CARRFS eNews Volume 3, Issue 4, September/October 2013
CARRFS eNews
Volume 3, Issue 4, September/October 2013
Canadian Alliance for Regional Risk Factor Surveillance - Quarterly eNewsletter
CARRFS Feature
The Obesity Epidemic
A Complex Health Care Challenge CARRFS Interview Food Insecurity Dr. Valerie Tarasuk, Professor, University of Toronto
CARRFS Profile Dr. Ali Artaman, Manager, Epidemiology,
Surveillance and Research, Eastern Ontario Health Unit 1
CARRFS eNews
Volume 3, Issue 4, September/October 2013
CONTENTS in this Issue... The Obesity Epidemic: A Complex Health Care Challenge 4 CARRFS eNews deconstructs one of the biggest and most complex challenge that the health care system in Canada is currently facing. By PAUL WEBSTER CARRFS Interview 11 Dr. Valerie Tarasuk, University of Toronto, outlines in the interview the critical issues associated with her research of Household Food Insecurity in Canada and its impact on public health in Canada. By JOSTEIN ALGROY Surveillance Facts 16 Dr. Bernard Choi, Public Health Agency of Canada, outlines Part IV of his series about the Past, Present, and Future of Public Health Surveillance. By BERNARD CHOI PHAC: Indicator Framework for Chronic Diseases and Associated Determinants 17 Dr. Gayatri J. Jayaraman describes the Public Health Agency of Canada’s new Indicator Framework for Chronic Disease Determinants. By JOSTEIN ALGROY CARRFS Profile 21 The CARRFS Member Profile: Dr. Ali Artaman, Manager, Epidemiology, Surveillance and Research, Eastern Ontario Health Unit. By JOSTEIN ALGROY
CONTRIBUTORS Mr. Jostein Algroy, Editor in Chief Ms. Xiaoyan Guo, Copy Editor Mr. Paul Webster, Senior Writer Dr. Bernard Choi, Science Writer Ms. Mary Lou Decou, Senior Writer Ms. Ahalya Mahendra, CARRFS Working Group Chair
PAN-CANADIAN EDITORIAL ADVISORY BOARD Mr. Jostein Algroy, Editor in Chief Mr. Paul Webster, Health Science Writer Ms. Mary Lou Decou, Epidemiologist, Public Health Agency of Canada Dr. Bernard Choi, Senior Research Scientist, Public Health Agency of Canada Dr. Elizabeth Rael, Senior Epidemiologist, Ontario Ministry of Health and Long-Term Care Mr. Larry Svenson, Director, Alberta Ministry of Health Dr. Drona Rasali, Director, British Columbia Provincial Health Services Authority More members to be added to the Board later.
SECRETARIAT SUPPORT Public Health Agency of Canada Ms. Mary Lou Decou
PUBLICATION DATES CARRFS eNews is a Quarterly Newsletter for the Canadian Alliance for Regional Risk Factor Surveillance (CARRFS) and is published in the months of March/April, June/July, September/October, and December/ January.
Table of Contents From the Editor ................................................................................. page 3 The Obesity Epidemic ................................................................. page 4 Obesity: Lifestyle or Disease? .................................................... page 8
CARRFS WEBSITE URL: WWW.CARRFS.ORG
Risk Factor Myopia .......................................................................... page 9 CARRFS Interview: Dr. Valerie Tarasuk ................................. page 11 Statistics Canada ............................................................................... page 15 Surveillance Facts ............................................................................. page 16
Photo Credits: Cover Photo: iStockPhoto_000012693128 Photo page 4: Ms. Penny McKinlay, www.wanderlustandwords.blogspot.ca.
Chronic Disease Indicator Framework ................................ page 17 Secretariat’s Message ..................................................................... page 20 CARRFS Member Profile ............................................................ page 21 Updates from Working Groups .............................................. page 23 Hello & Goodbye ............................................................................ page 24
Disclaimer: CARRFS is a pan-Canadian network of public stakeholders across Canada working together to enhance the capacity of Regional Risk Factor Surveillance in Canada. CARRFS is supported by the Public Health Agency of Canada (PHAC). The content in the CARRFS eNews does not necessarily reflect the official view of PHAC, Health Canada, the Government of Canada or the employer of its contributors.
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From the Editor
As CARRFS eNews evolves to deliver better insights and to serve the Canadian risk factor surveillance community better, we’re focusing on key themes in public health. In this issue, we look at obesity – one of the most significant public health challenges in history. Obesity – it’s an epidemic that’s difficult to understand. It can be seen as a lifestyle issue, an environmental issue, an economic issue, or – as recently announced by the American Medical Association – a disease. But none of these perspectives solely gives a complete view of what obesity is. And none of these perspectives offers solid solutions on how to solve one of the biggest and most complex public health issues Canada has ever experienced. As Dr. Diane Finegood, President and CEO at the Michael Smith Foundation for Health Research, and Professor in the Department of Biomedical Physiology and Kinesiology at Simon Fraser University, Vancouver, noted in an interview with CARRFS eNews medical writer Paul Webster, reductionist approaches to unpacking the obesity issue won’t work. It’s critically important that epidemiologists, bio-statisticians, health analysts, and policy makers wrap their heads around the complexity of this challenge. Although there seems to be no direct link between food insecurity and obesity in Canada, a study undertaken by University of Toronto professor Dr. Valerie Tarasuk is quite telling. In an interview with CARRFS eNews, Dr. Tarasuk emphasized the direct linkage between health and household food security. Almost 4 million Canadians – including over one million children, are living in some degree of food insecurity. It’s a stunning number! Not surprisingly, the highest ratio of food insecure households is in Nunavut, where the cost of food is so much higher than in the rest of Canada. It is surprising, however, that Newfoundland and Labrador has the lowest ratio of food insecure households nationally. Just exactly why it is hard to determine.
We’ll know more in a few years, as Tarasuk’s group has received funding from the Canadian Institutes for Health Research to study the phenomenon more closely. We will provide updates in the years to come. Stay tuned. Last, but not least, I will welcome the new member of the editorial team – Ms. Xiaoyan Guo from Alberta Health, who is the new copy editor for the CARRFS eNews. Jostein Algroy Editor in Chief
Volunteers for CARRFS eNews CARRFS eNews needs volunteers to help with specific sections of the newsletter. We need reviewers who would like to review “Epi” reports and share the information with the network. We are looking for a person who can write up a few blurbs about News & Trends taking place in the “Epi” community – nationally and internationally. If you are interested please contact jostein@sympatico.ca.
Send us your Story We urge all members of CARRFS to send us articles and ideas for upcoming issues. Please submit your story to jostein@sympatico.ca.
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CARRFS Feature... CARRFS eNews
Volume 3, Issue 4, September/October 2013
The Obesity Epidemic A Complex Health Care Challenge
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The Obesity Epidemic Reductionist approaches to unpacking the issue won’t work Medical journalist Paul Webster takes a closer look at the complexities surrounding obesity. The Good Food Junction, a grocery store housed in a utilitarian bunker in Saskatoon’s gritty west end, seems like any other ordinary no-nonsense urban grocer/groceteria. But many people living near the store consider it to be somewhat of a miracle. Long-abandoned by major supermarket chains, food security experts describe the area around the store as a “food desert”. To overcome the lack of access to good food in the area, community members formed a co-op, built the store, and opened it for business in October 2012. “This all began with a dream,” explains co-op board member Karen Archibald. “We needed a food store in a neighbourhood where the major food retailers had abandoned the inner city.” According to a study published earlier this summer by researchers with the Saskatoon Health Region’s Public Health Observatory, Saskatoon’s most deprived neighbourhoods have significantly fewer supermarkets than its wealthy neighbourhoods do (see figure on next page), while hosting significantly more fast food outlets. The Good Food Junction was created specifically to help rebalance the situation. Now, at the University of Saskatoon, nutritionist Rachel Engler-Stringer is probing whether the opening of the Good Food Junction is yielding health benefits to residents in the area. Using data from a city-wide dietary survey conducted within a set of studies of the food environment for families with children in Saskatoon, over the course of the next two years, EnglerStringer will closely monitor health conditions, including body weight, among children in the neighbourhood to probe whether supermarket access is a risk factor for obesity. It’s all part of “Smart Cities, Health Kids,” a multi-year investigation funded by the Canadian Institutes for Health Research (CIHR), the Saskatchewan Health Research Foundation, and the Heart and Stroke Foundation. “We want to understand the factors that drive obesity better,” Engler-Stringer explains. The interest in obesity and its causes is hardly unique to Saskatoon. With approximately one in four Canadian adults and almost ten percent of children and youth aged six to 17 obese, according to Obesity in Canada – a 2011 report co-published by Public Health Agency of Canada (PHAC) and the Canadian Institute for Health Information (CIHI), obesity risk factors are an increasingly dynamic research area. Between 1981 and 2007/08, obesity rates roughly doubled, the PHAC/CIHI report reveals. But as the report notes, explanations for why this is happening remain tentative. And while factors that are known to influence obesity include physical activity, diet, socio-economic status, ethnicity, immigration, and environmental conditions, the report notes, “our collective understanding of the determinants of obesity will continue to evolve” as risk factor research becomes more refined. Numerous significant initiatives related to childhood obesity and physical inactivity have been kickstarted in recent years, notes Mark Tremblay, Director of Healthy Active Living and Obesity Research at the Children’s Hospital of Eastern Ontario, in Kingston, Ontario. These include a >>
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CARRFS Feature... Federal/Provincial/Territorial framework for action to promote healthy weights, implementation of the nutrition labelling initiative, announcement of the Public Health Agency of Canada's innovation strategy funding related to obesity, publication of the Canadian Health Measures Survey physical activity findings, release of new Canadian physical activity and sedentary behaviour guidelines, the start of the Canadian Paediatric Weight Management Registry, and the National Obesity Summit in Vancouver last May. Alongside these efforts, Tremblay urges, Canada needs to craft innovative approaches to investigating the nature of the obesity epidemic itself, as well as the factors driving the epidemic. By way of example, Tremblay points to the need for more refined observations of the linkages between physical inactivity – or sedentary behaviour, as he calls it – and obesity. To really understand what drives obesity, Tremblay argues, researchers need to begin closely studying the ways that Canadians eat, sleep,
and move. “We need to know much more about lifestyle factors to know what’s driving it,” he argues. “The minutiae of our daily activities has changed, and we need to shift risk factor research to understand how this drives obesity.” Michelle Stone, assistant professor of kinesiology at Dalhousie University in Halifax, Nova Scotia, agrees. After conducting a series of studies on physical inactivity among Toronto schoolchildren, she concluded that alongside limits on sports and vigorous physical activities, risk factors for childhood obesity include the ability of children to have independent, unsupervised mobility and outdoor play. Patricia Parkin, Research Director with the Paediatric Outcomes Research Team at Sick Kids Hospital in Toronto, and a member of the Canadian Task Force on Preventive Health Care, notes that preschoolers in Canada are dramatically understudied. The main national dataset on obesity, the Canadian Health Measures Survey, launched in 2007, collects direct physical measurements such as >>
“Our collective understanding of the determinants of obesity will continue to evolve.”
Proximity to nearest supermarket, Saskatoon, Saskatchewan
LEGEND Distance to nearest supermarket (in metres) 36 - 499 500 - 999 1000 - 1499 1500 - 1999 2000 - 3733 Non-residential neighborhoods
0
1
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3 km
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blood pressure, height, weight and physical fitness, alongside information related to nutrition, smoking habits, alcohol use, medical history, current health status, sexual behaviour, lifestyle and physical activity, the environment and housing characteristics, as well as demographic and socioeconomic variables. But it does not track children under the age of three, Parkin notes. “That’s a huge gap,” she worries, while calling for research on risk factors such as children’s eating patterns, dietary selfregulation, bottle use, and breastfeeding prevalence. Even the use of child strollers warrants attention as a risk factor for child obesity, she asserts. Risk factor specialists interested in obesity should also be looking at mental health issues, suggests Yue Chen, a professor in the Department of Epidemiology and Community Medicine at the University of Ottawa. In a recent study, Chen established that lifelong stress is associated with obesity. The trouble is, Chen explains, it’s not clear whether stress leads to obesity, or vice versa. “Mental health is clearly an important issue these days, yet very few studies have probed the links between stress and obesity.” Chen also suggests
Volume 3, Issue 4, September/October 2013
Measured Prevalence of Obesity in Canada Ages 18 Years and Older
13.8%
1978
14.8%
1989
23.1%
2004
25.4%
that risk factor researchers look at the role of chemicals – known as obesogons – in the environment that may drive obesity. A growing body of research indicates that environmental contaminants such as flame retardant chemicals used in plastics, carpets and textiles may play a role in driving obesity. After echoing Parkin’s warning about the lack of attention to preschoolers, David Lau, a University of Calgary medical professor who serves as President of Obesity Canada, warns that national surveillance efforts are piecemeal and incomplete compared to those of the United States, where the Centres for Disease Control’s National Health and Nutrition Examination Survey stages a program of studies designed to assess the health and nutritional status of adults and children in the United States using interviews and physical examinations. “There aren’t many national datasets available here in Canada,” Lau laments. “There are significant gaps in our understanding of obesity prevalence. I’d call it a dire lack of basic information to inform public health policies.” <>
2008
Source: PHAC/CIHI Obesity in Canada, 2011
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Obesity: Lifestyle or Disease? American Medical Association has recognized obesity as a disease. Paul Webster explains why this is controversial. Resolution 420 from the American Medical Association’s (AMA) annual general meeting in Chicago last June recognized obesity “as a disease state”. It was a startling decision. Not surprisingly, the AMA resolution included copious ammunition to defend it. In labelling obesity as a disease, the AMA cited “an overabundance of clinical evidence to identify obesity as a multi-metabolic and hormonal disease state including impaired functioning of appetite dysregulation, abnormal energy balanced, endocrine dysfunction including elevated leptin levels and insulin resistance, infertility, dysregulated adipokine signaling, abnormal endothelial function and blood pressure elevation, nonalcoholic fatty liver disease, dyslipidemia, and systemic and adipose tissue inflammation.” Obesity, the AMA resolution continued, “is directly related to co-morbidities including type 2 diabetes, cardiovascular disease, some cancers, osteoporosis, polycystic ovary syndrome.” And obesity is a treatable disease the AMA asserted, citing “progress in the development of lifestyle modification therapy, pharmacotherapy, and bariatric surgery options has now enabled a more robust medical model for the management of obesity as a chronic disease”. Given all of this, the AMA resolution charged, suggesting that obesity is not a disease but rather a consequence of a chosen lifestyle, “is equivalent to suggesting that lung cancer is not a disease because it was brought about by individual choice to smoke cigarettes.” The AMA’s decision is not unique. The World Health Organization, the US Food and Drug Administration, the US National Institutes of Health, the American Association of Clinical Endocrinologists, the US Internal Revenue Service, and CIGNA – one of the largest US health insurance companies, have all recognized obesity as a disease. But there are many organizations and experts who disagree with this position. Just days before the AMA resolution passed, the AMA’s very own Council on Science
and Public Health issued a report warning that “without a single, clear, authoritative, and widely accepted definition of disease, it is difficult to determine conclusively whether or not obesity is a medical disease state. Similarly, a sensitive and clinically practical diagnostic indicator of obesity remains elusive." The Canadian Medical Association responded to the AMA resolution cautiously, suggesting it would welcome a debate. Dr. David Lau, Professor of Medicine, Biochemistry and Molecular Biology at the University of Calgary and President of Obesity Canada, a not-for-profit organization, says labelling obesity as a disease in Canada would be an “expedient” way to promote action. But Dr. Arya Sharma, Professor of Medicine & Chair in Obesity Research and Management at the University of Alberta and founder and Scientific Director of the Canadian Obesity Network – a network of over 6000 obesity researchers and clinicians, warms that crude diagnoses of obesity based on Body Mass Index measurements can be misleading and harmful and may result in the over-treatment or under-treatment of millions of individuals deemed to be in one category or another simply because their body weight divided by the square of their height happens to fall below or above a rather arbitrary cutoff. “Health cannot be measured by stepping on a scale,” he warns. “This is a very messy question” observes Diane Finegood, President and CEO Michael Smith Foundation for Health Research and Professor in the Department of Biomedical Physiology and Kinesiology at Simon Fraser University. “It’s complex. I can see some of the arguments on both sides.” The best argument in supporting of classifying obesity as a disease, says Finegood, is that it helps practitioners and therapeutics innovators take it more seriously. The best argument opposing categorization is that it reinforces stigmas and may pathologize people who are perfectly healthy. <>
“Crude diagnoses of obesity based on Body Mass Index measurements can be misleading and harmful.“
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Risk Factor Myopia . . .
In an interview with the CARRFS eNews medical writer Paul Webster, Dr. Diane Finegood outlines her view on how misguided risk factor surveillance and a reductionist perspective for understanding obesity can be. Dr. Diane Finegood was appointed President and CEO Michael Smith Foundation for Health Research, British Columbia in March, 2012. She is also a Professor in the Department of Biomedical Physiology and Kinesiology at Simon Fraser University, Vancouver (on leave). From 2000-2008, Dr. Finegood was inaugural Scientific Director, Institute of Nutrition, Metabolism and Diabetes, part of the Canadian Institutes of Health Research. In that role, she guided the national health research agenda across that Institute’s mandate and within its own strategic priority of obesity and healthy body weight. Dr. Finegood’s efforts helped stimulate obesity research
and knowledge translation through the support of innovative research platforms and partnerships. Dr. Finegood has received numerous awards, including the 2006 Canada’s Top 100 Women Award in recognition of her trailblazing and trendsetting work and the 2008 Frederick G. Banting Award from the Canadian Diabetes Association for her leadership and significant contributions in the Canadian diabetes community. She obtained her doctoral degree in physiology and biophysics from the University of Southern California and held appointments at the University of Alberta before coming to BC.
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Dr. Diane Finegood (cont’d) What are the innovations risk factor specialists should be pursuing? The challenge here is that obesity is complex. There are hundreds of relevant and interdependent factors that contribute to obesity. As a result, looking for the causes through risk factor surveillance may not be all that helpful. We are used to looking for causal relationships underlying a problem and then focusing inter ventions on these causes. But when a problem is complex and there are many interdependencies, this is not all that helpful. Solutions to complex problems may not have anything to do with the causes of the problem; and because of the large number of interdependencies, addressing complex problems by first looking for the cause may have unintended consequences. Reductionist approaches want to believe that if you understand a problem, you can fix it. And I don’t believe that.
“A reductionist perspective is not very helpful. The solutions may not have anything to do with the causes of the problem.”
So, traditional risk factor surveillance pinpointing specific causes is unsuitable to the obesity problem? When I think about risk factor surveillance, the first things that come to mind are about individuals, e.g. blood pressure and other things at the level of the individual. If we star t to go to the level of the system – food security is about the system – then it’s a little better. If I think about risk factors in terms of individuals and in terms of clinical parameters or genetic parameters or family-based parameters, I worry because it reinforces that we are trying to figure out the causes for an individual, so we can solve them. If we think about the system – things like food security – I’m less worried because I think those are impor tant upstream factors and I don’t think they are as steeped in the reductionist paradigm of the epidemiologist. What are the most important innovations in obesity risk factor surveillance you would recommend? I want a much more solution-oriented approach. What we should be monitoring are process variables not outcomes. Things like how many schools have become full-fledged health promoting schools over a period of time? What is the shift in food company por tfolios from non-healthy to healthy products? Things like skills in preparing healthy food. Outcomes take longer to achieve; and if you don’t reach your target, the outcome variable does not tell you why. Functional goals and the metrics of whether they have been achieved are more process-oriented and will help you know what to do if the result is not as intended. <>
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CARRFS Interview... CARRFS eNews
Volume 3, Issue 4, September/October 2013
Measuring Food Insecurity and Health Dr. Valerie Tarasuk, Professor, University of Toronto
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CARRFS Interview... What inspired you to work on the issue about household food insecurity? Back in the 1980s when I was a graduate student in Toronto, food banks had just started and my Master’s thesis was to look at food problems for low-income single-parent families in Regent Park, Toronto. My first research project as faculty member at the University of Toronto was to do a study on nutritional vulnerability and food insecurity among women in families who use food banks. In the beginning, all we knew was how many people were going to food banks. But in the mid-90’s, we started to see individual questions about food insecurity on national surveys – very basic questions like “is your child going hungry”. It wasn’t until 2004 that we finally started to use a standardized, validated instrument on a national survey. Statistics Canada incorporated the 18-item module – the Household Food Security Survey Module – into their Canadian Community Health Survey (CCHS). That module can be used to
1.6 million
Canadian households experienced food insecurity
This amounts to nearly one in eight households
3.9 million
individuals, including 1.1 million children
generate prevalence estimates, but it also provides a measure of the severity of food insecurity – a very treasured measure. The module is being administered regularly, so we can now look at trends over time. What are the challenges you encounter using the CCHS? The CCHS is a health survey; and if we want to understand the social and economic conditions that give rise to this problem, we need to know something about household characteristics. CCHS, like all health surveys, has only bare bones socio-demographic variables. We can get measures about income and income source, but they are very limited. For example, the variable that asks you what your main source of income is has an option for social assistance. To be on social assistance is to be at very high risk of food insecurity, so this is important. But there are at least two programs that run under that umbrella in most jurisdictions. One is the general welfare program and the other is a program that provides income support for people with disabilities. People who are considered to be disabled typically get better benefits and therefore are probably less at risk of food insecurity than people receiving welfare. These details don’t get captured in the CCHS. It is important to understand food insecurity within a broad social policy framework (including income and other sociodemographic variables) because any mitigation of the problem will require policy interventions in these areas. Our report on Household Food Insecurity is based on the 2011 CCHS data. CCHS has a census metric variable that provides us with estimates for the largest cities in Canada, but the household-level weights necessary to calculate population prevalence estimates for household food insecurity have not been calibrated at the level of census metropolitan areas. So, while we have calculated household food insecurity rates for cities, we have had some concerns about the stability of these estimates because of the need to use household weights. Despite those constraints, we have some very interesting findings from our examination of the data for cities. The beauty with this food security module is that it has now been run for multiple years of CCHS data. This allows us to look at changes over time, and we are seeing profound change in some census metropolitan areas as well as quite dramatic variation in prevalence rates from one city to the next. What is interesting is that lots of cities are setting up food policy councils and food strategies. Things are happening at the community level around food; and in the case of Calgary at least, we are seeing initiatives to reduce poverty. It >>
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CARRFS Profile (cont’d)
would be very valuable for those councils and government and non-profit stakeholders generally to have a benchmark around food insecurity rates. Increasingly, cities are becoming leaders in implementing policy. When you think about it, it is really important for Calgary to know what its food insecurity rates are prior to looking at its local programming to find out how well they are meeting the needs of the population over time.
employment income. So when we look at the Newfoundland story, we have to look at two groups of people – the people on social assistance and the people in lower paying jobs. We already know from our preliminary work that the probability of being food insecure if you are on social assistance has fallen in this province since 2007, but that is only one part of the story. So there is a huge complexity here. It is not going to be one policy, but multiple changes that have taken place. What I love about the Newfoundland story though is that it shows that things can change, and change for the better.
“Increasingly cities are becoming leaders in implementing [social] policy.”
In your report, Newfoundland and Labrador comes out with the lowest rate of Food Insecurity in Canada, why is that? In the report that we released, we looked at the prevalence Have you been able to link food insecurity with obesity? rate from 2005 to 2011. Not every province and territory We have looked at the relation between food insecurity and had data on food insecurity for every year, because some obesity. The relationship is not straightforward. Literature had opted out of the food security module on cycles of CCHS when it was optional; but still, we had quite a few years to work with. From 2007 onward, we see a steady decrease in food insecurity in Newfoundland and Labrador. In 2007 they looked very much the same as the other Atlantic Provinces. Then they started to look different. By 2011, their prevalence had dropped by one third from 15.7 16.8% 36.4% percent in 2007 to 10.6 percent in 2011. In 15.2% fact, in 2011, they had the lowest food insecurity rate in the country. What changed over time? Well, in 2006, 11.0% 10.6% Newfoundland launched a very aggressive 12.3% 11.8%12.4% poverty reduction strategy. But is that what 12.5% led to the drop in food insecurity, or is it 11.9% 15.4% because of an upswing in the economy? 17.1% We don’t know yet. We are in the process of trying to figure 16.5% out what drove the change in Newfoundland and Labrador, but I think we will quickly reach the limits of the demographic variables shows that at the cross-sectional level – when we look at on the CCHS. Maybe what we need to do is to link CCHS body weight and food insecurity – we can see a slightly to other data sources - income tax records, for example – in higher rate of obesity amongst women in food insecure order to see the effect of the taxation policy. If we look at households in Canada, but no similar association is seen for who is food insecure – from looking at the national data men or children. Does that mean that food insecurity over time, we know a couple of things – we know that predisposes people to obesity? There have been a few there are two groups that are particularly vulnerable. One is longitudinal studies in the US and they don’t show that. They those on social assistance, and the other is people in the don’t show that becoming food insecure leads to weight low-income end of the workforce. About 61 percent of gain. Is there a cause and effect relationship here? In fact I food insecure households in 2011 were reliant on doubt it! >>
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CARRFS Profile (cont’d)
We have done quite a lot of work to look at the relationship between food insecurity and a broad spectrum of health measures. Food insecure adults in Canada have systematically poorer health. That is true whether we look at self-rated health or we look at the physician-diagnosed conditions. But it doesn’t seem to fall into a particular pattern. It doesn’t matter if we are looking at back problems, or migraines or diabetes. That said, the relationship between food insecurity and mental illness is by far the strongest. Almost half of the women in severe food insecure household in Canada have been diagnosed with mental illness. This is very dramatic and obviously cause for concern and further investigation. The most common interpretation of observed associations between food insecurity and all of these health measures is that food insecurity causes people’s health to diminish. I am sure it does, but another scenario is that to be low income with a chronic disease is to be more vulnerable to food insecurity. Our research is pointing in this direction; and if we are right, the implications for both policy and practice are huge. At the same time, there is definitely something about food insecurity that is creating a health disadvantage. There are some very important papers coming out from the National Longitudinal Survey of Children and Youth which started to track children in 1994. The lead investigator in this work is Dr. Lynn McIntyre from University of Calgary. If you look at children over time that have lived in a severely food insecure household, they are more likely to have been diagnosed with a whole range of health issues such as asthma and depression – significant chronic health problems that are carrying on into adolescence and early adulthood. What the studies tell us is that the circumstances for children in Canada living in food insecure households are bad enough to predispose them to some fairly significant health problems going forward.
people who are elderly appear to be at much lower risk of food insecurity. What is it about the policies that kick in at the age of 65 that seem to be so effective? Another direction that we are moving in, working in partnership with scientists from the Centre for Addiction and Mental Health (CAMH), is to look at CCHS data that have been linked to health services utilization data (OHIP) records. Our purpose of doing that is two-fold: one is to enable us to estimate the cost of food insecurity from a health care perspective. We know that people who are food insecure are more likely to be unhealthy. There are studies that suggest that if food insecure individuals have chronic disease(s), they will be less able to manage their disease(s). There is some literature that suggests that food insecurity could give rise to health problems as I referred to earlier in the work done with the National Longitudinal Survey of Children and Youth. We want to link CCHS food insecurity measures to individuals’ health records to document these trajectories and estimate the health service utilization costs of this problem. We think it is really important since the kind of policy recommendations that emerge to reduce food insecurity include interventions that will cost money. Raising social assistance rates, improving tax benefits for working poor, and providing drug benefits for low-income people etc., are all interventions with a price tag. It is important to look at the health care costs associated with the current problems. If we can get a cost estimate from the linkage of these data sets, we would then be able to say: “you can pay this way or you can pay that way!” – either an investment in prevention or paying the cost in health care.
“Food insecure adults in Canada have systematically poorer health.”
What is your next project? We have the good fortune to have funding from the Canadian Institutes for Health Research (CIHR) to try to identify effective policy interventions. Part of our work will be to tease apart what changed in Newfoundland and Labrador and what caused those changes. In our team, there is also a group at the University of Calgary (led by Herb Emery and Lynn McIntyre) who have been looking at pensions and guaranteed annual incomes. One of the observations they have made from the CCHS data is that
Anything that an organization like CARRFS can help out with? I think it is important for people at the local level to start using these data. If indeed it turns out that the household weight is a problem for local level/health region analysis – then I think an organization like CARRFS can go to battle for it. If we were able to generate data on the local level, it would be very important as an informative action. It could be as simple as requesting that Statistics Canada can do a little more work on survey weights, which is not a huge ask. <> By Jostein Algroy
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Statistics Canada
The Canadian Community Health Survey requires substantial work and effort. Dr. Valerie Tarasuk explains some of the challenges in an interview with CARRFS eNews. When Statistics Canada runs a survey like the Canadian Community Health Survey (CCHS), they need to be cost efficient and minimize the time it takes, or what is called the “respondent burden.” Therefore they are always looking to do what is necessar y and not to do anything more. This is a difficult task as they have multiple agendas that they are trying to achieve with a single survey. And so, it has been a very long process to get the 18-item Household Food Secur ity Survey Module on this survey. For years, I have worked closely with the staff at Health Canada – the Office of Nutrition Policy and Promotion – which is involved in monitoring food insecurity, to try to get better questions asked on these surveys. The core question has been: how do we monitor the problem on a national level; and what is it that needs to be done? At the same time, my research group has been working to learn as much as we possibly could about food insecurity in this country from whatever questions did get included on national surveys. We published a paper on earlier questions of food insecurity based on the National Population Health Survey. In that survey, they used only three questions. Nevertheless, we managed to analyze the relationship between social demographic characteristics and health outcomes with some remarkable findings [Household Food Insufficiency Is Associated with Poorer Health, The Journal of Nutrition, 2003].
In 2001, I went on sabbatical and Health Canada contracted me to write a discussion paper on the issue of food security measurement [Discussion Paper on Household and Individual Food Insecurity, 2011]. The paper went through a peer review process and was translated into French. It became a working document for the government as they carried on the conversation on the measurement of food insecurity. In 2004, there was a special cycle of the CCHS that focused on Nutrition – including detailed dietar y intake measures. Because of the focus on nutrition we needed to do it right – meaning including food insecurity in the survey. That sets the precedent and there has been no looking back. The Household Food Security Sur vey Module is now mandatory content on the CCHS on alternate cycles, and I hope this will continue. Statistics Canada is preparing to do another focus survey on Nutrition in 2015. It is a smaller sample than the regular annual cycle of the CCHS survey, but invaluable insofar as it gives us a chance to look at the effects of food insecurity on people’s diets. I am part of an expert advisory group regarding the 2015 survey and was recently at a meeting where again, on the table were the questions: “Must we ask all the 18 questions on this module and can we produce a shorter module? If we must, must we measure food security? What do we learn by having it on the 2015 survey? Do we need to take that much time?” The answer of course, is YES – we have to measure it and we need to measure it properly. <>
“They [Statistics
Canada] are always looking to do what is necessary and not to do anything more.”
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Surveillance Facts
...
Part IV in a series about the Past, Present and Future of Public Health Surveillance. Written by Dr. Bernard Choi, Senior Research Scientist, Chronic Disease Surveillance, Public Health Agency of Canada and CARRFS eNews science writer. Past
Comprehensive analysis and interpretation was introduced by John Graunt (1620–1674), a haberdasher and serious amateur scientist in London, who analyzed the weekly bills and published in 1662 his book Natural and Political Observations Made upon the Bills of Mortality. For this work, he was subsequently elected a fellow of the Royal Society, whose members initially were uncomfortable with the idea of a haberdasher being elected. Graunt was the first to quantify the patterns of disease and to understand that numerical data on a population could be used to study the cause of disease. He was the first to estimate the population of London and to count the number of deaths from specific causes. John Graunt’s method of data analysis was to reduce voluminous data to a few perspicuous tables. Using this method, he was the first to recognize that there were more male than female deaths in London. He tried to interpret the findings and was able to explain the observation by noticing that there were more males than females by counting the number of births, and he suggested that this phenomenon in London should be searched for elsewhere. In Graunt’s words, “There have been Buried from the year 1628, to the year 1662, exclusivè, 209436 Males, and but 190474 Females: but it will be objected, that in London it may indeed be so, though otherwise elsewhere; because London is the great Stage and Shop of business, wherein the Masculine Sex bears the greatest part. But we Answer, That there have been also Christned within the same time, 139782 Males, and but 130866 Females, … What the Causes hereof are, we shall not trouble our selves to conjecture, as in other Cases, onely we shall desire, that Travellers would enquire whether it be the same in other Countries”.
Present
Data Collection – After defining the public health decisions that require information (data framework), the data collection stage begins by choosing the best sources and methods for gathering the data that are needed. This may need to balance competing needs for timeliness, simplicity, and completeness. Key data
collection approaches include the following: (1) Health Surveys. (2) Administrative Data. (3) Mandatory Reports. (4) Voluntary Reports. (5) Studies of Special Groups. Data sources vary from country to country depending on the stage of development and sophistication of public health services and laboratory facilities, and the availability of computers and computer networks. Advantages and disadvantages have been discussed of the various data sources for public health surveillance. Data Analysis/Interpretation – Surveillance data initially are analysed in terms of time, place, and person, by looking at time trends and geographic distribution and comparing age, sex, and population groups. More advanced data analyses for surveillance data are available. Examples include space-time clustering, time-series analysis, geospatial analysis, life tables, logistic regression, trend and small area analysis, mathematical models to study the dynamics of infection within communities of people, and methods for the forecast of epidemics based on surveillance data. Data analysis must be followed by interpretation. Interpretation involves consideration of whether the apparent increases in disease occurrence, within a specific population at a particular time and place, represent true increases. Understanding of the sources of possible study biases can help interpretation of results.
Future
Improving Methods of Data Collection – Telephone surveys have been a powerful tool for data collection. However, the use of telephone-based random-digit-dialling methods in public health surveys and surveillance is now at a crossroads. Rapid changes in telecommunication, declines in participation rates, increases in the required level of effort and associated costs are becoming key challenges for telephone surveys. It will be important to continue to improve existing methodology and develop new cost-effective and valid data collection methodologies for the future. Future surveys should collect physical measurements as part of its ongoing operation. Improving Methods of Data Collection – In future, standards need to be developed that are common to all datasets as well as unique to individual datasets. Examples include minimum lists of demographic variables and ICD codes, standardized codes for demographic variables, a minimum set of statistical tests, common definitions of statistical tests, and rules for minimum cell size suppression. <>
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CHRONIC DISEASE Indicator Framework ...
Public Health Agency of Canada (PHAC) has recently developed an Indicator Framework for Chronic Disease and Associated Determinants. CARRFS eNews talked with Dr. Gayatri C. Jayaraman, Associate Director, Chronic Disease Surveillance Division. Two years ago, the Centre for Chronic Disease Prevention, Public Health Agency of Canada (PHAC) began to discuss the need for consistent statistics to inform policy and programmatic decisions to prevent chronic diseases. The idea was to systematize the reporting of chronic diseases and associated determinants in Canada by providing consistent and reliable information of data .The Framework was originally meant as an internal tool for PHAC. But after a lengthy consultation process, both internal and external, it became clear that there was a larger need to provide high-level, easy to access data to public health policy analysts and practitioners involved in chronic disease prevention at the federal, provincial, territorial, and local levels. To help keep focused, the development team developed four guiding principles of the Framework.These are: - Life Course Approach – incorporating indicators for the various stages of life beginning before birth, through early childhood and continuing to the end of life so as to capture the impact of chronic diseases and associated determinants across one’s life span. - Chronic Disease Prevention – given the renewed focus on prevention, to identify actionable upstream indicators for risk and protective factors related with chronic diseases; - Health Equity – being able to identify social and environmental determinants of health so as to capture the fact that the burden of chronic diseases is unequally distributed in the population; - Multi-morbidity – to capture complex disease interactions and multiple risk factors associated with chronic disease. “Based on an extensive literature review process, we started out with well over 200 indicators. Far too many! But through consultations with experts - both internal and external - we were able to narrow the numbers down to about 70 indicators” says Dr. Jayaraman, Associate Director, Chronic Disease Surveillance Division. >>
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Indicator Framework (cont’d)
But the really hard analytical work had just begun. Not only (smoking, for example,) that will show various disaggregated did they have to find out what data would be available at the data in both charts and tables. pan-Canadian level, but they also had to go back to the ! What role could CARRFS play in the implementation original data source and figure out if the survey questions phase of the Indicator Framework? over time had changed.This was important as one of the “Our stakeholders play a very important part both in the basic functions with the design and the framework was to do trend implementation of the Indicator Framework: Main Components analysis.Through this Framework. this process, the team includes the CARRFS HEALTHY EQUITY APPROACH managed to whittle down network. I see the number of indicators CARRFS as our reality 1. Social and 2. Early Life/ 3. Behaviorial Risk to 41 – knowing that Environmental Childhood Risk and and Protective check as they do have Determinants Protective Factors Factors there are a few data gaps their ears to the within the mix. ground. We want to - Smoking - Physical Activity But the work was not make sure that the - Education - Birth Weight - Sedentary Behaviour - Income - Breastfeeding - Healthy Eating done. “As we moved indicators remain - Employment - Second-hand smoke - Unhealthy Eating along, it became clear - Alcohol Use relevant and in use.This - Chronic Stress that it was equally includes helping us to important to structure evaluate the 4. Risk Conditions 5. Disease Prevention 6. Health Outcomes/ Practices Status the framework around framework and its themes from which the usefulness over time - General Health (selfContact with Health reported health, LE, HALE) indicators are grouped” have the indicators - Healthy Weight Care Professional - Morbidity (prevalence) - Elevated Blood Glucose says Gayatri. - Disease Screening - Morbidity (incidence) been used, how have - Elevated Blood Pressure (colorectal, breast, - Multi-morbidity - Elevated Blood Cholesterol The themes and they been used, how cervical cancer) Disability Associated with - Metabolic Syndrome - Vaccination (influenza) Selected CDs indicators incorporated can we improve on - Mortality into the framework were: them?” Gayatri asks. (1) Social and As a pan-Canadian Environmental Determinants; (2) Early Life/Childhood Risk and network. Gayatri is keen to work with CARRFS in defining Protective Factors; (3) Behavioural Risk and Protective how the framework can be adopted to become more Factors; (4) Risk Conditions; (5) Disease Prevention Practices; relevant at the local level as well as to identify, define and and (6) Health Outcomes/Status (see table). develop types of analysis that would make the information A variety of data gaps were identified. “For example, under useful and relevant to those in the field. <> risk conditions, we included four main areas – which are By Jostein Algroy smoking, alcohol, unhealthy eating, and physical inactivity – but there are many more emerging issues that are really important such as environmental factors, vitamin D, sleep or lack thereof,” says Gayatri.. “We need to think through what they mean in relation to chronic disease prevention and how to report on them. To make the framework as useful as possible, the team developed a Quick Stats document - a hard and e-copy that charts out the 41 indicators.The Quick Stats provides highlevel information (without disaggregation). Disaggregation is available through an online tool via - “The Best Practice Portal” (see page17). It is anticipated that the online tool will be available in the fall.The drop-down menus allow users to select the indicators they’re interested in. Under risk behavior, there are 5 or 6 indicators from which one can select
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> MESSAGE > PROFILE > UPDATE
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Secretariat’s Message
Mary Lou Decou, CARRFS Project Lead, Public Health Agency of Canada gives a status update on CARRFS achievements over last quarter and what is in store for the CARRFS over the months. It is hard to believe that summer has come and gone since the last issue of the CARRFS eNews. It always feels like there is an opportunity to catch our breath and slow down over the summer and get energized to “rev-up” in the fall. This year is no different. We have lots of excitement in our CARRFS horizon. We have a new cochair with Dr. Ali Artaman. Ali has a strong breadth and depth of experience at the regional level so his ongoing contributions to the CCC and now as the co-chair are welcomed. Just prior to the deadline, a new chair for the CARRFS’s CCC was elected. We welcome Ms. Betty ReidWhite as the new Chair. An update will be provided in the next issue of CARRFS eNews. As mentioned in the last newsletter, CARRFS were required to meet accessibility requirements by July in order to maintain a web presence. Our strategy was to take a “phased-in” approach. The public-facing home page was the first to be addressed and we were able to remain “live”. Posted documents and the log-in portion of the site have been more labour intensive and they continue to be addressed. Microsoft SharePoint has been the solution for the login portion, and documents will be posted as they become accessible. Another area that we are excited to share with the network is a project that is being undertaken with PHAC. We are looking at the feasibility of applying PHAC’s Indicator Framework at the regional level. There are several steps to this project. In the newsletter, there is an interview with Dr. Gayatri Jayaraman, manager of the project. In September, Dr. Marisol Betancourt led an e-
learning session entitled “The Indicator Framework for the Surveillance of Chronic Diseases and Associated Determinants in Canada – Applicability at the Regional Level”. And finally, in the fall, focus groups will be held to discuss the feasibility further. We continue to keep training as a focus of the network. Members have expressed the value of the opportunities, the high level of presenters, and the appreciation of providing relevant topic areas. Bi-monthly e-learning sessions are a highlight of the activities. Based on the evaluation of the first eForum, a similar event is being planned for the spring of 2014. This one will be expanded and an international committee has the planning underway. Finally, we want to send out an invitation to the membership. We are always looking for fresh eyes and ideas for the work of the network. There are many opportunities and ways that you can put your stamp on things. We welcome members to participate on working groups and committees. We are always interested in articles for CARRFS eNews, presentations for the elearning sessions, and notes of interest that can be shared with the membership at large. If you would like to discuss further, don’t hesitate to contact one of the working groups’ chair or the secretariat. Look forward to connecting and sharing your ideas. Mary Lou Decou CARRFS Project Lead, PHAC Secretariat
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CARRFS Profile... To help build our community, the CARRFS eNew profiles a leading member in each issue. In this issue we profile Dr. Ali Artaman, Manager, Epidemiology, Surveillance and Research, Eastern Ontario Health Unit. What is your background? I have a varied educational background: general medicine, health administration and epidemiology. In the mid-1990s, I was primarily involved in clinical practice as a general practitioner and field physician in West Asia. In the late 90s, I participated in an international health internship program in Central Asia. The internship, funded by the Canadian International Development Agency, was related to HIV epidemiology. At that time, Central Asian countries had a very low prevalence rate but a relatively high incidence rate of HIV infection. This activity stimulated my interest in epidemiology and global health. In the early 2000s, I was a public heath consultant in Central Asia and the Caucasus. I worked with a number of medical and research centers, particularly cancer institutes, on system-level issues related to health information and data management. In the mid 2000s, while working on my master’s in epidemiology at Michigan State University, I coordinated a CDCfunded data centre for autism surveillance and research. Subsequently, I managed a large NIH-funded retrospective study in Michigan related to perinatal and childhood cancer epidemiology. In 2008, I started my work as an epidemiology manager in Essex County dealing with epidemiological issues related to the Great Lakes region. For over a year, I have been in Eastern Ontario – not too far from Ottawa. What inspired you to become an epidemiologist? Epidemiology is indeed a product of the marriage between statistics and medicine. It is a very interesting ambit for someone who has a broad spectrum of scientific interests, for a person who wants to learn both qualitative and quantitative methodologies of health research. While a graduate student in health administration, my mentors at the University of Ottawa encouraged me to pursue a graduate degree in epidemiology. I ended up completing a PhD in epidemiology in Michigan. What do you spend the most time on in your current position? A good part of my current job is about descriptive epidemiology. I have been working on data summary, disease surveillance and health status reports. The small team of epidemiologists I manage work with the data on >>
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CARRFS Profile (cont’d)
communicable diseases, chronic disease risk factors, child health, and program evaluation. We are also committed to providing support related to indigenous population health in the border region of Akwesasne. Another matter of interest to us is exploring the possibility of syndromic surveillance which requires real-time communication with various clinical institutions. Our other activities include access to new data sources, spatial epidemiology, and professional mentorship. What was your motivation to become a member of the CARRFS? Initially, I became a member of the Environmental Scan Working Group whose main task was to provide a snapshot of risk factor surveillance in various parts of Canada and other countries. For the past two years, I have had the pleasure of being a member, and most recently a co-chair, of the CARRFS Canadian Coordination Committee. I have met a number of wonderful professionals who are ambitious enough to discuss a possible national surveillance strategy and promote risk factor surveillance innovation. How do you see the current role of the CARRFS in Canada today? The CARRFS at minimum provides a networking opportunity for health professionals and any others interested to share knowledge of public health surveillance in general and risk factor surveillance in particular. The CARRFS is currently in transition from its infancy period while facing governance, budgetary and strategic challenges. We have discussed various options for working group structures, the format of national forums, functionality and publicity of the Website. What are the opportunities for the CARRFS? This grassroots network has been run with a relatively low budget, but with a considerable membership pool representing different geographic areas and health professional groups. The CARRFS has great potential to be a Canadian portal for the surveillance of disease risk factors. I am hopeful that this alliance can stimulate discussions around technical and administrative procedures which relate to the linkage between disease and risk factor surveillance. The funding issues, due to austerity measures, make it a challenge to drive a pan-Canadian network. A possible solution is to transform the CARRFS from an alliance having face-toface interaction to a highly virtual network. We also need to make sure that we reach out to any potential organizational partners to attract new members and seek support towards the mandate of the CARRFS. <>
Call for Interest Are you interested in and available to contribute to setting strategy for CARRFS ? Do you have time to volunteer? We are looking for members for the working groups (training, tools & resources, and surveillance innovation) and the coordinating committee. These are two-year terms. Each group has a specific focus. The Training Working Group coordinates opportunities including bi-monthly e-Learning sessions and an eForum which will be informed by an updated needs assessment. The Tools and Resources Working Group identifies what tools and resources are out there and how to link those who “have” with those who “need”. They are looking at creative ways to make it easier to connect – including more use of our Twitter account and other networking options. The Surveillance Innovation Working Group is still in its initial stages, and there are opportunities to influence the direction that this group takes.The Coordinating Committee provides advice on the operation of CARRFS, and takes the lead in specific areas including the e-Newsletter and web presence. We have openings and would be pleased to hear from you if you want additional information, would like to nominate a colleague, or volunteer yourself. The strength of CARRFS lies in its membership: We encourage your contributions! <>
By Jostein Algroy
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Update...
Updates from each CARRFS Working Group Chairs on recent activities. All working groups need members. Please get in touch with the Chair or a member of the working group and join! Training Working Group
Tools and Resources Working Group
As we enter the fall, lots of activities are underway for CARRFS. The bi-monthly e-Learning sessions started again at the end of September. In the first session Dr. Marisol Betancourt gave details about “The Indicator Framework for the Surveillance of Chronic Diseases and Associated Determinants in Canada”. Plans are underway for the November e-learning session. There are two areas CARRFS members should watch for in the fall. First, plans are underway to survey the network for information on how we are doing and what areas we should focus on as we go forward. Second, we are organizing another e-Forum. The evaluation of the first e-Forum indicated that this format was a good fit for CARRFS members – as details unfold, we will get the information out to you. <>
The Tools and Resources Working group is working on updating and refreshing the list of organizations and the relevant contact people, that are engaged in risk factor surveillance. This will continue to provide those working in Risk Factor Surveillance an quick and easy way to have a comprehensive list of organizations collecting these types of data and whom to contact. In addition, the Tools and Resources working group continues to use Twitter as a quick and fun way of engaging its members and providing them with updates on what is current in public health. <>
CARRFS Committees Canadian Coordination Committee (CCC)
Chair: Co-Chair:
Betty Reid-White Ali Artaman
MANDATE CARRFS is a network of public health stakeholder interested in working together to build capacity for regional/local area chronic disease risk factor surveillance in Canada that will be used for chronic disease prevention and control.
Tools and Resources Working Group (TRWG)
Chair: Co-Chair:
Ahalya Mahendra Vacant
Training Working Group (TWG)
Chair: Co-Chair:
M. Nawal Lutfiyya Vacant
VISION
MISSION
A sustainable and effective regional/local collection, analysis, interpretation and use of risk factor data to inform program and policy decisions in Canada.
To build and strengthen the capacity for regional/local risk factor surveillance in Canada.
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Hello & Goodbye...
This is the place to welcome new members to the CARRFS Steering Committee - The Canadian Coordinating Committee (CCC) and honour those who have to leave the committee to pursue or fulfill other commitments. Michelina Mancuso Welcome to Michelina Mancuso as the newest member of the CCC. Mickey is the Executive Director, Performance Measurement of New Brunswick Health Council. Mickey has been involved with CARRFS since before its inception. She was involved with the original Think Tank Forum and was a member of the panel presentation at that time. Mickey was a very active member of the Environmental Scan Working Group and her contributions were significant to the successful completion of that group`s mandate. Mickey is chair of the Surveillance Innovation Task Group and her thoughtful leadership has been instrumental in guiding all the activities to date. She recently joined the CCC and her direction has already been significant in the restructuring of the Surveillance Innovation Working Group into a more focused task group. We are looking forward to Mickey`s insights and contributions at the CCC table. Mary Lou Decou, Public Health Agency of Canada
Dan Otchere Goodbyes are one of the hardest things about life. But that is also a part of life. People will have to leave and move on. For Dan, this is not a goodbye. It is an encounter. I came to know Dan in 1995 when I was “borrowed” by the Faculty of Dentistry of the University of Toronto (from the Faculty of Medicine) to teach epidemiology to dentists. Dan was a public health dentist working out of the City of North York Health Department. We met and collaborated in dental research at the University of Toronto. In 2008, when we were planning the Think Tank Forum (which subsequently led to the creation of the CARRFS). Dan participated actively in the organizing committee. After CARRFS was created in fall of 2008, Dan became a member of the CCC. He made significant contributions to the formulation of approaches to support regional risk factor surveillance. He initiated an environmental scan for risk factor surveillance activities in Canada, and co-chaired the CARRFS Environmental Scan Working Group which developed the charter and implementation of the project. He has recently stepped down from being the chair of the Surveillance Innovation Task Group; but he will continue to be an active member of the Group and an active CARRFS member. When I recently spoke with Dan, he said “working on the CCC has been fun and very educating”. His torch is now passed on to other members of CARRFS. Dan has these encouraging words: “Although I shall miss working on the CCC, I do not regret my leaving because all the members are only a phone call/email away. So it seems I am still there but in a different form.” Bernard Choi, Public Health Agency of Canada
Send us your Story We urge all members to send us articles for upcoming editions. Since we are promoting a bilingual newsletter, articles will be published in the language they are submitted - English or French. Please submit your story to the CARRFS eNews Editor in Chief at jostein@sympatico.ca. 24