Ontario’s Action Plan for Healthcare:
Childhood Obesity Strategy
Recommendations by the Canadian Diabetes Association
to the Healthy Kids Panel of Ontario
September 30, 2012
Introduction
The Canadian Diabetes Association is pleased to respond to the invitation of the Healthy
Kids Panel to offer the following recommendations to reduce obesity and chronic illness
in Ontario. We thank the panel for this important opportunity.
The Canadian Diabetes Association is a leading authority on diabetes in Canada and
around the world. It has a heritage of excellence and leadership, and its co-founder, Dr.
Charles Best, along with Dr. Frederick Banting, is credited with the co-discovery of
insulin. Across the country, the Association leads the fight against diabetes by helping
people with diabetes live healthy lives while it works to find a cure. The Association is
supported in its efforts by a community-based network of volunteers, employees, health
care professionals, researchers, and partners. By providing education and services,
advocating on behalf of people with diabetes, supporting research, and translating
research into practical applications, the Association is delivering on its mission.
Diabetes in Ontario
In 2010, the Ontario Diabetes Cost Model estimated that 1,169,000 people in Ontario
were diagnosed with either type 1 or type 2 diabetes – representing approximately 8.3%
of the population. This number is expected to increase by 63% (734,000) over the next
decade — the second highest increase in prevalence across provinces — to 1,903,000 or
11.9% of the population unless immediate action is taken to address this coming
tsunami.1 The prevalence of diabetes in Ontario was higher than the national average of
7.6% in 2010, and is forecasted to be higher than the national average of 10.8% for 2020
as well.2
The increasing rate of diabetes and its complications is also a burden on our healthcare
system and our economy. In 2010 the economic burden of diabetes in Ontario was
estimated to be $4.9 billion (measured in 2009 dollars). By 2020, this cost will increase
by 42% — the second highest increase in cost across provinces — to over $6.9 billion in
direct healthcare costs (hospitalization, general practitioners, specialists and
medications), and indirect costs such as lost productivity due to disability and
premature death.3
In addition, over 2 million Ontarians live with prediabetes, a condition characterized by
blood glucose levels that are higher than normal, but not yet high enough to be
diagnosed as type 2 diabetes (i.e. a fasting plasma glucose level of 7.0 mmol/L or
higher). About 50% of those with prediabetes will develop type 2 diabetes. Research has
shown that some long term complications associated with diabetes (e.g., heart disease
and nerve damage) may begin during prediabetes.4
Unhealthy Weights in Children and Chronic Disease
According to Statistics Canada, 61% of Canadian adults are overweight or obese.5 Among
5 to 17-year-olds (approximately 1.6 million children), 31.5% are overweight (19.8%) or
obese (11.7%) in 2009 to 2011. The percentage that was overweight was similar across
1
age groups. However, important differences exist in the prevalence of obesity between
boys and girls (15.1% versus 8.0%), most notably at ages 5 to 11, among whom the
percentage of boys who were obese (19.5%) was more than three times the percentage of
girls who were obese (6.3%). The prevalence of unhealthy weights has risen among
children and adolescents in Canada over the past 35 years.6
The link between unhealthy weights and type 2 diabetes is clear. According to the
Canadian Diabetes Association’s 2008 Clinical Practice Guidelines, an estimated 8090% of people with type 2 diabetes are overweight or obese, and this condition is a
major modifiable risk factor for the development of type 2 diabetes.7 Given that almost
two-thirds of Canadian adults and almost one-third of Canadian children and youth are
currently overweight or obese, if these rates remain constant, diabetes rates will
continue to climb for the foreseeable future.8 As the Association’s CPGs point out, “Type
2 diabetes in children has increased in frequency in North America over the past 2
decades. . . Limited Canadian prevalence data are available. . . .Data from the United
States suggest a 10- to 30-fold increase in the number of children with type 2 diabetes
over the past 10 to 15 years.”9
The Association’s CPGs, Statistics Canada, the Ontario Action Plan for Health Care, the
House of Commons Standing Committee on Health, and others have both noted the link
between unhealthy weights in children and serious chronic diseases such as type 2
diabetes (previously considered to be an adult-onset condition) as well as hypertension,
poor emotional health and diminished social well-being, heart disease, gallbladder
disease, stroke, joint problems, and certain types of cancer including breast and colon
cancer.10,11,12,13
The rising rate of obesity in Ontario is a significant risk factor for the development of
type 2 diabetes in both adults and children. As the Ontario Action Plan for Health Care,
Statistics Canada and others have pointed out, the majority of children with excess
weight become adults with unhealthy weights.14 In fact, the health implications of excess
weight for children are so serious that the Standing Committee on Health has stated that
“The Committee shares the fears of many experts who predict that today’s children will
be the first generation for some time to have poorer health outcomes and a shorter life
expectancy than their parents.”15
Maintaining a healthy weight is not only essential to prevent type 2 diabetes, it is key to
prevent those living with prediabetes from developing diabetes, and also delaying or
avoiding altogether the secondary complications of diabetes. For the more than 1.2
million Ontarians living with diabetes and prediabetes, maintaining a healthy weight is
one of the most important elements in managing their disease.
Recommendations
Solutions are available to achieve healthy weights and lessen the burden of diabetes,
including healthy eating and increased physical activity. In fact it is estimated that:
 over 50% of type 2 diabetes could be prevented or delayed with healthier eating and
increased physical activity; and
2
 Weight loss of 5 -10% has been shown to significantly reduce the risk of diabetes. In
turn, a modest reduction in diabetes prevalence would have a significant financial
impact. A 2% reduction in prevalence would lead to a 9% reduction in direct
healthcare costs.16
To achieve these outcomes for adults and children in Ontario, the Canadian Diabetes
Association recommends the following:
1. Refocus the Ontario Diabetes Strategy to include a broad-based healthy
weights strategy.
As noted above, maintaining a healthy weight is key to both preventing both diabetes
and diabetes-related complications. An Ontario healthy weights strategy would increase
the percentage of Ontarians maintaining a healthy weight and focus on five main goals:
 Identifying and understanding the underlying societal causes of unhealthy weights.
As noted by Statistics Canada, “the factors associated with overweight and obesity
are complex,7 and include health behaviours, such as eating habits and daily physical
activity, and broader social, environmental and biological determinants that
influence these health behaviours.”17 For example, the contribution of unhealthy
eating to obesity is well known. The consumption of sugar-sweetened beverages has
been associated with the development of childhood obesity and may be responsible
for as much as one pound per month weight gain in adolescents.18 Other factors
influencing the development of obesity include low socioeconomic status19, even
among children.20 Some research has noted the link between food insecurity and
obesity.20 Given that approximately 30% of Ontarians live with food insecurity21 and
that food insecurity almost doubles the risk of diabetes21, strategies to improve the
availability and affordability of healthy foods will have an important impact on
diabetes prevention. The built environment has also been identified as an important
modifiable risk factor for obesity and diabetes. 22 Accordingly, policies to enhance
the walkability of neighbourhoods, increase access to public transit and improve
local access to recreational activities should also lead to reduced levels of obesity and
diabetes
 Setting targets to increase the number of Ontarians achieving healthy weights,
specifically within high-risk populations. The Canadian Diabetes Association
applauds the Ontario Action Plan for Health Care goal to reduce childhood obesity
by 20% over 5 years. To achieve maximum benefits for all Ontarians, the Canadian
Diabetes Association recommends that the Ontario Action Plan for Health Care
expand the Childhood Obesity Strategy to include overweight children as well.
Expansion of the Strategy is critical to prevent ongoing increases in the incidence of
diabetes as these children age. The Institute of Clinical Evaluative Sciences has
observed, while obese persons have the highest individual risk of diabetes (27.4%),
the largest number of new cases of diabetes will come from the much larger
population of people who are overweight but not obese. This finding reinforces the
need for population based approaches rather than clinical approaches directed to
those who are obese.23
 Improving access to programs and services for high-risk populations. While data
are limited for Canada concerning the prevalence of type 2 diabetes in children
3


within populations at higher risk for diabetes, most of the children who have
incurred type 2 diabetes in North America in the past two decades have been from
populations at higher risk for diabetes, e.g., Aboriginal, African, Hispanic or Asian
descent.24 Given this, it is crucial that special efforts are made to provide enhanced
programs and services to children from these populations to maintain a healthy
weight and decrease their risk of incurring type 2 diabetes.
Initiating a public education campaign across all sectors of society.
Incorporating a multisectoral approach involving governments, non-governmental
organizations, the private sector and all Ontarians as individuals.
These components will mean a significant shift in government approach, private sector
involvement and most of all, a widespread personal and societal change.
2. Examine and consider available regulatory options to promote healthy
eating.
Such measures may include, but not be limited to:
 Ensuring availability of affordable, nutritious foods for Ontario’s north. The federal
government recently ended its food mail program that subsidized the cost of mailing
food to northern communities. Instead, the subsidy will be given directly to food
retailers. The Canadian Diabetes Association is concerned that some retailers may
not include the full subsidy in pricing. If so, nutritious food will be more expensive in
the north, and people with diabetes who can’t afford healthy foods will be at risk of
not being able to affordable these foods, which are essential to good selfmanagement of their disease.
 Enhanced nutrient labeling for food products, building on the achievements of food
labeling introduced to Canada in 2005.
 Calorie labeling for menus in large chain restaurants as the governments of New
York City, California and numerous other U.S. states and municipalities have already
done.
 Taxation of calorie dense foods with little nutrient value.
 Legislative measures concerning broader social policy environment. For example, BC
and QC are the only jurisdictions with overweight/obesity rates lower than the
national average and QC has the lowest rate of obesity for ages six to 11 in Canada. 25
One factor in curbing childhood obesity in QC may be its Consumer Protection Act
(1980), which bans all commercial advertising directed at children, including
unhealthy foods.
3. Establish social policies and programs to improve access and availability
of healthier food options.
The Canadian Diabetes Association believes that all Canadians should have access to
affordable, sufficient, safe and nutritious food. For people living in remote or northern
communities, or those with below average income, the affordability of healthy food
choices should not be a barrier.
4
As noted above, food security is a key social determinant of health and is a public health
issue that affects many Canadians living with or at risk of developing diabetes. Diabetes
can often be prevented or well-managed with proper nutrition. Individuals living with
food insecurity often consume low-cost foods which may be calorically dense and
nutritionally inadequate. To support people in choosing healthy food, it must be
affordable and readily available in the local community. It is equally important that
people are educated about healthy eating, including meal planning, food budgeting, and
food preparation.
The Ontario government should develop and implement social policies and programs,
including educational programs, to ensure all Canadians have food security.26
Conclusion
Working together, we can make a difference. We can enhance and save lives and at the
same time improve our economic health and the future prosperity of Ontario. Once
again, thank you for the opportunity to provide the Canadian Diabetes Association’s
recommendations and we look forward to discussing these recommendations with the
Panel.
Endnotes
1
Canadian Diabetes Association (2010). The Cost of Diabetes in Ontario. Ottawa, ON: Canadian
Diabetes Association. Available at: http://www.diabetes.ca/documents/get-involved/ON-CostModel.pdf.
2
Canadian Diabetes Association (2011). Diabetes: Canada at the Tipping Point – Charting a New Path.
Ottawa, ON: Canadian Diabetes Association. Available at: http://www.diabetes.ca/advocacy/reportsand-information/diabetes-canada-at-the-tipping-point/
3
Canadian Diabetes Association (2010). The Cost of Diabetes in Ontario. Ottawa, ON: Canadian
Diabetes Association. Available at: http://www.diabetes.ca/documents/get-involved/ON-CostModel.pdf
4
Canadian Diabetes Association (2009). An Economic Tsunami: the cost of diabetes in Canada.
Ottawa, ON: Canadian Diabetes Association Available at: http://www.diabetes.ca/documents/getinvolved/FINAL_Economic_Report.pdf.
5
Statistics Canada (2010). “Canadian Health Measures Survey, 2007 to 2009” The Daily. Available at:
http://www.statcan.gc.ca/daily-quotidien/100113/dq100113a-eng.htm
6
Statistics Canada (2012). “Overweight and obesity in children and adolescents: Results from the
2009 to 2011 Canadian Health Measures Survey,” Health Reports. Available at:
http://www.statcan.gc.ca/pub/82-003-x/2012003/article/11706-eng.htm.
7
Canadian Diabetes Association (2008). “Canadian Diabetes Association 2008 Clinical Practice
Guidelines for the Prevention and Management of Diabetes in Canada” Canadian Journal of Diabetes,
September 2008, Supplement 1. Available at: http://www.diabetes.ca/files/cpg2008/cpg-2008.pdf.
8
Canadian Diabetes Association (2011). Diabetes: Canada at the Tipping Point – Charting a New Path.
Ottawa, ON: Canadian Diabetes Association. Available at: http://www.diabetes.ca/advocacy/reportsand-information/diabetes-canada-at-the-tipping-point/
9
Canadian Diabetes Association (2008). “Canadian Diabetes Association 2008 Clinical Practice
Guidelines for the Prevention and Management of Diabetes in Canada” Canadian Journal of Diabetes,
September 2008, Supplement 1. Available at: http://www.diabetes.ca/files/cpg2008/cpg-2008.pdf.
5
10
Canadian Diabetes Association (2008). “Canadian Diabetes Association 2008 Clinical Practice
Guidelines for the Prevention and Management of Diabetes in Canada” Canadian Journal of Diabetes,
September 2008, Supplement 1. Available at: http://www.diabetes.ca/files/cpg2008/cpg-2008.pdf.
11
Statistics Canada (2012). “Overweight and obesity in children and adolescents: Results from the
2009 to 2011 Canadian Health Measures Survey,” Health Reports. Available at:
http://www.statcan.gc.ca/pub/82-003-x/2012003/article/11706-eng.htm.
12
Ministry of Health and Long-Term Care (May, 2012). Healthy Kids Panel To Help Reduce Childhood
Obesity. “McGuinty Government Keeping Ontario Kids Healthy,”. Available at:
http://news.ontario.ca/mohltc/en/2012/05/healthy-kids-panel-to-help-reduce-childhood-obesity.html.
13
House of Commons Standing Committee on Health (2007). Healthy Weights for Healthy Kids.
Report of the Standing Committee on Health. Available at:
http://www.parl.gc.ca/content/hoc/Committee/391/HESA/Reports/RP2795145/hesarp07/hesarp07e.pdf.
14
Ministry of Health and Long-Term Care (May, 2012). Healthy Kids Panel To Help Reduce Childhood
Obesity. “McGuinty Government Keeping Ontario Kids Healthy.” Available at:
http://news.ontario.ca/mohltc/en/2012/05/healthy-kids-panel-to-help-reduce-childhood-obesity.html
15
House of Commons Standing Committee on Health (2007). Healthy Weights for Healthy Kids.
Report of the Standing Committee on Health. Available at:
http://www.parl.gc.ca/content/hoc/Committee/391/HESA/Reports/RP2795145/hesarp07/hesarp07e.pdf.
16
Canadian Diabetes Association (2009). An Economic Tsunami: the cost of diabetes in Canada.
Ottawa, ON: Canadian Diabetes Association Available at: http://www.diabetes.ca/documents/getinvolved/FINAL_Economic_Report.pdf.
17
Statistics Canada (2012). “Overweight and obesity in children and adolescents: Results from the
2009 to 2011 Canadian Health Measures Survey,” Health Reports. Available at:
http://www.statcan.gc.ca/pub/82-003-x/2012003/article/11706-eng.htm.
18
House of Commons Standing Committee on Health (2007). Healthy Weights for Healthy Kids.
Report of the Standing Committee on Health. Available at:
http://www.parl.gc.ca/content/hoc/Committee/391/HESA/Reports/RP2795145/hesarp07/hesarp07e.pdf.
19
Canadian Institute for Health Information (2003). Obesity in Canada: Identifying Policy Priorities.
Available at: http://secure.cihi.ca/cihiweb/products/CPHI_proceed_e.pdf.
20
Statistics Canada (2005). Study: Socio-economic status and obesity in children. Available at:
http://www.statcan.gc.ca/daily-quotidien/051104/dq051104b-eng.htm.
21
Canadian Council on Social Development. Stats and Facts: Demographics of the Canadian
Population, 2004. Available at: http://www.ccsd.ca/factsheets/demographics/
V. Tarasuk and J. Vogt. “Household food insecurity in Ontario,” Canadian Journal of Public Health.
2009 May-Jun;100(3). Available at: http://journal.cpha.ca/index.php/cjph/article/view/1787/1971.
22
Booth, G., Creatore, M., Moineddin, R., Gozdyra, P., Weyman, J., Matheson, F., Glazier, R.(2012)
Unwalkable Neighborhoods, Poverty, and the Risk of Diabetes Among Recent Immigrants to Canada
Compared With Long-Term Residents. Diabetes Care Sep 17, 2012.
23
Institute for Clinical Evaluative Science (2010). How Many Canadians Will Be Diagnosed with
Diabetes Between 2007 and 2017? Available at:
http://www.ices.on.ca/file/Diabetes%20Risks%20June%2016%202010.pdf
24
Canadian Diabetes Association (2008). “Canadian Diabetes Association 2008 Clinical Practice
Guidelines for the Prevention and Management of Diabetes in Canada” Canadian Journal of Diabetes,
September 2008, Supplement 1. Available at: http://www.diabetes.ca/files/cpg2008/cpg-2008.pdf.
25
Shields, M. (2004). Canadian Community Health Survey. Statistics Canada Available at:
http://www.statcan.gc.ca/pub/82-620-m/2005001/article/child-enfant/8061-eng.htm
26
Canadian Diabetes Association. Food Security Position Statement (no date). Available at:
http://www.diabetes.ca/files/about-us/FoodSecurity.pdf.
6