Report to/Rapport au : Ottawa Board of Health Conseil de santé d’Ottawa Monday 7, May, 2012/le lundi 7 mai 2012 Submitted by/Soumis par : Dr./Dr Isra Levy, Medical Officer of Health/Médecin chef en santé publique   Contact Person/Personne-ressource : Sherry Nigro, Manager/Gestionnaire Health Promotion and Disease Prevention/Promotion de la santé et prévention des maladies Ottawa Public Health/Santé publique Ottawa 613-580-2424, ext./poste 28971, Sherry Nigro@ottawa.ca City Wide / À l’échelle de la ville ACS2012-OPH-HPDP -0003 SUBJECT: HEALTHY EATING, ACTIVE LIVING STRATEGY OBJET : STRATÉGIE SAINE ALIMENTATION ET VIE ACTIVE REPORT RECOMMENDATIONS That the Board of Health for the City of Ottawa Health Unit approve: 1. The three-year Healthy Eating, Active Living Strategy (HEAL), as outlined in this report. 2. That the Chair of the Board of Health write a letter to the Ontario Minister of Health and Long-Term Care recommending that the Ministry include in their upcoming Childhood Obesity Strategy a substantial investment in diverse physical activity opportunities in schools and other organizations to help youth to meet the physical activity minimum requirements. 3. That the Chair of the Board of Health write a letter to the Ontario Minister of Education recommending: a. That the Ministry provide direction and funding to school boards for monitoring and reporting as it relates to the Daily Physical Activity Policy (PPM 138) in elementary schools. b. That the Ministry provide direction and funding to school boards for monitoring and reporting as it relates to the Ontario School Food and Beverage Policy (PPM 150).  4. That the Chair of the Board of Health write a letter to the federal Minister of Health and Ontario Minister of Health and Long-Term Care recommending the development and promotion of menu labelling policies for franchises of 10 or more or at least $10 million in revenue. 5. That staff report back to the Board of Health in Q4 of 2013 on the progress to date. RECOMMANDATIONS DU RAPPORT Que le Conseil de santé de la circonscription sanitaire de la Ville d'Ottawa approuve: 1. La stratégie triennale Saine alimentation et vie active décrite dans ce rapport. 2. Que la présidente du Conseil de santé fasse parvenir une lettre au ministre de la Santé et des Soins de longue durée de l’Ontario recommandant au ministère d’inclure, dans sa stratégie à venir sur l’obésité infantile, un investissement considérable en vue de la mise en œuvre de diverses possibilités d’activité physique dans les écoles et au sein de divers organismes afin d’aider les jeunes à respecter les exigences minimales en matière d’activité physique.   3. Que la présidente du Conseil de santé écrive au ministre de l'Éducation de l'Ontario et lui soumette les recommandations suivantes : a. Que le ministère donne des directives et du financement aux conseils scolaires au chapitre du contrôle et des rapports à soumettre entourant la Politique sur l'activité physique quotidienne (PPM, 138) dans les écoles primaires. b. Que le ministère donne des directives et du financement aux conseils scolaire au chapitre du contrôle et des rapports à soumettre entourant la Politique sur les aliments et les boissons dans les écoles de l'Ontario (PPM, 150).    4. Que la présidente du Conseil de santé écrive au ministre fédéral de la Santé et au ministre de la Santé et des Soins de longue durée de l’Ontario recommandant la création et la promotion de politiques d'étiquetage des menus couvrant les entreprises de dix franchises ou plus ou dont les recettes atteignent au moins 10 millions de dollars. 5. Que le personnel soumette un rapport au Conseil de santé au quatrième trimestre 2013 sur les progrès réalisés à ce jour. EXECUTIVE SUMMARY The issue of overweight and obesity continues to be a growing health concern in Canada as well as other developed countries. In Ottawa, over 20% of youth and more than half (52%) of adults are either overweight or obese. A web of complex influencers including biological, behavioural, social, psychological, technological, environmental and economic factors are well documented in the literature and severely compound the challenge of addressing this health issue. Unhealthy eating, physical inactivity and social, physical and built environments are contributing factors to current rates of overweight and obesity. There is a need to change daily habits, social norms and physical and social environments. Trends in unhealthy eating include inadequate intake of vegetables and fruit, increased reliance on fast and processed foods and increased consumption of energy dense, nutrient poor foods such as sugar sweetened beverages. Approximately 80% of school age students report drinking at least one sugar sweetened beverage in the week prior to being surveyed. Trends in physical inactivity include inadequate amounts of daily physical activity and over-reliance on vehicular modes of transportation. Only 10% of residents (? 15 years) reported that their primary mode of transportation to and from work was walking or cycling. At the same time, societal preoccupation with weight, as opposed to healthy behaviours, as well as myths related to energy balance, may contribute to the fact that 65% of Ottawa students reported that they were trying to affect their weight either by avoiding weight gain, trying to lose weight or trying to gain weight. In recent years, Ottawa Public Health (OPH) has focused increased attention on working with partners in the health sector, the education sector and social service providers to promote healthy eating and physical activity in settings such as schools, workplaces and community houses, to raise awareness and build skills to change behaviours related to healthy eating and active living. There are also a number of partners and local champions working in the community to address these issues. OPH recognizes that for this work to effect sustained change it must be integrated with our existing partners as well as engaging non-traditional partners such as the food industry, municipal planners and developers. In order to begin addressing issues related to unhealthy eating, physical inactivity and social and physical environments, OPH has refocused efforts for 2012 – 2014 under the Healthy Eating Active Living (HEAL) strategy. The HEAL builds on lessons learned from local public health practice, emerging epidemiological reports, environmental scans, a review of best practice literature and consultation with key municipal and community partners. The three main objectives of the HEAL strategy are: 1. To decrease consumption of energy dense, nutrient poor foods and beverages; 2. To increase physical activity through walking and active transportation; 3. To engage the ‘whole-of-community’ to change social and physical environments. In order to meet these objectives, the HEAL strategy takes a multipronged approach that provides knowledge and skill building opportunities to individuals, creates supportive environments and advocates for changes to public policies that impact healthy eating and active living. Through the adoption of its HEAL Strategy, OPH acknowledges the importance of the individual and social determinants of health in helping its residents eat healthy, be active and maintain a healthy body image. RÉSUMÉ Le problème de l’embonpoint et de l’obésité demeure une préoccupation croissante en matière de santé au Canada ainsi que dans d’autres pays développés. À Ottawa, plus de 20 % des jeunes et plus de la moitié (52 %) des adultes font de l’embonpoint ou sont obèses. Une foule d’éléments entrent en compte, notamment des facteurs biologiques, comportementaux, sociaux, psychologiques, technologiques, environnementaux et économiques. Tous sont d’ailleurs abordés abondamment dans la documentation disponible. Leur effet conjugué aggrave le défi que représente la résolution de ce problème de santé. De mauvaises habitudes alimentaires, la sédentarité ainsi que les milieux sociaux, naturels et l’environnement bâti sont d’autres facteurs contribuant aux taux actuels d’embonpoint et d’obésité. Il faut changer les habitudes quotidiennes, les normes sociales et les milieux naturels et sociaux. Par mauvaises habitudes alimentaires, aujourd’hui, on pense à une consommation insuffisante de légumes et de fruits, la dépendance accrue sur des aliments prêts-à-manger et des aliments transformés et une consommation accrue de produits alimentaires à forte teneur énergétique et pauvres en nutriments comme des boissons sucrées. Environ 80 % des enfants d’âge scolaire ont affirmé avoir consommé au moins une boisson sucrée au cours de la semaine précédant le sondage. En ce qui concerne la sédentarité, la plus grande partie de la population ne fait pas suffisamment d’activité physique quotidienne et dépend beaucoup trop sur les modes de transport motorisés. Seulement 10 % des résidents (? 15 ans) ont mentionné qu’ils marchaient, la plupart du temps, pour se rendre au travail et en revenir ou qu’ils utilisaient leur bicyclette. Concurremment, la préoccupation sociale au sujet du poids, en opposition à des comportements sains, ainsi que les divers mythes associés au bilan énergétique pourraient contribuer au fait que 65 % des étudiants d’Ottawa ont mentionné qu’ils ont essayé de modifier leur poids soit en évitant d’en prendre, en essayant d’en perdre ou d’en gagner. Au cours des dernières années, Santé publique Ottawa (SPO) a collaboré de plus en plus avec des partenaires du secteur de la santé et de l’éducation et des fournisseurs de services sociaux pour promouvoir une alimentation saine et l’activité physique dans divers milieux comme l’école, le milieu de travail et les centres communautaires. Cet effort vise à sensibiliser la population et à aider les gens à développer des compétences pour changer l’attitude générale face à une alimentation saine et à une vie active. Par ailleurs, plusieurs partenaires et des champions locaux œuvrent déjà au sein de la collectivité afin de trouver des solutions à ces questions. SPO reconnaît que, pour que ces efforts aient une incidence durable, il faut que ses partenaires actuels y adhèrent, mais également d’autres partenaires de secteurs moins traditionnels comme l’industrie alimentaire, les planificateurs municipaux et les promoteurs. Pour commencer à remédier aux problèmes liés à une mauvaise alimentation, à l’activité physique et aux milieux sociaux et naturels, SPO a réorganisé ses efforts pour 2012 – 2014 en vertu de la stratégie Saine alimentation et vie active. La stratégie Saine alimentation et vie active mise sur les leçons apprises dans le cadre des diverses pratiques utilisées localement en matière de santé publique, dans les rapports sur les données épidémiologiques émergentes, les analyses de l’environnement, un examen de la documentation sur les pratiques exemplaires et des consultations avec les principaux partenaires municipaux et communautaires. Les trois principaux objectifs de la stratégie Saine alimentation et vie active sont : 1. Réduire la consommation de produits alimentaires et boissons à forte teneur énergétique et pauvres en nutriments; 2. Augmenter l’activité physique en faisant la promotion de la marche et du vélo comme moyen de transport; 3. Solliciter la participation de l’ensemble de la collectivité afin de changer les milieux sociaux et naturels. Pour atteindre ces objectifs, la stratégie Saine alimentation et vie active a adopté une approche à multiples facettes qui propose des occasions d’acquisition de connaissances et de compétences aux personnes, permet de créer des milieux favorables et plaide en faveur des changements aux politiques publiques qui ont une incidence sur un mode de vie actif prônant une alimentation saine et une vie active. Avec l’adoption de la stratégie Saine alimentation et vie active, SPO reconnaît l’importance des déterminants individuels et sociaux de la santé pour aider les résidents à manger sainement, à être actif et à maintenir une image corporelle saine. BACKGROUND The issue of overweight and obesity continues to be a growing health concern in Canada as well as other developed countries. For the first time in history, academics and researchers are predicting this generation of children could have a shorter life expectancy than their parents (1). Health conditions related to obesity, including cardiovascular disease, several types of cancer and diabetes are of public health concern for entire populations; other health conditions such as gestational diabetes and polycystic ovarian disease affect specific sub-populations (2). Obesity is also linked to increased risk for injury, reduced immunity (3), poor self-esteem, bullying and depression (4). A web of complex influencers including biological, behavioural, social, psychological, technological, environmental, economic and social factors are well documented in the literature and severely compound the challenge of addressing this health issue. Over recent years, an intense interest in reducing obesity has developed at all levels of governmental and non-governmental agencies, who as a result, have released position statements and guidance documents related to healthy eating, active living and obesity prevention.  The World Health Organization (5-6), the Ontario Chief Medical Officer of Health (7), the Federal, Provincial and Territorial Ministers (8), the International Society for Physical Activity and Health (9), the Canadian Paediatrics Society (10), the Ontario Medical Association (11), Cancer Care Ontario and Public Health Ontario (12), the Ontario Professional Planners Institute (13) and most recently, the Ontario Government (14) which proposes a Childhood Obesity Strategy to be released in the fall of 2012, as part of the Action Plan for Health Care.  Despite increased awareness and a proliferation of community based interventions, obesity remains a growing health issue. Best practice evidence relating to population-level interventions to reverse the trend is limited. There are promising results with the “Ensemble Prévenons l’Obésité Des Enfants” (EPODE) in Europe (15) as well as in Nova Scotia with the Annapolis Valley Health Promoting Schools Program (16). OPH is watching with interest innovative projects sponsored by New York City that range from food carts to partnerships with bodegas, to social marketing campaigns on consumption of sugar sweetened beverages (17-19). In recent years, OPH has focused attention on promoting healthy eating and physical activity in settings such as schools, workplaces and community houses, to raise awareness and build skills to change behaviours related to healthy eating and active living. OPH’s local partnerships include the five-year multi-agency Active Ottawa Actif initiative (20); Fuel to Xcell vending program with the City of Ottawa’s Parks, Recreation and Cultural Services; the Champlain Cardiovascular Disease Prevention Network; School Travel Planning with school boards and Green Communities Canada; and the Taking Action Together to Prevent Childhood Obesity community forum (21). Despite OPH and the community’s efforts to address the issue, overweight, obesity and other nutrition and physical activity related illnesses remain major public health concerns in Ottawa. Negative trends persist in eating habits, the local food environment, physical activity rates, the preponderance of barriers to physical activity and in attitudes towards weight impacting mental health. In spring 2011, the Board of Health set its Strategic Priorities for 2011 – 2014. Three Strategic Priorities are directly related to these health issues, specifically: 1) increasing access to healthy foods through municipal policies, 2) increasing nutrition skills in priority populations and 3) increasing active transportation as well as leisure physical activity. These priorities and local consultations are the basis on which OPH has refocused efforts for 2012 – 2014 under the Healthy Eating Active Living (HEAL) strategy. The HEAL strategy builds on lessons learned from local public health practice, emerging epidemiological reports, environmental scans and a review of best practice literature. Based on this, OPH will focus on three factors contributing to obesity: 1) poor nutrition, 2) inactivity and 3) the societal preoccupation with weight. The first contributing factor which the HEAL strategy will focus on is poor nutrition. Protective factors include eating regular meals, breastfeeding, meals prepared and eaten together at home and eating enough vegetables and fruit every day. Trends of increased reliance on fast and processed foods and increased consumption of energy dense, nutrient poor beverages such as sugar sweetened beverages are of concern. For example, 80% of school age students report drinking at least one sugar sweetened beverage in the week prior to being surveyed. The second contributing factor which the HEAL strategy focuses on is inactivity. Protective factors include having family and peers that are physically active, living in communities with infrastructure that support active transportation and access to facilities to participate in physical activities. Trends of concern include increased sedentary behaviours both at work and during leisure time with television and computers, increased reliance on vehicular transportation and lifestyles that generally require little physical exertion. Emerging research shows increased risks for negative health outcomes from sedentary behaviour for periods longer than one hour (22-23). Only 10% of residents (? 15 years) in Ottawa report that their primary mode of transportation to and from work was walking or cycling. The third contributing factor which the HEAL strategy aims to improve is the weight centred focus that currently exists in our cultural and social environment. It creates confusion about the contributors of overweight and obesity and perpetuates myths related to energy balance, what unhealthy eating is and the relationship of obesity to physical inactivity. Weight bias has crept into cultural attitudes, which undermines people’s ability to engage in healthy behaviours. Evidence shows that engaging in healthy behaviours can improve one’s health status regardless of weight lost. Mental health issues, eating disorders, social isolation and dieting are all indicators that weight should be de-emphasized and the focus should be on the healthy behaviours that will, in turn, ensure overall health. In Ottawa, 65% of students reported that they were trying to affect their weight either by avoiding weight gain, trying to lose weight or trying to gain weight. OPH recognizes that this is a complex issue that requires a complex response from the whole community. There are a number of local champions and leaders in the Ottawa community that OPH can work with on this issue. Innovative initiatives include the Ottawa District School Board pilot project to provide non-academic credits to students who participate in physical activity outside of school hours, and Stone Soup Foodworks converted a chip truck at the University of Ottawa to offer local healthy food instead. The 2012 – 2014 HEAL strategy outline revitalized and expanded partnerships and programming response to this pressing health issue. DISCUSSION Best practise literature and environmental scans informed the HEAL strategy. The following themes were considered when selecting activities: 1) Comprehensive Partnerships: OPH is leveraging traditional partnerships from the health, education, and social service sectors, other City departments and various workplaces, while endeavouring to engage non-traditional partners through innovative partnerships. In building the HEAL strategy, OPH consulted with key partners both municipally and in the community. 2) Accessibility: The HEAL Strategy takes into consideration how factors such as income, literacy, language, mental health and geography impact people’s ability to eat well and be active. Designing programming and policies that reduce these barriers and are sensitive to cultural and social norms will improve outcomes. 3) Sustained Focus: OPH recognizes that these issues are going to take sustained efforts and resourcing over many years to see long-term change in behaviours and in social and physical environments. The HEAL Strategy will engage a critical mass of community commitment and engagement that will support the successful implementation of policies and shift social norms and attitudes. RECOMMENDATION 1 1. The three-year Healthy Eating, Active Living Strategy (HEAL), as outlined in this report. HEALTHY EATING, ACTIVE LIVING STRATEGY (HEAL) FOR 2012-2014 The HEAL strategy has three specific objectives: 1. To decrease consumption of energy dense, nutrient poor foods and beverages; 2. To increase physical activity through walking and active transportation; 3. To engage the ‘whole-of-community’ to change social and physical environments. In order to meet these objectives, the HEAL strategy takes a multipronged approach that provides knowledge and skill building opportunities to individuals, creates supportive environments and advocates for changes to public policies that impact healthy eating and active living. 1. Decreasing consumption of energy dense, nutrient poor foods and beverages Decreasing consumption of energy dense, nutrient poor foods is not simple. There are communities in Ottawa, referred to as food deserts that do not have access to healthy and affordable food. Unable to easily access good quality food, those living in food deserts are often served by corner, convenience and fast food outlets that offer cheap, unhealthy foods high in fats, sugars, and salts. In addition, due to lack of knowledge and skills people are not eating enough vegetables and fruit, while increasingly rely on pre-prepared, packaged and restaurant foods which are high in calories and sodium. In Ottawa, 55% of adults (? 20 years) and 49% of youth report consuming less than 5 vegetables and fruit on a daily basis. Less than a quarter of adults reported that they did not consume restaurant, fast food or ready to eat foods in the week prior to the survey. In order to decrease the consumption of energy dense nutrient poor foods OPH will: a) Get “back to basics” by promoting food preparation and meal routines particularly with parents, low income families and seniors. * Expand programming to teach basic food and nutrition skills such as portion sizes, meal planning, shopping and cooking skills. * Expand NutriStep screening with parents of young children 18 months to 5 years of age to assess eating habits and identify nutrition problems. b) Increase awareness of the health risks of sugar. * Social media campaign on health effects of consuming sugar sweetened beverages including soft drinks, energy and sports drinks, flavoured milks and juices. c) Increase access to vegetables and fruit. * Increase the distribution and local availability of fresh, healthy food through vendors, street carts and mobile markets, particularly where food deserts exist, in partnership with local food programs in Ottawa such as the Good Food Box. d) Promote point of purchase strategies such as calorie and sodium labeling on menus in places where food is served and sold including municipal facilities, restaurants and cafeteria programs. * Assess community and restaurant franchise owners’ readiness to implement menu labeling and provide support to them for voluntary labeling. * Continued support for Ontario Food and Beverage Policy (PPM 150) in schools though work with school boards, teachers and students. * Participate in the Champlain Cardiovascular Disease Prevention Network initiative on Healthy Food Environment in Hospital Cafeterias. 2. Increasing active transportation and walking The majority of Ottawa adults do not meet the Canadian Physical Activity Guidelines of accumulating 150 minutes of moderate-to-vigorous physical activity per week. Active transportation is one source of physical activity that can help residents accumulate sufficient daily physical activity. In order to increase walking and active transportation behaviours, OPH will: a) Improve neighbourhood walkability. * Complete Neighbourhood Profiles including walkability assessments that identify barriers and assets such as safe routes to school and how to access food. * Work with municipal and neighbourhood groups to remediate specific problematic areas identified in Neighbourhood Profiles. * Promote web-based route mapping programs and mobile apps such as mapmywalk.com and mapmyride.com to facilitate access to utilitarian and leisure walking and cycling opportunities. b) Initiate peer-led walking groups with champions in community settings and support community-based programming to increase walking. * Initiate walking groups in neighbourhoods, workplaces and seniors residences. * Promote the uptake of the Every Step Counts pedometer library lending program to increase users daily step count to the recommended 10 000 steps per day. * Expand Active and Safe Routes to School initiatives to increase the number of school aged children who use active transportation to and from school. * Continue support to Green Communities Canada to implement the School Travel Planning project. 3. Engaging the whole of community to change social and physical environments The settings where we live, work and play have a major impact on our physical and mental health. The social, physical and built environments should make it easy and convenient for residents to eat healthily, be active and feel good. The following activities are intended to progressively change our social norms, our attitudes and our built environment: a) Dispel myths and adopt common messaging to shift from a weight focus to a healthy behaviours approach. * Work with CHEO to train professionals from the health, education and social service sectors to refocus messaging on the themes of Eat Well, Be Active and Feel Good about Yourself. b) Influence public policy and municipal plans through partnerships, advocacy and surveillance. * Implement the Baby-Friendly Initiative™ as required as part of the Board of Health’s accountability agreement to normalize breastfeeding up to 6 months of age and complementary breastfeeding to two years of age and beyond. * Increase access to healthy food through partnerships with City departments and community organizations such as Just Foods and Centretown Community Health Centre. These activities will range from the inclusion of nutrition requirements in food vendor permits and purchasing policies for City facilities and programs to increased availability and distribution of healthy foods in underserved neighbourhoods. * Inform key municipal plans including, but not limited to, the Official Plan, the Transportation Master Plan, the Pedestrian Plan, the Cycling Plan and the Parks and Recreation Master Plan through surveillance data and Neighbourhood Profiles identifying existing and potential barriers to active transportation in neighbourhoods. * Work with Safer Roads Ottawa, a joint corporate program between OPH, Ottawa Police Services, Public Works Department, Ottawa Paramedic Service and Ottawa Fire Services, to promote pedestrian and cyclist safety. * Create healthier food environments in municipal facilities such as child care and recreational facilities through reviewing food and beverage procurement policies. c) Profile and celebrate the contributions of the community regularly and visibly to better leverage local assets and progress. * Host an annual stakeholder forum for networking and celebration of local successes to inform, inspire, and leverage contributions from partners. RECOMMENDATION 2 2. That the Chair of the Board of Health write a letter to the Ontario Minister of Health and Long-Term Care recommending that the Ministry include in their upcoming Childhood Obesity Strategy substantial investment in diverse physical activity opportunities in schools and other organizations to help youth to meet the physical activity minimum requirements. Few (22%) Ottawa students in grades 7 to 12 reported meeting physical activity recommendations of 60 minutes per day with some Ontario schools reporting as few as 30% of high schools students enrolled in physical education (24). Adolescent participation in regular physical activity is linked to higher academic performance (25), development of lifelong physical activity habits and contributes to improved overall health and social outcomes (26). Policy options with incentives to attract youth to physical activity and reduce barriers to physical activity such as access to sports equipment or programs are important components for consideration. Opportunities identified by Active Healthy Kids Canada (2011) include school-community partnerships and training, youth leadership, policy and investment support (27). RECOMMENDATION 3 3. That the Chair of the Board of Health write a letter to the Ontario Minister of Education recommending: a. That the Ministry provide direction and funding to school boards for monitoring and reporting as it relates to the Daily Physical Activity Policy (PPM 138) in elementary schools. b. That the Ministry provide direction and funding to school boards for monitoring and reporting as it relates to the Ontario School Food and Beverage Policy (PPM 150).  Currently the Daily Physical Activity Policy (PPM 138) in elementary schools states “School boards will monitor the implementation of the policy on daily physical activity to ensure that all elementary students are provided with the opportunity to be active for at least twenty minutes each day during instructional time.” However, informal discussions with parents and teachers suggest that the policy is not consistently implemented across elementary schools in Ottawa. Almost all children spend approximately 30 hours per week at school; therefore schools are the setting that can reach the largest proportion and greatest diversity of children. There is evidence to show that providing elementary school students with opportunities to be physically active can have a positive impact on their physical, mental and social well-being as well as academic achievement, and readiness to learn (28). Over the past three years, the national surveillance organization called Active Healthy Kids Canada has produced an annual Report Card on Physical Activity for Children and Youth which calls for sustained commitment from the Ministry of Education to ensure that children are receiving daily, quality physical activity in the elementary school setting (29, 30, 31). One of the major concerns outlined in these reports is the lack of accountability and evaluation of Daily Physical Activity and Physical and Health Education in Ontario (32). The Ministry of Education implemented the Ontario School Food and Beverage Policy (PPM 150) in September 2011. The policy states that school boards are required to ensure that all food and beverages sold on school premises for school purposes meet the requirements of this memorandum, including the nutrition standards set out in the Appendix to this memorandum, by September 1, 2011. To date there has been no formal monitoring plan put in place. RECOMMENDATION 4 4. That the Chair of the Board of Health write a letter to federal Minister of Health and Ontario Minister of Health and Long-term Care recommending the development and promotion of menu labelling policies for franchises of 10 or more or at least $10 million in revenue. Access to nutritional information, including caloric content and nutritional values help consumers make informed decisions about their food and beverage choices. Although some restaurants voluntarily post nutrition information on websites and in brochures, food retailers are not required to make the information available, unlike packaged foods. Researchers have found that restaurant patrons typically underestimate calories and overestimate the healthfulness of menu items. Some jurisdictions in the United States, such as New York City and the State of California, have passed laws requiring at least calorie labelling. In Canada supporters of menu labelling include, among others, Ontario Chief Medical Officer of Health, Canadian Institute for Health Information, Heart and Stroke Association, Canadian Public Health Association, Cancer Care Ontario, Public Health Ontario and Ontario Medical Association. Although OPH will be actively working on voluntary menu labeling locally, a significant barrier are franchises that do not have local autonomy to participate in menu labeling or do not have the capacity to have the nutritional analysis done. OUTCOMES The foundation to OPH’s approach is the integration with partners and leveraging the existing momentum in Ottawa to engage the broader community to address this issue. With our partners, the outcomes expected for 2012 include: * Progress in priority partnerships such as: o School boards to expand Active and Safe Routes to School programming in 30 additional schools; o The Champlain Cardiovascular Disease Prevention Network to develop and implement Healthy School Age Children and Healthy Foods in Hospitals initiatives; and o The Children’s Hospital of Eastern Ontario Centre of Active Healthy Active Living (CHEO CHAL) to train professionals from the health, education and social service sectors to refocus messaging on the themes of Eat Well, Be Active and Feel Good about Yourself. * Improve food environments in 17 Municipal Childcare Centres. * Complete community profiles of walkability and food environments in 15 Ottawa neighbourhoods. * Implement food skill demonstrations at 4 new locations for the Food Hamper program. * Expand NutriStep screening to reach 600 families with children ages 18 months to 5 years. * Launch social marketing campaigns focusing on walking and sugar sweetened beverages. * Develop and implement guidelines for procurement and advertising of food and beverages in municipal facilities. * Attain Baby Friendly Initiative™ certification. RURAL IMPLICATIONS Rural communities may have inequitable access to healthy foods, neighborhood recreational opportunities and infrastructure for active transportation. Tailored, locally developed strategies will be implemented that build on local assets in rural communities. For example, opportunities related to agriculture and farming will be explored. CONSULTATION In March and April 2012, OPH completed internal and external partner consultations with key stakeholders on the HEAL strategy. Stakeholders consulted included corporate partners and community partners from the health, education and social service sectors. Partners from all sectors expressed support for the HEAL strategy. The four Ottawa School Board were consulted and indicated that the HEAL Strategy aligns well with their existing work on the implementation of the Ontario School Food and Beverage Policy (PPM 150), Daily Quality Physical Activity Policy (PPM 138) and Health and Physical Education Curriculum. Representatives indicated that we would pleased to continue to partner with OPH to support the HEAL Strategy. In the first quarter of 2012, OPH staff began consulting with a number of corporate partners including the Transportation Strategic Planning, Planning and Growth Management and Ottawa Light Rail Transit to discuss active transportation. In March 2011, OPH hosted the Taking Action Together to Prevent Childhood Obesity community forum. Local experts from CHEO, Champlain Cardiovascular Disease Prevention Network, OPH and a variety of other organizations came together to outline priority focus areas aimed at preventing childhood obesity. The outcome from this forum was a clear message that the community is ready for collaborative action. LEGAL IMPLICATIONS There are no legal impediments to the implementation of the report recommendations. FINANCIAL IMPLICATIONS The cost to develop the strategy has been funded within the OPH budget. OPH is actively seeking opportunities for strengthening funding sources. A one-time funding application for the walkability strategy is pending response from the Ministry of Health and Long-term Care. In addition, this area will be identified as a budget pressure in 2013. TECHNICAL IMPLICATIONS There are no technology implications associated with this report. DISPOSITION Ottawa Public Health, in collaboration with community partners and City of Ottawa Departments, will implement the Healthy Eating, Active Living Strategy, as approved by the Board of Health. Ottawa Public Health will continue to consult all relevant City departments, including Legal Counsel in the City Clerk and Solicitor Department on agreements between the Board of Health and outside organizations, as well as the implementation of the strategy. The Board of Health Secretary will send letters to the appropriate Ministers as detailed in the report recommendations.  References 1. 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