www.carrfsenews.ca
Volume 5 Issue 1 Winter 2015
CARRFS eNews
Canadian Alliance for Regional Risk Factor Surveillance - Quarterly eNewsletter
CARRFS Feature Early Childhood Development:
Probing Early Life Risk Factor Surveillance
CARRFS Interview
Child Hunger Dr. Lynn McIntyre Professor, University of Calgary, Alberta
CARRFS Profile
John Cunningham Epidemiologist, Leeds, Grenville & Lanark District Health Unit, Ontario
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
CONTENTS in this Issue... Early Childhood Development: Probing Early Life Risk Factor Surveillance 6 CARRFS eNews explores a range of issues associated with Early Childhood Development and Risk Factor Surveillance. By PAUL WEBSTER
From Society to Cells 12 CARRFS eNews explores the latest science in epigenetics and its impact on childhood development. By JOSTEIN ALGROY
CARRFS Interview 14 Dr. Lynn McIntyre talks to CARRFS eNews about child hunger and its effect on a person’s general health later in life. By JOSTEIN ALGROY
Surveillance Facts 18 Dr. Bernard Choi, Public Health Agency of Canada,
CONTRIBUTORS Jostein Algroy, Editor-in-Chief Steven Frei, Senior Copy Editor Paul Webster, Health Science Writer Dr. Bernard Choi, Science Writer Mary Lou Decou, Senior Writer Betty Reid-White, Canadian Coordination Committee, Chair
PAN-CANADIAN EDITORIAL ADVISORY BOARD Jostein Algroy, Editor-in-Chief Paul Webster, Health Science Writer Anne Simard, Chief Public Affairs Officer, Public Health Ontario 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 Larry Svenson, Director, Alberta Ministry of Health Dr. Drona Rasali, Director, British Columbia Provincial Health Services Authority
provides Part VIII of his series on the evolution of Public Health Surveillance. By BERNARD CHOI SECRETARIAT SUPPORT
CARRFS Profile 22 The CARRFS Member Profile: John Cunningham, Manger, Leeds, Grenville & Lanark District Health Unit, Ontario. By JOSTEIN ALGROY
Public Health Agency of Canada Mary Lou Decou
PUBLICATION CARRFS eNews is a quarterly newsletter for the Canadian Alliance for Regional Risk Factor Surveillance (CARRFS) and is published in Winter, Spring, Summer, and Fall.
Table of Contents From the Editor ................................................................. page 3 News & Trends Canada .................................................... page 4 News & Trends International ............................................. page 5
CARRFS WEBSITE URL: www.carrfs-acsrfr.ca
Probing Early Life Risk Factor Surveillance ……………… page 6 Canadian CHILD Study ………………………..………… page 10 Early Childhood Development: From Society to Cells ...... page 12 CARRFS Interview: Dr. Lynn McIntyre ............................... page 14 Surveillance Facts .............................................................. page 18 Chair’s Message ................................................................ page 21 CARRFS Profile: John Cunningham …………………….. page 22 Hello & Goodbye ................................................................. page 24
Photo Credits: Cover Photo: iStock_48702872
Photo page 6: iStock_18165985
Photo page 12: iStock_52206146
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.
2
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
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 take a closer look at Early Childhood Development and Risk Factor Surveillance. Last Fall, to coincide with the National Child Day 2014, the Royal College of Physicians and Surgeons of Canada warned that Canada was not doing enough to support early childhood care and learning. Currently Canada spends only 0.6% of its GDP on early childhood care and learning, trailing France, Sweden and most other industrialized countries, and falling below the 1% benchmark set by the Organization for Economic Cooperation and Development. Given increasing evidence linking early childhood development and chronic diseases in adulthood, Canada needs to do more to support young children’s healthy development.
Dr. McIntyre points out that psycho-social stress–the mental health deprivation that comes from an impoverished environment–causes enormous harm. And coming home with a couple of bags from a food bank will not mitigate the stress, nor will it meaningfully reduce child hunger in Canada. It is clear that we must care about early childhood risk factors. Better information about child development in relation to lifetime chronic diseases is a key objective for public health. We hope you enjoy this issue of CARRFS eNews. Jostein Algroy Editor-in-Chief
And as Paul Webster’s article “Probing Early Life Risk Factor Surveillance” in this issue of CARRFS eNews reveals, work must also be done to address the national deficiency in surveillance of children under the age of five—the most formative years in a person’s life. According to Dr. Paul Roumeliotis, Medical Officer of Health at the Eastern Ontario Health Unit, the early development of healthy neural networks in the brain is vital for a long and healthy life. In our interview this issue, Roumeliotis points out, based on the latest science in epigenetics, that children who have been exposed to adversity in the form of abuse, violence, toxins, stress or simply day-to-day neglect in early childhood tend to develop chronic diseases later in life at a higher rate than children who have grown up in a positive environment surrounded by “tender loving care.” Extreme poverty, lack of adequate housing, hunger and inadequate food also take a huge toll on children, notes Dr. Lynn McIntyre of the University of Calgary.
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 idea or story to jostein@sympatico.ca.
3
C A N A D A
News & Trends
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
10 Years after the Edmonton Charter The University of British Columbia will be hosting the 2015 International Conference on Health Promoting Universities and Colleges at its Okanagan Campus in Kelowna from June 22 to 26, 2015. The conference entitled “10 Years after the Edmonton Charter” will look back on what has been learned since 2005 when the Edmonton Charter for Health Promoting Universities and Institutions of Higher Education was established. The conference will also provide updates on regional and global network activity, relationship building and the design of a new Charter. The conference aims to create a dynamic meeting place for researchers, practitioners, administrators, students and policy-makers from around the world to explore pressing issues and identify promising paths for healthy and sustainable campus development. Some conference themes are: Population Health, Community Health and Sustainability; Health and Place; Development of Knowledge, Policy, Practice and Evaluation; Communication Technologies, Networking and Education; and Campuses as Health Promoting Settings and Communities.
Canadian Obesity Summit April 2015 The Canadian Obesity Network (CON) and the Canadian Association of Bariatric Physicians and Surgeons (CABPS) are planning the fourth Canadian Obesity Summit in Toronto, from April 28 to May 2, 2015. The annual summit, which normally attracts over 1,200 health professionals, researchers, and policy makers, is a research conference with separate tracks for health practitioners and an array of inspiring workshops. Conference themes include: Prevention and Public Health; Psychology & Mental Health; Environments Conducive to Healthy Lifestyles; Diet, Physical Activity & Healthy Living; Advertising to Children & School Programs; and Molecular Biology, Genetics & Physiology.
CIHI’s Analytical Plan 2014 to 2016 The Canadian Institute for Health Information (CIHI) has launched a new website that allows Canadian hospitals, health regions, provinces and territories to compare how they measure up on 37 indicators. These relate to access, quality of care, patient safety and emerging health trends across Canada. The tool provides comparable and interactive data so that hospitals, regions, and the provinces and territories can compare themselves with peer groups and the pan-Canadian average. The data sets include: Social Determinants; Health Status; Appropriateness and Effectiveness; and Safety and Access. This data should help health systems work more efficiently, safely and transparently. The website can be found at: http://yourhealthsystem.cihi.ca
4
News & Trends International
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
Maximizing Healthy Life Years Bain & Company recently released their Insights Report titled: Maximizing Healthy Life Years: Investments that Pay Off [http://www.bain.com/about/press/pressreleases/future-of-healthy-2015-press-release.aspx]. According to the report, noncommunicable diseases (NCDs) are a key threat to a population’s health and therefore to a country’s economic growth and competitive advantage. An unhealthy population is expensive. Globally it is estimated that $47 trillion of cumulative output will be lost between 2012 and 2030 as a result of NCDs and mental disorders. The report stresses that healthy populations should be seen as an investment rather than a cost. Even minor health-related policy changes can reap large economic rewards. In Singapore, for example, officials estimate that a program subsidizing healthier cooking oil for use in meals outside the homes will not only reduce coronary heart disease by 2020 but will generate an ROI (return on investment) of 1,100%.
The 2015 WARFS Global Conference in Antigua The 2015 WARFS (World Alliance for Risk Factor Surveillance) Global Conference will be held in St. John's, Antigua (Caribbean) November 17-20, 2015. Themes of the conference include (1) the role of big data and innovative technology in future surveillance, (2) tracking of positive health, and (3) global inequity in surveillance capacity. WARFS is the Global Working Group on Surveillance under the International Union for Health Promotion and Education (IUHPE). It supports the development of behavioural risk factor surveillance (BRFS) as a tool for evidence-based public health, acknowledging the importance of this information source to inform, monitor and evaluate disease prevention and health promotion policies, services and interventions. Dr. Bernard Choi of CARRFS is on the WARFS International Scientific Committee to plan for the program of the 2015 WARFS Global Conference. For further information please visit the WARFS http://www.warfs15.com. The WARFS website has a link to the CARRFS website. http://www.warfs.info/links.html. by Bernard Choi
Redefining Mental Health Late last year the British Psychological Society released a report “Understanding Psychosis and Schizophrenia” which explored alternative ways of talking about certain experiences that have traditionally been described as symptoms of mental illness. According to the report, experiences such as schizophrenia or psychosis could, under certain circumstances, more helpfully be described using a psychological approach which sees the experiences as more akin to anxiety or shyness rather than as mental disorders. In the United Sates, the National Institute of Mental Health, which funds most of the research on mental illness in the US, is exploring new ways of classifying mental disorders such as depression and schizophrenia which under traditional classifications are seen as distinct biological diseases. The Research Domain Criteria project applies modern research approaches in genetics, neuroscience and behavioural science to the study of mental disorders, empathizing the interaction of neurodevelopment with the environment. The importance of the environment on neurodevelopment suggests that social experience has a significant impact on mental illness. This in turn implies that mental illness requires social intervention as well as traditional methods of treatment.
5
CARRFS eNews
www.carrfsenews.ca
CARRFS Feature...
Volume 5, Issue 1, Winter 2015
Probing Early Life Risk Factor Surveillance
6
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
CARRFS Feature...
Early Childhood Development
For Children Under the Age of Five, We Do Far too Little
Paul Webster explores a range of issues associated with Early Childhood Development and Risk Factor Surveillance. “It’s estimated that by the end of childhood, 40 percent of Canada’s children are dealing with complications of overweight or obesity, asthma, injury, behaviour problems or learning difficulties,” says Dr. Jonathon Maguire, a pediatrician and researcher at the Li Ka Shing Knowledge Institute of Toronto’s St. Michael’s Hospital. But Maguire’s warning extends far beyond children’s health. Because health in childhood presages health in adulthood, he emphasizes, the implications of Canada’s child health crisis will resound for decades to come. “Unknowingly,” Maguire laments, “we are marching our children down a thorny path to a battle with adult chronic disease.” Maguire’s worries are well-grounded in data from numerous large, long-running surveillance efforts monitoring the health of Canadian children. These include the Canadian Community Health Survey and the Canadian Health Measures Survey, which are both coordinated by Statistics Canada, as well as The Public Health Agency of Canada’s Health Behaviour in School-Aged Children Study and the Canadian Pediatric Surveillance Program, which involves a network of 2,500 pediatricians probing rare conditions. It’s a respectably comprehensive mix, Maguire acknowledges. But it suffers from a gaping deficiency, he warns. “Although we do a good job gathering information about kids over the age of five, when it comes to >> 7
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
CARRFS Feature... CARRFS Feature (cont’d) surveillance of children under the age of five, we do far too little. And we know now that much of what happens through one’s life is set up in the first five years.” To help overcome the dearth of detailed health data for children under five, Maguire and a small number of other ambitiously innovative Canadian researchers have launched probes into early-life risk factors for a broad suite of diseases ranging from diabetes to depression. It’s not an easy task. Doing it requires close collaboration with very young children and their families in the face of logistical, emotional and legal barriers that deter surveillance of very young children. These barriers can prove defeating: Just months ago, the US National Institutes of Health cancelled an ambitious, multi-decade study of environmental influences on children's health after spending US$1.2 billion on the effort and enrolling roughly 5,700 children in a pilot study at 40 centres. One of the key problems that defeated the study was the difficulty of recruiting children and families. In Toronto, Maguire helps lead two major studies probing early-life risk factors. The first of these is TARGet Kids!, a Canadian Institute for Health Research-funded effort involving 7,000 newborn children enrolled with 50 physicians. So far, says Maguire, the study has generated 25 published articles. Some of the most interesting work has focused on nutrition. Maguire’s co-investigator Dr. Patricia Parkin, who is research director with the pediatric outcomes research team at The Hospital for Sick Children in Toronto, has found that more than 15 percent of children under five suffer from iron deficiencies likely stemming from overconsumption of cows’ milk – with between one and two percent suffering iron deficiency anemia significant enough to impact brain development. “The gap in data on this topic was pretty substantial,” says Parkin. “There are simply no national data on iron deficiency in children. The TARGetKids! study is amassing good data on this now.” Catherine Birken, another researcher at The Hospital for Sick Children, serves alongside Maguire and Parkin as a co-leader for the TARGetKids! study.
Her focus is on childhood obesity. Once again, she says Canada lacks national data for very young children on this issue. “We’re doing a terrible job collecting national numbers,” Birken complains. Through TARGetKids!, Birken aims to address this deficiency. “We’re gathering longitudinal growth data on the kids enrolled in the study, and very deep information on child health behaviours including screen time and sleep patterns.” The key to the TARGetKids! study, Parkin, Maguire and Birken all agree, is the integration of family physicians into the project. This allows the TARGetKids! team to use “fly on the wall” techniques to gather data collected from children during routine appointments and checkups – an approach Maguire refers to as “practice-embedded” and one that takes advantage of the fact that “kids go to the doctor all the time.” Although the study largely relies on routine data, it also gathers data from non-routine sources such as blood samples, Parkin notes. “We’re not aware of any other studies of this sort which are embedded in primary care settings,” she adds. But TARGetKids! aspires to do more than simply track data gathered during children’s encounters with doctors. Within the framework of a second study known as the Ontario Family Health Study, clinical data from the TARGetKids! cohort is being meshed with administrative data from the Ontario Health Insurance Plan as well as with data from two large studies of Ontario newborns. The hope, says Maguire, who co-leads the Ontario Family Health Study, is to expand the cohort to a total of 20,000 children in order to “reconstruct early childhood and probe the roots of disease” utilizing data from what he describes as one of the “largest, most comprehensive and technologically sophisticated pregnancy and early childhood cohorts in the world.” The long-term goal, explains Laura Anderson, a research fellow with both TARGetKids! and the Ontario Family Health Study, is to follow the >>
“…Canada lacks national data for very young children…We’re doing a terrible job collecting national numbers.”
8
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
CARRFS Feature (cont’d) children though infancy and childhood in order to investigate “the gene-environment interactions that establish developmental trajectories to health, learning and social functioning.” By using advanced technologies to “predict sub-optimal human potential and expose early causal pathways and relationships in the first 4 years of life,” says Anderson, she and the other researchers involved hope “to develop interventions that can be applied to children early in life to take advantage of the plasticity of a child’s developmental systems.” Although the Toronto-based Ontario Family Health Study and TARGetKids! are the most ambitious efforts to track early childhood risk factors yet attempted in Canada, several other important studies are underway elsewhere in the country. The longest-running of these is the Quebec Longitudinal Study of Child Development, which began tracking a cohort of more than 2,000 children from their births in 1998. Focusing on themes in social, mental and physical health, this study has generated hundreds of journal articles, MA and PhD theses and research reports. Data from the first phase of the study (1998-2002) enabled researchers to evaluate the influence of family, child care and the broader social environment, alongside studies of motor, social and cognitive development, behaviour, diet, and sleep. Data from the second phase of the study (2003-2010) yielded reports on vocabulary acquisition, school readiness and adjustment to the school environment, physical activity and health, help with homework, summer child care, excess weight in children, diverse and changing family structure, child care, sleep, motivation, peer victimization, and predicting academic achievement. A third phase of the study launched in 2011 aims to examine themes in adolescence including work-school-play balance, romantic relationships, risky behaviour (smoking, alcohol and drug use, gambling), school motivation and educational aspirations, bullying, school violence and dropping out.
Three other studies currently underway also promise to widen understanding of early-life risk factors for chronic diseases. In Alberta, the Alberta Pregnancy Outcomes and Nutrition (APrON) study has been tracking the role of nutrition in mental and neurodevelopmental disorders and long-term neurocognitive function in a cohort of 2,300 women since 2013. The focus areas so far have largely been postpartum depression and the impacts of breastfeeding. In Hamilton, Ontario, the Canadian Healthy Infant Longitudinal Development Study (CHILD) is probing the root causes of allergies and asthma, including genetic and environmental triggers and the ways in which they interact from pregnancy through childhood, in 3,629 families. The aim is to probe a suite of risk factors, including some which are already wellrecognized such as trafficrelated air pollution, dust mites, and cockroaches, as well as newer hypotheses, including semi-volatile organic compounds such as phthalates. On a similar theme, at Health Canada in Ottawa, the Maternal-Infant Research on Environmental Chemicals (MIREC) study has recruited close to 2,000 women from cities across Canada during the first trimester of pregnancy. The study measures the extent to which pregnant women and their babies are exposed to environmental chemicals, as well as tobacco smoke, to assess what health risks, if any, are associated with exposure to elevated levels of environmental chemicals. Although smaller in number of participants than several international studies, this study has one of the most extensive datasets on prenatal exposure to multiple environmental chemicals in the world. <>
“…the Toronto-based Ontario Family Health Study and TARGetKids! are the most ambitious efforts to track early childhood risk factors yet attempted in Canada…”
9
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
Ontario Mental Health Report 2012
Canadian CHILD Study Canadian Healthy Infant Longitudinal Development (CHILD) Study’s purpose is to understand the root causes of allergy and asthma including genetic and environmental catalysts. The results from this study should provide significant and measurable knowledge which can be used to help reduce the number of children who develop life-long allergy and asthma disorder.
THE MAIN HYPOTHESIS OF THE CHILD STUDY AND 7 SUB-HYPOTHESES The development of childhood asthma is dependent on the interactions of genetic predisposition and critical prenatal and early childhood environments including physical and microbial environments, nutrition, infections and social environment (socioeconomic status and stress). 1 Innate immunity
Early life innate immune responses determine the onset of adaptive immune driven atopy and asthma.
2 Nutrition and Intestinal Microbiome
Pre-natal and post-natal nutrition and intrapartum care affect the development of childhood asthma through changes in the developing immune system and intestinal tract microbiome.
3 Infant Lung Function and Infection
Development of asthma is directly related to lung function in early childhood and the impact of viral infections on the lung.
4 Psychosocial
Early childhood socioeconomic status, through life stressors, material deprivation, and inadequate living conditions, interacts with the physical environment and genotype to influence the development of asthma.
5 Exposures
The impact of the physical environment on the development of childhood allergy and asthma, through modulation of the developing immune system, can be explained by exposures that collectively contribute to chronic inflammation via oxidative stress pathways. The Physical Environment: Indoor Air: Multiple exposures have been associated with wheeze.
6 Genetics
Specific gene-environment interactions predict the development of allergic and asthmatic phenotypes.
7 Epigenetics
Epigenetic mechanisms mediate the effects of early life environments to persistently alter the expression of genes and functions of cells critical to the development of allergic diseases and asthma.
Source: canadianchildstudy.ca
10
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
Ontario Mental Health Report 2012
Canadian CHILD Study CHILD Methods by Topic Methods
Summary
Clinical assessments
Clinical assessment of infants at 1, 3 and 5 years in entire cohort. Birth anthropometric data extracted from birth chart. Anthropometric measures made at 3 month home visit. Anthropometrics, skin testing and clinical exam occur in a clinic setting (1, 3 and 5 years).
Nutrition and Intestinal Microbiome
Vancouver and Toronto sub-cohorts: innate immune function is assessed using cord blood samples.
Adaptive immune function will be assessed in child blood samples collected at 1 and 5 years using high-throughput, multiplexed analyses.
Nutrition
Pre-and post-natal nutrition in mothers and children collected by questionnaires and FFQs.
Breast-feeding questionnaires and breast milk collected (3 months).
Microbiome
Child stool is collected at birth (meconium), 3 months and 1 year for microbiota profiling.
Respiratory Infections
Toronto sub-cohort: respiratory symptom diary, biannual time -activity logs, health questionnaires; nasal swabs (3 months, at 1 year and during acute viral lower respiratory infection in first year). Full CHILD cohort: nasal swabs (3 months, 1 year).
Pulmonary Function Testing
Toronto sub-cohort: lung function assessed using raised volume rapid thoraco-abdominal compression and multiple breath washout (birth, 3 months, 1 year and 2 years), and spirometry (4 years). Entire CHILD cohort: lung function assessed using spirometry 5 years.
Psychosocial, Stress, SES
Standardized detailed pre-and post-natal assessments focused on family's socioeconomic (SES) status, stress present in the home, and the quality of the parent-child relationship.
Environmental exposure assessments
Comprehensive questionnaires (3 months, 1, 3 and 5 years) along with biannual updates (time-activity, smoking and changes in residence).
Home assessment at 3 months with dust sampling (for analysis of allergens, endotoxin, mould, air pollution, phthalates) and questionnaires;
Smoke exposure assessed by questionnaires, urinary cotinine measurements.
Source: canadianchildstudy.ca
11
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
Early Childhood Development:
From Society to Cells Recent research has discovered that the environment shapes the way genes are activated and expressed. Early childhood is a very sensitive period in human development; it is during the first two to three years that the brain and, especially, the circuitry that governs attention, emotion, self-control and stress are formed. 12
CARRFS eNews
www.carrfsenews.ca
In November 2014 the Royal College of Physicians and Surgeons of Canada (RCPSC) warned that Canada is not spending enough on early childhood care and learning. Citing a recent OECD (Organization of Economic Cooperation and Development) study in which Canada trailed most other rich countries, the College recommended that the Federal government boost its current spending on early childhood care and learning from 0.6 percent of GDP to the OECD-recommended one percent of GDP, and far from the Nordic countries which spend close to two percent of GDP on early childhood development. A 2006 OECD report placed Canada last in spending on early childhood programs, leading to a study initiated by the Senate Committee on Social Affairs Science and Technology and , culminating in the 2009 report “Early Childhood Education and Care: The Next Steps”. The report recommended that the Government of Canada collaborate with the provinces and territories to “create an adequately funded, robust system of data collection, evaluation and research, promoting all aspects of quality human development and in early childhood programming including the development of curricula, program evaluation and child outcome measures”. While Canada’s commitment has progressed since 2006, the recent RCPSC recommendation is made in light of compelling evidence that chronic diseases often have their roots in the early years of childhood. “We do know today that something happens to the development of the children who have been exposed to adversity in the form of abuse, violence, toxic stress or simply day-to-day neglect in their early childhood. The exposure to significant stress—either prenatal or postnatal, can have long term consequences seen decades later, including higher rates of metabolic syndrome (hypertension, cardiovascular diseases, diabetes), mental health issues or even cancer”, says pediatrician Dr. Paul Roumeliotis, Medical Officer of Health and CEO for Eastern Ontario Heath Unit and author of the newly released book Baby Comes Home: A Parent's Guide to a Healthy and Well First 18 Months. “So something is obviously going on”, adds Roumeliotis. This ‘something’ can today be explained from a biological and neurological perspective. Exposure to toxic or chronic stress, i.e. “non-physical” environmental factors, influences the heritable state in gene expression without altering the DNA sequence. These are called epigenetic changes. Close to 20,000 human genes have been identified. Cells use a system that regulates how genes are expressed, with ‘switches’ that turn genes on and off. It is
Volume 5, Issue 1, Winter 2015
believed that this genetic control system determines what a cell can do, and can potentially shape what diseases an individual may be prone to. Changes in gene expression can manifest themselves as disease later on in life, but can initially go undetected. Furthermore, these epigenetic changes can be passed on from one generation to another. In addition to epigenetic changes, exposure to adverse events during early brain development and sculpting can affect the body’s sophisticated hormonal control system (HypothalamicPituitary-Axis - HPA). The primary hormonal mediators of stress responses have both protective and potentially damaging effects on the body. These “stress” hormones are essential for adaptation, maintenance of homeostasis, and survival in the short run. However, if the HPA is misdeveloped due to external adverse events, such as lack of bonding and nurturing during infancy, the stress hormone response will be abnormal. The presence of these abnormally regulated and consistently high stress hormones represents an “allostatic load” that can accelerate disease process in the long run. Allostasis due to aberrent brain responses to environmental stress factors can affect the body at the tissue level, resulting in the generation of various chronic diseases. If a baby is exposed to negative environmental factors in the form of violence, poverty, lack of adequate housing, hunger and inadequate food (also see the interview with Dr. Lynn McIntyre in this issue) this increases stress hormones and the overburden of steroid, cortisone, and adrenaline, leading the cells to turn off the system’s building blocks – the proteins. This alteration of DNA-binding and regulatory proteins can be passed on from one generation to the next. “The long-term allostatic load effects and epigenetic changes actually originate during a neglected baby’s first sensitive years,” says Dr.Roumeliotis. “A negative environment will not only impact their learning ability and academic success, as their neural network will not develop properly, with the risk of failing in school and later in life. But notwithstanding the psychological effects, we now understand that early exposure to negative environments also has long-term biological adverse effects on humans.” <>
“Changes in gene expression can manifest themselves as disease later on in life, but can initially go undetected. Furthermore, these epigenetic changes can be passed on from one generation to another.”
By Jostein Algroy
13
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
CARRFS Interview...
Child Hunger Dr. Lynn McIntyre
Professor, University of Calgary, Alberta
In this interview with CARRFS eNews, Dr. McIntyre describes how hunger and severe food insecurity 14 in children has life-long consequences.
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
CARRFS Interview... How would you define child hunger? The actual term that we use in Canada and the United State is Food Insecurity - which is simply defined as lack of access to food due to financial constraint. There is a gradation of food insecurity— from marginal to moderate to severe: A marginally food insecure household is one worrying about running out of food; a moderate would have some diet quality issues associated with the food that they are able to acquire; and a severely food insecure household is really the one that has to do with deprivation. What we think about as child hunger is a child that lives in a household with severe food insecurity. It means that the child is food deprived—maybe skipping meals, maybe not eating for the whole day, and certainly having to compromise in both the quantity and quality of food. When I use the term child hunger in my research I refer explicitly to the parents that actually answer yes to a specific question: “Has your child ever experienced being hungry because the family has run out of food or money to buy food?” This question is from the National Longitudinal Survey of Children and Youth (NLSCY) and is thus very specific to that particular “state”. Otherwise the preferred term is child-level severe food insecurity.
studies in Canada show little difference between children living in food secure and food insecure households. For children, the health harm does not seem to be through nutritional deficiencies but rather the experience of food insecurity is a psycho-social stress associated with anxiety, worrying and tension. It is important to make a distinction between “first world” and “third world” hunger. We have been able to show that in Canada, instances of actual nutrient deficiencies are few. “Stunting” for example, is pervasive in lower income countries where it is very much nutrition and infection associated. In higher income counties, child poverty has different results. It appears to be the stress that comes from an impoverished environment that is the main factor that causes harm. Stress manifests itself physiologically (see article From Society to Cells). Chronic stress seems to influence the neural circuitry of the child and can create long term epigenetic changes. We have been exploring that hypothesis with our NLSCY data and can show why depression, but not selfesteem and other kinds of capabilities, is higher in children that have experienced hunger. In other words, severe food insecurity is created sociologically, but has physiological effects. We need to recognize how dangerous it is to have children experience severe food insecurity in their households and we need to understand that giving them a little bit of extra food cannot undo that. Child poverty to the point of child hunger has to be addressed as it is totally unnecessary. In fact it does not require a lot of money to keep a family out of severe child food insecurity (see sidebar Cost of Poverty).
“We need to recognize how dangerous it is to have children experience severe food insecurity in their households and we need to understand that giving them a little bit of extra food cannot undo that.”
How do you actually measure it? Canada, the United States and many other countries have adopted the same measurement tool, namely the Household Food Security Survey Module. For households with children, it contains 18 questions that are answered in a phased approach ending with deprivation. The NLSCY with its single question on child hunger predates this instrument. How does food insecurity manifest itself in bad health? Food insecurity for children and adults is very much related to health—and particularly poor health and poor mental health. The results of nutritional intake
Isn’t the Food Bank network a good compensation or substitute for food insecure families? Absolutely not and never! One must be absolutely clear that food is not what is required in a household that is food insecure. Income is what is required. The discretionary income is used to buy food and it is the only flexible part of the budget which is why it is >>
15
CARRFS eNews
www.carrfsenews.ca
CARRFS Interview (cont’d)
compromised in households that can barely meet their needs for shelter, transportation, heating and other necessities. We know that one-third of food insecure households never seek help from a Food Bank for a variety of well documented reasons ranging from lack of access to stigma to pride. Coming back from the Food Bank with a couple of bags does not change the social stress. Food Banks provide very few meals in relation to what is required throughout a month. It is a place of last resort—and people who use the Food Bank really need it. But the Food Bank has absolutely no curative effect on whether the children are being harmed by food insecurity. And the health effect from food insecurity is not going to be mitigated or reduced by Food Banks.
Volume 5, Issue 1, Winter 2015
is not means- tested, one is not judged. It is not about being on welfare. It is a universal entitlement and gives one the ability to meet basic needs. The health gains alone will easily pay for such a solution. When you measure food insecurity - how do you make sure that the answers you get are valid–that the respondent due to pride or other reasons will not admit that their children go hungry therefor will not answer those questions “truthfully”? A huge amount of work has gone into the process ensuring both the validity and reliability of household food insecurity measurement. The Household Food Insecurity Survey Module comes with a built-in progression of questions—for instance, if you answer yes to the question “do you worry about running out of food?” we will then go to the next question, and it does have a screener. It is done either through face-to-face or over the telephone. It is not selfadministered. These surveys are done in trusting and safe conditions with confidentiality and they have been reproduced in millions of households where they have been answered by the person with the best knowledge of the household. In one of the studies that we published, we realized that some females in married households reported more food insecurity than the husbands in a very similar household—the difference in food insecurity it revealed is not likely a result of true versus false reporting, but what we would call imperfect information. It may be that some women may hide their circumstances from their husbands who are doing their very best to provide for the family. Similarly in our longitudinal national study of children and youth we asked the parents about child hunger when the child was little and later we asked the child about the same thing and got higher response rates from youth. This raises the question as to whether the youth are exaggerating? Not necessarily. In fact, youth health problems were more correlated with youth self-report of child hunger than parental report. Maybe the >>
“…the Food Bank has absolutely no curative effect on whether the children are being harmed by food insecurity. And the health effect from food insecurity is not going to be mitigated or reduced by Food Banks.”
Which groups in Canada experience most child hunger? If we take the north into account the most disadvantaged in Canada are of course the aboriginal children. If we talk about the majority of the society–the advanced ticket to child hunger is to live in a mother-led lone-parent household. Living on the income from the social assistance or welfare system is today a virtual guarantee that you will be a food insecure household. It is very difficult or even impossible for a mother with children who is reliant on social welfare to live without food insecurity. And there are certainly low income households—a parent working full time on minimum wage, for example— that are equally guaranteed to be food insecure. This is really an income issue. How can we reduce the rate of child hunger in Canada? I have walked away from minimum wage or increased social assistance rates because they are too narrow as solutions. A guaranteed annual income is really the universal solution. It has worked beautifully for seniors’ poverty reduction and it is what we need for households and for all individuals. It is a universal solution for access to basic needs and in fact it will more than pay for itself. It avoids stigmatization–one
16
CARRFS eNews
www.carrfsenews.ca
CARRFS Interview (cont’d)
mother didn’t even know or realize that her children were going hungry because they cleverly hid their hunger. I have found in studies that children ‘trick’ their mother into eating when she looks like she is sparing food for the children. But this is more about family dynamics rather than being untruthful. These are the kinds of stresses that are taking a huge toll on individuals, but don’t affect the prevalence rates of food insecurity in Canada. What are the next steps? In 1994 we started out with a representative cohort of children from all the provinces in Canada and we have followed them every two years until 2008-2009. They were one to 11 years old when we started and 14-25 years old when we finished. Every two years we have learnt about their health, school, family, mom and dad, and about their hunger. I have studied these 768 children over the course of 16 years. We have been able to look at what happens to their health over time, their educational outcomes, early fertility, mental health, depression, suicidal thinking and so on. Today, we know that hunger is not another example of poverty–but something unique. We have been able to show that child hunger has a lasting effect on a person’s general health–that early on it is related to generally poorer health and as children grow to adolescence, they have more chronic conditions, particularly asthma. We also know that child hunger in youth and young adulthood is independently related to depression and suicidal ideation even taking into account biological factors such as mother’s depression etc. We can also show—independent of many other “bad” things that happens in a child’s life—that if you experience hunger as a child you are less likely to graduate from high school than other poor kids. I hope to publish more papers on these 768 children in order to understand more about the unique stress they encountered and how this had damaging long term effects. I am also working on how a guaranteed annual income actually could be very cost effective for society in solving this very difficult situation for many families across Canada. <> By Jostein Algroy
Volume 5, Issue 1, Winter 2015
The Cost of Poverty Ensuring adequate funding for early childhood development makes economic sense. According to a 2012 special report by TD Economics entitled “Early Childhood Education has Widespread and Long Lasting Benefits”, the benefits of high-quality early childhood education far outweigh the costs, with savings to society of up to three dollars for every dollar spent with even higher returns when disadvantaged children are factored in. Return on investment from early childhood development is even more significant when looking at high-risk families specifically; for example, the British Columbia government’s 2009 Comprehensive Policy Framework for Early Human Capital Investment in BC concluded that reducing the provincial rate of child vulnerability from 27% to 15% by 2015/16 would create social benefits that outweigh the cost by a factor of more than six to one. A 2011 report by the Canadian Centre for Policy Alternatives, BC “The Cost of Poverty in BC”, points to similar conclusions on the benefits of funding efforts to reduce poverty. If the province were to lift the poorest 20% (1st quintile) of the population up to the income level of the 2nd quintile, the savings in the health care system alone could be $1.2 billion annually. The cost of poverty to Canadian society is clear. Dr. Elizabeth Lee Ford-Jones, a social pediatrician and a professor in the Department of Pediatrics at the University of Toronto, wrote last fall in the Toronto Star that “mounting evidence in the field of social epidemiology shows that poverty limits the futures of children, especially babies, who lack living environments with family support and opportunities to learn and be active, mentally and physically. We won’t resolve this problem without providing access to jobs that pay a living wage and appropriate community supports for every Canadian.”
17
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
Surveillance Facts
... Part VIII in a series about the Past, Present and Future of Public Health Surveillance. Written by Dr. Bernard Choi, Senior Research Scientist, Chronic Disease Surveillance and Epidemiology Division, Public Health Agency of Canada and CARRFS eNews science writer. Past John Snow (1813–1858), an anaesthesiologist, is famous for his investigations into the causes of the 19th century cholera epidemics in England and is also known as the father of modern epidemiology. In 1849, Snow mapped cholera cases in London and identified the source of the outbreak as the public water pump on Broad Street (now Broadwick Street). Using a dot map, he illustrated the cluster of cholera cases around the pump. On September 8, 1854, Snow removed the pump handle and the epidemic waned. Snow’s work is a good illustration of collection, analysis, interpretation, and dissemination of data leading to public health intervention. During the same period in the United States, it was proposed that surveillance be linked to statewide public health infrastructure. In 1850, Lemuel Shattuck published his “Report of the Massachusetts Sanitary Commission”, based on a survey of sanitary conditions in the state. This report was a landmark publication that related death, infant and maternal mortality, and communicable diseases to living conditions. Shattuck proposed the creation of a permanent statewide public health infrastructure, and recommended establishing health offices at the state and local levels in order to gather statistical information on public health conditions. He recommended “a decennial census, standardization of nomenclature for diseases and causes of death, and the collection of health data by age, sex, occupation, socioeconomic level, and locality”. Although the legislature did not adopt his comprehensive plan, his specific proposals became routine public health activities over the course of the twentieth century.
Present Surveillance versus Monitoring: Surveillance is the routine tracking of disease (disease surveillance) or,
less commonly, risk behaviour (behavioural surveillance), using the same data collection system over time. Surveillance helps describe an epidemic and its spread and can contribute to predicting future trends and developing prevention programs. In other words, surveillance is the routine tracking before (or in the absence of) an intervention (policy, program, or action), which can lead to the development of an intervention. On the other hand, monitoring is the routine tracking of priority information about a program and its intended outcomes. Monitoring helps determine which areas are in need of greater effort and flags questions which might contribute to an improved response, but that can only be answered by more refined outcome research methods than those used in routine surveillance and monitoring. In other words, monitoring is routine tracking after an intervention is implemented, and can lead to the improvement of the intervention. Surveillance versus Evaluation: Evaluation is a collection of activities designed to determine the value or worth of a specific program, intervention or project. In other words, it is the determination of the relevance, effectiveness and impact of a program with respect to its objectives. It involves three steps: information, expectation, and attribution. Evaluation uses the same methods to collect information as in surveillance. But it goes two steps further than surveillance. It compares the actual program impacts to the expected level as specified by the program objectives (expectation). It also tries to attribute changes due to the development and implementation of the program (attribution). There is a difference between a program’s monitoring and evaluation. Monitoring tracks changes in outcomes following the implementation of a program or project, but is not able to attribute those changes directly to the intervention. Evaluation is designed specifically to be able to attribute the changes to the intervention itself as opposed to non-program factors. >>
18
CARRFS eNews
www.carrfsenews.ca
Future
Building the Future Based on Lessons Learned from the Past: The author and A.W.P. Pak have proposed 12 challenges for public health surveillance in the 21st century: (1) expand the current surveillance system to include, besides deaths, also new cases for diseases; (2) develop long-term plans for surveillance systems and avoid ad hoc systems; (3) develop ground rules on when and how to add or delete or change the definitions of variables under surveillance when new scientific evidence arises; (4) develop large scale and widespread data collection systems that are population-based; (5) expand the current surveillance system, which is based mainly on health outcomes, to also include risk factors and intervention indicators; (6) develop novel analysis tools and new statistics to facilitate development of disease prevention and control strategies; (7) develop surveillance systems that are closely integrated with etiologic research; (8) develop better and more accurate methods for forecasting; (9) develop a more direct and effective mechanism to feed information into the public health decisionmaking process; (10) develop better evaluation protocols for public health programs and intervention using surveillance data; (11) develop better ways of disseminating information to all those who need to know; (12) ensure that the surveillance system would achieve health for all, on an equal basis and without prejudice. Building Surveillance Capacity: To avoid fragmentation in national surveillance efforts, there is a need for federal agencies to provide national facilitation to foster stakeholder collaboration. Public health surveillance systems can be strengthened by (1) allocating resources, including human resources, for the effective use of health surveillance data and tools and (2) recognizing the need for existing staff to acquire new skills. <>
Volume 5, Issue 1, Winter 2015
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 twoyear terms. Each group has a specific focus. The Training Working Group coordinates opportunities including bi-monthly e-Learning sessions and an e-Forum 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! <> 19
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
> MESSAGE > PROFILE > GOODBYE >
20
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
Chairâ&#x20AC;&#x2122;s Message Betty Reid-White, Chair for the Canadian Coordination Committee, (CCC) gives a status update on CARRFS achievements over the last quarter and what is in store for CARRFS over the months ahead. Welcome to this latest edition of the CARRFS eNews. The Canadian Alliance for Regional Risk Factor Surveillance (CARFFS) was launched in 2008 through the efforts of a group of public health leaders who recognized the need for enhanced regional and local surveillance of chronic disease risk factors. CARRFS has grown into a large network of local, provincial/territorial, and federal public health professionals. The Canadian Coordinating Committee (CCC) plans and supports the work of CARRFS. Together, all CARRFS members hope to advance public health through improved local and regional surveillance. The Public Health Agency of Canada (PHAC) functions as the secretariat for the CARRFS and is also its primary financial contributor. In this regard, PHAC is currently sponsoring an evaluation of the CARRFS network. During the evaluation process various members of CARRFS will be interviewed for their feedback and comments on the value of the network and how its work can be enhanced. The evaluation will be completed by March 2015. We look forward to receiving the evaluation results and report.
finalization of the proof of concept paper, and the development of a CARRFS eNews website. Information on these activities was provided in the previous edition of the eNews. I would like to thank Nawal Lutfiyya, who has completed her term with the CCC. Nawal was a member of the CCC as well as chair of the Training Working Group. Thank you, Nawal, for your support of CARRFS and your contributions to continuing education for CARRFS members. We wish you well in all your future endeavors. It is only through the work of volunteers that CARRFS can continue to meet its objective of improved regional risk factor surveillance. We are currently looking for dedicated professionals to join the CCC and support the ongoing work of CARRFS. If you wish to contribute, either by providing ideas and suggestions for future planning, or by joining a working group or the CCC, please contact Mary Lou Decou.
This is your network. Make it work for you!
Betty Reid-White Chair, Canadian Coordination Committee, CCC
In working toward its objectives, the CCC, through the support of the individuals and working groups involved, plans to continue with the development of a database of subject matter experts, the
21
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
CARRFS Profile... To help build our community, the CARRFS eNews profiles a leading member in each issue. In this issue we profile John Cunningham, Epidemiologist, Leeds, Grenville & Lanark District Health Unit, Ontario. What is your background? My non-academic background consists of working for the Department of National Defence for 15 years, specializing in military engineering and running my own business for 8 years. My educational background is quite varied. I studied forestry at MacDonald College in Montreal in the early ‘80s and then geography and geology at Concordia. After returning to university in the late ‘90s to study biology at Queen’s, I focused on plant ecology and particularly spatial aspects of interspecies plant competition. This, along with my training in geography, really piqued my interest in spatial analysis and Geographic Information Systems (GIS). I also completed a Masters in Community Health and Epidemiology at Queen’s, in emergency medicine research, and then worked at Queen’s doing research epidemiology. I began my career in public health in 2006 at the Leeds, Grenville & Lanark District Health Unit in Eastern Ontario and have worked there ever since. I am a bit of a learning junkie and have continued to complement my professional skills by taking epi-related courses online and through the Canadian Field Epidemiology Program, as well as many professional GIS courses. >>
22
CARRFS eNews
www.carrfsenews.ca
CARRFS Profile (cont’d)
What inspired you to become an epidemiologist? It was on a fishing trip in Newfoundland with a good friend I had met while serving in the Canadian Army that things started falling into place. We had been discussing what I might do with all of the education and experience I had gathered. He turned to me matter-of-factly while casting his line into the river and said “Have you ever thought about epidemiology?” “Epidemi-what?” I asked. And so it began. There was no blinding flash of brilliance or epiphany on my part. Just a fishing trip. I do see now that there was a common thread throughout my educational experience that led nicely to epidemiology. I believe that this is true for many people who find a career that they are passionate about.
At the time I didn’t have a lot of public health experience to offer, but I did come away impressed by the plenary and breakout sessions. I immediately saw the value of bringing together so much talent and knowledge to ruminate on the ideas of coordinating and sharing public health surveillance information across all agencies in Canada. The goal of a national “network of networks” was clearly evident to me.
“I think that CARRFS has a major role to play in bringing together the enormous amount of information related to public health surveillance in terms of synthesizing how surveillance is done in different agencies across Canada and beyond.”
What do you spend the most time on in your current position? I am privileged to have a role in a public health unit that allows me to both be generalist and specialist at the same time. I spend about 60 percent of my time doing the day-today epidemiology and analysis that supports population health assessment and surveillance and program planning and evaluation. This includes reporting to our staff, Board of Health, community organizations and the media. I also provide epidemiological consultation to health unit staff. The other 40 percent of my time is spent working on indepth research projects within both the health unit and for external stakeholders, and doing syndromic surveillance. I am also a keen advocate of adding an element of spatial analysis to the work I do. I am very fortunate that the health unit has seen the value in spatial epidemiology and has sustained my work by providing software, training and IT support. I have worked hard to take our GIS beyond the “Gee whiz” effect that it gives to data visualization and add statistical testing for the spatial and space-time effects that can occur in local disease distributions. What was your motivation to become a member of the CARRFS? I attended the CARRFS Think Tank Forum in 2008 and was impressed by the breadth and depth of expertise and attendance from all regions of Canada.
Volume 5, Issue 1, Winter 2015
How do you see the current role of the CARRFS in Canada today? I think that CARRFS has a major role to play in bringing together the enormous amount of information related to public health surveillance in terms of synthesizing how surveillance is done in different agencies across Canada and beyond. This alone is an enormous task. Canada is large and diverse in terms of geography and the jurisdictional and political arrangements of our health agencies. Having a central repository of surveillance information, methodologies and training is fundamental to its efficient communication and sharing. As well, I believe that CARRFS can be a key player in disseminating new ideas and trends in health surveillance as they evolve.
What are the future opportunities for the CARRFS? CARRFS is well-positioned to leverage current and future developments and innovations in data gathering, analysis and communication methods for risk factor surveillance. I believe that advances in computing power and software coding as well as novel data collection methods and large relational databases make it a very exciting time for all forms of public health surveillance, and see CARRFS as being able to play a key role in coordinating with and educating public health professionals in the continued learning and communicating of novel methodologies and processes. I also see the potential for CARRFS to extend its repository of knowledge and skills to a broader community in terms of academic and non-academic research. <> By Jostein Algroy
23
CARRFS eNews
www.carrfsenews.ca
Volume 5, Issue 1, Winter 2015
Hello & Goodbye...
This is the place where we welcome new members to the CARRFS Steering Committee - The Canadian Coordination Committee (CCC) and honour those who have to leave the committee to pursue or fulfill other commitments. Dr. Nawal Lutfiyya
Dr. Nawal Lutfiyya has been a key member of CARRFS since 2008 and a key lead in the development and evolution of the CARRFS network. She joined CARRFS as part of the first Symposium Planning Committee in 2008. Over the years, she has provided guidance and advice as the Chair of the Training Working Group and has been a valuable member of the Canadian Coordinating Committee. CARRFS has benefited over the years as Nawal has shared her expertise and counsel â&#x20AC;&#x201C; she has presented numerous e-learning sessions, keynote addresses and has been the lead for several workshops. Dr. Lutfiyya is now Senior Research Scientist at the National Center for Inter-professional Practice and Education, and Professor, Pharmacy Care and Pharmaceutical Sciences, at the University of Minnesota-Twin Cities Campus in Minneapolis, Minnesota. We thank Nawal for all her contributions over the years and for being so open in sharing her knowledge and wisdom. We wish her well! By Mary Lou Decou
CARRFS Committees Canadian Coordination Committee (CCC)
Chair: Betty Reid-White Co-Chair: Ali Artaman
Tools and Resources Working Group (TRWG)
Chair: Ahalya Mahendra Co-Chair: Vacant
MANDATE CARRFS is a network of Public Health stakeholders 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.
Training Working Group (TWG)
Chair: Vacant Co-Chair: Audrey Layes
Surveillance Innovation Task Group (SWTG)
Chair: Michelina Mancuso Co-Chair: 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.
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