Policy options to support healthy eating in schools

Promoting healthy school food environments and nutrition in Canada: a systematic review of interventions, policies, and programs

CONTEXT

The school food environment is a critical interface for child and adolescent nutrition, and there is a need to understand existing literature on Canadian school food environments to identify equity gaps and opportunities, and empower decision-makers to plan for future action.

OBJECTIVE

Literature on Canadian school food and nutrition interventions, policies, programs, and their effects on diets and nutritional status are synthesized and appraised in this systematic review.

DATA SOURCES

A search strategy was developed for each database used (Medline, Embase, PsycINFO, ERIC, Cochrane Collaboration, Canadian Electronic Library, BiblioMap), with a combination of free text and controlled vocabulary, for articles published from 1990 to 2021. Unpublished data and grey literature were also searched.

DATA EXTRACTION

Quantitative and qualitative studies with an observational or intervention study design, reviews, or program evaluations conducted in Canadian schools with participants aged 5-19.9 years were included. Key study characteristics and risk of bias were extracted independently by 2 investigators using a standardized tool.

DATA ANALYSIS

A total of 298 articles were included (n = 192 peer reviewed and 106 from the grey literature), which were mostly conducted in Ontario (n = 52), British Columbia (n = 43), and Nova Scotia (n = 28). Twenty-four interventions, 5 nonevaluated programs, and 1 policy involved Indigenous populations. Overall, 86 articles measured and reported on effectiveness outcomes, including dietary intake; anthropometry; knowledge, attitudes, and practices; and physical activity. The literature remains largely heterogenous and primarily focused on nutrition education programs that use subjective assessments to infer changes in nutrition. A key facilitator to implementation and sustainability was community engagement, whereas key barriers were staff capacity, access to resources and funding, and consistent leadership.

CONCLUSIONS

This review provides insight into Canadian school food and nutrition interventions, programs, and policies and uncovers important evidence gaps that require careful examination for future evaluations. Governments must create supportive environments that optimize nutrition for children and adolescents through equitable policies and programs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022303255.

Sustainable and Nutritional Recommendations for the Development of Menus by School Food Services in Spain

BACKGROUND

Recommendations for the development of school menus can promote healthier, more sustainable food systems. In Spain, these recommendations depend on regional governments (Autonomous Communities-CCAAs) that develop their own guides. The objective of this study was to explore the nutritional and sustainability recommendations for the development of menus by school food services in Spain.

METHODS

Guides were reviewed that were available on the official web pages of the councils of health and education. Twenty-four variables were studied and organized into three categories: characteristics, nutritional recommendations and sustainability. The number of recommendations included in each guide was counted. The weekly frequency of the suggested food provision for each food group was calculated, as was the average, median, standard deviation, confidence interval and interquartile index.

RESULTS

Overall, 13 guides were reviewed from different CCAAs. All of them included at least three of the nutritional recommendations, two suggested restrictions in the provision of foods with high quantities of salt and six suggested restrictions in foods with high levels of trans and saturated fats and sugars. All except one guide recommended the weekly provision of foods by food group: protein-rich foods (n = 8), cereals and root vegetables (n = 6), vegetables (n = 5.2) and fruit (n = 4.3). Of the eight criteria for sustainability studied, nine guides included one or none.

CONCLUSIONS

Guides for the provision of meals at school in Spain promote the incorporation of healthy foods; however, they rarely restrict foods with high levels of fat, salt and sugar, and the promotion of food sustainability is only just beginning. These guides should be reviewed and updated to include recommendations that promote healthy and sustainable food systems.

School lunch menus in Spain. A review on recommendations and policy

INTRODUCTION

An appropriate diet in childhood is essential for suitable growth and development, but it is also essential for preventing the development of non-communicable diseases in later stages. The School stage is fundamental. A significant proportion of students in Spain make use of the school lunch. We review the current situation in Spain, as well as public policy on school lunch and a nationwide review of specific legislation on each Autonomous Community.

MATERIAL AND METHODS

National public policy and specific considerations in every Autonomous Community were reviewed. Only considerations on the composition of the school menu were considered.

RESULTS

There are relatively recent state regulations but on school lunch menus also specific to each Autonomous Community. In general, and within a certain heterogeneity, they refer to the distribution of the diet and foods to be restricted. They usually provide guidelines, examples of daily menus, and graphic representations. Regarding school menus, there is a trend towards improvement in nutritional adequacy, but there is still room to improve. There are certain aspects related to the best solutions yet to be elucidated: management model, type of supervision, sustainability and local consumption, as well as school lunch schedules.

CONCLUSIONS

The nutritional contributions made in the school canteens are qualitatively and quantitatively important. In addition, it must fulfill educational and social equity functions. Although these concerns address specific recommendation in every Autonomous Community, there is huge heterogeneity on practical implementations.

[School lunch menus in Spain. A review on recommendations and policy]

INTRODUCTION

An appropriate diet in childhood is essential for suitable growth and development, but it is also essential for preventing the development of non-communicable diseases in later stages. The School stage is fundamental. A significant proportion of students in Spain make use of the school lunch. We review the current situation in Spain, as well as public policy on school lunch and a nationwide review of specific legislation on each Autonomous Community.

MATERIAL AND METHODS

National public policy and specific considerations in every Autonomous Community were reviewed. Only considerations on the composition of the school menu were considered.

RESULTS

There are relatively recent state regulations but on school lunch menus also specific to each Autonomous Community. In general, and within a certain heterogeneity, they refer to the distribution of the diet and foods to be restricted. They usually provide guidelines, examples of daily menus, and graphic representations. Regarding school menus, there is a trend towards improvement in nutritional adequacy, but there is still room to improve. There are certain aspects related to the best solutions yet to be elucidated: management model, type of supervision, sustainability and local consumption, as well as school lunch schedules.

CONCLUSIONS

The nutritional contributions made in the school canteens are qualitatively and quantitatively important. In addition, it must fulfill educational and social equity functions. Although these concerns address specific recommendation in every Autonomous Community, there is huge heterogeneity on practical implementations.

Priority setting for school nutrition research: developing a collaborative research agenda

Priority setting in health research can assist stakeholders to identify research and policies that have the greatest potential for benefits to public health. Priority setting has been utilized by researchers to identify barriers, facilitators, and recommendations for future public health research. This commentary describes how a priority-setting approach was used as part of a workshop activity on the school nutrition environment in Ontario, Canada, to facilitate brainstorming, sorting, and rating of concepts related to the school nutrition environment. This work demonstrates an interesting and concrete case of priority setting, of interest for various planning activities (both programming and research), particularly those around school-based healthy eating programs or a related research agenda.

L’alimentation en milieu scolaire : appuyer l’offre d’aliments et de boissons sains

L’adoption de politiques et de directives alimentaires dans les écoles canadiennes permet d’accroître l’offre et la consommation d’aliments riches en nutriments tout en réduisant l’accès à des aliments et des boissons riches en sucres, en sodium et en gras saturés. Ces politiques favorisent des changements positifs pour la santé des enfants et des adolescents, tels qu’un meilleur indice de masse corporelle. Cependant, elles ont des effets mitigés sur la performance scolaire. Le présent document de principes présente les principaux éléments des politiques alimentaires en milieu scolaire, notamment les normes nutritionnelles. Ces politiques doivent respecter les recommandations du Guide alimentaire canadien et promouvoir la consommation d’aliments et de boissons riches en nutriments, dont la teneur en gras saturé, en sucre et en sodium est plus faible.

School nutrition: Support for providing healthy food and beverage choices in schools

The implementation of nutrition policies and guidelines in Canadian schools has increased the availability and consumption of nutrient-rich foods while reducing access to and consumption of foods and beverages that are high in sugars, sodium, and saturated fats. Positive changes in health outcomes for children and youth, such as improved body mass indices, have been observed. However, observed impacts of school nutrition policies on academic performance have been mixed. This statement reviews key elements of school nutrition policies, with specific focus on nutrition standards. School nutrition policies should align with recommendations in Canada's Food Guide and promote nutrient-rich foods and beverages that are lower in saturated fat, sugar, and sodium.

School-based nutrition interventions for Indigenous children in Canada: a scoping review

BACKGROUND

Indigenous children in Canada (First Nations, Inuit, and Métis) are disproportionately affected by nutrition-related chronic diseases such as obesity and diabetes. Comprehensive school-based nutrition interventions offer a promising strategy for improving children's access to healthy foods and sustaining positive eating behaviors. However, little is known about school-based nutrition interventions for Indigenous children. The objectives of this scoping review were to identify school-based nutrition interventions for Indigenous children in Canada and describe their components.

METHODS

The scoping review consisted of searches in seven peer-reviewed databases and a general web search for grey literature. Eligibility criteria were applied by two reviewers, and data were extracted and charted by one reviewer using components of the comprehensive school health approach (social and physical environment, teaching and learning, policy, partnerships and services) and additional components with relevance to Indigenous interventions (cultural content, Indigenous control and ownership, funding source, evaluation). Numerical and descriptive summaries were used to present findings.

RESULTS

Thirty-four unique interventions met the inclusion criteria. The majority (97%) of interventions targeted the social and physical environment, most often by offering food programs. Over half of interventions also incorporated teaching and learning (56%) and partnerships and services (59%), but fewer included a policy component (38%). Many interventions included a cultural component (56%) and most (62%) were owned and controlled by Indigenous communities (62%). Finally, over half of interventions disclosed their source(s) of funding (59%), but less than half (41%) included an evaluation component.

CONCLUSIONS

The review suggests that school-based interventions for Indigenous children can be more comprehensive by incorporating culturally relevant nutrition education and professional development opportunities for teachers, written school nutrition policies, and activities that actively engage families and community members. The continued focus on Indigenous control and ownership and incorporation of content specific to individual communities may enhance cultural relevancy and sustainability of interventions. Furthermore, there is a need to increase intervention evaluation and the sharing of resources related to funding. These recommendations may be used by communities, as well as by researchers and professionals working with communities, in developing comprehensive school-based nutrition interventions to improve the eating behaviors of Indigenous children.

Alexander First Nations Parents' Perceptions of a School Nutrition Policy

Purpose: A school nutrition policy (SNP) is one promising school-based health promotion strategy to improve the food environments of First Nations children. The aim of this study was to explore First Nations parents' perceptions of a SNP. Methods: A process evaluation of policy implementation was conducted using a mixed-methods design. Parents (n = 83) completed a 19-question survey to capture their perceptions of the policy. Survey responses informed questions in an 11-question semi-structured interview guide. Transcripts from interviews with parents (n = 10) were analyzed using content analysis to identify barriers and facilitators to policy implementation. Results: Parents were supportive of the SNP and the school's food programs, which they perceived as helping to address community concerns related to nutrition. However, some parents opposed the restriction of unhealthy foods at school celebrations and fundraisers. In addition, despite being aware of the SNP, parents were unable to demonstrate an understanding of the SNP content. Finally, parents struggled to provide their children with healthy foods to bring to school due to lack of affordable and accessible food in the community. Conclusions: Although SNPs may be well-received in First Nations communities, their implementation must be supported by parent involvement and consideration of wider socioeconomic conditions.

Measuring lunchtime consumption in school cafeterias: a validation study of the use of digital photography

OBJECTIVE

The present study tested the validity of a digital image-capture measure of food consumption suitable for use in busy school cafeterias.

DESIGN

Lunches were photographed pre- and post-consumption, and food items were weighed pre- and post-consumption for comparison.

SETTING

A small research team recorded children's lunchtime consumption in one primary and one secondary school over seven working days.ParticipantsA primary-school sample of 121 children from North Wales and a secondary-school sample of 124 children from the West Midlands, UK, were utilised. Nineteen children were excluded because of incomplete data, leaving a final sample of 239 participants.

RESULTS

Results indicated that (i) consumption estimates based on images were accurate, yielding only small differences between the weight- and image-based judgements (median bias=0·15-1·64 g, equating to 0·45-3·42 % of consumed weight) and (ii) good levels of inter-rater agreement were achieved, ranging from moderate to near perfect (Cohen's κ=0·535-0·819). This confirmed that consumption estimates derived from digital images were accurate and could be used in lieu of objective weighed measures.

CONCLUSIONS

Our protocol minimised disruption to daily lunchtime routine, kept the attrition low, and enabled better agreement between measures and raters than was the case in the existing literature. Accurate measurements are a necessary tool for all those engaged in nutrition research, intervention evaluation, prevention and public health work. We conclude that our simple and practical method of assessment could be used with children across a range of settings, ages and lunch types.

First Nations students' perceptions of school nutrition policy implementation: A mixed methods study

AIM

School nutrition policies can improve healthy food access for Indigenous First Nations children in Canada. This study explored First Nations students' perceptions of a school nutrition policy.

METHODS

The research was a process evaluation of school nutrition policy implementation using a mixed-methods design. Students in grades 4-12 (n = 94) completed a 17-question survey to capture their perceptions of the policy. Survey data informed an 11-question semi-structured interview guide. Transcripts from interviews with students (n = 20) were analysed using content analysis to identify barriers and facilitators to policy implementation.

RESULTS

Key facilitating factors to policy implementation were student support for the policy and taste preferences. Most students (87%) agreed that only healthy foods should be served at school and, in interviews, expressed a preference for healthy food choices. Barriers to policy implementation included foods available at school and lack of communication between students and their teachers and parents. Half (50%) of surveyed students reported that their eating habits at school were average; interviews explained that their diets could be improved by consuming more fruit and vegetables at school. Both surveys and interviews found that communication between students and their parents and teachers about what they ate and drank at school was low.

CONCLUSIONS

To support children's healthy eating at school, the school nutrition policy could provide clear guidelines on foods permissible in the school, while considering social and environmental barriers to healthy eating. The involvement of First Nations children in the implementation and evaluation of school nutrition policies is recommended.

Examining changes in school vending machine beverage availability and sugar-sweetened beverage intake among Canadian adolescents participating in the COMPASS study: a longitudinal assessment of provincial school nutrition policy compliance and effectiveness

Background

School nutrition policies can encourage restrictions in sugar-sweetened beverage (SSB) availability in school food outlets in order to discourage students’ SSB intake. The main objective was to examine how beverage availability in school vending machines changes over three school years across schools in distinct school nutrition policy contexts. Secondary objectives were to examine how students’ weekday SSB intake varies with time and identify longitudinal associations between beverage availability and SSB intake.

Methods

This longitudinal study used data from the COMPASS study (2013/14–2015/16), representing 7679 students from 78 Canadian secondary schools and three provincial school nutrition policy contexts (Alberta – voluntary guidelines, Ontario public – mandatory guidelines, and Ontario private schools – no guidelines). We assessed availability of 10 beverage categories in schools’ vending machines via the COMPASS School Environment Application and participants’ intake of three SSB varieties (soft drinks, sweetened coffees/teas, and energy drinks) via a questionnaire. Hierarchical regression models were used to examine whether: i) progression of time and policy group were associated with beverage availability; and, ii) beverage availability was associated with students’ SSB intake.

Results

Ontario public schools were significantly less likely than the other policy groups to serve SSBs in their vending machines, with the exception of flavoured milks. Vending machine beverage availability was consistent over time. Participants’ overall SSB intake remained relatively stable; reductions in soft drink intake were partially offset by increased sweetened coffee/tea consumption. Relative to Ontario public schools, attending school in Alberta was associated with more frequent energy drink intake and overall SSB intake whereas attending an Ontario private school was associated with less frequent soft drink intake, with no differences in overall SSB intake. Few beverage availability variables were significantly associated with participants’ SSB intake.

Conclusions

Mandatory provincial school nutrition policies were predictive of more limited SSB availability in school vending machines. SSB intake was significantly lower in Ontario public and private schools, although we did not detect a direct association between SSB consumption and availability. The findings provide support for mandatory school nutrition policies, as well as the need for comprehensive school- and broader population-level efforts to reduce SSB intake.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0754-5) contains supplementary material, which is available to authorized users.

Moving from Policy to Practice: A Report of School Nutrition Policy Adherence in Nova Scotia

PURPOSE

School food and nutrition policies have the potential to encourage healthier eating among children and youth to address rising concerns of poor diet quality. Despite their widespread implementation, there is little reported monitoring of policy adherence. This short report describes adherence to the provincial school food and nutrition policy in Nova Scotia (NS) that was implemented in 2006.

METHODS

An online survey was distributed to NS public schools in 2014-2015 to assess adherence to the directives and guidelines of the policy. Descriptive information was obtained for schools and indicators for policy adherence were explored.

RESULTS

A total of 242 schools completed the survey (73% response rate) and policy adherence was variable across the different components. Few schools adhered to the policy standard related to the sale of unhealthy foods and there was inconsistency in school adherence reported for other policy indicators.

CONCLUSIONS

This research suggests that further action is need to ensure "minimum nutrition" food and beverages are not available in schools and that healthy eating is reinforced through prioritizing key policy actions like pricing strategies, discontinuing fundraising with unhealthy food, and ensuring food programs are available in a nonstigmatizing manner.

Examining associations between school food environment characteristics and sugar-sweetened beverage consumption among Canadian secondary-school students in the COMPASS study

Objective

To examine associations between Canadian adolescents’ sugar-sweetened beverage (SSB) consumption and several school food environment characteristics, and to investigate differences in these characteristics between schools in provinces with voluntary (Alberta) v. mandatory (Ontario) provincial school nutrition policies.

Design

We used a questionnaire to assess the number of weekdays participants consumed three SSB categories (soft drinks, sweetened coffees/teas, energy drinks) and various sociodemographic and behavioural characteristics. We examined the in-school water fountain accessibility, vending machines’ contents and presence of various food outlets within schools’ 1 km buffer. We developed hierarchical Poisson regression models to identify associations between student- and school-level characteristics and students’ SSB outcomes.

Setting

Alberta and Ontario, Canada.

Subjects

Adolescents (n 41 829) from eighty-nine secondary schools.

Results

Compared with their Ontarian counterparts, Albertan participants had a significantly higher rate of SSB intake across all drink categories and SSB availability was significantly greater in Albertan schools’ vending machines. Availability of sweetened coffees/teas in school vending machines and access to restaurants within the school’s 1 km buffer were associated with increased SSB intake in three of the final models. Overall, the school food environment-level characteristics examined had a modest to negligible impact on student days of SSB intake.

Conclusions

We identified that the school food environment characteristics examined here had little impact on adolescents’ days of SSB consumption. While schools should adopt or maintain a comprehensive policy approach to discourage students’ SSB intake, population-level interventions focusing on other contexts (e.g. home and community) are needed to complement existing school-based interventions.

Health promotion initiatives at school related to overweight, insulin resistance, hypertension and dyslipidemia in adolescents: a cross-sectional study in Recife, Brazil

Background

The emergence of diseases such as dyslipidemia, systemic arterial hypertension, insulin resistance and metabolic syndrome in children and adolescents has brought about a change in the epidemiologic profile of the pediatric population. As action to promote health in the school environment is a useful tool for changing the pattern of health/disease in the young population, the present study aimed to identify schools that promote healthy eating and physical activity and to study the relationship between these practices and the prevalence of overweight, hypertension, insulin resistance and hypercholesterolemia in adolescents.

Methods

A cross-sectional population-based study was conducted with 2400 adolescents aged from 12 to 17 years old and participating in the “Study of Cardiovascular Risk in Adolescents” (ERICA – Estudo de Riscos Cardiovasculares em Adolescente). The association between dependent (overweight, insulin resistance, hypertension and dyslipidemia) and independent variables (implementation of health promoting initiative in schools) was investigated using the chi-square test and prevalence ratio (PR) with a confidence index (CI) of 95%.

Results

The unsatisfactory implementation of a “health promoting environment” (PR = 1.02; CI 95%: 1.0; 1.04) and “partnerships with the health sector” (PR = 1.03; CI 95%: 1.01; 1.05) were linked to a high prevalence of overweight in adolescents. Hypercholesterolemia was found to be higher in the schools with unsatisfactory implementation of “healthy eating and health on the scholar curriculum” (PR = 1.71; CI 95%: 1.22; 2.44) and those lacking a “healthy-eating promoting environment” (PR = 1.29; CI 95%: 1.10; 1.54). Schools with unsatisfactory implementation of a “health-eating promoting environment” (PR = 1.36; CI 95%: 1.04; 1.79) and those lacking “partnership with the health sector” (PR = 2.12; CI 95%: 1.38; 3.24) had more adolescents with insulin resistance. There was no association between hypertension and any other component studied.

Conclusion

Schools which have implemented adequate health promotion in their curriculums showed a lower prevalence of overweight, insulin resistance and hypercholesterolemia in adolescents.

Reproducing or Reducing Inequity? Considerations for School Food Programs

It is important to consider health inequities when exploring the extent to which school food programs may contribute to the stigmatization and social exclusion of families experiencing food insecurity. As part of a broader school-based project, this paper considers evidence derived from a secondary analysis of research in Nova Scotia (NS). In the original research, interviews were conducted with key stakeholders involved in supporting health promotion activities across NS elementary schools. For this article, data were re-examined using tenets of critical discourse analysis to evaluate if school practices were addressing the root social issues by identifying patterns in language and institutional norms. Our findings suggested that further illumination of programs may be needed to ensure that they do not contribute to the stigmatization and social exclusion of families experiencing food insecurity. Nutrition professionals are in a position to engage families experiencing food insecurity in policy action that will shift from a focus on individual determinants towards the social-structural conditions that underlie the complex issue of food insecurity.

Examining school-day dietary intakes among Canadian children

Understanding how dietary intakes vary over the course of the school day can help inform targeted school-based interventions, but little is known about the distribution or determinants of school-day dietary intakes in Canada. This study examined differences between school-hour and non–school-hour dietary intakes and assessed demographic and socioeconomic correlates of school-hour diet quality among Canadian children. Nationally representative data from the Canadian Community Health Survey were analyzed using 24-h dietary recalls falling on school days in 2004 (n = 4827). Differences in nutrient and food-group densities during and outside of school hours and differences in School Heathy Eating Index (School-HEI) scores across sociodemographic characteristics were examined using survey-weighted, linear regression models. Children reported consuming, on average, 746 kcal during school hours (one-third of their daily energy intakes). Vitamins A, D, B12, calcium, and dairy products densities were at least 20% lower during school hours compared with non-school hours. Differences in School-HEI scores were poorly explained by sociodemographic factors, although age and province of residence emerged as significant correlates. The school context provides an important opportunity to promote healthy eating, particularly among adolescents who have the poorest school-hour dietary practices. The nutritional profile of foods consumed at school could be potentially improved with increased intake of dairy products, thereby increasing intakes of protein, vitamin A, vitamin D, calcium, and magnesium.

Preschool and School Meal Policies: An Overview of What We Know about Regulation, Implementation, and Impact on Diet in the UK, Sweden, and Australia

School meals make significant contributions to healthy dietary behaviour, at a time when eating habits and food preferences are being formed. We provide an overview of the approaches to the provision, regulation, and improvement of preschool and primary school meals in the UK, Sweden, and Australia, three countries which vary in their degree of centralisation and regulation of school meals. Sweden has a centralised approach; all children receive free meals, and a pedagogical approach to meals is encouraged. Legislation demands that meals are nutritious. The UK system is varied and decentralised. Meals in most primary schools are regulated by food-based standards, but preschool-specific meal standards only exist in Scotland. The UK uses food groups (starchy foods, fruit and vegetables, proteins and dairy) in a healthy plate approach. Australian States and Territories all employ guidelines for school canteen food, predominantly using a "traffic light" approach outlining recommended and discouraged foods; however, most children bring food from home and are not covered by this guidance. The preschool standards state that food provided should be nutritious. We find that action is often lacking in the preschool years, and suggest that consistent policies, strong incentives for compliance, systematic monitoring, and an acknowledgement of the broader school eating environment (including home provided food) would be beneficial.

Compliance with school nutrition policies in Ontario and Alberta: An assessment of secondary school vending machine data from the COMPASS study

OBJECTIVES

We investigated the extent to which a sample of Ontario and Alberta secondary schools are being compliant with their respective provincial nutrition policies, in terms of the food and beverages sold in vending machines.

METHODS

This observational study used objective data on drinks and snacks from vending machines, collected over three years of the COMPASS study (2012/2013-2014/2015 school years). Drink (e.g., sugar-containing carbonated/non-carbonated soft drinks, sports drinks, etc.) and snack (e.g., chips, crackers, etc.) data were coded by number of units available, price, and location of vending machine(s) in the school. Univariate and bivariate analyses were undertaken using R version 3.2.3. In order to assess policy compliancy over time, nutritional information of products in vending machines was compared to nutrition standards set out in P/PM 150 in Ontario, and those set out in the Alberta Nutrition Guidelines for Children and Youth (2012) in Alberta.

RESULTS

Results reveal a decline over time in the proportion of schools selling sugar-containing carbonated soft drinks (9% in 2012/2013 vs. 3% in 2014/2015), crackers (26% vs. 17%) and cake products (12% vs. 5%) in vending machines, and inconsistent changes in the proportion selling chips (53%, 67% and 65% over the three school years). Conversely, results highlight increases in the proportion of vending machines selling chocolate bars (7% vs. 13%) and cookies (21% vs. 40%) between the 2012/2013 and 2014/2015 school years.

CONCLUSION

Nutritional standard policies were not adhered to in the majority of schools with respect to vending machines. There is a need for investment in formal monitoring and evaluation of school policies, and the provision of information and tools to support nutrition policy implementation.

RE-AIM Analysis of a School-Based Nutrition Education Intervention in Kindergarteners

BACKGROUND

Few nutrition interventions in kindergarten classes have been evaluated, and none has been tested for program effectiveness, implementation, and dissemination. Building a Healthy Me (BHM) is a nutrition intervention for kindergarteners that is classroom-based and includes a family component. This study evaluated the public health impact of BHM in California kindergarten classrooms using the RE-AIM (reach, efficacy, adoption, implementation, and maintenance) framework.

METHODS

A quasi-experimental design assessed pre-to-post changes in nutrition knowledge, dietary consumption, and parent behaviors of 25 intervention classrooms (414 students, 264 parents); and postintervention differences in nutrition knowledge between the intervention classrooms and 4 control classrooms measured at postintervention only (103 students).

RESULTS

Intervention students improved in knowledge of food groups and healthy breakfast/snack options, and scored higher than control students in food group knowledge at postintervention (ps < .05). Parents of intervention group children increased their use of food labels, and intervention group children increased intake of several healthy foods and decreased intake of candy and fried potatoes (ps < .05). The BHM program reached 41% of kindergarteners attending public schools in California, and teachers implemented most lesson material.

CONCLUSIONS

The BHM program was effective, implemented with fidelity, and broadly disseminated, highlighting its potential public health impact for kindergarteners.

Participation in School Food and Nutrition Activities among Grade 6-8 Students in Vancouver

This study examined student-reported participation in school food and nutrition activities in Vancouver, British Columbia (BC), and whether engagement differed by gender and between elementary and secondary school students. A cross-sectional survey of grade 6-8 public school students (n = 937) from 20 elementary and 6 secondary schools assessed student-reported participation in a range of food and nutrition activities. Statistical analyses included descriptive statistics and multilevel logistic regression to examine associations between participation with gender and school type. Overall, <50% of students reported engaging in most of the food and nutrition activities examined in the 2011-2012 school year, including: food preparation (36%), choosing/tasting healthy foods (27%), learning about Canada's Food Guide (CFG) (45%), learning about foods grown in BC (35%), gardening (21%), composting (32%), and recycling (51%). Females were more likely to report recycling and learning about CFG and BC-grown foods (P < 0.05). Secondary students were more likely to report activities focused on working with or learning about food/nutrition (P < 0.05). Despite local and provincial efforts to engage students in food and nutrition experiences, participation in most activities remains relatively low, with few students exposed to multiple activities. Continued advocacy is needed from the dietetics community to improve student engagement in food and nutrition activities.

Exploring Implementation of the Ontario School Food and Beverage Policy at the Secondary-School Level: A Qualitative Study

PURPOSE

The purpose of this study was to explore the implementation of the Ontario School Food and Beverage Policy (P/PM 150) from the perspective of secondary-school students.

METHODS

This research, informed by the ANGELO framework, undertook three focus groups with secondary students (n = 20) in 2 school boards representing both high- and low-income neighbourhoods in fall 2012. Focus groups were transcribed verbatim for subsequent analysis. Key themes were generated deductively from the research objectives and inductively as they emerged from transcripts.

RESULTS

Perceived impacts of P/PM 150 included high-priced policy-compliant food for sale, lower revenue generation, and food purchased off-campus. Limited designated eating spaces, proximity to external, nonpolicy-compliant food, and time constraints acted as key local level barriers to healthy eating.

CONCLUSIONS

Pricing strategies are needed to ensure that all students have access to nutritious food, particularly in the context of vulnerable populations. Recognition of the context and culture in which school nutrition policies are being implemented is essential. Future research to explore the role of public health dietitians in school nutrition policy initiatives and how to leverage local resources and stakeholder support in low income, rural and remote populations is needed.

RE-AIM analysis of a randomized school-based nutrition intervention among fourth-grade classrooms in California

Childhood overweight and obesity are major health problems. School-based programs enable intervening with large groups of children, but program overall health impact is rarely completely assessed. A RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) analysis tested the overall public health impact of the fourth-grade "Nutrition Pathfinders" school-based nutrition-education program. A randomized controlled trial in 47 fourth-grade California classrooms (1713 students) tested program efficacy, and a secondary analysis of archival data tested program dissemination. Desired effects were seen in child nutrition knowledge, attitudes, consumption of low-nutrient high-density foods, sugar-sweetened beverages, proteins, grains, and parent willingness to serve new foods. The program was disseminated to ∼25 % of public school fourth-grade classrooms in California and cost about $1.00 per student to implement. The Nutrition Pathfinders program demonstrates potential for moderate to high public health impact due to its wide dissemination, effectiveness in altering attitudes and behaviors, and its relatively inexpensive cost of implementation.

Moving Forward with School Nutrition Policies: A Case Study of Policy Adherence in Nova Scotia

Many Canadian school jurisdictions have developed nutrition policies to promote health and improve the nutritional status of children, but research is needed to clarify adherence, guide practice-related decisions, and move policy action forward. The purpose of this research was to evaluate policy adherence with a review of online lunch menus of elementary schools in Nova Scotia (NS) while also providing transferable evidence for other jurisdictions. School menus in NS were scanned and a list of commonly offered items were categorized, according to minimum, moderate, or maximum nutrition categories in the NS policy. The results of the menu review showed variability in policy adherence that depended on food preparation practices by schools. Although further research is needed to clarify preparation practices, the previously reported challenges of healthy food preparations (e.g., cost, social norms) suggest that many schools in NS are likely not able to use these healthy preparations, signifying potential noncompliance to the policy. Leadership and partnerships are needed among researchers, policy makers, and nutrition practitioners to address the complexity of issues related to food marketing and social norms that influence school food environments to inspire a culture where healthy and nutritious food is available and accessible to children.

The influence of chronological period of data collection on differences in reported dietary intake among school-aged children surveyed in 39 countries

OBJECTIVE

To examine whether dietary intake reported by school-aged children relates to the chronological period of data collection.

DESIGN

Cross-sectional surveys in 39 countries in different monthly periods of the 2009-2010 school year.

SETTINGS

Questionnaires were completed in schools anonymously.

PARTICIPANTS

Children from 39 countries, aged 11, 13, and 15 years (n = 209,320).

MAIN OUTCOME MEASURES

Daily consumption of fruits, vegetables, sweets, and soft drinks, derived from a food frequency questionnaire.

ANALYSIS

Multivariate logistic regression (applied for 3 countries); 2-level random intercept logistic regression (applied for 36 countries).

RESULTS

Monthly variations in food intake among students from Canada, England, and Norway, where data collection took place almost all months of the school year, revealed significantly lower daily consumption of food items in January to February. A 2-level random intercept logistic regression model for 36 countries, where questionnaires were administered in relatively shorter periods, indicated the lowest likelihood of fruit and soft drink consumption when the data were collected in March to April (β = -0.30; P = .006, compared with October to December) and in January to February (β = -0.65; P = .018, compared with May to June), respectively.

CONCLUSIONS AND IMPLICATIONS

The chronological period of data collection must be considered when comparing children's reported food consumption, but this effect is small relative to cross-national variations in dietary patterns.

Examining local-level factors shaping school nutrition policy implementation in Ontario, Canada

OBJECTIVE

Increasing numbers of overweight and obese youth draw attention to the school as an important setting for targeted nutrition interventions, given that it is where they spend a majority of their waking time. The objective of the present study was to explore local-level factors shaping the implementation of a school nutrition policy.

DESIGN

In-depth, semi-structured interviews were conducted in person or via the telephone (a maximum of 60 min). An interview guide was informed by the Analysis Grid for Environments Linked to Obesity (ANGELO) framework, research objectives and literature. Key themes centred on policy implementation, including facilitators and barriers (i.e. resources, capacity), user satisfaction (i.e. students) and communication strategies.

SETTING

Secondary schools in Ontario, Canada.

SUBJECTS

Twenty-two participants from local agencies supporting school nutrition programming (n 8) and secondary-school principals, vice principals and teachers (n 14) from nine schools across three Ontario school boards.

RESULTS

Results are organized according to environments outlined in the ANGELO framework. The cost of healthy food for sale, revenue loss (economic), proximity of schools to off-site food outlets (physical), the restrictive nature of policy, the role of key stakeholders (political), the role of stigma and school culture (sociocultural) act as local-level barriers to policy implementation.

CONCLUSIONS

Gaps in policy implementation include the high cost of food for sale and subsequent revenue generation, the close proximity of internal and external food environments, the need for consultation and communication between stakeholders, and strategies to reduce stigma and improve the school nutrition culture.

Improving diet and physical activity to reduce population prevalence of overweight and obesity: an overview of current evidence

OBJECTIVE

The aim of this study is to provide an overview of interventions to reduce or prevent overweight or obesity and improve diet or physical activity.

METHODS

A review of meta-analyses and/or systematic reviews of these interventions in any setting or age group were conducted. Narrative systematic reviews were included for intervention categories with limited meta-analyses available. Summary measures including weighted mean difference, standardised mean difference, and I-squared, were examined.

RESULTS

A total of 60 meta-analyses and 23 systematic reviews met the inclusion criteria. Dietary interventions and multi-component interventions targeting overweight and obesity appeared to have the greatest effects, particularly in comparison with workplace or technology or internet-based interventions. Pharmaceutical and surgical interventions produced favourable results for specific population sub-groups (i.e. morbidly obese). Population-wide strategies such as policy interventions have not been widely analysed. The effectiveness of the interventions to assist in maintaining behaviour or weight change remains unclear.

CONCLUSIONS

Various individually targeted interventions were shown to reduce body weight, although effect sizes were typically modest, and the durability of effects has been questioned. New approaches to evaluating population-based interventions, such as taxes and regulation, are recommended. Future research modelling the long-term effects of interventions across the lifespan would also be beneficial.

Exploring the school nutrition policy environment in Canada using the ANGELO framework

Excess body weight has become a major public health issue. Given the link between poor nutrition, obesity, and chronic disease in youth, increasing attention is being paid to the school as an ideal setting for promoting nutritious eating practices. Informed by the ANGELO (Analysis Grid for Environments Linked to Obesity) framework, we employ a documentary analysis to investigate the context of school nutrition in Canada, particularly the relationship between regional- and upper-level policies. In doing so, we examine policy documents and technical reports across three levels. We used mixed methods to analyze relevant English language policy documents and technical reports across Canada (n = 58), published between 1989 and 2011. Results reveal distinct differences across federal, provincial, and regional levels. The availability of nutritious food in schools and having nutrition education as part of the curriculum were key components of the physical environment across federal and provincial levels. Federal and provincial priorities are guided by a health promotion framework and adopting a partnership approach to policy implementation. Gaps in regional-level policy include incorporating nutrition education in the curriculum and making the link between nutrition and obesity. Policy implications are provided, in addition to future research opportunities to explore the connections between these environments at the local level.

School nutritional capacity, resources and practices are associated with availability of food/beverage items in schools

BACKGROUND

The school food environment is important to target as less healthful food and beverages are widely available at schools. This study examined whether the availability of specific food/beverage items was associated with a number of school environmental factors.

METHODS

Principals from elementary (n=369) and middle/high schools (n=118) in British Columbia (BC), Canada completed a survey measuring characteristics of the school environment. Our measurement framework integrated constructs from the Theories of Organizational Change and elements from Stillman's Tobacco Policy Framework adapted for obesity prevention. Our measurement framework included assessment of policy institutionalization of nutritional guidelines at the district and school levels, climate, nutritional capacity and resources (nutritional resources and participation in nutritional programs), nutritional practices, and school community support for enacting stricter nutritional guidelines. We used hierarchical mixed-effects logistic regression analyses to examine associations with the availability of fruit, vegetables, pizza/hamburgers/hot dogs, chocolate candy, sugar-sweetened beverages, and french fried potatoes.

RESULTS

In elementary schools, fruit and vegetable availability was more likely among schools that have more nutritional resources (OR=6.74 and 5.23, respectively). In addition, fruit availability in elementary schools was highest in schools that participated in the BC School Fruit and Vegetable Nutritional Program and the BC Milk program (OR=4.54 and OR=3.05, respectively). In middle/high schools, having more nutritional resources was associated with vegetable availability only (OR=5.78). Finally, middle/high schools that have healthier nutritional practices (i.e., which align with upcoming provincial/state guidelines) were less likely to have the following food/beverage items available at school: chocolate candy (OR= .80) and sugar-sweetened beverages (OR= .76).

CONCLUSIONS

School nutritional capacity, resources, and practices were associated with the availability of specific food/beverage items in BC public schools. Policies targeting the school environment are increasingly being considered as one of the strategies used to address childhood obesity, as a result it is important to further understand the factors associated with the availability of specific food/beverage items at school.

Implementing elementary school nutrition policy: principals' perspectives

PURPOSE

We assessed principals' perceptions about the level of school nutrition policy (SNP) implementation in Prince Edward Island elementary schools, objectively evaluated how closely elementary schools are following SNP regulations for types and frequency of foods offered at school, and explored principals' beliefs about the key enablers and barriers to SNP implementation.

METHODS

Phase I involved a cross-sectional survey of principals' assessment of perceived and actual adherence to SNP components. Phase II included in-depth interviews to explore principals' perceptions about factors influencing policy adherence. Descriptive statistics were generated. Thematic content analysis was used to identify themes.

RESULTS

Forty-one (93%) principals participated in Phase I, and nine of these participated in Phase II. The level of implementation of SNP components varied. Seventy-four percent of all foods sold were categorized as allowed by the SNP; 68% of schools sold at least one "not allowed" food. Key barriers included lost revenue, a higher cost of healthy foods, and limited availability of policy-allowed foods. Enablers were a high level of community support, ready access to food suppliers, and active parent volunteers.

CONCLUSIONS

While schools are making progress in implementing the SNP, challenges remain. Identifying and communicating strategies for healthy fundraising activities and finding ways to involve parents in SNP implementation are recommended.

From paper to practice: barriers to adopting nutrition guidelines in schools

OBJECTIVE

To explore the barriers associated with the adoption of the Alberta Nutrition Guidelines for Children and Youth in schools according to characteristics of the innovation (guidelines) and the organization (schools).

DESIGN

Cross-sectional telephone survey.

SETTING AND PARTICIPANTS

Schools in Alberta, Canada. Principals from 357 schools.

MAIN OUTCOME MEASURE

Barriers to adopting the nutrition guidelines.

ANALYSIS

A 19-question telephone survey, including open- and closed-ended questions, was used to obtain information regarding schools' characteristics and barriers to adopting the guidelines. Qualitative data were coded according to common themes a priori, based on constructs from the Diffusion of Innovations framework.

RESULTS

Schools reported many barriers related to the relative advantage, compatibility, and complexity of adopting the guidelines. Parents' resistance to change and cost were the key reported barriers. Lack of knowledge, student preferences, the physical location of the school, and barriers related to the provision of healthful food were also reported.

CONCLUSIONS AND IMPLICATIONS

Disseminating guidelines without providing adequate support for their implementation may not promote change within the school setting. School nutrition initiatives need to involve the parents and have access to sufficient financial and human resource support.

Stakeholder engagement for improved school policy: development and implementation

The health and education departments of government share a responsibility for promoting the health of children through policies in the school setting. These policies can be enhanced through the involvement of such stakeholders as school personnel, students, parents or caregivers, health professionals, the non-profit sector and industry. Although there is little evidence-based literature on the roles of stakeholders in school policy development and implementation, stakeholder involvement appears to be critical throughout the policy process. This article discusses stakeholder involvement in the development and implementation of school policies that promote and support healthy eating and physical activity. Canadian examples illustrate stakeholder engagement in this context.