Implementing elementary school nutrition policy: principals' perspectives

Grocery and chain restaurant foods and beverages allowed for sale in Ontario schools: an evaluation against Ontario's School Food and Beverage Policy

The Ontario School Food and Beverage policy, also known as Policy/Program Memorandum 150 (PPM150), was established in 2010 to promote healthier food choices among children by setting nutrition standards for foods and beverages sold in publicly funded elementary and secondary schools. Schools face barriers to complying with the PPM150 nutrition standards including a lack of human resources, technical tools, and financial means. Therefore, to support school food providers in sourcing foods that meet the nutrition standards in PPM150, this cross-sectional study assessed the alignment of foods and beverages from grocery stores and menu offerings from chain restaurants with the PPM150 nutrition standards. We compared nutrition data for foods and beverages available at grocery stores and menu items available at chain restaurants from the Food Label Information and Price (FLIP) 2020 (n = 35 103) and Menu-FLIP 2020 (n = 18 649) databases, respectively, against the PPM150 nutrition standards. Half of foods from grocery stores (51%) and most from chain restaurants (85%) did not meet PPM150 standards and are not permitted for sale. For beverages, 91% from grocery stores and 98% from chain restaurants are not permitted at elementary schools. At secondary schools, 56% of beverages from grocery stores and 94% from restaurants are not permitted. Findings suggest few foods, beverages and chain restaurant menu items meet the PPM150 nutrition standards, potentially posing an additional barrier for Ontario schools to procure and offer healthy foods to students.

Food environment research in Canada: a rapid review of methodologies and measures deployed between 2010 and 2021

Numerous research methodologies have been used to examine food environments. Existing reviews synthesizing food environment measures have examined a limited number of domains or settings and none have specifically targeted Canada. This rapid review aimed to 1) map research methodologies and measures that have been used to assess food environments; 2) examine what food environment dimensions and equity related-factors have been assessed; and 3) identify research gaps and priorities to guide future research. A systematic search of primary articles evaluating the Canadian food environment in a real-world setting was conducted. Publications in English or French published in peer-reviewed journals between January 1 2010 and June 17 2021 and indexed in Web of Science, CAB Abstracts and Ovid MEDLINE were considered. The search strategy adapted an internationally-adopted food environment monitoring framework covering 7 domains (Food Marketing; Labelling; Prices; Provision; Composition; Retail; and Trade and Investment). The final sample included 220 articles. Overall, Trade and Investment (1%, n = 2), Labelling (7%, n = 15) and, to a lesser extent, Prices (14%, n = 30) were the least studied domains in Canada. Among Provision articles, healthcare (2%, n = 1) settings were underrepresented compared to school (67%, n = 28) and recreation and sport (24%, n = 10) settings, as was the food service industry (14%, n = 6) compared to grocery stores (86%, n = 36) in the Composition domain. The study identified a vast selection of measures employed in Canada overall and within single domains. Equity-related factors were only examined in half of articles (n = 108), mostly related to Retail (n = 81). A number of gaps remain that prevent a holistic and systems-level analysis of food environments in Canada. As Canada continues to implement policies to improve the quality of food environments in order to improve dietary patterns, targeted research to address identified gaps and harmonize methods across studies will help evaluate policy impact over time.

Identifying barriers and facilitators in the development and implementation of government-led food environment policies: a systematic review

CONTEXT

Policy-specific actions to improve food environments will support healthy population diets.

OBJECTIVE

To identify cited barriers and facilitators to food environment policy (FEP) processes reported in the literature, exploring these according to the nature of the policy (voluntary or mandatory) and country development status.

DATA SOURCES

A systematic search was conducted of 10 academic and 7 grey-literature databases, national websites, and manual searches of publication references.

DATA EXTRACTION

Data on government-led FEPs, barriers, and facilitators from key informants were collected.

DATA SYNTHESIS

The constant-comparison approach generated core themes for barriers and facilitators. The appraisal tool developed by Hawker et al. was adopted to determine the quality of qualitative and quantitative studies.

RESULTS

A total of 142 eligible studies were identified. Industry resistance or disincentive was the most cited barrier in policy development. Technical challenges were most frequently a barrier for policy implementation. Frequently cited facilitators included resource availability or maximization, strategies in policy process, and stakeholder partnership or support.

CONCLUSIONS

The findings from this study will strategically inform health-reform stakeholders about key elements of public health policy processes. More evidence is required from countries with human development indices ranging from low to high and on voluntary policies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42018115034.

Enablers and barriers to implementation of and compliance with school-based healthy food and beverage policies: a systematic literature review and meta-synthesis

OBJECTIVE

Schools have been recognised as a potential setting for improving young peoples' food and beverage choices; however, many schools fail to adhere to healthy food and beverage policy standards. The current study aimed to explore the enablers and barriers to effective implementation of and compliance with school-based food and beverage policies.

DESIGN

Systematic review and meta-synthesis. Eight electronic databases were searched for articles in June 2019. Studies were eligible for inclusion if they reported on implementation and/or compliance of school-based food and/or beverage policies with outcomes relating to enablers and/or barriers. This review had no restrictions on study design, year of publication or language. Seventy-two full-text articles were assessed for eligibility, of which twenty-eight were included in this review.

SETTING

Studies conducted globally that focused on schools.

PARTICIPANTS

School-based healthy food and beverage policies.

RESULTS

Financial (cost of policy-compliant foods, decreased profit and revenue), physical (availability of policy-compliant foods, close geographical proximity to unhealthy food outlets) and social (poor knowledge, understanding, and negative stakeholders' attitudes towards policy) factors were the most frequently reported barriers for policy implementation. Sufficient funding, effective policy communication and management, and positive stakeholders' attitudes were the most frequently reported enablers for policy implementation.

CONCLUSIONS

There is a need for better communication strategies, financial and social support prior to school-based food policy implementation. Findings of this review contribute to a thorough understanding of factors that underpin best practice recommendations for the implementation of school-based food policy, and inform those responsible for improving public health nutrition.

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.

Factors Influencing the Implementation of Nutrition Policies in Schools: A Scoping Review

BACKGROUND

Although school nutrition policies (SNPs) have been highlighted as an important intervention to support childhood nutrition, their implementation and maintenance within real-word settings is complex. There is a need to understand the factors that influence implementation by consolidating existing research and identifying commonalities and differences.

AIMS

The purpose of this review is to determine what is known about the influence of broad and local system factors on the implementation of SNPs internationally.

METHOD

This scoping review involved identifying and selecting relevant literature that related SNP implementation in primary and secondary schools. Following the search process, 2,368 articles were screened and 59 articles were synthesized and charted and emerging themes were identified.

RESULTS

Across the final studies identified, factors emerged as barriers and facilitators to the implementation of SNPs, with system implications that related to five areas to support policy action: providing macro-level support may encourage policy implementation; addressing the financial implications of healthy food access; aligning nutrition and core school priorities; developing a common purpose and responsibility among stakeholders; recognition of school and community characteristics.

DISCUSSION

While SNPs can help to support childhood nutrition, strategies to address issues related to policy implementation need to be taken to help schools overcome persistent challenges.

CONCLUSION

The results of this review provide opportunities for action across multiple system levels to ensure synergy and coordinated action toward SNP goals to foster the creation supportive nutrition environments for children.

Understanding System-Level Intervention Points to Support School Food and Nutrition Policy Implementation in Nova Scotia, Canada

Supporting the implementation of school food and nutrition policies (SFNPs) is an international priority to encourage healthier eating among children and youth. Such policies can improve equitable access, resources, and supports for healthy eating. However, despite the potential impact of SFNPs, several implementation barriers have been reported. This study sought to examine the system-level intervention points within a school food system using a complex systems framework. We conducted semi-structured interviews with various stakeholders working to influence the school food system in Nova Scotia, Canada. We sought to understand their roles and experiences with the SFNP by applying the Intervention Level Framework (ILF), a novel, solutions-oriented approach to better understand how complex systems function. Participants (n = 33) included teachers, parents, cafeteria workers, public health staff and non-profit organizations. Interview transcripts were first coded, then themed and finally analyzed using the ILF, resulting in three intervention points within the school food system. These were defined as: (1) Actors and Elements, (2) System Regulation and Interconnections and (3) Purpose and Values. We concluded that understanding the interactions between these system levels and stakeholder roles can help to inform the development of relevant policy strategies that better support healthier school food environments in this jurisdiction.

Food and beverage marketing in primary and secondary schools in Canada

BACKGROUND

Unhealthy food marketing is considered a contributor to childhood obesity. In Canada, food marketing in schools is mostly self-regulated by industry though it is sometimes restricted through provincial school policies. The purpose of this study was to document the type of food marketing activities occurring in Canadian schools and examine differences by school characteristics.

METHODS

An online survey was sent to public primary and secondary schools from 27 school boards in Ontario, British Columbia, and Nova Scotia and was completed by 154 Principals in spring 2016. This survey queried the type of food marketing occurring in schools including advertisements, food product displays, fundraising, exclusive marketing agreements, and incentive programs, among others. The occurrence of food marketing was described using frequencies, medians, and ranges. Chi-square and Fisher Exact tests were conducted to assess school-level differences in the frequency of marketing activities by school type (primary versus secondary), province (Ontario versus British Columbia), and the socio-economic status of most students (low versus middle/high income). The significance level was set at α < 0.05 for all tests.

RESULTS

Overall, 84% of schools reported at least one type of food marketing and the median number of distinct types of marketing per school was 1 (range 0-6). The most frequently reported forms of marketing were the sale of branded food, particularly chocolate, pizza, and other fast food, for fundraising (64% of schools); food advertisements on school property (26%), and participation in incentive programs (18%). Primary schools (n = 108) were more likely to report participating in incentive programs (25%) and selling branded food items (72%) compared to secondary schools (n = 46; 2 and 43% respectively; p < 0.01). Conversely, secondary schools were more likely to report food advertising on school property (56%), exclusive marketing arrangements with food companies (43%), and food product displays (19%) than primary schools (13, 5 and 2%, respectively; p < 0.01).

CONCLUSION

The presence of food marketing in most participating schools suggests that the current patchwork of policies that restrict food marketing in Canadian schools is inadequate. Comprehensive restrictions should be mandated by government in both primary and secondary schools to protect children and youth from this marketing.

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.

Culture matters: a case of school health promotion in Canada

Rising concerns of poor health behaviours of children and youth have stimulated international support for a comprehensive approach to promoting the development of healthy behaviours in the early years. Health promoting schools (HPS) is increasingly adopted as an approach to guide supportive practices, but there is limited research that has reported how to effectively implement HPS at a population level. The purpose of this research was to qualitatively explore the factors preventing and facilitating implementation of HPS practices in the Canadian province of Nova Scotia. Interviews (n = 23) were conducted with school stakeholders (principals, teachers and parents) from a diverse sample of schools (n = 9) and data were analysed to develop an understanding of how school circumstances and experiences influenced HPS implementation. At a broad level, the reported barriers were structural and systemic, whereas the facilitating factors were related to organizational capacity and political leadership. It was evident that implementing and sustaining HPS required a shift in values and integration of supportive school health practices into school priorities. The results suggest that, without addressing the competing culture, which is persistently reinforced by strict academic mandates and unhealthy community norms, HPS will be vulnerable to circumstances that prevent implementation. Considering the emerging importance of mental wellbeing, it will also be important to provide schools with adequate and appropriate staff capacity and support to address this issue. Sustaining the positive effects of HPS will require continuous engagement and collaboration with multiple stakeholders to embed health promotion into school community norms.

School food environments associated with adiposity in Canadian children

BACKGROUND/OBJECTIVES

Targeting obesogenic features of children's environment that are amenable to change represents a promising strategy for health promotion. The school food environment, defined as the services and policies regarding nutrition and the availability of food in the school and surrounding neighborhood, is particularly important given that students travel through the school neighborhood almost daily and that they consume a substantial proportion of their calories at school.

SUBJECTS/METHODS

As part of the Quebec Adipose and Lifestyle Investigation in Youth (QUALITY) cohort study, we assessed features of school indoor dietary environment and the surrounding school neighborhoods, when children were aged 8-10 years (2005-2008). School principals reported on food practices and policies within the schools. The density of convenience stores and fast-food outlets surrounding the school was computed using a Geographical Information System. Indicators of school neighborhood deprivation were derived from census data. Adiposity outcomes were measured in a clinical setting 2 years later, when participants were aged 10-12 years (2008-2011). We conducted cluster analyses to identify school food environment types. Associations between school types and adiposity were estimated in linear regression models.

RESULTS

Cluster analysis identified three school types with distinct food environments. Schools were characterized as: overall healthful (45%); a healthful food environment in the surrounding neighborhood, but an unhealthful indoor food environment (22%); or overall unhealthful (33%). Less healthful schools were located in more deprived neighborhoods and were associated with greater child adiposity.

CONCLUSIONS

Despite regulatory efforts to improve school food environments, there is substantial inequity in dietary environments across schools. Ensuring healthful indoor and outdoor food environments across schools should be included in comprehensive efforts to reduce obesity-related health disparities.

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.

Interventions to Support System-level Implementation of Health Promoting Schools: A Scoping Review

Health promoting schools (HPS) is recognized globally as a multifaceted approach that can support health behaviours. There is increasing clarity around factors that influence HPS at a school level but limited synthesized knowledge on the broader system-level elements that may impact local implementation barriers and support uptake of a HPS approach. This study comprised a scoping review to identify, summarise and disseminate the range of research to support the uptake of a HPS approach across school systems. Two reviewers screened and extracted data according to inclusion/exclusion criteria. Relevant studies were identified using a multi-phased approach including searching electronic bibliographic databases of peer reviewed literature, hand-searching reference lists and article recommendations from experts. In total, 41 articles met the inclusion criteria for the review, representing studies across nine international school systems. Overall, studies described policies that provided high-level direction and resources within school jurisdictions to support implementation of a HPS approach. Various multifaceted organizational and professional interventions were identified, including strategies to enable and restructure school environments through education, training, modelling and incentives. A systematic realist review of the literature may be warranted to identify the types of intervention that work best for whom, in what circumstance to create healthier schools and students.

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.

Influence of school architecture and design on healthy eating: a review of the evidence

We examined evidence regarding the influence of school physical environment on healthy-eating outcomes. We applied a systems perspective to examine multiple disciplines' theoretical frameworks and used a mixed-methods systematic narrative review method, considering both qualitative and quantitative sources (published through March 2014) for inclusion. We developed a causal loop diagram from 102 sources identified. We found evidence of the influence of many aspects of a school's physical environment on healthy-eating outcomes. The causal loop diagram highlights multilevel and interrelated factors and elucidates the specific roles of design and architecture in encouraging healthy eating within schools. Our review highlighted the gaps in current evidence and identified areas of research needed to refine and expand school architecture and design strategies for addressing healthy eating.

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.

Adopting and implementing nutrition guidelines in recreational facilities: tensions between public health and corporate profitability

OBJECTIVE

Little is known about how public entities can partner with industry to achieve public health goals. We investigated industry's perspective of factors that influenced their adoption and implementation of voluntary, government-issued nutrition guidelines (Alberta Nutrition Guidelines for Children and Youth, ANGCY) in recreational facilities.

DESIGN

In-depth semi-structured interviews were conducted. Data were analysed using directed content analysis.

SETTING

Food services in recreational facilities.

SUBJECTS

Seven managers from industry participated; five from companies that had adopted and implemented the ANGCY (adopters) in recreational facilities and two from companies that had not (non-adopters).

RESULTS

Industry views nutrition guidelines through the lens of profitability. Non-adopters were unwilling to implement the ANGCY for fear of sacrificing short-term profitability, whereas adopters adhered to them in an attempt to position themselves for long-term profitability. Adopters faced barriers including few resources, no training, complex guidelines, low availability of and demand for ANGCY-compliant products, competitive pressures and substantial declines in revenue. Managers believed widespread voluntary adoption of the ANGCY was unlikely without government incentives and/or a mandate, as the environmental context for voluntary action was poor. All managers supported government-mandated implementation of the ANGCY to level the playing field upon which companies compete.

CONCLUSIONS

Public-private partnerships in recreational facilities can embrace public health goals in the short term, provided industry perceives potential for long-term financial gain. Widespread uptake of voluntary nutrition guidelines in this setting is unlikely, however, as market mechanisms do not encourage industry to sell and promote healthier options. Government legislation may therefore be warranted.