School wellness policies and foods and beverages available in schools

Evaluation of School Wellness Policies in Low-Income California Districts After the 2016 USDA Final Rule

BACKGROUND

Districts with federal nutrition programs must have an updated local school wellness policy (LSWP) to promote nutrition, physical activity, and student wellness. This study evaluates factors associated with LSWP quality among low-income districts.

METHODS

In 2018, we collected LSWPs from websites of 200 randomly selected, county-stratified, low-income-serving California public districts. Multivariable linear regression assessed associations between district characteristics, model LSWP use (national, state, none), and adoption date on policy quality.

RESULTS

On the WellSAT 3.0 scale of 0-100, mean (95% CI) comprehensiveness was 65.0 (63.2-66.7) and strength was 37.3 (35.3-39.2). Nearly verbatim adoption of model LSWPs was high (68.5% state model, 13.0% a national model). Half were adopted before mandated updates. District size (≥1000 students) and national model LSWP adoption were associated with higher comprehensive scores. National model LSWP adoption was associated with higher strength scores in updated policies compared with those not updated.

IMPLICATIONS

LSWPs have improved school food and activity environments, but district engagement in LSWP is low. Integration into education frameworks that reduce learning barriers could provide synergy for re-engagement.

CONCLUSIONS

High adoption of model policies and low update compliance indicate little district engagement in LSWP. Mixed methods studies of districts with high-quality LSWP are needed.

A Descriptive Qualitative Study of the Perceptions of Regulatory Authorities, Parents, and School Canteen Owners in the South of Ecuador about the Challenges and Facilities Related to Compliance with the National Regulation for School Canteens

The prevalence of overweight and obesity in the Ecuadorian school population continues to increase. An important factor in children's nutrition is the food offered in school canteens. The objective of this study was to explore the perceptions of the challenges faced by and facilities of school canteens in the provinces of southern Ecuador in terms of complying with national regulations. For this qualitative descriptive study, semi-structured interviews were conducted in 2021 with six school canteen owners, six school directors, five health experts, and seven parents of children attending school from three provinces, Cañar, Azuay, and Morona Santiago, in Ecuador. The data were transcribed and subsequently analyzed in ATLAS ti. The participants indicated several challenges to comply with the regulations of school canteens, such as the expenses generated by them, the lack of control of street food vendors in the surroundings of the schools, and the lack of trained personnel. Regarding the facilities, they highlighted that the regulation for cleaning and hygiene are more easily fulfilled. Standards and control of the food stipend in school canteens are required to ensure a supply of healthy food for the children. Multiple challenges and strategies are proposed to improve the eating habits of the school population and to improve the nutrition of schoolchildren.

Disparities in Local Wellness Policies Implementation Across Maryland Schools

BACKGROUND

School-level implementation of district-level local wellness policies (LWPs) is needed to create school environments that promote nutrition and physical activity (PA). Disparities in classroom-specific LWPs implementation were examined.

METHODS

An administrator survey (N = 756 schools; 24/24 districts) included 6 classrooms LWP best-practice items (fully/not fully implemented: restricting food celebrations or rewards, incorporating PA breaks or integrating PA in curricula, restricting withholding or using PA as punishment). A sum score (alpha = .71; elementary and middle/high examined separately) was used to examine associations with student body income (free-and-reduced priced meals (FARMS): ≤40%, 41-75%, ≥75%), race/ethnicity, and school location (rural/urban/suburban), accounting for district-level clustering, with moderation examined.

RESULTS

Classroom implementation scores were: elementary = 3.1 ± 1.8 (range: 0-6/6 items) and middle/high = 2.3 ± 1.6 (range:0-5/5 items). Among elementary and middle/high schools, 65% and 55% had >40% FARMS, 39% and 46% had ≥50% white student body, and 24% and 23% were urban, respectively. Elementary schools with >40% of FARMS-eligible students and middle/high schools with <25% white students reported implementing fewer items. Location was not associated with classroom practices nor was moderation observed.

CONCLUSIONS

Disparities in classroom-specific LWP best practices implementation were observed by income and race/ethnicity. Tailored support may be needed to improve classroom LWP implementation in schools serving low-income students.

Prevalence and nutritional quality of free food and beverage acquisitions at school and work by SNAP status

BACKGROUND

The dual burden of poor diet quality and food insecurity makes free food-food acquired at no cost-a very important part of the nutrition safety net for low-income families. The goal of this study was to determine the national prevalence and nutritional quality of free food acquired separately in two settings: 1) by children at school; and 2) by employees at work; both stratified by participation in the Supplemental Nutrition Assistance Program (SNAP).

METHODS

Using National Household Food Acquisition and Purchase Survey data (2012; n = 4,826 U.S. households containing 5,382 employed adults and 3,338 school-aged children), we used survey-weighted proportions to describe free food acquisition and linear regression to compare the 2010 Healthy Eating Index (HEI-2010) for free/non-free food acquisition events (i.e., meals) by SNAP status. Analyses were conducted in 2019-2020.

RESULTS

SNAP households had more free acquisition events (29.6%) compared to non-SNAP households (<185% federal poverty level (FPL) = 22.3%; ≥185%FPL = 21.0%, p's<0.001). For SNAP-participant children, free acquisition events at school had a higher mean HEI-2010 compared to non-free acquisition events at school (50.3 vs. 43.8, p = 0.033) and free acquisition events by SNAP-non-participant children ≥185%FPL at school (50.3 vs. 38.0, p = 0.001). Free and non-free acquisition events at work had relatively low HEI-2010s, with no differences by SNAP status.

CONCLUSIONS

Over one fifth of all food acquisition events were free, but free food acquisitions at school and work were relatively unhealthy. For children participating in SNAP, free food acquired at school had higher nutritional quality. Improving the dietary quality of free foods could improve the health of families, especially those participating in SNAP.

State Wellness Policy Requirement Laws Matter for District Wellness Policy Comprehensiveness and Wellness Policy Implementation in the United States

Beginning with the school year 2006-2007, U.S. school districts participating in the federal Child Nutrition Programs were required to adopt and implement a local wellness policy (LWP) that included goals and/or standards for nutrition education, school meals, other foods sold or served in schools, and physical activity. A primary challenge with LWPs has been inconsistent implementation. This study examined whether state wellness policy requirement laws and district LWP comprehensiveness influence district level implementation, using law/policy data from the National Wellness Policy Study and school food authority (SFA)-reported district LWP implementation from the School Nutrition and Meal Cost Study. Generalized linear and structural equation models were used, controlling for SFA and district characteristics. SFAs in states with wellness policy requirement laws (vs. those in states without) reported implementing significantly more practices (59.56% vs. 44.57%, p < 0.01). State wellness policy requirement laws were associated with district LWP comprehensiveness (coeff.: 0.463; 95% CI: 0.123, 0.803) and district-level implementation (coeff.: 1.392; 95% CI: 0.299, 2.485). District LWP comprehensiveness was associated with district implementation (coeff.: 0.562; 95% CI: 0.072, 1.053), but did not mediate the state law-district implementation relationship. This study highlights the important role that state laws and district LWPs can play in facilitating wellness policy implementation.

Local Data for Action: Statewide Dissemination of School Wellness Policy Evaluations in Wisconsin

School settings can influence child health, including physical activity and diet, through the promotion of high-quality wellness policies. Many studies have analyzed the quality of school wellness policies, but evidence is lacking regarding the dissemination of the policy evaluation results to school districts. This study describes the process the Wisconsin Health Atlas followed to disseminate tailored school wellness policy data reports and interactive dashboards to school districts throughout the state and the results of the statewide dissemination efforts. Prioritizing the translation of research to practice, the process included collaborating with key stakeholders and partners to provide formative feedback on the dissemination activities. The electronic and hard copy reports were disseminated to 232 districts through email and U.S. mail. Each district received a tailored report featuring an executive summary, local data for action, personalized policy recommendations, best practices, and a unique code to enter into interactive data dashboards to explore additional local, regional, and state-level data. In the utilization follow-up survey (20.3% response rate), respondents indicated that the report will help their district to improve the quality of their school wellness policy. Additionally, respondents who had used the report specified they used the data to identify areas for policy improvement and to support their triennial assessment, suggesting that districts value the technical support. To support school districts in improving the quality of school wellness policies, we recommend researchers prioritize collaborative dissemination efforts and provide actionable policy data when conducting school wellness policy evaluations.

School Wellness in Wisconsin: Evaluating Policies for Practices to Prevent Pediatric Obesity

BACKGROUND

We examined written language in Wisconsin school wellness policies (SWPs) for federal mandate compliance, quality related to obesity prevention, and school characteristics associated with variations in quality. This is the first near census of Wisconsin SWPs and examines whether adhering to federal mandates results in strong policies aimed at preventing pediatric obesity.

METHODS

Policies were coded using the WellSAT 2.0. Policy quality was computed as comprehensiveness and strength based on 6 subscales and 2 overall scores. Variations in policy quality were examined by district size, free/reduced lunch percentage, and year of last revision.

RESULTS

We received SWPs from 91% of districts. Six of the 8 federal mandates were addressed by the majority of districts, although less than one fourth addressed all. Most comprehensiveness scores were weak to moderate, and strength scores were weak. All school characteristics were significantly related to overall policy quality; effect sizes were small.

CONCLUSIONS

Our results confirm the necessity of statewide focus on SWP improvement and suggest that while districts may be meeting federal mandates related to pediatric obesity, few policies include health promotion practices beyond those required. Policies remain fragmented and lack focus on obesity prevention practices; we identify modifiable areas for improvement.

Public Policies to Reduce Sugary Drink Consumption in Children and Adolescents

Excess consumption of added sugars, especially from sugary drinks, poses a grave health threat to children and adolescents, disproportionately affecting children of minority and low-income communities. Public policies, such as those detailed in this statement, are needed to decrease child and adolescent consumption of added sugars and improve health.

Disparities in Supports for Student Wellness Promotion Efforts Among Secondary Schools in Minnesota

BACKGROUND

We examined whether there are differences in the presence of supports for student wellness promotion (1) between schools in city, suburban and rural locations and, (2) among rural schools, according to distance from a metropolitan center.

METHODS

The analysis was conducted in a sample of 309 secondary schools using 2012 Minnesota School Health Profiles surveys and National Center for Educational Statistics Common Core Data. Scores for overall support addressed school health improvement coordination (range: 0-29), collaboration on health education activities (range: 0-5), and teachers' professional preparation (range: 0-7).

RESULTS

Mean overall scores for health improvement coordination (10.5 ± 7.3), collaboration on health education activities (3.0 ± 1.5) and professional preparation (4.0 ± 1.9) indicated supports are lacking in schools across city, suburban, and rural locations. Comparison of overall scores did not identify disparities; however, weaknesses and strengths of particular relevance for rural schools were identified in examining specific aspects of support. For example, the proportion of rural schools having a written school improvement plan was 54.8% compared to 84.6% of city schools and 64.3% of suburban schools (p = .01).

CONCLUSIONS

Tailored training and technical assistance are needed to better support schools in implementing recommended wellness policies and practices.

Measures of the food environment: A systematic review of the field, 2007-2015

BACKGROUND

Many studies have examined the relationship between the food environment and health-related outcomes, but fewer consider the integrity of measures used to assess the food environment. The present review builds on and makes comparisons with a previous review examining food environment measures and expands the previous review to include a more in depth examination of reliability and validity of measures and study designs employed.

METHODS

We conducted a systematic review of studies measuring the food environment published between 2007 and 2015. We identified these articles through: PubMed, Embase, Web of Science, PsycINFO, and Global Health databases; tables of contents of relevant journals; and the National Cancer Institute's Measures of the Food Environment website. This search yielded 11,928 citations. We retained and abstracted data from 432 studies.

RESULTS

The most common methodology used to study the food environment was geographic analysis (65% of articles) and the domination of this methodology has persisted since the last review. Only 25.9% of studies in this review reported the reliability of measures and 28.2% reported validity, but this was an improvement as compared to the earlier review. Very few of the studies reported construct validity. Studies reporting measures of the school or worksite environment have decreased since the previous review. Only 13.9% of the studies used a longitudinal design.

CONCLUSIONS

To strengthen research examining the relationship between the food environment and population health, there is a need for robust and psychometrically-sound measures and more sophisticated study designs.

Perceived barriers to achieving a healthy weight: a qualitative study using focus groups at public and private schools in Guatemala City

BACKGROUND

Overweight prevalence among Guatemalan girls is higher in public than in private schools. Little is known about adolescent girls' perceptions of the right ways to achieve a healthy weight. This study examines public and private school adolescent girls' perceptions of a "healthy weight," and barriers and facilitators to achieving it.

METHODS

We conducted 4 focus groups in public and private schools in Guatemala City with girls from 13 to 15 years old. The discussion guide included open-ended questions and activities aimed at examining perceptions of "healthy weight" and barriers and motivators to achieving it within the school environment. Focus groups were audio-recorded and transcribed. Data analyses followed established methods of content analysis.

RESULTS

Twenty-eight girls (private school, n = 12; public school, n = 16) of ages ranging from 13.1 to 15.9 years (median, 14, IQR, 13.6-14.9) participated in the study. Girls identified images of thin and fit women as healthy. They cited healthy eating and physical activity as ways to achieve a healthy weight. Within the school environment, barriers to maintaining a healthy weight included a lack of healthy food options and the prioritization of sports for boys over girls. In public schools, facilities were less than optimal; in private schools, girls' access to facilities was limited. Public school girls stated that their uniforms were inappropriate for exercising.

CONCLUSION

Our findings support the need to provide more healthy food options in Guatemalan schools. In addition, physical activity for girls should be promoted and facilities made available for their use.

Nutrition Quality of US School Snack Foods: A First Look at 2011-2014 Bid Records in 8 School Districts

BACKGROUND

As part of the Healthy, Hunger-Free Kids Act, snacks, and desserts sold in K-12 schools as of the 2014-2015 school year are required to meet the "Smart Snacks" nutritional guidelines. Although studies exist in tracking progress in local and national efforts, the proportion of snack food procured by school districts compliant with the Smart Snacks standard prior to its full implementation is unknown.

METHODS

We repurposed a previously untapped database, Interflex, of public bid records to examine the nutritional quality of snacks and desserts procured by school districts. We selected 8 school districts with at least 90% complete data each year during 2011-2012, 2012-2013, and 2013-2014 school years and at locations across different regions of the United States. We quantified the amount of calories and sugar of each product contained in the won bids based on available online sources and determined whether the produce complied with Smart Snack guidelines.

RESULTS

In all 8 districts (snack expenditure analyzed ranging from $152,000 to $4.4 million), at least 50% of snack bids were compliant with the US Department of Agriculture Smart Snacks standard during the 2013-2014 school year. Across sampled districts, we observed a general trend in lower caloric density (kcal per product) and sugar density (grams of sugar per product) over a 3-year period.

CONCLUSIONS

Many districts across the country have made headway in complying with the Smart Snack guidelines, though gaps remain.

Implementation of Local Wellness Policies in Schools: Role of School Systems, School Health Councils, and Health Disparities

BACKGROUND

Written local wellness policies (LWPs) are mandated in school systems to enhance opportunities for healthy eating/activity. LWP effectiveness relies on school-level implementation. We examined factors associated with school-level LWP implementation. Hypothesized associations included system support for school-level implementation and having a school-level wellness team/school health council (SHC), with stronger associations among schools without disparity enrollment (majority African-American/Hispanic or low-income students).

METHODS

Online surveys were administered: 24 systems (support), 1349 schools (LWP implementation, perceived system support, SHC). The state provided school demographics. Analyses included multilevel multinomial logistic regression.

RESULTS

Response rates were 100% (systems)/55.2% (schools). Among schools, 44.0% had SHCs, 22.6% majority (≥75%) African-American/Hispanic students, and 25.5% majority (≥75%) low-income (receiving free/reduced-price meals). LWP implementation (17-items) categorized as none = 36.3%, low (1-5 items) = 36.3%, high (6+ items) = 27.4%. In adjusted models, greater likelihood of LWP implementation was observed among schools with perceived system support (high versus none relative risk ratio, RRR = 1.63, CI: 1.49, 1.78; low versus none RRR = 1.26, CI: 1.18, 1.36) and SHCs (high versus none RRR = 6.8, CI: 4.07, 11.37; low versus none RRR = 2.24, CI: 1.48, 3.39). Disparity enrollment did not moderate associations (p > .05).

CONCLUSIONS

Schools with perceived system support and SHCs had greater likelihood of LWP implementation, with no moderating effect of disparity enrollment. SHCs/support may overcome LWP implementation obstacles related to disparities.

Translating Institutional Change to Local Communities: The Role of Linking Organizations

We examine the processes and mechanisms of translating broader field-level change to the local community, drawing on insights from the inhabited institutions perspective and community-based institutionalism. In particular, we develop the concept of linking organizations as key actors in institutional change that connect the broader field and community levels. We use multiple forms of qualitative data, collected over a two-year time frame, to study the processes of a community foundation, the ‘Rainbow Wellness Foundation’, as a linking organization that engaged five community coalitions to embed a new wellness approach, locally. Our findings suggest that linking organizations interpret the central tenets of the approach, define them locally around relevant aims, and regulate community organizations’ adherence, to ensure legitimacy with the field. In addition, by engaging and negotiating with the community and helping manage ambiguity, linking organizations enable local ‘filling-in’ of these models with practices that meet community needs and interests. This study contributes to the literature on institutional change by identifying the activities of linking organizations as agents that translate broader field change, locally.

District wellness policies and school-level practices in Minnesota, USA

OBJECTIVE

To compare the strength of district wellness policies with corresponding school-level practices reported by principals and teachers.

DESIGN

District-level wellness policy data were collected from school district websites and, if not available online, by requests made to district administrators in the autumn of 2013. The strength of district policies was scored using the Wellness School Assessment Tool. School-level data were drawn from the 2012 Minnesota School Health Profiles principal and teacher surveys and the National Center for Education Statistics Common Core Data. Generalized estimating equations which accounted for school-level demographics and the nesting of up to two schools within some districts were used to examine ten district policy items and fourteen school-level practices of relevance to nutrition standards, nutrition education and wellness promotion, and physical activity promotion.

SETTING

State-wide sample of 180 districts and 212 public schools in Minnesota, USA.

RESULTS

The mean number of energy-dense, nutrient-poor snack foods and beverages available for students to purchase at school was inversely related to the strength of district wellness policies regulating vending machines and school stores (P=0·01). The proportion of schools having a joint use agreement for shared use of physical activity facilities was inversely related to the strength of district policies addressing community use of school facilities (P=0·03). No associations were found between the strength of other district policies and school-level practices.

CONCLUSIONS

Nutrition educators and other health professionals should assist schools in periodically assessing their wellness practices to ensure compliance with district wellness policies and environments supportive of healthy behaviours.

Influence of home and school environments on specific dietary behaviors among postpartum, high-risk teens, 27 States, 2007-2009

Introduction

The objective of this study was to determine whether perceptions of the home and school food environments are related to food and beverage intakes of postpartum teens.

Methods

Our study was a baseline, cross-sectional analysis of 853 postpartum teens enrolled in a weight-loss intervention study across 27 states from 2007 through 2009. Eight-item scales assessed perceived accessibility and availability of foods and beverages in school and home environments. Associations between environments and intakes were assessed by using χ² and using logistic regression with generalized estimating equations (GEE), respectively.

Results

Overall, 52% of teens perceived their school food environment as positive, and 68% of teens perceived their home food environment as positive. A positive school environment was independently associated with fruit consumption and 100% fruit juice consumption. A positive home environment was independently associated with fruit, vegetable, and water consumption and infrequent consumption of soda and chips (χ²P < .05). Having only a positive school environment was associated with fruit consumption (GEE odds ratio [OR], 3.1; 95% confidence interval [CI], 1.5–6.5), and having only a positive home environment was associated with fruit (GEE OR, 2.9; 95% CI, 1.6–5.6), vegetable (GEE OR, 3.1; 95% CI, 1.5–6.2), and water (GEE OR, 2.6; 95% CI, 1.7–4.0) consumption and infrequent consumption of soda (GEE OR, 0.5; 95% CI, 0.3–0.7). Results for positive home and school environments were similar to those for positive home only.

Conclusion

Home and school environments are related to dietary behaviors among postpartum teens, with a positive home environment more strongly associated with healthful behaviors.

Development of the policy indicator checklist: a tool to identify and measure policies for calorie-dense foods and sugar-sweetened beverages across multiple settings

OBJECTIVES

We developed the policy indicator checklist (PIC) to identify and measure policies for calorie-dense foods and sugar-sweetened beverages to determine how policies are clustered across multiple settings.

METHODS

In 2012 and 2013 we used existing literature, policy documents, government recommendations, and instruments to identify key policies. We then developed the PIC to examine the policy environments across 3 settings (communities, schools, and early care and education centers) in 8 communities participating in the Childhood Obesity Research Demonstration Project.

RESULTS

Principal components analysis revealed 5 components related to calorie-dense food policies and 4 components related to sugar-sweetened beverage policies. Communities with higher youth and racial/ethnic minority populations tended to have fewer and weaker policy environments concerning calorie-dense foods and healthy foods and beverages.

CONCLUSIONS

The PIC was a helpful tool to identify policies that promote healthy food environments across multiple settings and to measure and compare the overall policy environments across communities. There is need for improved coordination across settings, particularly in areas with greater concentration of youths and racial/ethnic minority populations. Policies to support healthy eating are not equally distributed across communities, and disparities continue to exist in nutrition policies.

Little association between wellness policies and school-reported nutrition practices

BACKGROUND

The Child Nutrition and WIC Reauthorization Act of 2004 mandated written school wellness policies. Little evidence exists to evaluate the impact of such policies. This study assessed the quality (comprehensiveness of topics addressed and strength of wording) of wellness policies and the agreement between written district-level policies and school-reported nutrition policies and practices in 48 low-income Michigan school districts participating in the School Nutrition Advances Kids study.

METHOD

Written wellness policy quality was assessed using the School Wellness Policy Evaluation Tool. School nutrition policies and practices were assessed using the School Environment and Policy Survey. Analysis of variance determined differences in policy quality, and Fisher's exact test examined agreement between written policies and school-reported practices.

RESULTS

Written wellness policies contained ambiguous language and addressed few practices, indicating low comprehensiveness and strength. Most districts adopted model wellness policy templates without modification, and the template used was the primary determinant of policy quality. Written wellness policies often did not reflect school-reported nutrition policies and practices.

CONCLUSIONS

School health advocates should avoid assumptions that written wellness policies accurately reflect school practices. Encouraging policy template customization and stronger, more specific language may enhance wellness policy quality, ensure consistency between policy and practice, and enhance implementation of school nutrition initiatives.

Policy outcomes of applying different nutrient profiling systems in recreational sports settings: the case for national harmonization in Canada

OBJECTIVE

To assess agreement among three nutrient profiling systems used to evaluate the healthfulness of vending machine products in recreation and sport settings in three Canadian provinces. We also assessed whether the nutritional profile of vending machine items in recreation and sport facilities that were adhering to nutrition guidelines (implementers) was superior to that of facilities that were not (non-implementers).

DESIGN

Trained research assistants audited the contents of vending machines. Three provincial nutrient profiling systems were used to classify items into each province's most, moderately and least healthy categories. Agreement among systems was assessed using weighted κ statistics. ANOVA assessed whether the average nutritional profile of vending machine items differed according to province and guideline implementation status.

SETTING

Eighteen recreation and sport facilities in three Canadian provinces. One-half of facilities were implementing nutrition guidelines.

SUBJECTS

Snacks (n 531) and beverages (n 618) within thirty-six vending machines were audited.

RESULTS

Overall, the systems agreed that the majority of items belonged within their respective least healthy categories (66-69 %) and that few belonged within their most healthy categories (14-22 %). Agreement among profiling systems was moderate to good, with κ w values ranging from 0·49 to 0·69. Implementers offered fewer of the least healthy items (P<0·05) and these items had a better nutritional profile compared with items in non-implementing facilities.

CONCLUSIONS

The policy outcomes of the three systems are likely to be similar, suggesting there may be scope to harmonize nutrient profiling systems at a national level to avoid unnecessary duplication and support food reformulation by industry.

Development of a report card on healthy food environments and nutrition for children in Canada

OBJECTIVE

The purpose of the Report Card on Healthy Food Environments and Nutrition for Children is to assess how current environments and policies in Canada support or create barriers to improving children's dietary behaviours and body weights.

METHOD

In 2014 we reviewed the literature to identify indicators of the quality of children's food environments and related policies. Scoring systems used to monitor and report on progress on a variety of public health activities were consulted during development of a grading scheme. The Report Card was revised following reviews by an Expert Advisory Committee.

RESULTS

The Report Card assigns a grade to policies and actions (42 indicators and benchmarks) within 4 micro-environments (physical, communication, economic, social) and within the political macro-environment. Grade-level scores of A through F are assigned that reflect achievement of, supports for, and monitoring of indicator-specific benchmarks. A Canadian Report Card will be released annually starting in 2015.

CONCLUSION

The Report Card is a novel tool to monitor the state of children's food environments and supportive policies, inform stakeholders of the state of these environments and policies, engage society in a national discussion, and outline a policy-relevant research agenda for further study.