Defeating Diabetes Targeting Diabetes through Healthy Eating and Public Health Education in Canada

Sonia Sidhu, Member of Parliament for Brampton South Chair, All Party Diabetes Caucus

Throughout the summer of 2017, Sonia Sidhu, Member of Parliament for Brampton South, engaged Canadians across the country to discuss the epidemic of diabetes, and how the Government of Canada should work to combat it. By engaging with ongoing studies (Canada’s Healthy Eating Strategy, M2K and revisions to Canada’s Food Guide) MP Sidhu, as chair of the All-Party Diabetes Caucus, looked to solutions and recommendations from Canadians to help the 11 million Canadians living with diabetes, and stem the surge of new diagnoses.

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Defeating Diabetes Table of Contents

   Acknowledgments: Executive Summary - 3 Many thanks to former Health Minister Jane Philpott for her leadership towards achieving greater health Dr. Karen Cross - 5 for all Canadians. I would also like to thank former Dr. Hertzel Gerstein - 5 Parliamentary Secretary Joël Lightbound for his support and encouragement in our work towards Canadian Beverage Association - 6 defeating diabetes. I look forward to working with the new Minister Ginette Petitpas-Taylor and Parliamentary Novo Nordisk - 6 Secretary Bill Blair to move forward on these important Regeneration Brampton – 7 issues. Toronto General Hospital - 7 Thank you to everyone who joined in these consultations and shared their views. Each person JDRF Alberta - 8 who participated is contributing to a better future for Canada, through active engagement in our Alberta Health Services-Diabetes, democracy on such an important issue. Obesity & Nutritional Strategic Clinical Network - 9 I would also like to thank Diabetes Canada for their support of the All Party Diabetes Caucus, and my Alberta Health Services – Nutrition caucus colleagues for their dedication to finding and Food Services – 9 solutions to diagnosis, treatment and eventually, a BC Dairy Association - 10 cure for diabetes. Community Consultations On behalf of the 11 million Canadians living with diabetes or prediabetes, thank you for taking the time Brampton/Peel- 12 to read this report. Ottawa - 13 ~ Sonia Montreal - 14

Winnipeg - 15

Vancouver - 16

Appendix A (Questions) - 17

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Executive Summary

As Chair of the All Party Diabetes Caucus, I wanted to take the opportunity this summer to speak to Canadians about a number of issues relating to diabetes, including healthy eating and healthy living. As Health Canada opened consultations on Canada’s Healthy Eating Strategy, revisions to Canada’s Food Guide, and on strategies to reduce marketing of unhealthy food to children (M2K), I chose to add to each of these consultations the lens of diabetes, which impacts 11 million Canadians today.

Throughout the consultation period, I met with numerous stakeholders and community groups who were eager to share their feedback. The main findings of these consultations were:

1. Canadians have access to sufficient nutrition information, however knowledge does not equate to behavioral change. In order to encourage healthier eating habits, we must incentivize environmental and behavioral change to encourage Canadians to act. Innovation is the key to finding new solutions to health challenges, and lessening the burden on the Canadian Health Care System. Public Health Agency of Canada’s multi sectoral approach involving all segments of society addresses complex social issues and prevention of chronic diseases such as diabetes. Funded projects such as Right to Play: Play for Diabetes help address the prevention needs of urban First Nations, Inuit and Métis populations by focusing on education, awareness and promotion of healthy living.

2. Despite the problems that come with diabetes alone, the complications of untreated diabetes cause significant health issues which are not being addressed in synchronization with diabetic care. In regards, mental health is a significant issue related to diabetes; however it is not usually connected with diabetes care.

3. Much of the information and imagery relating to diabetes comes across as patient blaming, causing internalization of negative feedback. We must find a way to inform Canadians about diabetes and the risks of unhealthy choices without placing blame on those who develop the disease.

4. Food insecurity continues to be a significant problem for Canadians, often resulting in unhealthy food choices as a matter of financial necessity and availability.

5. At risk communities need to participate in designing education and programming for themselves, and should include community leaders to set examples. Health information needs to be inclusive and accessible in order to be successful. Projects such as Lifestyle Prescriptions and Supports to Reduce the Risk of Diabetes in Rural and Remote Communities target overweight and obese children, youth and their families at risk for developing Type 2 diabetes in rural/remote Canadian communities.

6. Food labelling does not aid in making healthy choices, but rather complicates it. Nutrition labelling needs to be standardized and simplified to have an impact. Visual

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signals on food labels would make understanding a health ranking system simple. Amending the Food Guide to visually specify calories on the front is a suggestion that will help problems faced by consumers and their food choices.

7. Many participants spoke in favor of restricting marketing of unhealthy foods to young Canadians. Bill S-228 amends the Food and Drugs Act, prohibiting food and beverage marketing directed at children.

8. Overall, participants suggested that there is a clear need for a national and strategic plan to address the epidemic of diabetes in Canada.

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Dr. Karen Cross Throughout the consultation period, several physicians and researchers were engaged in one-on-one meetings, one of which was Dr. Karen Cross, a researcher at St. Michael’s Hospital.

Problem: Undiagnosed and untreated diabetes often leads to diabetic foot ulcers, requiring amputation.

Diabetic Foot Ulcers (DFU’s) occur in 1.9% of adults with diabetes annually, and the number of amputations is expected to increase to 630,000 by 2020. Expenses are high to remove ulcers and it is already costly for people that are diagnosed and living with diabetes as it is.

Solutions:

The solution Dr. Cross suggests is that optical devices combined with mHealth (Mobile Health) are to be used by diagnosed patients. This technology works with MIMOSA (Multispectral Mobile Tissue Assessment Device) which is attached on a mobile device of the patient, it records photographs using infrared light that determines the health of skin tissue and highlights any signs of DFU and helps prevent amputations with detecting early signs of tissue damage.

To further enhance the prevention and treatment of DFU’s, with the use of Coordinated Care Centres, different healthcare professionals and specialists can directly consult with one another and remotely monitor patient’s health using the MIMOSA technology. Remote motoring helps patients living in remote areas to send updates to their health care providers without the long trip to the centers. ______

Dr. Hertzel Gerstein, McMaster University Dr. Gerstein met with MP Sidhu to discuss his findings and the potential impact on the Canadian healthcare landscape.

Problem: Though diabetes is linked to genetic predisposition, Dr. Gerstein believes that environmental factors play a significant role in the onset and complications of diabetes.

He noted that 1 in 10 Canadians live with diabetes, he stated that there is a misconception among society that diabetes is usually caused by personal health faults, such as poor diet and insufficient exercise. On the contrary, Dr. Gerstein noted that genetics play a more significant role in determining which individuals will develop Type 2 diabetes.

Solutions:

Estimating the cost of diabetes on the Canadian health care system at $13-20 billion per year, Dr. Gerstein suggested action to promote nutritious eating and normalize physical activity should be priorities of the federal government. Dr. Gerstein suggested attention to the onset and complications of diabetes should be an important priority for Health Canada.

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Canadian Beverage Association MP Sidhu met with the Canadian Beverage Association to discuss industry-led solutions as well as problems faced by industry in attempts to reduce negative impacts of their products.

Problem: Industry suggests that proposed changes to food guide and market ing regulations harm industry and do not address caloric content sufficiently.

 Beverage calories have been falling, down 20% from 2004-2014 but obesity is on the rise.  4% of beverage calories are sugar sweetened  Balancing calories is an industry commitment to reduce sugar sweetened calories

Front of Pack Labelling

 Proposal only had sugar, fat, and salt requirements. However it is wise to show the calorie requirements as well  Imagery suggests warning would lead to diversion.

100% Juice

 Industry suggests 100% fruit juice should be retained on the food guide, because of nutrient properties

Solutions:

The Canadian Beverage Association suggests greater focus on caloric content in food labelling. While support of restrictions on marketing to young Canadians, industry suggests using fact based diversions rather than imagery. Taxation on drinks has no lowered impact; an example of this is Mexico, where obesity has increased after taxation on consumption of food.

______

Novo Nordisk As a global pharmaceutical company and the top producer of insulin, Novo Nordisk is well positioned to speak to issues relating to diabetes, including prevention and treatment.

Problem: Novo Nordisk believes insufficient public attention is paid to the disease.

 Believe early childhood education for diabetes would contribute to reducing the number of people impacted  Concern over health access and education for new Canadians negotiating the Canadian Health Care system for the first time

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Solutions:

 Projects/Research “Value in Healthcare Project” by the World Economic Forum (WEF) Currently in Phase 1 (outreach)  World Economic Forum (WEF) is looking to pilot this project in Ontario within the area of diabetes (Type II).  Want to move from “volume-based” to “value-based” health care. This is done by 1. Defining targeted outcomes that matter to patients 2. Understanding gold standards of health maintenance & healthcare mgmt. / delivery 3. Contributing to personalized medicine 4. Establishing new business models 5. Understanding key success factors to implement VBHC and drive change

Vision for project: “To contribute to a continuously improving value-based health care system in Canada that reduces the prevalence of diabetes and rate of complications in the Canadian population by 2021, while significantly improving quality of life and reducing the average cost per patient outcome (clinical, quality of life, socioeconomics)

______

Regeneration Brampton– Shelter and Meal Provider

Although Regeneration Outreach works hard to provide healthy meal choices to clients, representatives noted that they have difficulty overcoming assumptions about healthy food (i.e.: it doesn’t taste good). Education on healthy eating is the key piece missing from nutrition information, they said. Education should be hands on, and Regeneration is working hard to fill that gap. The organization runs a large community garden in Brampton, where vegetables for the kitchen are grown. Clients participate in the gardening, learning about different produce and learning how to grow food. Costs associated with diabetes treatment make it inaccessible, and therefore many people with housing insecurity, living in extreme poverty do not have access to the basic needs to treat their disease. This leads to additional mental health complications, further health problems, and greater costs to the health care system. ______

Toronto General Hospital Centre for Global eHealth Innovation – University Health Network

The Global Centre for eHealth Innovation is a research institute part of the University Health Network and one of the few institutes devoted to eHealth in the world, combining research and expertise to develop health technologies.

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Problem: “Given the global prevalence of both Type 1 and Type 2 diabetes, there is a need to provide self-management tools appropriate for patients of all ethnicities in diverse settings.” –eHealth Innovation

Solutions:

Innovation simplifies the management of diabetes and allows for the accommodation of different age groups and ethnicities with support in 11 different languages. A pilot study showed that adolescents with Type 1 Diabetes reported high satisfaction rates with the ability to monitor their diabetes with 87.5% reporting they would continue to use the system. A 49.6% increase in the daily average frequency of blood glucose measurements was also observed highlighting the potential of mobile health and the management of diabetes.

A further study published by researchers at eHealth Innovation, entitled “The Systematic Design of a Behavioral Mobile Health Application for the Self-Management of Type 2 Diabetes”, focused on the development of serious complications from diabetes due to problems faced by diabetes patients such as “limited self-management skills, the inability to adhere to care regimens, and psychosocial factors”.

1. Self-monitoring of blood glucose, physical activity, diet and weight; 2. Identification of glycemic patterns in relation to lifestyle; 3. Remedial decision making and 4. Positive behavior change through incentives.” ______JDRF Alberta and Northwest Territories Duane Schreiner, Regional Manager, Alberta & NWT

For over 40 years, JDRF has been a global leader in the search for an end to type 1 diabetes (T1D), through both research funding and advocacy. The organization actively promotes healthy and active lifestyles and has embarked on a program to serve athletes with type 1 diabetes.

Some current challenges include the stigma associated with both Type 1 and Type 2 Diabetes, a need for additional guidance for specific audiences, and a need for more clear guidelines for consumers.

JDRF has a number of recommendations:

1. Informing that there is commonness of both types in the population and that a diagnosis of diabetes is treatable

2. More guidance for more specific circumstances such as diabetes, celiac disease, etc.

3. Providing consistent, easily understandable, and readily available guidelines that are consistent both for home use and for outside the home.

4. Ensuring that the national strategy encourages healthy choices and improves the ease for people to make those choices.

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Alberta Health Services Diabetes, Obesity and Nutrition Strategic Clinical Network

There is high level guidance, like Eating Well with Canada’s Food Guide but almost no-one actually knows what the recommendations are.

People receive education generally after there is a problem, receiving delayed diagnoses. But even if people do receive education, it’s difficult in the current food environment for people to make the healthiest choices. Education about moderation in portions might help simplify the messaging. People have also asked for clear direction about foods to avoid.

We have to make healthy eating easier for consumers. This means we have to change the food environment so that consumers are not forced to read every food label before making a purchase. Even at home, consumers are eating more ready-to-eat meals e.g. restaurant take-out, ready-made dinners, etc.

Researchers at the Alberta Diabetes Institute conduct research available to the scientific community and some research is available to the general public on a variety of different topics such as nutrition, eating behavior, development of educational interventions, community-based initiatives

A diabetes prevention strategy can’t just be aimed at individuals. In order to change the food environment, there has to be a multi-pronged strategy that takes into account health care systems, food production, food processing, sustainability, education, public health strategies.

______Alberta Health Service - Nutrition & Food Services

Alberta Health Services (AHS) is Canada’s first and largest province wide, fully-integrated health system, responsible for delivering health services to the over four million people living in Alberta, as well as to some residents of Saskatchewan, B.C. and the Northwest Territories.

Problem: The general population may not be receiving enough guidance and education on healthy eating as it relates to preventing diabetes/ chronic disease. Identifying accurate evidence-based information can be challenging for Canadians.

Solutions:

1. Starting education programs and messages early in life.

2. Creating partnerships with NGOs and health services.

3. Creating policies that may considerably alter the conditions that influence consumption choices

4. Working with high risk populations when developing services, to address unique needs and barriers to treatment

5. Developing public awareness for reducing stigma and encouraging self-management

6. Developing a comprehensive national strategy, including policies and regulations that target the food

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Letter from BC Dairy Association

Thank you for the opportunity for BC Dairy Association to contribute to the All-Party-Diabetes Caucus. I hope our response provides additional insight into the prevention and treatment of prediabetes and diabetes.

1. Do Canadians receive enough guidance and education to make healthy eating choices? a. Yes and no. Canadians have access to a number of resources for healthy eating guidance. Of timely importance is Eating Well with Canada’s Food Guide (CFG), a resource used not only for the promotion of healthy eating in the general population, but also for management of chronic diseases like type 2 diabetes. Data from Health Canada’s own 2015 Evidence Review stressed that the majority of Canadians have low intake of fruits and vegetables, whole grains, and milk and alternatives.

2. What more could Health Canada do to encourage Canadians across the country to make healthy eating choices at home or in restaurants? a. More resources are needed to establish goals and track their progress towards making dietary improvements. It is important to develop resources that provide Canadians opportunities to self-assess their diet compared to current dietary guidelines. 3. What can be done to reduce the chances of high risk populations of developing diabetes? a. Self-assessment, goal creation, and goal tracking are key components that must accompany Canadian dietary guidelines. For individuals seeking dietary information from registered dietitians, British Columbia’s Health Link has a wonderful free of charge provincial phone service called 8-1-1. At the recent Society for Nutrition Education and Behavior Annual Conference, Dr. Lindsey Allen presented one group of particular concern were South Asian populations. A recent study conducted amongst Indian mothers and their offspring. Babies born B12 deficient to mothers suffering from pernicious anemia (low-B12 status), were unable to recover 100% of their cognitive functions after birth, even with supplementation.

4. Are there any considerations that Health Canada should take into account to address diabetes in Canada’s Healthy Eating Strategy? a. Refining messages to CFG should be included regarding specific nutrients and the impact on disease development. Of interest to this caucus, dairy foods have a unique preventative and protective effect as they relate to the development of prediabetes and diabetes. There is a real need to continue with the overall framework of healthy eating outlined in Canada’s Food Guide combined with opportunities for self-assessment and goal setting. 5. How can your organization promote healthy eating and healthy living (promoting an active lifestyle) in an effort to decrease the rate of diabetes across Canada? At BC Dairy Association we have a proven track record of providing nutrition education since the 1970’s. Our in-school nutrition education programs provide teachers with the tools and resources needed to deliver effective nutrition education to their students. Each program’s content links to BC’s school curriculum and is appropriate to the grade and skill level of students. The role of government, in the broadest context, is to develop the overall guidelines. It is the responsibility of provincial and local organizations to develop strategies for implementation. Part of the strength of our track record at BCDA has been the development of partnerships with government designed to promote healthy eating strategies. For example, the BC provincial government and BCDA developed both the Healthy Eating at Schools and Better Together platforms to support nutrition in schools and within the community. BCDA currently is responsible for running these programs and has the resources to ensure their continuation.

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At BCDA we are not just about in-school nutrition education. We also provide workshops and resources that focus on self-assessment strategies, goal creation, and goal tracking that can be used by the public. Our materials are a community service to individuals living in BC, and are most often utilized by health professionals and educators looking to make an impact in the lives of their patients or students. - Government and local organizations develop strategies together and then shift the day-to-day operations to the local level. - Developing more in-school nutrition education that also promotes 60 minutes of physical activity every day. - Look at the Partnership for a Healthier America (PHA) as a framework for institutions to develop policies and procedures for the sale and consumption of food and beverages. - One of the most important areas of healthy eating is establishing a routine for eating that includes having enough time in a pleasant environment for meals and snacks.

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Community Consultations

In addition to meeting with physicians, industry and community groups, MP Sonia Sidhu visited five communities and engaged two communities via teleconference. These meetings were open to community members, health care educators and professionals, and stakeholder groups with an interest in healthy eating, food guide revisions and ultimately, defeating diabetes.

Brampton: June 29, 2017 Participants were asked about the quantity and quality of information provided to Canadians on healthy eating. Is there enough? Is it sufficient?

 Participants stated that the nutrition fact table on food labels is unclear, and difficult for many Canadians – and new Canadians – to understand and put into practice  Many participants indicated that front-of-package labelling would be a better approach, but requires a clear display of nutritional value to properly inform consumers  Participants were supportive of plant-based suggestions on the food guide as a means of encouraging more wholesome food consumption  Support throughout the room was given for proposals to limit marketing of unhealthy foods to children  Participants noted that putting the onus on the individual to make these choices is insufficient, especially where food insecurity and lack of food literacy exist  Targeting public health education at young Canadians is an important way to raise a generation of healthier Canadians  The cost of less healthy options often makes these choices more attractive to individuals with lower economic access  Case study: Dufferin Catholic School Board runs a program to teach children nutritious cooking skills, which has shown an increase in healthy eating among students. Even more significant, this program has seen students teaching their parents about healthy and nutritious eating choices, and has influenced family meals.  There are many high-risk sub-populations in Canada with greater prevalence of diabetes, including the South Asian and Indigenous communities in Canada. Looking to resolutions for this, participants suggested that public health approach though advertising to promote healthy eating, and discourage unhealthy choices  Early detection of diabetes can prevent significant complications and comorbidities, reducing the strain on the health care system. In order to promote early detection and reduce stigma associated with diabetes, participants suggested:  Removing any messaging that blames patients for their diabetes, in order to reduce the stigma of diagnoses. Recommendations for food guide revisions included:

 Use of plain language that people will understand, with cultural language incorporated for better understanding  Incorporate electronic media (YouTube) for greater reach of dietary advice  Incorporate more pictures than words for visually-based learners

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Finally, Participants suggested that there should be more interconnectivity between organizations to combat diabetes and promote nutritional health choices this (such as doctors coming together with educators who come together with etc. etc.)Regular communication would create a living strategy with multifaceted approaches to healthy eating/defeating diabetes.

______Ottawa: July 25, 2017 A small meeting was held in Ottawa with healthcare professionals from The Ottawa Hospital, and representatives of Diabetes Canada. This meeting provided important insight into the role and struggles of dieticians and endocrinologists as they work to defeat diabetes.

While Ottawa has a highly educated population and good access to health care, the participants noted that many aren’t being screened for diabetes. When patients are admitted into the hospital, more than 30% of those admitted already have diabetes, but may not know about it. Early diagnosis could lead to fewer complications and fewer people requiring hospital admittance

There was a significant emphasis in this meeting on the note that information will not create behavioural change, and that the environment in which we purchase food, cook and consume food must change. Labeling foods as good and bad can translate these qualities to the individual, and has been seen to be detrimental to changing behaviours.

Regarding high-risk communities, participants said they want to see culturally-sensitive and inclusive plans to inform and educate on healthy/wholesome eating. This must include community and faith leaders, and should come from members of each community rather than being dictated from above

Specific to diabetes, there was much discussion over the imagery and messaging that is delivered to the public about this disease. Alternatives were suggested, such as:

1. A public health campaign about the cause and complications of diabetes 2. Include resources for easy and fast home-cooked meals to deter from highly processed take-out food. 3. Messaging from the federal level which puts ownership of healthy changes in the hands of the individual Diabetes and mental health are complexly related, participants said, because roughly 30% of people with diabetes experience depression. When patients are treated for mental health the treatment often results in weight gain, which has significant health complicating factors.

Diabetes Canada representatives spoke in support of a tax implemented on sugar-sweetened beverages, suggesting it would reduce consumption immediately and long term. However, conflicting information was provided with reference to low-income families, and the affordability gap between sugar-sweetened beverages and healthy beverages.

Regarding the Food Guide, participants said that the guide as it is today does not make common sense, and requires work to be simplified. Participants suggested that we should not be concerned with calories and/or fats but should be promoting wholesome and nutritious foods.

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Technology provides many options and solutions to integrate healthy living. Participants suggested that the government could help promote digital applications that encourage healthy choices and encourage youth to be active.

Participants suggested that the federal government could influence industry to make healthier foods more affordable, and more accessible to all Canadians, while combatting food insecurity.

______Montreal, July 26 Quebec presents the second lowest rate of obesity in Canada. When asked about this, participants suggest that a unique Quebec lifestyle could be a significant factor, emphasizing cycling as a primary means of transportation, and a diet that contains fewer carbohydrates.

With regard to high risk populations, participants suggested that the information on healthy eating is available, but is neither used nor implemented sufficiently. Affordability of food was again noted as a factor, noting that processed foods are more affordable than healthy foods, and even with information suggesting healthier options, cost is a barrier to making dietary changes.

Food labelling was noted as a problem. Labels aren’t effective, and they are often too small to read, have ingredient lists that are too hard to decipher resulting in labels being hard for people to read and understand. People need help understanding ingredient lists, such as which preservatives are okay and which ones are not.

Many suggestions were made for financial incentives to healthy eating, which would lower the impact on the healthcare system through preventative health. Additionally, participants noted that the removal of the children’s activity tax credit reduces accessibility to physical activity for Canadians, especially those in lower income families.

Regarding the Food Guide, participants said it is not effective, especially for immigrant populations. Many suggested community-based learning should be encouraged, with community and faith leaders setting examples of health eating and healthy living. An example of community programming is school gardening led by Québec en forme. However, without core funding (currently funded by the province), this program will soon end.

Private sector has a role to play, participants said, in keeping Canadians healthy. An example of this is corporate healthy policies, where companies provide healthy snacks on specific days, and provide gym memberships as an employment benefit.

To prevent the stigma of diabetes diagnoses and promote early detections, participants suggested that support groups are needed to inform patients of how to manage diabetes. Public information campaigns were suggested as a way to ensure Canadians are familiar with the symptoms associated with diabetes. There are lessons to be learned from other groups, such as those focusing on breast cancer, on how they tackled stigma around the topic.

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Winnipeg, July 27 In Winnipeg, participants said clearly that food insecurity is a major barrier to healthy eating. While people know what food they should be consuming, many cannot access it due to high costs, especially in northern regions of the province. Even with sufficient information on healthy eating and healthy living, many people do not have time to cook at home, or the knowledge of what to cook. What is missing is guidance and access to guidance – especially for vulnerable population groups.

A significant focus of the Winnipeg meeting was on Indigenous People, as they are one of the highest risk populations for development of diabetes. While food insecurity is a known problem here, there are also factors that encourage consumption of unhealthy food items.

Additionally, health care practitioners in First Nations communities are often related to the patients, making stigma more significant and causing late diagnosis with interrelated health problems. Mental health is a significant corresponding health issue in First Nations communities.

In some regions, where diabetes is prevalent, it is important to promote early detection and treatment to prevent onset and reduce health impacts of diabetes.

New Canadians are an emerging group with diabetes, we need to target them and make learning accessible to them and focus on damaging impacts of unhealthy lifestyles.

Participants spoke about the language we use to discuss nutrition. The dichotomy of healthy and unhealthy eating is damaging to people who struggle with disordered eating. Often, people develop an off and on the wagon mentality, which is not helpful to maintaining positive overall health.

Mental health was also discussed. Participants suggested that prior to treatment with medication; physicians need to look at other factors that contribute to mental health. Current diabetes treatment does not look at psychological transition after diagnosis, as such; mental health needs to be added to current treatment options.

Additionally, participants suggested that the stigma around diabetes is stigma around body size and shape. Obesity and diabetes are not interrelated. Most people with diabetes embody blame and shame.

While early detection would be beneficial, variances in access to health care services means there is often no primary care access, and even where screening is provided, there is no follow up.

With regard to the food guide, participants said they are happy with the proposed changes, and are hopeful that lobbying will be kept out of the final product to ensure proper nutritional information is provided.

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Vancouver, July 28 While Canadians have sufficient information about healthy eating, there is not enough guidance on this topic. There needs to be shift from a focus on weight to healthy eating. However, information by itself is not enough. Most people can tell you what is healthy, but a gap exists in what people know and what they do. This is largely due to the influence of environment and socioeconomic status.

This group suggested that for meaningful change to happen, grocery stores and food manufacturers must be part of the process. Moreover, people are losing the skills to cook; not due to lack of skill, but rather food security and the ability to have time or afford to make quality food being tied to income.

At risk populations aren’t receiving enough guidance either. South Asian populations, for example, need to be targeted at their own level. When immigrants transition from their original countries to Canada they are likely to pick up unhealthy lifestyle habits. Moreover, there is a problem with misinformation and information contradictory to leading a healthy lifestyle. There are many initiatives that are already struggling against misinformation that is leading to slow uptake with their programs or from being effective as they can be. Overall, participants suggested that Canadians need to be reached with fact based information and they need a central place to get this information – right now the Health Canada website isn’t user friendly and people aren’t using it. This needs to change to the point where Health Canada is the go- to place.

When asked how Government could encourage healthy eating at home or in restaurants, participants noted that we need to inform people on healthy dining. Some suggested looking to the US model, which identifies natural vs. added sugars, or the UK has a traffic light system to identify good and poor choices. One such focus within Canada could be to encourage less eating of meats in restaurants.

Putting the responsibility on the consumer doesn’t factor income inequalities. Moreover, we need to properly define what “healthy food” and “healthy eating” is. This, and educating the general population and youth is what is important toward the goal of encouraging healthy eating choices. Employers can play a role too in incentivizing healthy eating; Health Canada should work with them.

Food itself shouldn’t be stigmatized in the path forward to creating a new guide, as the impact on mental health is great.

Early diagnoses would be a significant help to people who are unaware of the symptoms they present. However, as testing has a financial cost, many do not undergo testing and remain undiagnosed.

Looking to a national strategy on diabetes, participants suggested that medical cost coverage needs to be standardized across the country. Participants suggested that a cost analysis should be with a system that has coverage for pumps, strips, and lancets, and a system without. Right now, it is important to provide early diagnoses and treatment to all patients, make it easier for them to access these facilities and support their financial and socioeconomic needs for treatment and other factors such as mental health.

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Appendix A Questions for roundtable participants

 Do Canadians receive enough guidance and education to make healthy eating choices?

 What more could Health Canada do to encourage Canadians across the country to make healthy eating choices at home or in restaurants?

 What can be done to reduce the chances of high risk populations (South Asian and Indigenous) of developing diabetes?

 Sometimes, diabetes goes undiagnosed due to stigma. How can we work together to erase the stigma and promote early detection, while creating awareness about the risks of unhealthy eating?

 Are there any considerations that Health Canada should take into account to address diabetes in Canada’s Healthy Eating Strategy?

 How can your organization promote healthy eating and healthy living (promoting an active lifestyle) in an effort to decrease the rate of diabetes across Canada?

 In your view, what would a national strategy for diabetes prevention look like?

 How could Canada’s Food Guide be revised to support the variety of diets across Canada for all age groups, while encouraging healthy eating choices?

 How should the connection between diabetes and mental health be addressed?

 How should the connection between diabetes and retinopathy be addressed?

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Sonia Sidhu: Defeating Diabetes