August 1, 2024

The Honourable Mark Holland, P.C., M.P., Minister of Health House of Commons
Ottawa, ON
K1A 0A6

Sent via email: mark.holland@parl.gc.ca

Dear Minister,

We are writing on behalf of Ontario Dietitians in Public Health (ODPH) to urge you to increase funding for the Community Action Program for Children (CAPC) and the Canada Prenatal Nutrition Program (CPNP), both managed by the Public Health Agency of Canada (PHAC). The 2023-24 Departmental Plan has prioritized ensuring that Canadians can access the services they need when and where they need them. Despite a significant rise in the cost of basic living and the complex challenges faced by families across the country, these programs have not seen a funding increase in over 20 years. Adjusting funding levels to align with inflation is essential to enable CAPC and CPNP projects to effectively provide support for vulnerable families when they need it.

ODPH serves as the official voice of Registered Dietitians in Ontario’s public health system, dedicated to advancing public health nutrition through collaboration with members and partners to enhance population health and health equity at local and provincial levels.

ODPH’s Family Health Nutrition Advisory Group of public health dietitians work directly with pregnant people, families, and community agencies, we have witnessed firsthand the significant impacts of CAPC and CPNP. These programs improve the health of pregnant people and children from birth to age 6 who face challenges that put their health at risk. CAPC and CPNP are often the first point of contact with community services for pregnant people and families. These programs provide an opportunity for important screening and early referral to programs and services such as primary care, infant feeding supports, and social services including addictions and mental health.

These programs equip clients with food literacy skills, increase breastfeeding rates, and provide prenatal and parenting education. By providing opportunities to reduce social isolation, these programs support parent, infant and children’s mental health.

Over the past two decades, CAPC and CPNP programs have demonstrated success, as evidenced by PHAC’s program evaluations. Unfortunately, staff involved in CAPC and CPNP report an increased number of families in financial distress, more complex mental health challenges, and a rise in children requiring support for developmental and behavioral issues.

Despite the proven effectiveness and growing necessity of these programs, funding has remained stagnant for over 25 years, leading to significant challenges. These challenges include:

• the inability to offer competitive wages, resulting in high staff turnover and difficulties in filling vacant positions.
• hampers programs’ ability to provide consistent and reliable services, preventing the establishment of trusting relationships with clients. This can lead to reluctance to access community supports and adversely affect the client’s mental health.
• the insufficient funding exacerbates reliance on partners for in-kind services, which places further strain on community support systems and ultimately increases the burden on our overextended healthcare system.

We urge you to consider an immediate increase in funding for CAPC and CPNP to bring funding levels in line with inflation, as this will ensure these vital programs can continue to provide essential services to families in need across Canada.

Thank you for your attention to this critical matter.

Sincerely,

Andrea Licursi, MSc, RD
ODPH, Chair of the Executive 

Paula Ross, RD 
Family Health Nutrition Advisory Group

e-mail to: bns-bsn@hc-sc.gc.ca

February 26, 2024

Bureau of Nutritional Sciences, Food Directorate Health Products and Food Branch, Health Canada 251 Sir Frederick Banting Driveway

Mail stop 2203E Ottawa, ON K1A 0K9

Re: Regulatory Modernization of Foods for Special Dietary Use and Infant Foods

Dear Sir/Madam:

Thank you for the opportunity to provide feedback on the proposed restructured framework regarding Foods for Special Dietary Use (FSDU) and infant foods, currently regulated within Divisions 24 and 25 of Canada’s Food and Drug Regulations (FDR).

Ontario Dietitians in Public Health (ODPH) is the official voice of Registered Dietitians working in Ontario’s Public Health System. Our mission is to advance public health nutrition through member and partner collaboration to improve population health and health equity locally and provincially.

ODPH supports Health Canada’s efforts to apply a risk-based approach in developing the proposed regulatory amendments and is pleased with improved regulatory oversight of food products that strive to meet a variety of nutritional needs for Canadians.

While there are advantages to the proposed regulations, ODPH has provided feedback below to Health Canada’s consultation questions regarding regulatory changes for products and processes applicable to infants and young children. These products include infant formula, prepackaged human milk, conventional infant foods, and formulated nutritional food for children. ODPH supports evidence-informed decision making as it relates to infant feeding and we endorse the tenets of the World Health Organization’s Baby-Friendly Initiative to protect and promote breastfeeding.

We acknowledge that all individuals, regardless of sex and/or gender identity or expression may be in a feeding relationship with their baby/child. The term parent is used throughout this document and refers to a parent or caregiver who is involved in the child’s care.

Q 1 – Do you support the proposal to restructure Divisions 24 and 25 of the FDR into a division for Food for Special Dietary Purpose (FSDP) and one for foods that are not FSDP?

Yes. We recognize that a streamlined framework for regulating infant formula and foods reduces duplication across the regulatory divisions and has advantages both for the federal government as the body responsible for market approval of such products, and for the food industry to expedite entry of products into the Canadian market.

Q 2 – Do you support the proposal for infant formula?

Partially. ODPH applauds Health Canada’s efforts to better align Canada’s policies with

the International Code of Marketing of Breastmilk Substitutes (WHO Code) and Codex Alimentarius Commission standards (Codex). We also support improved clarity with respect to labelling requirements and stronger legislative oversight of advertising restrictions. However, ODPH presents the following considerations:

1) The proposed regulatory framework falls short in meeting Canada’s obligation as a signatory to the WHO Code to support and promote breastfeeding.

The WHO Code prohibits:

• Donations of free or subsidized supplies of infant formula or other products in any part of the health care system. As written, proposed restrictions will not address aggressive marketing of infant formula to new parents within hospital settings through hospital donations.
• All forms of promotion of infant formula.

Below are some of the examples that ODPH has been made aware of regarding infant formula product promotion. Examples such as these would not be addressed through the proposed regulations.

– 2 –

WHO Code prohibition	Examples of existing prohibited promotional activities in Canada
Manufacturers and distributors shall not “perform educational functions” (Article 8.2)	Register | Coupons & Parental Support | Nestlé Baby & me (nestlebaby.ca).
Manufacturers and distributors shall not give away “samples or…discount coupons” (Article 5.3)	Register | Coupons & Parental Support | Nestlé Baby & me (nestlebaby.ca) Similac® Club | Free Baby Formula Samples, Coupons & More. How to Get Enfamil Baby Formula Coupons & Offers | Enfamil A+ Canada
“There shall be no advertising or other form of promotion to the general public of products within the scope of this Code.” (Article 5.1)	Meet Baby Nyles! | Nestlé Baby & me (nestlebaby.ca) – This website is announcing the winner of the Canadian 2023 photo search who is titled the “2023 Gerber Spokesbaby & Chief Growing Officer”
“Sponsor meetings of health professionals and scientific meetings” (UNICEF, 2023)	Dietitians of Canada National Conference 2023 Children’s Healthcare Canada – A Bright Future for Child Health in Canada Conference 2022 Canadian Paediatric Society – Annual Conference 2023

Therefore, it is recommended that:

i)   To better align with the WHO code and to further protect breastfeeding, updated regulations include enhanced language to prohibit any advertisement or promotion of infant formula in Canada. Advertising restrictions should be extended to ensure enforcement of regulations across all communication platforms including online and social media.

ii)  Unless medically required, legislation should include mechanisms to regulate, monitor and enforce the prohibition of donations of free or subsidized supplies of infant formula within Canadian health systems.

2) The labelling changes proposed within the regulatory framework will not adequately ensure that manufacturers meet Article 9 of the WHO Code requiring that infant formula labelling provides “clear, conspicuous, easily readable and understandable messages.”

Proposed mandatory information regarding infant formula products will improve caregivers’ ability to make informed product selection decisions. However, proposed formats and language lack all necessary instructions crucial for diverse and vulnerable Canadian populations needing more complete information to properly use infant formula. Notably, principal display panels on infant formula packaging currently available for sale contain small and crowded text of varying font sizes, symbols, and images. As is, critical information regarding appropriate use of formula is often overlooked, disregarded (such as guidance to ‘use on advice of a health professional’) or misinterpreted and may result in unsafe consumption. There is room for improvement to clarify and enhance proposed label messaging details.

Therefore, it is recommended that:

1. Infant formula container sizes and shapes, as well as all mandatory statements including formula preparation, storage, and disposal, are standardized across all infant formula products with regard to colour, size, and location of mandatory label statements on product display panels.
2. The proposed label messaging is improved to strengthen clarity and consistency. Suggested revisions include:
   • Addition of a symbol instructing user not to add water for ready-to-feed infant formula instructions. This is to parallel the proposed symbol instructing users to add water for liquid concentrated infant formula instructions.
   • Directions to boil infant formula equipment to include time limit (i.e., 2 minutes).
   • Literacy-friendly language when communicating instructions and cautioning consumers. For example, use
     • “Do not add water or other liquids” instead of “do not dilute,” and
     • “amounts” instead of “proportions.”
   • A definition of “safe water.”
   • Advice that formula can be offered cold depending on preference. Formula does not need to be served at body temperature as the proposed instructions suggest.
   • Instructions on safe storage of pre-boiled water.
   • Instructions to clean bottles before sterilization. This step is absent from the proposed regulations.

Q 3 – Do you support the proposal for prepackaged human milk?

Partially. ODPH supports enhanced regulatory oversight with respect to safety and quality concerning prepackaged human milk (PPHM).

ODPH recommends that Health Canada considers the results of the World Health Organization’s systematic reviews on donor human milk banking processes anticipated in May 2024, before finalizing regulations for this food category.

Q 7 – Do you support the proposal for shortage provisions applicable to all FSDP?

Partially. ODPH supports the addition of these provisions to require infant formula manufacturers to report shortages and to imbed emergency importation policies within the FDR to accommodate shortages. It is uncertain however, given the lack of Canadian infant formula manufacturing, that these strategies alone will protect Canada’s vulnerable reliance on support from US and international markets during supply chain disruptions.

With respect to infant formula, human milk fortifiers (HMF), and dietary products for the treatment of inborn errors of metabolism (metabolic products), and human milk, ODPH recommends that regulations:

1. ensure safeguards for equitable distribution of products intended for infants most at- risk.
2. require a freeze on cost increases of all formulas, HMF and metabolic products during periods of shortages.
3. require manufacturers to report discontinued products.
4. prohibit the promotion of homemade infant formulas.

It is also recommended that Health Canada develop a plan to increase manufacturing of infant formula within Canada’s borders for availability to Canadians.

Q 8 – Do you support the proposal for stop-sale provisions applicable to all FSDP?

Partially. ODPH agrees that the Minister be given authority to quickly halt the sale of all FSDP products sold. This would be particularly important for infants and vulnerable populations for whom stop-sale provisions may be crucial to matters of nutritional adequacy, and product and food safety.

It is also recommended that regarding product safety, the stop-sale provisions should also be applied to all products related to FSDP. For example, regarding infant formula these products would include bottles, nipples, utensils, preparation equipment and formula dispensers.

Q 10 – Do you support the proposal for conventional infant food?

Partially. ODPH supports the addition of this important food category to the FDR. We also present the following recommendations to enhance the regulations regarding package labelling of conventional infant foods.

1. The prohibition of inappropriate promotion of commercially produced foods for infants and young children aged 6–36 months as per the WHO Code is not adequately addressed in the proposed regulations.

Inappropriate labelling of products currently available are a health risk to infants.

For example, Cerelac is a cereal product intended for children older than 12 months. While “Infant” is defined in the FDR, “baby” is not. This product, inappropriately labeled as a “baby” cereal, contains powdered honey. Health Canada advises that parents and caregivers not give honey to a child under 12 months of age to prevent infant botulism. The label reference to “baby” is confusing for parents and caregivers who have purchased these for their infants and may inadvertently feed their infants a potentially harmful ingredient.

Below are other examples of inappropriate staged labelling of foods intended for different ages:

1. • “Stage 1 – Supported Sitter” Rice Baby Cereal
   • ”Crawler” Mild Cheddar Lil’ Crunchies® | Gerber
   • “Junior” Alphabet Beef Baby Food

Finally, examples of product labelling for infant snacks include text and images suggestive that contents predominately contain vegetables and fruit when in fact the product contains negligent amounts of these foods. In working with the public, ODPH members have identified that parents typically purchase these items to replace whole vegetables and fruit. This type of product labelling may mislead many parents to believe that the nutritional contents of these products are superior than they actually are.

2. Limits within the proposed regulations to address intake of nutrients of concern among small children will not adequately address chronic disease risk.

Health Canada’s Nutrition for Healthy Term Infants recommends that children one year of age and older are offered foods prepared with little or no added salt or sugar. Although Statistics Canada collects limited data on consumption of sugar and sodium in young Canadian children, practice-based anecdotal information indicates that sodium and sugar consumption is above these recommendations. ODPH members who support families with young children report that caregivers often provide infant snack type foods multiple times per day, and often with a meal (e.g., rice rusks, puffs, dehydrated snacks).

Therefore, it is recommended that:

1. In addition to the proposed labelling requirement to include the age range of the intended user of the product, Health Canada should prohibit ambiguous product-label referencing, such as “baby,” “junior,” “crawler,” “sitter” etc.
2. The FDR prohibit the addition of sodium chloride or added sugars in any infant foods including infant “snack” type foods that are increasingly popular.
3. Regulations prohibit false promotion of vegetable and fruit content.

Q 12 – Do you support the proposal for formulated nutritional food for children?

Yes. ODPH supports the proposed mandatory labelling requirements for formulated nutritional foods for children and that staged product labelling of infant formula products for children beyond 12 months of age (i.e., Stage 3 or 4) be prohibited (Ref: 5.3.1).

Given that these products are not recommended by health care professionals, this will help parents and caregivers to differentiate these from infant formula which is intended as the sole source of nutrition for infants.

Thank you again for providing the opportunity to participate in this stakeholder consultation. We ask that you continue to engage and consult with health officials at various levels of government on this matter, including public health professionals to ensure that the health and safety of the population is protected and promoted.

Sincerely,

Laura Abbasi, RD, MHSc
Ontario Dietitians in Public Health Chair

Paula Ross, RD, MAN
Family Health Advisory Group Chair

January 2024 letter regarding areas of concern and recommendations in the “Your guide to a healthy pregnancy.”

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January 2024

Public Health Agency of Canada

130 Colonnade Rd

A.L. 6501H

Ottawa ON K1A 0K9

Sent via email: info@phac-aspc.gc.ca

Dear Public Health Agency of Canada,

Re: feedback on “Your guide to a healthy pregnancy” resource

Ontario Dietitians in Public Health (ODPH) is the independent and official voice of Registered Dietitians working in Ontario’s Public Health System. Our mission is to advance public health nutrition through member and partner collaboration to improve population health and health equity locally and provincially. We do this through evidence-informed, comprehensive population health promotion with a focus on health equity.

Access to high-quality information on pregnancy is a valuable role that the Public Health Agency of Canada plays for Canadians. As public health dietitians who work closely with staff, community partners and clients directly, we would like to draw your attention to the following areas of concern and recommendations in the “Your guide to a healthy pregnancy.”

1. Prenatal Section (page 9): BMI Table with Recommended Weight Gain

Recommendation: Remove the BMI table with recommended weight gain and the replace current text with the following: “Your body will experience many changes during pregnancy, including weight gain. Speak to your health care provider to determine what an appropriate amount of weight gain is for you.”

What is the weight made up of?
Baby	By the end of the third trimester, your baby will weigh approximately 2.5-3.5 kg or 6- 8 lb.
Breasts	Your breasts will get larger and feel heavier, as they get ready for breastfeeding.
Blood	Your blood volume almost doubles during pregnancy to get oxygen and nutrients to
you and your growing placenta and baby.

Extra Fluids	Mild swelling, build up of fluid, is normal and expected. Rapid weight gain due to swelling is a cause for concern and you should check with your healthcare provider right away.
Fat	It is normal for your body to store energy as fat during pregnancy. This helps prepare for labour and delivery as well as breastfeeding after your baby is born.
Placenta & Amniotic Fluid	The placenta is a temporary organ that develops during pregnancy to deliver oxygen and nutrients to your growing baby. The amniotic fluid is a protective liquid that surrounds the baby. It serves as a cushion and helps exchange water and nutrients.
Uterus	Your uterus adapts and expands many times its normal size, to make room for your growing baby.

2. Physical Activity Section (page 33): “Exercise is safe and encouraged for healthy pregnant individuals who are receiving prenatal care. Exercise can:…Help prevent you from gaining excess weight.”

Recommendation: Remove the bullet “Help prevent you from gaining excess weight.”

3. Breastfeeding Section (page 55): “It reduces the risk that your baby will have diarrhea…or be overweight/obese when they are older.”

Recommendation: Remove “or be overweight/obese when they are older.”

Supporting Evidence:

1. The body experiences many changes during pregnancy and weight gain is different for everyone.

Pregnant individuals may gain more or less weight than the guidelines used by Health Canada for a variety of reasons. These include nausea and vomiting, weight loss or weight gain prior to pregnancy, weight/dieting/disordered eating/food insecurity history, genetic variation, current health conditions, current life/relationship circumstances, etc.

While some may appreciate learning approximately how much weight gain to expect, that is not always the case. Others may find it distressing or lead to unrealistic expectations. Changes to body size and shape during pregnancy are expected and should be normalized. Public health should be challenging the unachievable societal examples and expectations for gestational parents (1,2) rather than continuing to perpetuate harmful body image messaging and weight stigma.

Stereotypes and misconceptions about obesity that perpetuate weight stigma can create an unpleasant experience for pregnant individuals living in larger bodies as they are often victims of weight stigma and feel judged for their weight and shape (3). This can lead to increased stress and depression which can have negative impacts on both the individual and fetus (4) and continue to pose a risk throughout the postpartum period, parenting, and the child’s life (5).

2. The public health field no longer identifies weight management as a benefit to exercise.

Historically public health used weight loss and weight maintenance messaging as an incentive for exercise, resulting in media and social messaging associating exercise and weight (6). Focusing on weight control as a benefit of exercise may increase weight stigma (7). There are many benefits to physical activity regardless of any impact on weight.

3. Breastfeeding is only one of a multitude of factors that are associated with future weight status in children based on observational research.

Due to the risk of increasing weight stigma and shaming parents (5), attention to this association should be avoided in resources designed for the public. A child’s body weight is determined by many complex factors and should not be distilled down to infant feeding practices. Recognizing the limitations of observational research as well as the risks of weight stigma, such strong and potentially harmful conclusions should not be drawn.

It is our position that weight stigma contributes to discrimination, oppression, and social injustices – which are a significant public health problem that leads to health inequities. Weight bias, stigma and discrimination are independently linked to poorer mental and physical health. Public health messaging that focuses on weight and obesity contributes to weight stigma.

We urge you to please consider adopting a weight neutral approach in public health messaging and modifying the “Your guide to a healthy pregnancy” resource with the suggestions put forth in this letter.

We look forward to hearing back from you and invite you to connect with us should you wish to meet or seek further clarification.

Sincerely,

Amy MacDonald, Chair
Body Diversity and Health Equity Working Group
amacdonald@hpph.ca

Paula Ross, Chair
Family Health Nutrition Advisory Group
rossp@phsd.ca

Laura Abbasi
ODPH Co-chair
executive@odph.ca

References

1. Incollingo Rodriguez AC, Dunkel Schetter C, Brewis A, Tomiyama AJ. The psychological burden of baby weight: Pregnancy, weight stigma, and maternal health. Social Science & Medicine, 2019, 235. DOI: 10.1016/j.socscimed.2019.112401.
2. Tang L, Tiggemann M, Haines J. #Fitmom: an experimental investigation of the effect of social media on body dissatisfaction and eating and physical activity intentions, attitudes, and behaviours among postpartum mothers. BMC Pregnancy Childbirth. 2022 Oct 12;22(1):766. doi: 10.1186/s12884-022-05089-w.

1. LaMarre, A., Rice, C., Cook, K., & Friedman, M. (2020). Fat reproductive justice: Navigating the boundaries of reproductive health care. Journal of Social Issues, 0(0), 1–25. https://doi.org/10.1111/josi.12371

1. Cook, K., LaMarre, A., Rice, C. & Friedman, M. (2019). “This isn’t a high-risk body”: Reframing Risk and Reducing Weight Stigma in Midwifery Practice. Canadian Journal of Midwifery Research and Practice, 18 (1), 26-34. https://www.cjmrp.com/files/v18n1-weight-stigma-and- pregnancy.pdf
2. Gorlick JC, Gorman CV, Weeks HM, Pearlman AT, Schvey NA, Bauer KW. “I Feel Like Less of a Mom”: Experiences of Weight Stigma by Association among Mothers of Children with Overweight and Obesity. Child Obes. 2021 Jan;17(1):68-75. doi: 10.1089/chi.2020.0199.

1. Cox CE. Role of Physical Activity for Weight Loss and Weight Maintenance. Diabetes Spectr. 2017 Aug;30(3):157-160. doi: 10.2337/ds17-0013.

1. Myre M, Glenn NM & Berry TR (2021) Exploring the impact of physical activity-related weight stigma among women with self-identified obesity, Qualitative Research in Sport, Exercise and

Health, 13:4, 586-603, doi: 10.1080/2159676X.2020.1751690.

December 13, 2023

Debbie Young

Customer Relations Manager InJoy Health Education

7107 La Vista Place Longmont, CO 80503

Sent via email: dyoung@injoyhe.com

Dear Debbie,

In response to your email correspondence on November 10, 2023, the Ontario Dietitians in Public Health (ODPH) decided that we would like to contact you to express our interest in working collaboratively with your Canadian subject matter expert on the nutrition content for the new 2024 Canadian Master InJoy Program.

ODPH is the independent and official voice of Registered Dietitians working in Ontario’s public health system. Registered Dietitians (RDs) are uniquely trained to advise on food and nutrition. Our members have a breath of experience working with partners from a variety of sectors on different provincial level resources and consumer resources, many which can be found on our website.

The Family Health Nutrition Advisory Group (FHNAG), a workgroup of ODPH, supports the Healthy Growth and Development guideline of the Ontario Public Health Standards for optimal preconception, pregnancy, newborn, and family health. FHNAG members value online prenatal educational resources such as InJoy, as this type of platform can help increase the reach of evidence-based information for priority populations including expectant families.

In the spring of 2023, FHNAG workgroup members reviewed the nutrition content of the InJoy Health Education Program. The working group strived to ensure the messaging in InJoy was aligned with Canadian evidence, current best practices, and Canada’s food guide. A trauma informed, strength-based approach was used to update content. Language is weight and culturally inclusive and food and gender neutral. Several resources were used to guide our decisions about use of language.

Given the scope of developing a new eClass, we would welcome the opportunity to work collaboratively with your Canadian subject matter expert on the nutrition content to ensure that the 2024 version of InJoy is one that meets the needs of consumers and users across the country.

Thank you for your consideration on this matter and we look forward to hearing from you soon.

Sincerely,

Laura Abbasi, Co-Chair Year 1
Ontario Dietitians in Public Health

Paula Ross, Chair
Family Health Nutrition Advisory Group

October 19, 2023

The Honourable Sylvia Jones Minister of Health

Ministry of Health

777 Bay Street, 5th Floor Toronto, ON M7A 2J3

Sent via email: sylvia.jones@ontario.ca; Catherine.Zahn@ontario.ca; angie.wong@ontario.ca; Kieran.Moore@ontario.ca; Chris.Dacunha@Ontario.ca; alex.millier@ontario.ca; Fgelinas-qp@ndp.on.ca; ashamji.mpp.co@liberal.ola.org

Dear Minister Jones,

Re: Ontario Drug Benefits Program for Infants and Children with a Medical Diagnosis* Requiring Strict Avoidance of Standard Soy and Milk Proteins

Ontario Dietitians in Public Health and Food Allergy Canada are writing to you to recommend that specialized infant formula be covered through the Ontario Drug Benefit Program (ODB) for infants and children 0-24 months of age with a medical diagnosis* requiring the strict avoidance of standard soy and milk proteins.

The current infant formula shortage over the past 17 months has reinforced the necessity of access to infant formula. However, less recognized is the significant cost barrier faced by those Ontarians who require specialty formulas, an issue that existed long before the shortage.

The ODB program does not currently cover the cost of specialty infant formulas medically required by infants and children 0-24 months of age who need to avoid standard soy and milk proteins. Without this coverage, an estimated 5,125 infants and children each year in Ontario may be unable to meet their nutrient needs. Due to the high cost of these specialty formulas, families may be unable to afford the only infant formula option medically required to meet the nutrient requirements of these infants and children.

Early childhood malnutrition presents a considerable burden to the health care system in Ontario. Alternatives to the current situation exist and are proposed in the attached Call to Action.

We recommend that the Government of Ontario support and optimize infant and child growth and

development, reduce health inequities, and help the sustainability of Ontario’s health care system by:

• Expanding coverage for specialized infant formulas through the Ontario Drug Benefit Program; and
• Ensuring infants and children 0-24 months of age who are partially breastfed or non-breastfed with a medical diagnosis* requiring the strict avoidance of standard soy and milk proteins qualify for this coverage.

Thank you for considering these important recommendations. We welcome the opportunity to discuss these recommendations and look forward to a consultation.

Sincerely,

Laura Abbasi, RD, MHSC
Ontario Dietitians in Public Health

Jennifer Gerdts, Executive Director
ood Allergy Canada

*Medical diagnosis can include an IgE mediated food allergy and/or a non-IgE mediated food allergy, such as food protein-induced enterocolitis syndrome (FPIES), food protein-induced enteropathy (FPE), allergic proctocolitis (AP), eosinophilic esophagitis (EoE) and several others. Due to the variability in clinical presentation and lack of validated diagnostic tests, a diagnosis relies on a detailed medical history, physical examination and a trial elimination of the suspected food allergen.

Cc

Dr. Catherine Zahn, Deputy Minister of Health

Angie Wong, Drug Programs Policy and Strategy Branch (Health)

Dr. Kieran Moore, Chief Medical Officer of Health, Office of Chief Medical Officer of Health, Public Health Chris Dacunha, Executive Director, Policy, Minister’s Office (Health)

Alex Millier, Director, Stakeholders & Member Relations, Minister’s Office (Health) France Gélinas, Health Critic, New Democratic Party of Ontario

Dr. Adil Shamji, Critic for Health, Northern Development, Indigenous Affairs and Colleges and Universities, Ontario Liberal Party

Ontario Dietitians in Public Health (ODPH) is the independent and official voice of Registered Dietitians working in local public health units and provides leadership in public health nutrition. ODPH members apply evidence- informed nutrition information to enable healthy eating at every stage of life; advocate for and provide support to the creation of food policies and healthier eating environments; and implement and evaluate nutrition programs to improve the health of Ontario residents; and seek to remove barriers so that priority populations have equitable access and opportunities to reach their full health potential.

Food Allergy Canada is a national charity and the country’s leading patient organization committed to educating, supporting, and advocating for the more than 3 million Canadians impacted by food allergy, including over 600,000 children. The organization focuses on improving daily quality of life by providing education and support needed to effectively navigate this medical condition, building informed and supportive communities, and acting as the national voice on key patient issues.

August 23, 2023

Public Health Agency of Canada

130 Colonnade Rd

A.L. 6501H

Ottawa ON K1A 0K9

Re: feedback on new resource “Your guide to postpartum health and caring for your new baby”

Ontario Dietitians in Public Health (ODPH) is the independent and official voice of Registered Dietitians working in Ontario’s Public Health System. Our mission is to advance public health nutrition through member and partner collaboration to improve population health and health equity locally and provincially. We do this through evidence-informed, comprehensive population health promotion with a focus on health equity.

Access to high quality information for pregnancy, postpartum and early parenting is a valuable role that the Public Health Agency of Canada plays for Canadians. As public health dietitians working with community agencies, pregnant and postpartum clients directly, we would like to draw your attention to the following areas of concern and recommendations for the newly released resource:

1. Nutrition Section (page 18): “What should I do to lose my baby weight? …Breastfeeding also helps, as your body uses energy to make milk…Talk to your health care provider about a healthy goal for weight loss.”
   Recommendation: Replace current text with the following:
   “It is common to want to return to your previous weight and shape after having a baby. Losing weight is more complex than just nutrition and physical activity. Focus on taking care of your health by listening to your body, finding ways to be active that you enjoy, enjoying time with family and friends, and resting when you can. If you have concerns about your nutrition, talk to your healthcare provider.”
2. Physical Activity Section (page 20): “Regular exercise is important after your baby’s birth and can: …help you lose weight”
   Recommendation: Remove the bullet “help you lose weight”
3. Breastfeeding Section (page 52): “Breastfeeding helps reduce your baby’s risk of… being overweight when they are older.”
   Recommendation: Remove “or being overweight when they are older”
4. Caring for yourself: Body changes after birth (page 6-11):
   Recommendation: Consider including content about expecting and accepting your body changes in future revisions.

Supporting Evidence:

1. Breastfeeding should not be associated as a method for weight loss.

Breastfeeding is beneficial for many gestational-parental and infant health outcomes. However, there is insufficient evidence demonstrating a clear association between breastfeeding and postpartum weight loss (1,2).

We recognize that questions about postpartum weight loss are common as many individuals feel pressure to return to their previous shape and size. Weight stigma has a detrimental effect on mental health and well-being (3). Preconception, pregnant and postpartum individuals are particularly vulnerable to weight stigma, which can have a direct impact on their health and that of their offspring (4). Instead of taking a weight-centric approach, the focus should be on health promoting behaviours and helping readers identify the supports in their lives.

2. The public health field has moved away from identifying weight management as a benefit to exercise.

Historically public health used weight loss and weight maintenance messaging as an incentive for exercise, resulting in media and social messaging associating exercise and weight. However, newer evidence refutes the widely held belief that weight loss will come with increased physical activity and will result in sustained weight loss. Focusing on weight control as a benefit of exercise may increase weight stigma and decrease motivation to exercise if weight loss is not achieved or maintained (6).

There are many benefits to physical activity regardless of any impact on weight.

3. Breastfeeding is only one of a multitude of factors that is associated with future weight in children based on observational research.

Due to the risk of increasing weight stigma and the phenomenon of shaming parents (7), attention to this association should be avoided in resources designed for the public. A child’s body weight is determined by many complex factors that should not be distilled down to infant feeding practices.

Recognizing the limitations of observational research as well as the risks of weight stigma, such strong and potentially harmful conclusions should not be drawn.

4. Include content about expecting and accepting body changes.

Pregnancy and postpartum changes to body size and shape are expected and should be normalized. Public health should be challenging the unachievable societal examples and expectations for gestational parents (8,9) rather than continuing to perpetuate harmful body image messaging and weight stigma.

Stereotypes and misconceptions about obesity that perpetuate weight stigma can create an unpleasant experience for pregnant individuals living in larger bodies as they are often victims of weight stigma and feel judged for their weight and shape (10). This can lead to increased stress and depression which can have negative impacts on both the individual and fetus (11) and continue to pose a risk throughout the postpartum period, parenting and the child’s life (12).

www.odph.ca info@odph.ca @RDsPubHealthON

It is our position that weight stigma contributes to discrimination, oppression and social injustices – which are a significant public health problem that leads to health inequities. Weight bias, stigma and discrimination are independently linked to poorer mental and physical health. Public health messaging that focuses on weight and obesity contributes to weight stigma.

We urge you to please consider adopting a weight neutral approach in public health messaging and modifying the “Your guide to postpartum health and caring for your new baby” resource with the suggestions put forth in this letter. We would welcome the opportunity to collaborate with you in the future. We look forward to hearing back from you and invite you to connect with us should you wish to meet or seek further clarification.

Sincerely,

Amy MacDonald, Chair                  Paula Ross, Chair

Body Diversity and Health Equity Working Group      Family Health Nutrition Advisory Group amacdonald@hpph.ca                 rossp@phsd.ca

Laura Abbasi ODPH Co-chair

executive@odph.ca

References:

1. He X, Zhu M, Hu C, Tao X, Li Y, Wang Q, Liu Y. Breast-feeding and postpartum weight retention: a systematic review and meta-analysis. Public Health Nutr. 2015 Dec;18(18):3308-16. doi: 10.1017/S1368980015000828.
2. Neville CE, McKinley MC, Holmes VA, Spence D, Woodside JV. The relationship between breastfeeding and postpartum weight change–a systematic review and critical evaluation. Int J Obes (Lond). 2014 Apr;38(4):577-90. doi: 10.1038/ijo.2013.132.
3. Ontario Dietitians in Public Health. Health and Wellbeing Philosophy and Approach to Weight: Position Statement. 2018. Update forthcoming. https://www.odph.ca/addressing-weight-bias-resources
4. Hill B, Incollingo Rodriguez AC. Weight Stigma across the Preconception, Pregnancy, and Postpartum Periods: A Narrative Review and Conceptual Model. Semin Reprod Med. 2020 Nov;38(6):414-422. doi: 10.1055/s-0041- 1723775. Epub 2021 Mar 16. PMID: 33728621.
5. Cox CE. Role of Physical Activity for Weight Loss and Weight Maintenance. Diabetes Spectr. 2017 Aug;30(3):157-160. doi: 10.2337/ds17-0013.
6. Myre M, Glenn NM & Berry TR (2021) Exploring the impact of physical activity-related weight stigma among women with self-identified obesity, Qualitative Research in Sport, Exercise and Health, 13:4, 586-603, doiI: 10.1080/2159676X.2020.1751690.
7. Gorlick JC, Gorman CV, Weeks HM, Pearlman AT, Schvey NA, Bauer KW. “I Feel Like Less of a Mom”: Experiences of Weight Stigma by Association among Mothers of Children with Overweight and Obesity. Child Obes. 2021 Jan;17(1):68-75. doi: 10.1089/chi.2020.0199.
8. Incollingo Rodriguez AC, Dunkel Schetter C, Brewis A, Tomiyama AJ. The psychological burden of baby weight: Pregnancy, weight stigma, and maternal health. Social Science & Medicine, 2019, 235. DOI: 10.1016/j.socscimed.2019.112401.
9. Tang L, Tiggemann M, Haines J. #Fitmom: an experimental investigation of the effect of social media on body dissatisfaction and eating and physical activity intentions, attitudes, and behaviours among postpartum mothers. BMC Pregnancy Childbirth. 2022 Oct 12;22(1):766. doi: 10.1186/s12884-022-05089-w.
10. LaMarre, A., Rice, C., Cook, K., & Friedman, M. (2020). Fat reproductive justice: Navigating the boundaries of reproductive health care. Journal of Social Issues, 0(0), 1–25. https://doi.org/10.1111/josi.12371
11. Cook, K., LaMarre, A., Rice, C. & Friedman, M. (2019). “This isn’t a high-risk body”: Reframing Risk and Reducing Weight Stigma in Midwifery Practice. Canadian Journal of Midwifery Research and Practice, 18 (1), 26-34. https://www.cjmrp.com/files/v18n1-weight-stigma-and-pregnancy.pdf
12. Gorlick JC, Gorman CV, Weeks HM, Pearlman AT, Schvey NA, Bauer KW. “I Feel Like Less of a Mom”: Experiences of Weight Stigma by Association among Mothers of Children with Overweight and Obesity. Child Obes. 2021 Jan;17(1):68-75. doi: 10.1089/chi.2020.0199. Epub 2020 Dec 29. PMID: 33373542; PMCID: PMC7815062.
13. Public Health Agency of Canada. (2019). Addressing stigma: Towards a more inclusive health system. The Chief Public Health Officer’s Report on the State of Public Health In Canada. (Pub: 190383). Government of Canada. https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public- health-canada/addressing-stigma-toward-more-inclusive-health-system.html
14. Hambleton J, McColl K, Raoufi S, Manowiec E. (Sept 2019). Weight Bias and Public Health: Review of the Evidence. Toronto Public Health.

Obesity Canada

2-126 Li Ka Shing Centre for Health Research Innovation University of Alberta

Edmonton, AB T6G2E1

We represent Ontario Dietitians in Public Health (ODPH), the independent and official voice of Registered Dietitians working in Ontario’s public health system. We advocate for system approaches that mitigate harm while promoting health equity across all populations. One of our focuses is shifting the paradigm from a weight-centric approach to a weight-inclusive approach, which aims to address the systemic injustices that result from weight bias, stigma, and discrimination.

We are writing to express our deep concern with Obesity Canada’s public congratulatory blog post on January 10, 2023 regarding the release of the 2023 American Academy of Pediatrics Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity (AAP CPG). We urge Obesity Canada to not model the American recommendations when developing updated Canadian Clinical Practice Guidelines (CPG) for pediatric populations. The treatment recommendations in the AAP CPG are troubling, imposing possible mental, physical, and psychological harms to children and youth. We call on Obesity Canada to consider a weight-inclusive approach to care to better safeguard the children and families of our country.

We ask Obesity Canada’s Steering Committee to consider the following recommendations to inform upcoming guidelines:

1. Include studies that explore improvements to health independent of changes in weight status.

Healthcare interventions centered solely around weight neglect to acknowledge the decades of literature showing attempted weight loss results in weight regain 80-95% of the time, making long-term, sustained weight loss the exception, not the norm.^1,2 These weight-centric approaches also fail to acknowledge the emerging body of evidence demonstrating the harms of repeated weight-loss attempts, otherwise known as weight cycling. These harms include higher mortality of all causes including cardiovascular disease, poor cardiometabolic measures such as hypertension, dyslipidemia, and insulin resistance, increased risk of weight regain, and increased risk of disordered eating.^3,4 Further, growing evidence demonstrates successful improvements to health (i.e., blood pressure, cholesterol, cardiovascular fitness, mobility) can be achieved independent of changes to weight.⁴

Promoting health and well-being among children and youth should go beyond weight as an indicator. Instead, care should focus on fostering positive relationships with food, movement, body, and mind to encourage lifelong health behaviors regardless of how their growing bodies develop. The AAP CPG explicitly excluded studies that focused on health outcomes, rather than weight itself.⁵ We urge Obesity Canada’s Steering Committee to consider the benefits of including a wider range of evidence to promote healthy outcomes among children and youth,

avoiding what could be perceived as an unethical oversight.

2. Apply a comprehensive health equity lens, giving consideration to the social determinants of health.

Weight and body size are known to be complex and multifactorial, influenced by socio- ecological, genetic, and environmental factors. This includes, but is not limited to, genetics, racial or ethnic inequities, age, sex, living conditions, family history, trauma, income, culture, eating and physical activity habits, sleep, physical location, medical conditions, medications, and stress.⁶ Many of these are beyond individual control, and directly contribute to health inequities.⁷

Despite the established understanding of this complexity, clinical guidelines such as the recently released AAP CPG focus heavily on nutrition and physical activity behaviours as the primary means to address weight management.⁵ Writing guidelines that acknowledge the social determinants of health, but then go on to recommend solely individual solutions can worsen care outcomes and access.^6,8 Clinical practice guidelines should be created to support healthcare providers in doing comprehensive assessment that include addressing social challenges.⁹

We strongly urge Obesity Canada to adopt a health equity lens when formulating clinical practice guidelines, thereby better equipping health care professionals to assist individuals and families contending with systemic disparities. This holistic approach will not only lead to more inclusive and effective care but also contribute to the dismantling of inequities ingrained within our healthcare systems.

3. Endorse that all healthcare professionals participate in training and professional development in weight bias, stigma, and discrimination.

Frequently, practice guidelines maintain the notion of individual responsibility for health and weight control.⁹ This reinforces the cultural and societal preoccupations with weight, and places the blame and shame on individuals in larger bodies. As a result, people living in larger bodies often experience negative attitudes, assumptions, judgments, and even treatment as a result of these preconceived notions linked to their body weight, shape, or size. Increased childhood and adolescence experiences of weight bias, stigma and discrimination may lead to negative relationships with food and their body, deterring youth from enjoying and maintaining physical activity and healthy eating behaviors.¹⁰

Exploring how weight bias, stigma, and discrimination affects health care professionals, both consciously and subconsciously, is an essential step towards providing inclusive and equitable treatment to all. The AAP CPG provides surface level recommendations pertaining to weight bias, stigma, and discrimination, which disregards the impacts of these harms.⁵

We applaud Obesity Canada for their commendable effort by dedicating a chapter to address weight bias within the Clinical Practice Guidelines for Adults.¹¹ Our hope is that these insights and recommendations find their way into the forthcoming pediatric guidelines. Creating a healthcare system that is free of biases, stigma, and discrimination requires a multi-pronged approach where all players work together. We look forward to seeing further comprehensive projects that take a stance against weight bias, stigma and discrimination and that continue to include recommendations for practitioners to explore weight-inclusive evidence.

4. Recommend that healthcare professionals screen all clients, regardless of body size, for signs and symptoms of disordered eating and eating disorders.

Disordered eating and eating disorders can have severe consequences to mental and physical health, including cardiovascular, endocrine, gastrointestinal, and skeletal disorders, osteoporosis, dental problems, nutritional deficiencies, psychiatric disorders, and substance use.⁶ Across Canada, youth are experiencing a mental health crisis and growing eating disorder rates. In Ontario, 46% of students in grades 7-12 reported being preoccupied about their weight or body shape.¹² Similar to weight and body size, the existence of eating disorders is highly stigmatized as well. Contrary to common assumptions, less than 6% of people with eating disorders are classified as “underweight,” whereas 37-41% of people presenting for eating disorder treatment fall within the “overweight” or “obese” BMI classifications.³ This reinforces the notion that weight, BMI, and body size are poor indicators to guide health assessments and treatment.

The AAP CPG failed to acknowledge the risk of eating disorders among youth, only recommending screening for depression over 12 years of age.⁵ Children and youth living in larger bodies have likely experienced weight bias, stigma, and discrimination at the time of assessment, and have possibly had weight loss attempts. There is also a high prevalence of disordered eating and eating disorders among individuals seeking bariatric surgery; lifetime binge eating disorder prevalence rates range from 13-50%, compared to only a 4.5% lifetime prevalence among the general population.¹³ Incorporating trauma-informed, client-centred practices, as well as comprehensive disordered eating screening tools can significantly reduce harms for pediatric clients (e.g., Ottawa Disordered Eating Screen for Youth).¹⁴

5. Exclude pharmaceutical and surgical intervention recommendations for the pediatric population until further long-term research on safety is established.

The AAP CPG recommendation to consider invasive and metabolically altering surgery among growing, developing children and youth is especially alarming. Not only are short- and long-term harms largely unknown, capacity to understand the full extent of bariatric surgery may be limited in youth.¹⁵ Complications observed in adults, including malnutrition, increased risk of alcohol use disorder, ulcers, hernias, and the potential need for subsequent surgeries, pose a greater risk among young, developing bodies.¹⁶ This physiologically-altering surgery has lifelong implications, and the “success” of surgery later in adulthood could be impacted by factors like trauma, socioeconomic status, and living conditions that are largely unpredictable in children.¹⁷

As described in a recent AMA Journal of Ethics commentary:

“Pharmaceuticals have been described as the prescription for fat people of what is diagnosed as disordered in thin people …skipping meals (anorectics), diet pills (pharmacotherapeutics themselves), laxatives (orlistat), and vomiting (a common glucagon-like peptide 1-related adverse effect).”³

Considering the lack of data to support long-term safety outcomes, and the risk of eating disorder onset during adolescence, we urge Obesity Canada to consider the risks that these interventions (both surgical and pharmaceutical) pose among youth.

Comprehensive, evidence-informed guidelines that are sensitive to existing weight bias, stigma, and discrimination can help promote equitable and weight-inclusive healthcare. As a community of concerned healthcare professionals, we recommend that Obesity Canada and the appointed Steering Committee consider the above discussion and recommendations in the upcoming Canadian Pediatric CPG. We welcome the opportunity to discuss these recommendations and look forward to reviewing the guidelines anticipated for release in 2023.

Sincerely,

Laura Abbasi, Co-Chair Year 1
Ontario Dietitians in Public Health

Amy MacDonald, Chair 
Body Diversity and Health Equity Working Group

 

References

1. Mann, T., Tomiyama, J. A., Westling, E., Lew, A.-M., Samuels, B., & Chatman, J. (2007). Medicare’s search for effective obesity treatments. American Psychologist, 62(3), 220-223. https://escholarship.org/uc/item/2811g3r3
2. Chastain, R. (2021, November). Who Says Dieting Fails Most Of The Time? Weight and Healthcare. https://weightandhealthcare.substack.com/p/who-says-dieting-fails-the- majority
3. Floegel-Shetty, A. (2023). Should pharmaceuticals be used as weight loss interventions for adolescents classified as obese by BMI? AMA Journal of Ethics, 25(7), E478-495. https://journalofethics.ama-assn.org/article/should-pharmaceuticals-be-used-weight-loss- interventions-adolescents-classified-obese-bmi/2023-07
4. Bacon, L., & Aphramor, L. (2011). Weight science: evaluating the evidence for a paradigm shift. Nutrition Journal, 10(9). https://nutritionj.biomedcentral.com/articles/10.1186/1475-2891-10-9
5. Hampl SE, Hassink SG, Skinner AC, et al. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics. 2023;151(2): e2022060640
6. Weight Inclusive Nutrition and Dietetics (2023). AAP Guidelines Response Toolkit — Weight Inclusive Nutrition and Dietetics. https://www.weightinclusivenutrition.com/aap- response-project-toolkit
7. Government of Canada. (2023, June). Social determinants of health and health inequalities. Canada.ca. Retrieved September 28, 2023, from https://www.canada.ca/en/public-health/services/health-promotion/population- health/what-determines-health.html
8. Puhl, R.M. and Heuer, C.A. (2009), The Stigma of Obesity: A Review and Update. Obesity, 17: 941-964. https://doi.org/10.1038/oby.2008.636
9. Andermann, A., & CLEAR Collaboration (2016). Taking action on the social determinants of health in clinical practice: a framework for health professionals. CMAJ, 188(17-18), E474–E483. https://doi.org/10.1503/cmaj.160177
10. Haqq, A. M., Kebbe, M., Tan, Q., Manco, M., & Salas, X. R. (2021). Complexity and Stigma of Pediatric Obesity. Childhood obesity (Print), 17(4), 229–240. https://doi.org/10.1089/chi.2021.0003
11. Kirk SFL, Ramos Salas X, Alberga AS, Russell-Mayhew S. Canadian Adult Obesity Clinical Practice Guidelines: Reducing Weight Bias in Obesity Management, Practice and Policy. Available from: https://obesitycanada.ca/guidelines/weightbias. Accessed September 14, 2023.
12. Boak, A., Elton-Marshall, T., & Hamilton, H.A. (2022). The well-being of Ontario students: Findings from the 2021 Ontario Student Drug Use and Health Survey (OSDUHS). Toronto, ON: Centre for Addiction and Mental Health.
13. Devlin, M.J., King, W.C., Kalarchian, M.A., White, G.E., Marcus, M.D., Garcia, L., Yanovski, S.Z., & Mitchell, J.E. (2016). Eating pathology and experience and weight loss in a prospective study of bariatric surgery patients: 3 year-follow up. International Journal of Eating Disorders, 49(12), 1058-1067.
14. Obeid, N., Norris, M., Buchholz, A., Hadjiyannakis, S., Spettigue, W., Flament, M., Henderson, K., & Goldfield, G. (2019). Development of the Ottawa Disordered Eating Screen for Youth: The ODES-Y. Journal of Pediatrics, 215, 209-215. https://www.jpeds.com/article/S0022-3476(19)31002-9/fulltext
15. Rana Halloun, Ram Weiss; Bariatric Surgery in Adolescents with Obesity: Long-Term Perspectives and Potential Alternatives. Horm Res Paediatr 21 June 2022; 95 (2): 193–203. https://doi.org/10.1159/000520810
16. Shiau, J. & Biertho, L. (2020). Canadian Adult Obesity Clinical Practice Guidelines: Bariatric Surgery: Postoperative Management. Downloaded from: https://obesitycanada.ca/guidelines/postop. Accessed September 5, 2023.
17. Fox, M. (2021, May). Social determinants of health and surgery: An overview | The Bulletin. Bulletin of the American College of Surgeons. Retrieved September 28, 2023, from https://bulletin.facs.org/2021/05/social-determinants-of-health-and-surgery-an-overview/

CALL TO ACTION: ODB PROGRAM AMENDMENTS TO SUPPORT INFANTS ANDCHILDREN WITH A MEDICAL

DIAGNOSIS* REQUIRING STRICT AVOIDANCE 0F STANDARD SOY AND MILK PROTEINS

ISSUE

The Ontario Drug Benefit (ODB) Program does not cover the cost of specialized infant formulas required for infants and children 0-24 months of age with a medical diagnosis* requiring strict avoidance of standard soy and milk proteins.

Not covering these specialized infant formulas jeopardizes infant and child growth and development as well as perpetuates health inequities amongst Ontario residents.

RECOMMENDATIONS

To support and optimize infant and child growth and development, reduce health inequities, and help the sustainability of Ontario’s health care system, it is recommended that:

• The Government of Ontario expand coverage for specialized infant formulas through the Ontario Drug Benefit Program;

And that:

• Infants and children 0-24 months of age who are partially breastfed or non-breastfed with a medical diagnosis* requiring strict avoidance of standard soy and milk proteins qualify for this coverage.

BACKGROUND

British Columbia, Alberta, and Manitoba have programs that cover specialized infant formula (i.e., extensively hydrolyzed and elemental/amino acid-based nutritional products), when medically required for food allergies.

While specialized infant formulas are currently included in the ODB formulary, infants and children 0-24 months of age needing to avoid standard soy and milk proteins are excluded from the medical criteria¹ whether it is their sole source of nutrition or not.

CURRENT STATUS

An estimated 5,125 infants and children 0-24 months of age in Ontario have a medical diagnosis* requiring strict avoidance of standard soy and milk proteins^2,3 and must have specialized infant formula to meet nutrient needs, if not receiving breastmilk.

“We have not been able to contribute to RESP’s or savings for [our child] because we currently cannot afford to do so. For [their] birthday and Christmas, family members have given money to help with the cost of formula since [their] nutrition is much more important than any new toys or clothes.” – Parent of a child with the dual diagnoses of cow milk protein and soy protein allergies

ECONOMIC IMPACT ON FAMILIES

The Government of Ontario states that the “health care system should be guided by a commitment to equity and to the promotion of equitable health outcomes” (Connecting Care Act, S.O. 2019, preamble). Health equity “involves the fair distribution of resources needed for health, fair access to the opportunities available, and fairness in the support offered to people when ill”.⁴ Due to the high cost of specialized infant formulas (see Tables 1 and 2), these infants  and  children  face  inequitable  access  to resources needed for their health, and their families are at an economic disadvantage.

In response to the extreme cost of specialized infant formulas, families may make homemade infant formula, which can cause severe malnutrition and potentially fatal illness.⁵

“[Our child] struggled with breastfeeding and because [they were] fairly lethargic and not gaining much weight, we were told to give formula. The cost of our [their] formula has been financially draining for us, but we need to give [them] this formula so that [they] can thrive. While other babies over 1 year get to drink milk that the rest of our household drinks, [our child] still needs the special, extremely expensive formula, because without it, [they] would have nothing.” – Parent of a child with the dual diagnoses of cow milk protein and soy protein allergies