Jessie-Lee D. McIsaac

The impact of a population-level school food and nutrition policy on dietary intake and body weights of Canadian children

Objective The objective of this study is to assess population-level trends in childrens dietary intake and weight status before and after the implementation of a provincial school nutrition policy in the province of Nova Scotia, Canada. Method Self-reported dietary behavior and nutrient intake and measured body mass index were collected as part of a population-level study with grade 5 students in 2003 (n = 5215) and 2011 (5508), prior to and following implementation of the policy. We applied random effects regression methods to assess the effect of the policy on dietary and health outcomes. Results In 2011, students reported consuming more milk products, while there was no difference in mean consumption of vegetables and fruits in adjusted models. Adjusted regression analysis revealed a statistically significant decrease in sugar-sweetened beverage consumption. Despite significant temporal decreases in dietary energy intake and increases in diet quality, prevalence rates of overweight and obesity continued to increase. Conclusion This population-level intervention research suggests a positive influence of school nutrition policies on diet quality, energy intake and healthy beverage consumption, and that more action beyond schools is needed to curb the increases in the prevalence of childhood obesity.

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.

Modifying the food environment for childhood obesity prevention: challenges and opportunities.

The prevention of childhood obesity is a global priority. However, a range of complex social and environmental influences is implicated in the development of obesity and chronic disease that goes beyond the notion of individual choice. A population-level approach recognises the importance of access to and availability of healthy foods outside the home. These external food environments, in restaurants, supermarkets, and in school, or recreation and sports settings, are often characterised by energy dense, nutrient-poor food items that do not reflect the current nutritional guidelines for health. In addition, our understanding of these broader influences on nutritional intake is still limited. Particularly, lacking is a clear understanding of what constitutes the food environment, as well as robust measures of components of the food environment across different contexts. Therefore, this review summarises the literature on food environments of relevance to childhood obesity prevention, with a focus on places where children live, learn and play. Specifically, the paper highlights the approaches and challenges related to defining and measuring the food environment, discusses the aspects of the food environment unique to children and reports on environmental characteristics that are being modified within community, school and recreational settings. Results of the review show the need for a continued focus on understanding the intersection between individual behaviour and external factors; improved instrument development, especially regarding validity and reliability; clearer reported methodology including protocols for instrument use and data management; and considering novel study design approaches that are targeted at measuring the relationship between the individual and their food environment.

Food security status among grade 5 students in Nova Scotia, Canada and its association with health outcomes

OBJECTIVE Food security (FS) exists when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their needs. The present research sought to determine whether students from households experiencing moderate or severe food insecurity (FI) had poorer diet quality, higher body weights and poorer psychosocial outcomes than students from households classed as having high FS or marginal FI status. DESIGN Population-based survey conducted in schools. Multiple regression analysis was used to explore associations between FS status (high FS; marginal, moderate, severe FI), dietary behaviours and intake, and health-related outcomes (body weight, quality of life, mood, peer relationships, externalizing problems). SETTING Nova Scotia, Canada. SUBJECTS Grade 5 students (n 5853), aged 10-11 years, with complete information on FS status and student outcomes. RESULTS In this sample, rates of household FS were 73·5% (high FS), 8·3% (marginal FI) 10·2% (moderate FI) and 7·1% (severe FI status). Students living in households experiencing moderate or severe FI had poorer diet quality, higher BMI and poorer psychosocial outcomes than students classed as having high FS or marginal FI. CONCLUSIONS These findings provide important evidence for policy makers on the prevalence of FI among families in Nova Scotia with grade 5 children and its relationship with childhood nutrition, psychosocial and quality of life factors, and weight status.

Applying theoretical components to the implementation of health-promoting schools

Objective: Health-promoting schools (HPS) constitute an internationally recognised approach that connects health and education in a planned, integrated and holistic way. There is considerable variability, however, in how HPS is implemented and recent research has attempted to clarify the key functions of implementation. A provincial HPS strategy in Nova Scotia (NS) (Canada) provided a unique research opportunity to examine implementation related to emerging theory. The purpose of this exploratory study was to describe a provincial case study of HPS implementation using theoretical components identified in the literature. Design: Collective case study approach using qualitative research methods. Setting: The study was situated within a larger province-wide school-based research project examining the relationships between health, nutrition, physical activity, mental health and school performance of children in NS. As a follow-up to the provincial study, nine schools (n = 9) that varied in their HPS implementation strategies and characteristics (i.e. size and region) were invited to take part as case study schools. Method: Data collection included observations, interviews and documents from nine schools (n = 9). Data were analysed for emerging themes and using the a priori theoretical components. Results: The results revealed that schools assembled into three sequential categories based on the functioning of theoretical components. Higher level visioning and school-level leadership were critical in sustaining the adoption and implementation of HPS across schools and appeared to enable and integrate organisational processes, such as distributed leadership and a collaborative school culture, to enhance HPS implementation at school level. Conclusion: This study confirmed other reports that it is imperative to integrate HPS work with educational values so as to enable partnerships in both the health and education sectors, thereby promoting both health and prosperity among students.

Providing context to the implementation of health promoting schools: A case study

PURPOSE Issues related to program context are important components of population health interventions and particularly among complex, adaptive initiatives in schools. Health Promoting Schools (HPS) is a global approach to support early development of healthy behaviors among children and youth. The purpose of this study was to explicate the practical and contextual processes that influenced implementation of HPS in schools in Nova Scotia (Canada). METHODS Using a case-study approach, data was collected using interviews (n=14) with principals, teachers and parents, observations collected during school visits and document review in five diverse schools. RESULTS Case study schools reported a variety of HPS practices and three key themes emerged that provided context to the processes that facilitated their implementation. The results suggest that although school characteristics (theme 1), like staff allocation, physical location and resources, are important, these barriers can be mitigated by building organizational capacity (theme 2) and establishing a supportive school community culture (theme 3). CONCLUSIONS The study provided insight to the variability in implementation by describing how contextual barriers were experienced and mitigated by schools. Establishing a broad system to support HPS, with collaboration across health and education sectors, could help to progress adoption, implementation and sustainability of HPS.

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.

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.

The picture of health: examining school-based health environments through photographs

Health-promoting schools (HPS) is an effective approach to enhance the health and well-being of children and youth, but its measurement remains a challenge considering contextual differences across school environments. The purpose of this study was to qualitatively explore the physical features of the school environment through photographs of schools that had implemented an HPS approach compared with schools that had not. This study used a descriptive approach, wherein physical features of the school environment were distilled through visual images and qualitatively analyzed. School environment data were collected from 18 elementary schools (10 HPS, 8 comparison schools) from a school board in rural Nova Scotia (Canada). Evaluation assistants captured photographs of the physical school environment as part of a broader environment audit. Overarching themes included the promotion, access and availability of opportunities for healthy eating and physical activity, healthy school climate and safety and accessibility of the school. The photographs characterized diverse aspects of the school environment and revealed differences between schools that had implemented an HPS approach compared with schools that had not. There were increased visual cues to support healthy eating, physical activity and mental well-being, and indications of a holistic approach to health among schools that implemented an HPS approach. This research adds to understanding the environmental elements of HPS. The use of photographic data to understand school environments provided an innovative method to explore the physical features of schools that had implemented an HPS approach.

The Association between Health Behaviours and Academic Performance in Canadian Elementary School Students: A Cross-Sectional Study.

Background: Establishing early healthy eating and physical activity behaviours is critical in supporting children’s long-term health and well-being. The objective of the current paper was to examine the association between health behaviours and academic performance in elementary school students in a school board in Nova Scotia, Canada. Methods: Our population-based study included students in grades 4–6 across 18 schools in a rural school board. Diet and physical activity were assessed through validated instruments. Academic performance measures were obtained from the school board for Mathematics and English Language Arts (ELA). Associations between health behaviours and academic performance were assessed using multilevel logistic regression. Results: Students with unhealthy lifestyle behaviours were more likely to have poor academic performance for both ELA and Mathematics compared to students with healthy lifestyle behaviours; associations were statistically significant for diet quality, physical activity, sugar-sweetened beverage consumption for ELA; and breakfast skipping, not being physically active at morning recess, and not being physically active after school for Mathematics. The effects of diet and physical activity were independent of each other and there was no interaction between the two exposures. Conclusions: Our findings suggest that support for healthy behaviours may help to improve academic outcomes of students.