminants tend to accumulate in the food chain, so speciesfarmed in increasing numbers, but Atlantic still comprise that are higher up—top predators—may have industrialabout 85 per cent of the BC salmon farming industry (Ministry chemicals concentrating in their flesh. The two most commonof Agriculture and Lands, 2004a). and concerning contaminants in fish and seafood are mercury and persistent organic chlorides, such as polychlorinated84 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 105. Chapter 5: The Safety and Sustainability of Food and the Food Supplybiphenyls (PCBs). In response, some of the fish and fish oil in Polychlorinated biphenyls (PCBs): Polychlorinatedsalmon feed may be replaced with vegetarian alternatives to biphenyls (PCBs) were once used widely as industrial coolantsreduce the contamination of persistence organic compounds and in electrical transformers. Although they were bannedthat might otherwise be present. in 1976, they still persist in the environment. Along with other organochlorine compounds such as DDT—once usedMercury: Most fish contain trace amounts of mercury, extensively on crops to kill insects and banned in Canada inbut some types of fish have mercury levels that can lead 1970—PCBs have been linked to an increased risk of cancer.to significant increases in mercury exposure if consumed Although both wild and farmed fish can carry contaminants,frequently. Health Canada advises consumers to limit raw farmed salmon contain higher levels of organochlorineconsumption of swordfish, shark, or fresh and frozen tuna to contaminants—including PCBs, dioxins, toxaphene, andone meal a week due to potential mercury contamination. For dieldrin—than wild salmon. Notably, the source of theyoung children, pregnant women, and women of childbearing contamination was most likely from feed (Hites et al., 2004).age, the recommended limit is one meal per month. This Concentrations of contaminants were consistently higherrestriction does not apply to canned tuna, which tends to in farmed salmon from Europe than in farmed salmon fromcome from smaller and shorter-lived species possessing lesser the Americas. Individual levels of dioxins and PCBs found inamounts of mercury. the salmon tested fell well within Canada’s health guidelines,Health Canada has set guidelines for maximum mercury and both the salmon farming industry and the federal andcontent in commercial marine and freshwater fish at 0.5 parts provincial governments maintain that eating farmed salmon isper million (ppm). This limit is more stringent than many a healthy food option. Although farmed salmon are higher inother countries including the United States, where the limit contaminants than other protein sources such as beef, pork,(for methyl mercury alone) is 1.0 ppm (CFIA, 2002). Canadian chicken, and eggs, these other protein sources do not possessFood Inspection Agency has performed limited testing on the known health advantages of salmon (Hites et al., 2004).commercial fish species in BC. Unfortunately, this data The level of contaminants found in many fish signals thatwas not made available for publication in this report. such precautions must be taken to ensure that fish and otherinformation is necessary and should be made available to the seafood can continue to form part of a safe and healthy diet.public. The US Department of Health and Human Services Oceans are an important source of nutritious food and shouldand US Environmental Protection Agency have tested and not be the recipients of millions of tonnes of pollutants eachestablished guidelines for fish and shellfish consumption.4 year. Farmed fish make an increasingly vital contribution toMost fish such as salmon (fresh or frozen), cod, sardine, trout, the provision of protein for human consumption; yet we musttuna (canned, light), halibut, and snapper contain between ensure that fish farming practices do not pose risks to human0.014 to 0.118 traces of mercury ppm, which is significantly health, the health of our oceans, lakes, and rivers, or to thebelow the recommended 0.5 ppm level set by Canada. The health and regeneration of wild fish stocks and other marinehighest levels of mercury have been detected in mackerel species.king, shark, swordfish, and tilefish (Gulf of Mexico). For moreinformation on actual concentration in fish, please consultthe US Department of Health and Human Services and US Steps to Ensure the Safety of the Food SupplyEnvironmental Protection Agency website at http://vm.cfsan. The food safety issues identified in this chapter are mostfda.gov/~frf/sea-mehg.html. For general information on effectively identified and managed using a risk-basedsafety of mercury and fish consumption, please contact the assessment approach. An effective tool for managing foodCanadian Food Inspection Agency website at http://www. safety risks, which has gained international support, isinspection.gc.ca. the Hazard Analysis and Critical Control Points (HACCP) system. HACCP is a system of process analysis and control originally developed more than 30 years ago by the National4 Limited Canadian data from CFIA on mercury levels exists but is not available for publication. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 85
  • 106. Chapter 5: The Safety and Sustainability of Food and the Food SupplyAeronautic and Space Administration (NASA) to safeguard processing operations engaged in international trade, HACCP-food preparation for space flight. A critical control point based control programs can be applied to the food systemis any point in the process where the loss of control could from farm-to-fork, and therefore should be widely adoptedresult in an unacceptable safety risk. The original HACCP across the entire food spectrum.framework developed by NASA contained a seven-stepapproach; however, the system has been widely adapted Summaryto reflect the needs and diversity of the food industry. Theessential elements included in most HACCP programs are • Foodborne diseases are very common, striking anan analysis of the potential hazards and identification of the estimated 2 million Canadians each year. While thecritical control points; the establishment of critical limits for majority of cases go unreported, at least 10,000 cases areeach control point and actions to be taken when the limits are reported in Canada each year from which approximatelynot met; and an audit to ensure ongoing compliance with the 30 people die.identified controls. • The most common causes of foodborne disease areThe HACCP approach is an improvement from reliance on bacterial, viral, or parasitic infections, toxins created byrandom spot checks and random sampling of foods to look bacterial growth, or chemical contamination.for contamination. The process of random inspection and • Of the more than 40 pathogens linked to foodbornesampling is reactive rather than preventive and can only illness, the most common causes in BC are Norovirus,respond when an actual food safety hazard is found. HACCP Campylobacter, E.coli 0157:H7, Salmonella, and thesystems, instead, predict where a food safety hazard is most three bacteria associated with improper temperaturelikely to occur and prevent it from occurring or provide storage of foods: B. cereus, C. perfringens, and S. aureus.warning when it might have occurred. • Marine-based food poisonings are most commonly VibrioMost importantly, HACCP-based principles: parahaemolyticus, paralytic shellfish poisoning from red• Are based on sound science; tide, and Scombroid, which is a buildup of histamines in spoiling fish.• Focus on identifying and controlling the critical food safety steps in an operation; • The majority of food safety risks can be avoided with safe food handling, which includes good personal hygiene,• Permit efficient and effective government and public especially good handwashing, proper cooking and food health monitoring, through auditing how well a food storage, and avoidance of cross-contamination by keeping operation (producer, processor, distributor, or retailer) cooking surfaces and utensils clean. is complying with their food safety requirements over a period of time rather than how well they are doing at one • Intensive livestock operations (ILOs), which concentrate point in time on a given day; thousands of animals on a small plot of land, create potential health concerns through the amount of• Place appropriate responsibility for ensuring day-to-day manure produced, the use of antibiotics to fight illness safety of the food supply on the food operation, while and promote growth, and the potential for disease allowing the government and public health to more transmission to take hold when so many animals are effectively oversee and regulate the process. confined together.Given the food safety concerns raised in this chapter, HACCP- • All manure, even small amounts, can carry the risksbased programs set up a systematic system to oversee the of disease. But large amounts of manure producedconditions when food may become unsafe. Although they on ILOs, sometimes greater than 2,000 kilograms perhave gained acceptance in some areas, particularly for food hectare of land, can create additional problems in its86 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 107. Chapter 5: The Safety and Sustainability of Food and the Food Supply safe and effective removal. Manure poses risks to public • The feeding of rendered animal protein to cattle in their health because it may carry pathogens like E.coli 0157: feed is one of the likely sources of mad cow disease, or H7, Campylobacter, Salmonella, etc.; its nitrogen and bovine spongiform encephalopathy (BSE), particularly phosphorus may leach into water causing algae blooms; an outbreak in Britain in the 1980s. BSE, which has been it may contain antibiotics which promote the creation of linked to infectious protein particles called “prions,” can antibiotic-resistant microbes in the soil; and it may cause arise spontaneously. This practice has since been banned dust, moulds, and noxious gases. in Britain.• Uncontrolled antibiotic use in livestock is a public health • Eating the central nervous tissue of infected cattle such concern. More than 50 per cent of all antibiotics in North as brain, spinal cord, retina, or meat products containing America are used in livestock and this use is considered a neural tissues (as in mechanically recovered meats), has significant factor fuelling drug-resistant strains of bacteria been implicated in the transmission of variant Creutzfeldt- worldwide. Jakob Disease (vCJD) in humans.• The Canadian Integrated Program for Antimicrobial • To date in Canada, eight cases of BSE have been detected Resistance Surveillance (CIPARS), under the Public Health in cattle, none of which have contaminated the food Agency of Canada, has published two reports that create supply. No vCJD cases have arisen in Canada linked to an important baseline. The 2005 report found evidence Canadian beef, unlike Britain and France where 149 of increased resistance in isolates from meat samples: people have died from vCJD. isolates of E. coli were found in 88 per cent of swine, and • Genetically modified organisms have the potential to 84 per cent of samples were resistant to one or more make food more nutritious or food production more antimicrobials. In samples from humans, a large number efficient or economical; however, they also pose potential of strains of Salmonella were resistant to 1 or more of 16 risks. Concerns over the use of genetically modified antimicrobials. organisms include the transfer of allergenic proteins to• Contrary to public belief, only beef cattle are fed unrelated foods, augmentation of natural toxicities in hormones to promote growth, and these hormones have foods, transfer of genes that confer antibiotic resistance, been used for more than three decades. Six hormonal and outcrossing, which is the inadvertent mixing of growth promoters (HGPs) are approved for use in cattle genetically modified genes with wild related species. in Canada and the US. • Unlike Europe, Canada does not require genetically• While the scientific and public health communities modified foods to be labelled. in North America generally accept HGPs, their use • Canada’s expert panel on the future of food biotechnology is controversial in Europe, where HGPs are banned. recommended that Canada apply the “precautionary European scientists are particularly concerned about principle” to the introduction of genetically modified estradiol-17ß’s potential impact on pre-pubertal children. foods; this principle states that new technologies should• Health Canada’s Veterinary Drug Directorate conducted not be presumed safe unless there is a reliable scientific a scientific review of the European Union studies on basis to consider them safe. As such, the panel called for this issue and concluded that residues in meat from more rigorous testing of genetically modified foods. animals treated with hormonal growth promoters, when • A diet that includes regular consumption of fish and administered according to good veterinary practices, seafood is considered to be very good for health. pose no undue risk to human health. This conclusion is Consumption of certain species of fish has its concerns, consistent with that reached by the US Food and Drug particularly the potential concentrations of mercury and Administration. industrial pollutants, particularly PCBs, at the top of the fish food chain. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 87
  • 108. Chapter 5: The Safety and Sustainability of Food and the Food Supply• The overfishing of the oceans and the intensive farming approach to fish aquaculture is a concern. An environmentally sound and sustainable aquaculture, along with well-managed ocean fisheries, is an essential part of food security, so that future generations of British Columbians will have access to this healthy food source.• Potential risks in our food supply can often be predicted, prevented, and managed using a well-designed risk management approach. The Hazard Analysis and Critical Control Points (HACCP) approach first designed by NASA to keep food safe in space flight has now been widely adopted in the food industry. The HACCP approach is a sound public health approach to controlling risks in the food supply from farm-to-fork and should be widely supported.88 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 109. Chapter 6: Food and the Aboriginal PopulationThe health status of Aboriginal people in the past few decades unable to prove their status or have lost their status rights.has improved significantly in several key respects. Yet BC’s Many Indian people in Canada, especially women, lost theirAboriginal population continues to experience a higher Indian status through discriminatory practices in the past.incidence of poor health and a disproportionate rate of The Inuit (formerly referred to as Eskimo) live primarily inchronic diseases compared to other BC residents. In Chapter Nunavut, the Northwest Territories, and northern Labrador1, we examined the role that diet and nutrition can play as and Quebec. While not subject to the Indian Act, Inuit can bea significant risk factor for common chronic diseases. The subject to regulation by federal legislation in ways similar toevidence for high rates of obesity and Type 2 diabetes in that act.the Aboriginal population suggests the intricate relationshipbetween diet and health merits special attention for this Métis people are of mixed First Nation and European ancestry,group. distinct from First Nations and Inuit peoples. While their cultural roots are in what became the three Prairie provinces,Terminology Métis live throughout Canada, including BC. Métis are neither subject to the Indian Act, nor are they eligible for programsThe use of appropriate terminology avoids confusion and provided to status First Nations.misinformation when referring to specific indigenouspopulations. The federal Constitution Act recognizes three According to the 2001 Canadian Census, 170,025 AboriginalAboriginal peoples: Indians, Inuit, and Métis. The word people lived in BC in 2001. Of these individuals, 118,290 wereAboriginal is defined as being in place “before the arrival of Status Indians, 44,270 were Métis, 805 were Inuit, and 6,660colonists,” and acknowledges the existence of Aboriginal, were considered as other (BC Stats, 2001).Inuit, and Métis communities in British North America at thetime of confederation. Availability of DataWhile the term Indian continues to be a legal term used Although there is considerable interest in the health status offor legislative and statistical purposes, First Nations is now all Aboriginal peoples (including Métis, non-status, and Inuit),widely used. This term may refer to either individuals or to a in most cases, relevant data is only available for Status Indians.land-based community. When applied to individuals, it may Information to identify Status Indian data in this report wasrefer to either Status Indians or non-status people. Status obtained from the British Columbia Vital Statistics Agency,Indians are those recognized by the federal government as British Columbia Medical Services Plan, and the First Nationsbeing subject to provisions of the Indian Act and eligible for and Inuit Health Branch of Health Canada (British Columbiacertain programs and services, while non-status Indians are Vital Statistics Agency, 2004).not recognized under the Indian Act, either because they are Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 89
  • 110. Chapter 6: Food and the Aboriginal Population Health Outcomes in the leading to a greater burden of disease forThe Thrifty Gene Theory Aboriginal Population Aboriginal populations. All risk factors are more prevalent and more severe in theWhy are diabetes and obesity more prevalent In the Canadian First Nations population, general Aboriginal population. Initiativesin the Aboriginal population? The “thrifty gene (particularly Status Indians, for whom data that address the need to improve diet musthypothesis” suggests that some populations is available) obesity and Type 2 diabetes are work in concert with culturally appropriate,developed strong biological mechanisms considered major health problems, with Aboriginal-led collaborative initiativesfor conserving energy as fat to enable their over 50 per cent of this population having that address other risk behaviours likesurvival in times of periodic famine. Some one of these conditions (Young, Reading, tobacco use, and the broader contextualresearchers argue that the impact of the thrifty Elias, & O’Neil, 2000, as cited in Douketis, issues of education, employment, and self-gene is particularly evident among Aboriginal Paradis, Keller, & Martineau, 2005). This determination that accompany Aboriginalpopulations who have made rapid social in turn impacts both a range of chronic health issues.transitions from active hunter-gatherers tosedentary consumers. When the food supply is conditions, as well as life expectancy. Most indigenous populations worldwide,secure, the quick production of insulin can lead Obesity and Diabetes in theto health problems such as hyperglycemia, including the Canadian Aboriginalobesity, and diabetes (Young et al., 2000). population, share a pattern of premature Aboriginal Population morbidity. The key considerations are The epidemiological data on overweight a long history of colonization, cultural and obesity for Aboriginal populations in deprivation, political impotence, and North America is limited and generally systematic discrimination, as well as focused on specific communities. genetics, lifestyle, socio-economic factors, Nevertheless, studies reveal high poor quality housing and community prevalence rates for obesity. One small environments, unemployment, and low study of adults in two Ojibwa communities, levels of education. Some researchers have for instance, found a rate of obesity that focused on the role of genetics as a risk was twice the current Canadian average factor for adverse health outcomes and (deGonzague, Receveur, Wedll, & suggest that in the Canadian Aboriginal Kuhnlein, as cited in Canadian Institute for population, the gene-environment Health Information [CIHI], 2004). Obesity interaction may be particularly strong. has generally been linked to very high rates Others argue that socio-economic status, of chronic conditions, such as diabetes, along with health-damaging behaviours hypertension, heart disease, and cancer. such as smoking and the presence of two In fact, Type 2 diabetes has long been or more diseases together in an individual recognized as a serious health problem (co-morbidities), constitute health risk among many Aboriginal populations in factors, rather than having an “Aboriginal” North America, with indications of an background itself (Cass, 2004). emerging epidemic as early as the 1970s. Generally, Aboriginal communities Diabetes in particular has been considered experience significant and systemic indicative of the rapid sociocultural inequalities, with resulting poorer health changes experienced by Aboriginal people outcomes that cannot be accounted in the past several decades (Young et al., for by individual make-up or behaviour 2000). More recently, research is exploring alone (Cass, 2004). Chronic diseases the health implications of the radical shift have complex origins and researchers are from traditional diets to western diets, exploring the interplay of a range of factors and from hunting-gathering to sedentary 90 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 111. Chapter 6: Food and the Aboriginal Populationconsumption. Generally, risk factors for common chronicdiseases are increasingly pointing to the role of diet and Provincial Health Officer’s Report: Diabetes in the Firstnutrition. The issue of “dietary acculturation,” substituting Nations Populationmodern for traditional food items, furthers the challenge ofboth understanding and improving Aboriginal health status. The 2004 Provincial Health Officer’s report, The Impact of Diabetes on the Health and Well-being of People in British Columbia, devoted a chapter to First Nations inThis is particularly the case, given the argument that many British Columbia. The term First Nations is used since most data and informationAboriginal people consider the decline of hunting and fishing presented pertain to First Nations (in particular, those with Status for whom datato be the underlying cause of the diabetes epidemic (Young is available). Some of the key findings were:et al., 2000). • The prevalence of diabetes among the First Nations population in Canada has increased significantly in the last 50 years (Health Canada, 2000).Traditional Foods • The combination of a western diet high in carbohydrates, simple sugars, andThe traditional foods of BC’s Aboriginal population provided fats, and a sedentary, inactive lifestyle has more than likely contributed to thea diet high in protein, low in carbohydrates, and rich in epidemic of diabetes among the First Nations population.essential minerals and vitamins (Kuhnlein & Chan, 2000).In coastal communities, dried herring eggs on kelp were a • At the end of fiscal year 2003/2004, there were an estimated 5,600 Statusfavourite snack, with the eggs providing protein, calcium, Indians living with diabetes in British Columbia.iron, and thiamine. Smoked salmon and salmon eggs made a • The prevalence of diabetes in the Status Indian population is higher amongcommon breakfast. Local plants supplied a fresh and diverse females in almost all age groups.selection of fruits and vegetables, and nuts were often added • The prevalence rate of diabetes among Status Indians is about 1.4 times higherto meat stock to make tasty and nutritious soups. than other BC residents.At the time of colonization by Europeans, approximately • On average, each year, more than 100 Status Indians with diabetes die in Britishone-third of Canada’s native population lived in BC. The Columbia.abundance of seafood available year-round made it possiblefor coastal tribes to settle in permanent villages, often located • Status Indians with diabetes accounted for 24 per cent of all circulatory systemalong the shores of sheltered bays and inlets. When the deaths, 17 per cent of all malignant neoplasm (cancer) deaths, and 17 per cent of all respiratory system deaths among the Status Indian population.Europeans arrived, some village sites had been occupiedfor more than 4,000 years (Indian Affairs and Northern • When age-standardized to the overall population, the average health care costDevelopment Canada, 1996). Smaller numbers of Aboriginal per person with diabetes was $4,161 for Status Indians compared to $3,508 forpeople lived in BC’s Interior. Those in the Northern other BC residents. The higher health care costs for Status Indians reflect their(Subarctic) Interior spoke Athapaskan and lived a nomadic higher hospitalized co-morbidities and higher mortality.life of hunting and gathering. Southern Interior (Plateau) The report made six recommendations specific to addressing diabetes in BC’sAboriginals travelled around the region’s dry grasslands and Aboriginal population, including making healthy, affordable foods more available,forests in the summer, seeking seasonal food, and settled into supporting local food production, and reintroducing traditional diets. The reportsmall villages of pithouses for the winter. also reaffirmed five recommendations from the 2001 report, The Health and Well- being of Aboriginal People in British Columbia, particularly the need for improvedAn estimated 90 per cent of the dietary protein of coastal standards of living, and more autonomy, recognition, and respect. For moreAboriginal people was derived from the ocean, but land information on either of these reports, please refer to the website at:animals and plants were also important sources of nutrition http://www.healthservices.gov.bc.ca/pho/.(Mos et al., 2004). Salmon, halibut, smelt, and herringwere significant components of the traditional diet of mostAboriginal people, who relied on salmon runs on the FraserRiver and its tributaries and throughout the Columbia Riversystem. Wild game, such as deer, was another major source ofprotein, particularly in interior regions far from the ocean and Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 91
  • 112. Chapter 6: Food and the Aboriginal Populationits buffet of seafood. Studies show that wild game is healthier Tea made from the Labrador bush, a scraggly shrub withthan farmed animal food, which has a higher fat content. dense clusters of white flowers, was popular throughoutCompared with the farmed animals eaten today by most the province. The Sliammon prepared Labrador leaves byconsumers, most wild game has about one-half the calorie steaming them in a shallow pit, amidst layers of licorice ferncontent and is 50 per cent higher in other nutrients (Health rhizomes for flavouring, while the Haida drank Labrador tea asand Welfare Canada, 1985). a medicine for sore throats and colds (Turner, 1975). Spruce bark, which has a plentiful supply of vitamin C, was boiled toA wide variety of fresh fruits and vegetables that are now make a tea that prevented scurvy.known to be high in vitamins and minerals were integral tothe traditional Aboriginal diets. Seaweeds were eaten fresh Most food was only available seasonally, so food preservationor dried for the winter by coastal peoples. Cooked dandelion techniques were used to ensure sufficient food in times ofgreens supplied vitamins A and C, as well as calcium. Wild scarcity. Fish and game, such as deer, were smoked andclover roots and silverweed roots, consumed by the Coastal dried for the lean winter months. Berries were poured intoAboriginal population, were high in iron. Greens like fireweed wooden frames set on skunk cabbage leaves, and placed nearand salmonberry sprouts supplied folic acid, vitamins A and a fire to dry slowly for several days. Bulbs, roots, rhizomes,C, and important minerals like iron, calcium, and magnesium. tree cambium, and seaweed were also cleaned and dried forAltogether, 135 different kinds of plants were used as food, winter. Dried black tree lichen contained a carbohydrate thatdrinks, or for flavour in the traditional diet of BC’s Aboriginals swelled when mixed with liquid, giving those who ingested(Turner, 1978). it the sensation of a full belly. The lichen, also used for thickening soups, was rich in iron and was a source of calciumMany fats found in the traditional diet of BC’s Aboriginal as well (Health and Welfare Canada, 1985).population came from fish, seeds, and nuts. These fats, whichare known to help reduce blood cholesterol levels, were used Collecting and storing enough food for survival was a time-to cook meats, fish, and vegetables; and to preserve food. consuming and challenging task. It demanded constantSome traditional fats were a key source of fat-soluble vitamins activity and kept the Aboriginal population physically active(A, D, E, and K) and a source of essential fatty acids (Health and fit. Men hunted and fished together. Women workedand Welfare Canada, 1985). alongside each other digging edible roots and bulbs; cleaning fish and hanging them to dry in smokehouses; collectingMany plants also made a contribution to a balanced Aboriginal shellfish such as clams, oysters, and mussels; and gatheringdiet. The stalks of the rhubarb plant were eaten, but the berries in the summer and fall.leaves, which contain toxic amounts of oxalic acid, wereavoided. Blue camas bulbs provided an important source Change in Dietary Traditionsof carbohydrates in the form of a complex sugar calledinulin. Along with plants, fruits such as berries were also The first changes in the traditional Aboriginal diet began toan important part of the traditional diet. In BC, there were occur soon after European contact. Refined sweeteners, likemore than a dozen varieties including salmonberries and sugar and molasses, became readily available. Carbohydrates,wild strawberries, bog cranberries, thimbleberries, and salal such as potatoes, flour, rice, and beans, were instantlyberries. Berries were also used as a natural sweetener. All popular among Coastal and Interior Aboriginal groups. Thefood was considered to be sacred, and ceremonies were often consumption of traditional plant foods swiftly gave wayheld to celebrate the ripening of different kinds of berries and to “white man’s” fruits and vegetables (Turner, 1978). Asother fruits. industrialization and urbanization made commercial food more accessible, game meat was replaced by store-boughtAboriginal people traditionally had their own healthy version meat, natural foods by processed foods, and traditionalof today’s sweetened soft drinks. Using the stems, bark, beverages by pop, juice, and alcohol.or leaves of shrubs such as wild blackberry, they brewedbeverages that were consumed for pleasure or to cure illness.92 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 113. Chapter 6: Food and the Aboriginal PopulationFor millennia, Aboriginal people had (Mos et al., 2004). One study of the Nuxalkbeen sustained by the diverse harvests of Nation found that, with the exception of Salmon and Crabthe nearby land, ocean, rivers, and lakes. fish, very little traditional foods were stillSuddenly, over the course of a few decades, consumed (Hans, Hilland, & Kuhnlein, Traditional marine foods still play an importantthe traditional diet virtually vanished and 2003). role in some Aboriginal communities in BC. A survey of the Sencoten (Saanich) Firsta western diet was almost universally Generally, the western diet embraced Nation suggests that traditional marine foodsadopted. Instead of fresh, local fare, by a vast majority of BC’s Aboriginal continue to make a valuable contributioncommercial foods produced elsewhere population today is far less healthy than to people’s social and economic well-being,were consumed. Furthering the loss of particularly in the case of older adults. Salmon, a traditional diet since it represents anthe traditional diet, the establishment of traditionally the most significant marine increase in calories, carbohydrates, totalresidential schools separated children food, represented 42 per cent of marine meals fat, and saturated fat intakes (Mos et al.,from their families and communities, among those surveyed. Crab was the second 2004; Kuhnlein & Chan, 2000). It is alsohindering the custom of passing down most consumed marine food. Adults over 40 lower in nutrients than traditional food,traditional food knowledge from were far more likely to eat traditional marine and is thought by some researchers to havegeneration to generation. Other factors foods than younger generations (Mos et al., contributed to chronic diseases such assuch as commercial traplines, unsustainable 2004). diabetes among Aboriginal people (Turnerforestry, industrial pollution, and fish & Ommer, 2003). The combination of afarming may have also contributed to the western diet high in carbohydrates, simpleloss of the traditional diet. Lifestyles also sugars, and fats and a sedentary, inactivebecame far more sedentary after Aboriginal lifestyle has more than likely contributedreserves were established, contributing to to the epidemic of diabetes among thean increased risk of obesity and associated Aboriginal population.chronic diseases.The amount of carbohydrates consumed Health Significance of Dietaryby BC’s Aboriginal people was very limited Changeprior to the introduction of sugar, potatoes,wheat, and other starchy foods. Following Researchers differ in their assessment ofEuropean contact, flour and sugar the relative importance of diet to healthsoon became prominent features in the outcomes in the Aboriginal population.Aboriginal diet, and were used in a variety Some studies suggest diet is a pivotalof bread, cakes, and cookies. Today, market factor. Research on communities of Pimafood comprises the bulk of Aboriginal diets. Indians in the United States and Mexico,Across Canada, only about 15 per cent of found a prevalence of diabetes in theAboriginal people still obtain most of their former population despite their higheranimal proteins from hunting and fishing socio-economic status, and indicated the(Young et al., 2000). For the most part, critical difference lay in the consumption ofnutrient-rich traditional plant foods are no a western diet not available to their Mexicanlonger gathered for barter or sale, although counterparts (Baschetti, 1997, 1999).some people still collect them to share with Similarly, a group of Australian Aboriginesfriends and family (Turner, 1978). Many virtually recovered from diabetes in fivefish and shellfish, however, continue to weeks by returning to their traditional dietrepresent an important source of nutrition (O’Dea, 1984), while a group of obeseand culture for BC’s Aboriginal Peoples Hawaiians lost significant weight in three Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 93
  • 114. Chapter 6: Food and the Aboriginal Population weeks by consuming traditional foods to Canadian and other data generallyDoctor Day, Food Boxes, and satiety (Shintani, Hughes, Beckham, & indicate that low social status and living inCommunity Kitchens in Aboriginal O’Connor, 1991). poverty increases the risk of obesity and isCommunities associated with a 58 per cent increase in Other researchers are more skeptical, chronic conditions (Cass, 2004). However,BC’s five regional health authorities have arguing few dietary culprits for diabetes evidence in BC suggests a region’smade improving aboriginal health a priority. have been consistently identified and that health status is not always clearly linkedThe Vancouver Island Health Authority concerns about nutritional deficiencies to socioeconomic conditions. The 2001is emphasizing nutrition and diet in the or diabetic precursors in western dietsfollowing programs: Provincial Health Officer’s Annual Report are still somewhat speculative. In this entitled The Health and Well-being of• Doctor Day – a “traveling clinic” of health vein, a study of diabetic patients among Aboriginal People in British Columbia, professionals visits the semi-remote the James Bay Cree, who spent three noted that areas of lower socio-economic Pacheedaht First Nation on the west coast months in the bush living a traditional status for Aboriginal communities, such as of Vancouver Island on a monthly basis. lifestyle, found the change did not lead the Northern and Interior regions, had the The team includes a dietitian, a diabetes to marked improvement in body weight, best Aboriginal health status. These were nurse, and a public health nurse, as well as plasma glucose level, glycated hemoglobin the regions where formal health services an Aboriginal physician. The community concentration, and blood pressure. They nutritionist supports healthy eating for were also least available. The research cited were more physically active but they also families, healthy eating on a limited income, in the report suggested health outlooks bought large quantities of store-bought and nutrition during pregnancy. were favourably influenced by the degree foods for sustenance, which likely negated of social, cultural, and political integrity• Food Box is a collaborative of south island the effect of increased activity (Young et al., in those communities. It is evident that Aboriginal people. It provides reliable access 2000). improving access to traditional diets will be to good, nutritious food by coordinating However, it is increasingly evident that one way to strengthen community integrity. bulk purchase and delivery of healthy foods to individuals and families. More than 300 effective primary and secondary prevention Enhancing physical and economic access boxes are regularly delivered. to address chronic disease in the Aboriginal to sufficient, safe, and nutritious food to population should place stronger emphasis• Meal Bag Program provides a package of meet dietary and food preference needs is on diet and should do so at critical stages all ingredients for a nutritionally balanced an essential determinant of good health for of life. meal to small groups of community the Aboriginal population. members who gather to prepare and sample the meal and discuss preparation Socio-Economic Status and Aboriginal groups clearly experience a disproportionate level of food insecurity alternatives. This approach distributes Access to Food appropriate foods and information as well due to poverty. Many people living on low as building individual capacity in a social Aboriginal people living in BC generally incomes are unable to afford sufficient or setting. experience a standard of living that is 20 nutritious food. Those living on remote per cent below the provincial average, reserves also face additional challenges in No single program can suddenly change based on measures such as income, obtaining fresh and healthy food that musthealth status and outcomes, but these employment, educational attainment, and be transported long distances. Refrigerationcommunity initiatives are a step in the right housing adequacy (PHO, 2002). Child and freezer storage mean that a variety ofdirection. poverty is of particular concern because perishable foods are far more accessible of its association with a variety of poor than in the past, but, at the same time, outcomes later in life. Forty-one per cent for many, access to traditional foods has of Aboriginal children live in families with been reduced (Health and Welfare Canada, incomes under $20,000, compared to 17 1985). per cent for other BC children (PHO, 2002). 94 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 115. Chapter 6: Food and the Aboriginal PopulationAs detailed in Chapter 4, food insecurity is a precursor to many Red Tideshealth problems including malnutrition, low birth weight Red tides, or harmful algae blooms (HABs), remain ofbabies, unhealthy pregnancies, sub-optimal child development, particular concern to local Aboriginal people who continuepoorer health in seniors, and greater rates of chronic disease. to harvest shellfish as part of their traditional heritage. TheA disproportionate amount of calories are consumed as junk tides are caused by a species of algae called Alexandrium, afood because processed food is generally cheaper and more dinoflagellate microalgea food source for many filter-feedingreadily available than healthier foods like fruits and vegetables. shellfish. The algae produces a biotoxin (saxitoxin) that canSome programs have been initiated by BC’s health authorities be fatal to humans who eat the affected shellfish. Knownto provide remote communities with increased access to low- as paralytic shellfish poisoning (PSP), this nervous systemcost, healthy food as well as dietary information and education. disease produces symptoms that usually start with tinglingSuch programs require further support and coordination. and numbness. The toxin interferes with nerve function, causing temporary paralysis, and can result in death throughEvaluating the link between ethnicity, culture, socio- asphyxiation. The absence of red tide does not necessarilyeconomic status, and health is a difficult research challenge. mean HABs are not in the water; in certain circumstancesAwareness of the broader determinants of health can play the algae may be present in the water without the reda role in developing effective interventions to change diet appearance. Conversely, other algae may produce a redand physical activity patterns for specific populations. These pigment, but not contain toxin. Some species of shellfish thatinterventions must go beyond the assumption that risk for have accumulated toxin remain unsafe for consumption forchronic disease resides principally in the individual and his or up to one year after exposure to the toxin. To find out if anher behaviour. They must involve integrated, multidisciplinary, area is open for shellfish harvesting, contact the Departmentand comprehensive approaches that work at the individual, of Fisheries and Oceans (DFO) toll free at 1-866-431-3474, orcommunity, environmental, and policy levels. In addition, visit their website at http://www.pac.dfo-mpo.gc.ca.they must build in respect for and sensitivity to language andcultural issues (Young et al., 2000; Cass, 2004). The Provincial Measures have been taken to reduce the risk of paralyticHealth Officer’s 2001 report used not only health status shellfish poisoning along BC’s remote central and northindicators to measure Aboriginal health progress, but also coasts. Many of BC’s coastal Aboriginal people, in partnershipindicators to measure other factors affecting health, such as with the Canadian Food Inspection Agency’s (CFIA) Marinehigh school completion rate, unemployment rate, low-income Toxin Monitoring Program, run their own PSP-monitoringrate, and community control (PHO, 2002). programs. The Heiltsuk Nation, on the central coast, manages its own intertidal shellfish fishery. Harvests take place duringFood Safety and the Aboriginal Population months when there is a low likelihood of harmful algae blooms. The Nisga’a Nation has also worked with the CFIAAcross Canada, only 15 per cent of Aboriginal people still to reduce risks associated with toxic algae blooms. Theobtain most of their animal proteins from hunting and fishing Nisga’a have designated beaches central to their food, social,(Young et al., 2000). For the most part, nutrient-rich traditional and ceremonial shellfish harvests. The CFIA plan to set upplant foods are no longer gathered for barter or sale, although monitoring stations on these beaches to help the Nisga’asome Aboriginal people still collect them to share with friends determine safe periods for shellfish harvesting (Northwestand family (Turner, 1978). Fish, shellfish, and game, however, Fisheries Science Center and Washington Sea Grant Program,continue to represent an important source of nutrition and 2002).culture for BC’s Aboriginal population (Mos et al., 2004), andthese types of foods can pose health risks from potential Other harmful toxins monitored jointly by the CFIA andcontamination from natural or man-made sources. Aboriginal people through the shellfish program include diarrhetic shellfish poisoning caused by several toxins, and amnesic shellfish poisoning (ASP), caused by the toxin Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 95
  • 116. Chapter 6: Food and the Aboriginal Population domoic acid, produced by a species of in harvesting and consumption patternsBotulism in BC diatom in the Nitzia family (Pseudonitzia). (Wiseman & Gobas, 2002). Additionally, The first reported outbreak of ASP human health advisories were issued forIn August 2001, two separate botulism occurred in Canada in 1987, when over the consumption of shellfish organ meatsoutbreaks involving Aboriginal communities 100 people reported illness and 4 deaths and certain fish. While every effort mustoccurred in northwestern BC. Both were occurred. Symptoms of ASP are similar be made to reduce the discharges thatrelated to fermented salmon roe, a delicacy to PSP and may also include nausea and contribute to food contamination, withof Aboriginal people on the west coast. One vomiting within 24 hours, and loss of some exception, the benefits of consumingoutbreak resulted in the death of a 73-year-oldwoman. short-term memory. (Brett, 2003; Isbister & a traditional diet outweigh any risk. Kiernan, 2005).Botulism can begin with typical symptoms of Botulismfood poisoning such as vomiting and nausea. It Industrial Pollutantscan quickly progress to include blurred vision, Foodborne botulism is a rare, butslurred speech, and muscle weakness. In some Another challenge to traditional food potentially deadly, paralytic diseasecases, it can leave victims completely paralyzed sources is the increasing incidence of that disproportionately affects Canada’s(Public Health Agency of Canada, 2002). industrial contamination. Many traditional Aboriginal and Inuit peoples. The most marine food sources are now contaminated frequent sources are home-prepared with persistent organic pollutants such products like canned foods, fermentedContaminated Foods as methylmercury and polychlorinated Inuit food, and improperly stored marineOoligan grease and white sturgeon are biphenyls (PCBs). From a public health meat (Weir, 2001). C. botulinum is anamong the traditional foods found to contain perspective, it is sometimes necessary anaerobic, spore-forming bacilli commonlypersistent organic pollutants (POPs). Ooligan to close fisheries temporarily or even found in soil. As its spores reproduce, theygrease from BC’s north coast and rivers was permanently because of potential risks generate one of the most potent lethalfound to be contaminated with chlordane, posed by consuming contaminated food. substances known: a single teaspoonchlorobenzene, DDT, dieldrin, HCH, mirex, and Long-term exposure to mercury, for can kill 100,000 people (MOHS, 2002).PCBs. White sturgeon in the Upper Fraser River instance, can cause permanent damage to One case alone of foodborne botulismwere found to contain dioxin, furans, PCBs, andother contaminants (Kuhnlein & Chan, 2000). the brain and kidneys, and for pregnant constitutes a public health emergency, women, can cause damage to the as it may signal the beginning of a larger developing fetus (Chan & Receveur, 2000). outbreak. The health impacts of PCBs and other From 1971 to 1984, a total of 122 cases organochlorines are not fully understood, of foodborne botulism were recorded but in children they have been linked in Canada, mostly in northern Quebec, to developmental delays, endocrine the Northwest Territories, and British disruption, and neurobehavioral deficits Columbia. Twenty-one cases were fatal. The (Kuhnlein & Chan, 2000). majority of the victims were native people In 1988, crab, prawn, and shrimp industries and, of those, most were Inuit. About 60 along the BC coast were closed due to per cent of the outbreaks were caused high levels of dioxins and furans thought by raw, parboiled, or “fermented” marine to originate from nearby pulp mills. animal meats, while fermented salmon eggs Significant numbers of Aboriginal people or fish accounted for 23 per cent of the who regularly consumed shellfish were outbreaks (Hauschild & Gauvreau, 1985). affected, and the closure of Aboriginal fisheries brought about further changes 96 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 117. Chapter 6: Food and the Aboriginal PopulationBotulism can be avoided by canning seafood, meats, particular challenges such as poverty and food security facingand vegetables at high temperatures in pressure canners the Aboriginal population.(MOHS, 2002). The BC Centre for Disease Control does not The prevalence of diabetes among the First Nationsrecommend the consumption of fermented salmon roe due population in Canada has increased significantly in the lastto potential health risks. Recognizing that “stink eggs” are a 50 years (Health Canada, 2000). At the end of the fiscal yeartraditional Aboriginal food, however, the centre suggests that 2003/2004, there were an estimated 5,600 Status Indians (athe risk of botulism be reduced by using alternative methods proportion of First nations for whom data is available) livingof fermenting salmon eggs, such as curing or sun-drying. with diabetes in British Columbia. Status Indian prevalence rates are approximately 40 per cent higher than those forMicro-organisms in Game other BC residents. The gap between Status Indian femalesThe parasite trichinella, which in the past was most and other BC resident females is substantially larger than forcommonly associated with undercooked pork, is now almost males. (Figure 6.1)exclusively found in wild meats, particularly bear, wolf, and As can be seen in Figure 6.2, the age-standardized mortalityartic marine mammals. In BC, bear is the most common rates for cancer, diabetes, and circulatory system diseases forsource of the infection, trichinosis, and it is most common Status Indians is significantly higher than the rates for otheramong Aboriginal people. In 2005, 27 cases of trichinosis were BC residents.1 The Status Indian population also has muchdiagnosed in BC, primarily from eating bear meat (McIntyre et higher potential of life years lost due to the aforementionedal., 2006). chronic diseases compared to other BC residents (Figure 6.3).Recently, wild deer have been found to carry a variant of The potential of life years lost are the number of years of lifespongiform encephalopathy, similar to mad cow disease, lost when a person dies before a specified age (in this case 75which theoretically can transmit the infectious agent, called a years).prion, to humans who eat brain, spinal cord, retinal material, Compared to other British Columbians, Status Indians areand ground meat containing bits of central nervous system three times as likely to be admitted to hospital for conditionstissue. To date no known transmission from deer to humans that could be managed in the community (Figure 6.4). Thesehas been recorded. conditions include diabetes, asthma, hypertension, neurosis,The potential for food safety risks in traditional Aboriginal depression, or abuse of alcohol and other drugs (PHO, 2002).diets requires supporting access to traditional food, and The higher mortality and morbidity rates for BC’s Aboriginalcommunity capacity building in partnerships with scientific population are not reflected in their use of primary careand health organizations, to ensure the safe use of traditional services. This suggests that present primary care for Aboriginalfoods, particularly in regard to red tide, botulism, other people may be lacking, culturally inappropriate, inaccessible,microbial contaminants, and industrial pollutants. or in other ways less than optimal. For this reason in 2001, the Provincial Health Officer called for greater AboriginalImpact of Chronic Disease involvement in the design, delivery, and governance ofThe prevalence of heart disease, diabetes, and other chronic primary and community-based care (PHO, 2002).diseases are much higher in the Aboriginal population Appropriate public health interventions can help preventcompared to other BC residents. A combination of a diet high chronic disease. Research suggests effective primary andin carbohydrates, simple sugars, and fats, and a sedentary, secondary interventions to address chronic disease riskinactive lifestyle has more than likely contributed to the factors should be directed at critical stages of life. Thisepidemic of chronic disease. Given the higher rates of disease includes targeting children and youth, given the evidence ofamong Aboriginal people, the need to address prevention and significant challenges for diet, nutrition, and chronic diseasedisease management clearly depends on understanding the in this age group.1For a more detailed explanation and calculation of this and other figures please see Appendix A. Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia 97
  • 118. Chapter 6: Food and the Aboriginal Population Age-Standardized Prevalence Rates for Diabetes, Status Indians and Other BC Residents, BC, 1992/1993 to 2003/2004* Figure 6.1In 2003/2004, the age-standardized diabetes 7prevalence rate was 5.6 per cent for males 6and 5.9 per cent for females in the Status Rate (per 100 population)Indian population. For other BC residents, the 5prevalence rate was 4.7 per cent for males 4and 3.8 per cent for females. The gap betweenStatus Indian females and other BC resident 3females is substantially larger than for males 2(Figure 6.1). 1 0 1992/93 1993/94 1994/95 1995/96 1996/97 1997/98 1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 Year Female Status Indians Female Other BC Residents Male Status Indians Male Other BC Residents *Cases for 2003/2004 are adjusted to compensate for incomplete follow-up (12 months) of MSP component of the incident case definition. Trends for all populations are statistically significant (p < 0.001). Source: Population Health Surveillance and Epidemiology, Ministry of Health, 2005. Age-Standardized Mortality Rates for All Cancers, Diabetes, and Circulatory System Diseases,* Status Indians and Other BC Residents, BC, 2002 Figure 6.2 35 The age-standardized mortality rates for Status Indians Other BC Residents 31.1 Rate (per 10,000 population) 30 cancer, diabetes, and circulatory system diseases for Status Indians is significantly 25 21.3 higher than the rates for other BC residents 20 18.6 16.6 (Figure 6.2). 15 10 5 2.6 1.4 0 All Cancers Diabetes Circulatory System Diseases * Circulatory system diseases include ischemic heart disease, cerebrovascular disease, and diseases of the arteries. Source: BC Vital Statistics Agency, 2004 98 Provincial Health Officer’s Annual Report 2005 • Food, Health and Well-Being in British Columbia
  • 119. Chapter 6: Food and the Aboriginal Population Figure 6.3 Potential Years of Life Lost (Age Under 75 Years) for All Cancers, Diabetes, and Circulatory System The Status Indian population also has Diseases,* Status Indians and Other BC Residents, BC, 2002 much higher potential of life years lost due 20 Status Indians Other BC Residents 18 to chronic diseases compared to other BC 18 15.9 residents (Figure 6.3). The potential of life 16 Rate (per 1,000 population) years lost are the number of years of life lost 14 13.3 when a person dies before a specified age 12 (in this case 75 years) (Figure 6.3). 10 8 7.5 6 4 2 2 0.7 0 All Cancers Diabetes Circulatory System Diseases * Circulatory system diseases include ischemic heart disease, cerebrovascular disease, and diseases of the arteries. Source: BC Vital Statistics Agency, 2004 Preventable Admissions to Hospital, BC, 2000/2001 Figure 6.4 16 Status Indians Other BC Residents Status Indians are three times as likely to 14 be admitted to hospitals for conditionsCases per 1,000 population (age-standardized) that could be managed in the community. 12 These conditions include: diabetes, asthma, hypertension, neurosis, depression, or 10 abuse of alcohol and other drugs (Figure 6.4). 8 6 4 2 0 Interior Fraser Vancouver Vancouver Northern BC Total Coastal Island Note: Acute care hospitalizations (cases) with a primary diagnosis of diabetes, alcohol and drug-related conditions, neurosis, depression, hypertension, or asthma. Source: Morbidity Database. Unpublished tables prepared by Information Support, BC Ministry of Health, project 2001-288.