A systematic review of the effectiveness of school-based obesity prevention programmes for First Nations, Inuit and Métis youth in Canada

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 Unpublished data and grey literature were also searched.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.

A Systematic Review of Interventions to Increase Physical Activity Among American Indian and Alaska Native Older Adults

BACKGROUND AND OBJECTIVES

Physical activity (PA) is a powerful protective factor known to reduce risk for chronic conditions across the life span. PA levels are lower among American Indians and Alaska Natives (AIANs) when compared with other racial/ethnic groups and decrease with age. This evidence justifies a synthesis of current intervention research to increase PA levels among AIANs. This systematic review examines completed interventions to increase PA among AIAN older adults and considers recommended practices for research with Indigenous communities.

RESEARCH DESIGN AND METHODS

The systematic review was designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for systematic review protocols and reporting guidelines. Three electronic databases, PubMed, Web of Science, and PsycINFO, were searched for academic literature. Trials investigating interventions to increase PA among AIAN adults older than 50 years were eligible. The Quality Assessment Tool for Quantitative Studies was used to evaluate the quality of evidence.

RESULTS

Three published trials were identified, including one group-level, clinic-based and two individual-level, home-based interventions. All were 6 weeks in duration, took place in urban areas, and used self-report PA measures. Findings indicated an overall increase in PA levels, improved PA-related outcomes, and improved psychosocial health among participants. None described community-engaged or culture-centered research strategies.

DISCUSSION AND IMPLICATIONS

The narrow yet promising evidence represents a need for expanded research and a call to action for using culture-centered strategies. An advanced understanding of cultural and contextual aspects of PA may produce more impactful interventions, supporting health and mobility across the life span.

The essential conditions needed to implement the Indigenous Youth Mentorship Program: a focused ethnography

Background

The Indigenous Youth Mentorship Program (IYMP) is a 20-week communal, relationship-based afterschool healthy living program for Indigenous youth in Canada. IYMP embraces the Anishnaabe/Nehiyawak concepts of Mino-Bimaadiziwin/miyo-pimâtisiwin (“living in a good way”) via its core components of physical activities/games, healthy snacks, and relationship-building. A strength of IYMP is that it values autonomy, adaptability, and the school community context. However, this presents challenges when evaluating its implementation, given that traditional implementation science methods tend to oversimplify the process. In response, essential conditions for the implementation of school-based healthy living programs across diverse contexts have been developed. The purpose of this research was to understand the applicability of these essential conditions within the context of IYMP.

Methods

15 participants (n = 10 Young Adult Health Leaders; n = 5 coordinators) with experience implementing IYMP in the provinces of Alberta, Saskatchewan, Manitoba, and Quebec were purposefully sampled. Focused ethnography was the guiding method and one-on-one semi-structured interviews were used as the data generation strategy. The purpose of the interviews was to understand what conditions are needed to implement IYMP. The interview guide was based on previously established essential conditions developed by the research team. Interviews were audio-recorded and transcribed, and content analysis was used to identify patterns in the data.

Results

The overarching theme that emerged from the interviews was the applicability of the essential conditions when implementing IYMP. Participants felt the eight core conditions (students as change agents, school/community-specific autonomy, demonstrated administrative leadership, higher-level support, dedicated champion(s) to engage school community, community support, quality and use of evidence, and professional development) and four contextual conditions (time, funding and project support, readiness and understanding, and prior community connectivity) were necessary, but made suggestions to modify two conditions (youth led and learning opportunities) to better reflect their experiences implementing IYMP. In addition, a new core condition, rooted in relationship, emerged as necessary for implementation.

Conclusions

This research adds to the literature by identifying and describing what is needed in practice to implement a communal, relationship-based afterschool healthy living program. The essential conditions may support other researchers and communities interested in implementing and rippling similar programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12412-1.

Effectiveness of obesity interventions among South Korean children and adolescents and importance of the type of intervention component: a meta-analysis

BACKGROUND

Various interventions have been tested to prevent or treat childhood obesity in South Korea. However, the overall effect of those interventions is unclear, as very few reviews and meta-analyses were specific to Korean children and adolescents.

PURPOSE

We aimed to examine the overall effect of obesity interventions among Korean children and adolescents, while also examining differences by sex, age group, baseline weight category, intervention duration, number of intervention components, and type of intervention components.

METHODS

A meta-analysis was conducted for all intervention studies sampling Korean children and adolescents, with at least one control group and one month of follow-up, published between January 2000 and August 2020. Cohen d was calculated as an effect size for treatment effect, using the standardized difference between intervention group's body mass index (BMI) change and control group's BMI change.

RESULTS

The final sample included 19 intervention studies with 2,140 Korean children (mean age, 12.2 years). Overall, interventions were strongly favored over their controls (d=1.61; 95% confidence interval [CI], 1.12-2.09). The subgroup analysis showed that interventions with at least one physical activity component (d=2.43; 95% CI, 1.63-3.24) were significantly better than those that did not include physical activity (d=0.02; 95% CI, -0.26 to 0.31).

CONCLUSION

Type of intervention component appeared important, though no differential association was observed by sex, age, baseline weight category, intervention duration, and number of intervention components. Korean and non-Korean interventions may be substantively different. Additional studies are needed to understand why and how Korean interventions differ from non-Korean interventions.

Comprehensive Nutrition Interventions in First Nation-Operated Schools in Canada

Comprehensive school-based nutrition interventions offer a promising strategy to support healthy eating for First Nations children. A targeted strategic review was performed to identify nutrition interventions in 514 First Nation-operated schools across Canada through their websites. Directed content analysis was used to describe if interventions used 1 or more of the 4 components of the Comprehensive School Health (CSH) framework. Sixty schools had interventions. Nearly all (n = 56, 93%) schools offered breakfast, snack, and (or) lunch programs (social and physical environment). About one-third provided opportunities for students to learn about traditional healthy Indigenous foods and food procurement methods (n = 18, 30%) (teaching and learning) or facilitated connections between the school and students' families or the community (n = 16, 27%) (partnerships and services). Few schools (n = 10, 17%) had a nutrition policy outlining permitted foods (school policy). Less than 1% (n = 3) of interventions included all 4 CSH components. Results suggest that most First Nation-operated schools provide children with food, but few have nutrition interventions that include multiple CSH components. First Nation-operated schools may require additional financial and (or) logistical support to implement comprehensive school-based nutrition interventions, which have greater potential to support long-term health outcomes for children than single approaches.

Strategies and interventions for healthy adolescent growth, nutrition, and development

Adolescence is a pivotal point in the life course, characterised by transformative physical, cognitive, and emotional growth, an openness to change, and a drive to reshape the social environment. It offers unique opportunities to adopt changes in diet and physical activity that can persist into later life. Yet pre-existing nutritional problems, including micronutrient deficiencies, food insecurity, and poor-quality diets, persist at the same time as adolescents face the rapid emergence of an obesity epidemic. Adolescent growth and nutrition has been largely overlooked in intervention and policy research. Most intervention studies have emphasised micronutrient supplementation, with few taking into account the multiple drivers of adolescent diets. This Series paper highlights that effective interventions and policies will need to cut across sectors; be supported by multifaceted and multilevel policy; and extend across education, health, food systems, social protection, and digital media. Better data standardisation and systems will be essential in coordinating and monitoring these responses. In a context of shifts in planetary ecosystems and commercial drivers, resilient food systems will need to both ensure access to healthy and affordable foods and provide the infrastructure and incentives for continuing physical activity. Intergenerational partnerships with young people will be essential in bringing about transformative change and ensuring that food policies reflect their needs and aspirations.

Effectiveness of programs aimed at obesity prevention among Indigenous children: A systematic review

Given the significant health burden of childhood obesity, it is imperative that effective programs be better understood. When evaluating obesity prevention efforts, one must recognize the contextual factors which drive the disproportionate risk of obesity between populations. This systematic review sought to understand if programs aimed at obesity prevention and/or the promotion of healthy lifestyle behaviours for Indigenous children are effective. We conducted a search using Medline, EMBASE, PsychINFO, ERIC, CINAHL and iPORTAL databases from inception to August 13, 2019. We included experimental and quasi-experimental studies. The main outcomes of interest were change in anthropometrics, nutrition or physical activity. Our narrative synthesis included an assessment of study quality using the Effective Public Health Practice Project Quality assessment tool. A total of 34 studies met selection criteria. Most studies used a quasi-experimental design (n = 25) and were assessed as low to moderate quality (n = 32). Three studies showed a significant change in anthropometric measures, 14 studies demonstrated at least one significant nutrition-related behaviour or dietary-pattern change, and six studies demonstrated a significant impact on physical activity. This systematic review of programs to prevent obesity among Indigenous children finds a limited impact on anthropometric measurements. Future studies must prioritize Indigenous knowledge and ways of knowing to lead all phases of development, implementation, and evaluation of programs.

Exercise-based interventions for Indigenous adults with chronic lung disease in Australia, Canada, New Zealand, and USA: a systematic review

Indigenous peoples in Australia, New Zealand, Canada, and the United States of America (USA) have a higher burden of chronic lung disease than non-Indigenous people. Exercised-based interventions, such as pulmonary rehabilitation, are highly effective to manage chronic lung disease. The outcomes of these interventions for Indigenous people require evaluation. The aim of this review was to critically appraise the literature on the impact of exercise-based interventions on quality of life, exercise capacity and health care utilisation in Indigenous adults with chronic lung disease in Australia, New Zealand, Canada, and USA. The Cochrane Library, Medline, Embase, CINAHL, Scopus, Psychinfo, APAIS-Aboriginal Health and PEDro databases were searched for peer-reviewed and grey literature that evaluated exercise-based interventions, such as pulmonary rehabilitation for Indigenous adults with chronic lung disease in Australia, New Zealand, Canada, and USA. Two authors independently screened and reviewed titles and abstract and full texts of potentially eligible studies for inclusion. An Indigenous decolonisation methodological framework was also applied to evaluate Indigenous governance, involvement, and engagement in the studies. A total of 3,598 records were screened, nine full papers were reviewed, and one was study included, which was a cardiopulmonary rehabilitation program for Indigenous people in Australia. Participants with chronic respiratory or heart disease significantly improved functional exercise capacity and quality of life [six-minute walk distance mean change (95% CI) 79 metres (47 to 111); Chronic Respiratory Questionnaire Dyspnoea 0.9 points (0.2 to 1.5)]. Several items of the decolonisation framework were addressed. Only one study was able to be included in the review, highlighting the paucity of research about culturally safe exercise-based interventions for Indigenous adults with chronic lung disease. There is a need for further research with strong Indigenous governance, involvement, and engagement.

The Efficacy of School-Based Interventions in Preventing Adolescent Obesity in Australia

Current trends suggest that adolescent obesity is an on-going and recurrent decimal that is still on the rise in Australia and the social burden associated with it can significantly cause low self-esteem and lack of confidence in personal body image in adulthood. Nonetheless, evidence-based prevention programs are not widely implemented in schools, even though they are commonplace for easy access to adolescents. The primary objective of this systematic review was to assess the scope and efficacy of adolescent obesity intervention strategies in Australian schools, to guide future research. Seven electronic databases were searched for peer-reviewed school-based intervention articles written in the English language and targeting 12-18-year-old adolescents. Intervention characteristics were extracted, and quality, efficacy and outcome measures were assessed utilizing thirteen studies that met the inclusion criteria for this review. Most of the Australian adolescent obesity research emanated from the State of New South Wales and none were nationwide. Five studies successfully met all the requirements in all measured outcomes, four met at least one measured outcome and the remaining four were unsuccessful. Despite the weak evidence of intervention efficacy for most of the reviewed studies, school-based interventions with multi-component combinations of physical activity, nutrition and alignment to a theory yielded promising results. Our findings point to the need for future research to assess the perceptions of school stakeholders in relation to the barriers and enablers to establishing school-based prevention and intervention programs for adolescents.

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.

A systematic review of physical activity interventions to improve physical fitness and health outcomes among Indigenous adults living in Canada

The Indigenous population of Canada faces an increased burden of chronic disease, leading to decreased life expectancy. Physical activity is an important health behaviour that improves chronic disease risk factors and physical fitness. The objective of this systematic review was to evaluate physical activity interventions in the Indigenous population in Canada to determine effects on physical activity rates, physical fitness, and health outcomes. MEDLINE, PsycINFO, EMBASE, and CINAHL were searched for peer-reviewed journal articles. Inclusion criteria were studies that examined a physical activity intervention delivered in Indigenous communities in Canada for adults over 18 years of age. Data was extracted and two authors independently rated quality of the evidence. Five studies were included in the narrative synthesis. Interventions were community-based, and three were multi-component interventions focused on preventing or managing type II diabetes. The interventions varied in their success in altering physical activity rates, with increases (n = 2), a decrease (n = 1), or non-significant changes reported (n = 2). No study reported any measure of physical fitness. BMI was reported in four studies, with only one reporting a significant decrease. Decreases in systolic blood pressure and total cholesterol were reported in two studies. There is limited evidence and a lack of robust interventions that examine the impacts of physical activity on health and fitness status in the Canadian Indigenous population. Validated, culturally relevant tools for measuring physical activity may aid in program evaluation and focused educational materials could better support population health initiatives.

TRIAL REGISTRATION

The review protocol was registered prospectively with PROSPERO (registration number: CRD42017055363).

Aerobic capacity and future cardiovascular risk in Indian community from a low-income area in Cauca, Colombia

Background

Several studies indicates that children’s aerobic capacity levels are predictors of the future risk of non-communicable diseases. Therefore, the aim of this study was to establish the proportion of subjects whose aerobic capacity is indicative of future cardiovascular risk in Indian-Nasa community from a low-income area in Cauca, Colombia.

Methods

We performed a cross-sectional analysis of morphological component (height, weight, body mass index (BMI), waist circumference, triceps skinfold, subscapular skinfold, and body fat percent [BF%]), and the cardiorespiratory component (course-navette 20 m, shuttle run test and estimation of maximal oxygen consumption by indirect VO₂max) from 576 participants (319 boys and 257 girls) aged 10 to 17.9 years, using the standardized FUPRECOL test battery.

Results

We showed that the boys performed better than the girls in cardiorespiratory fitness. The proportion of subjects with an aerobic capacity indicative of future cardiovascular risk was 7.3%. By sex, 3.8% of boys and 11.7% of girls (X²p = 0.001) displayed an unhealthy aerobic capacity in this study.

Conclusion

The findings of this study that provide the first data on aerobic capacity health for Colombian Nasa Indian children and adolescents aged 10–17.9 years. Although the known loss of aerobic capacity is a serious consequence of the future risk of non-communicable diseases, the deterioration of physical fitness deserves increased attention among indigenous population.

Obesity and sexual abuse in American Indians and Alaska Natives

Mainstream American culture frequently minimizes the prevalence and significance of sexual abuse. Unfortunately, this denial of extensive victimization of women is also present in many underserved populations. In June 2007, Amnesty International released its report on sexual abuse in indigenous women, which states that, "One in three Native American or Alaska Native women will be raped at some point in their lives. Most do not seek justice because they know they will be met with inaction or indifference." This report highlighted an infrequently discussed issue namely, very high levels of sexual abuse in Native American and Alaska Native women. The relationship between sexual abuse and obesity has been delineated in several studies; overall about one quarter to one half of women with high levels of obesity have been sexually abused and it has been postulated that weight-gain serves as an adaptive response for many survivors of sexual abuse. It is also well known in Native American and Alaskan Native women that there is a high prevalence of obesity (about 40% greater than the population average) and that this obesity is associated with a many-fold greater risk of diabetes and increased risks of hypertension, cancer and cardiovascular disease. The link between the concomitantly high rates of sexual abuse and obesity in this population may or may not be partial causality but the issue is nonetheless important. If approaches are to succeed in reversing the trend of increasing levels of obesity in Native American and Alaskan Native women, the high prevalence of sexual abuse will need to be specifically and comprehensively addressed.