Assessing the nutritional quality of diets of Canadian children and adolescents using the 2014 Health Canada Surveillance Tool Tier System

Centre-based childcare in early childhood and child obesity: systematic review and meta-analysis protocol

OBJECTIVES

Centre-based childcare has been identified as a promising environment for obesity prevention in early childhood, but the longitudinal relationships between attending centre-based childcare and child obesity are not well understood. The objective of this systematic review is to evaluate the longitudinal associations between centre-based childcare attendance in early childhood and child body mass index compared with other childcare settings or parental care. Subgroup analyses will also be conducted to determine if socioeconomic factors and characteristics of the childcare setting modify the relationships.

METHODS

Databases that will be searched include MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Database and Web of Science. Longitudinal prospective cohort studies, retrospective cohort studies, case-control studies and intervention trials conducted in middle-income and high-income countries will be included in the search strategy. Sensitivity and subgroup analyses will be conducted to explore factors that may modify the findings. Study selection, data extraction, risk of bias and quality of evidence assessments will be conducted independently and in duplicate by two reviewers. Risk of bias will be assessed using the Risk Of Bias In Non-randomized Studies - of Exposure tool. Meta-analysis will be conducted using random effects models to account for between-study variation. Heterogeneity across included studies will be estimated using the I2 statistic. If meta-analysis is not possible, a narrative summary will be provided. The quality of the evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation tool.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study since no data will be collected. Findings aim to inform interventions and guide efforts in childcare settings to support optimal child growth. Results will be published in a peer-reviewed journal. Results may be of relevance for childcare and public health policy, researchers, parents and healthcare practitioners.

PROSPERO REGISTRATION NUMBER

CRD42023436911.

Modelling Food Substitution Using the Ofcom Nutrient Profiling Model on Population Intakes from the Canadian Community Health Survey-Nutrition 2015

This study aimed to model how substituting foods consumed by Canadians for alternatives with more favourable nutrient profiling (NP) scores would impact dietary intakes. The Ofcom NP system, developed to help the UK Office of Communication differentiate foods that can be advertised to children, was applied to foods consumed by Canadians aged 2 years and older in the 2015 Canadian Community Health Survey (CCHS) (n = 19,447). Foods were substituted for similar options from the Euromonitor branded food composition database (Scenario 1) or from the primarily aggregated food profiles in the CCHS survey food composition database (Scenario 2) with either the most favourable (optimistic; 1A and 2A) or a more favourable Ofcom score (realistic; 1B and 2B). Mean intakes of Ofcom scores, calories, saturated fat, sugars, and sodium from these scenarios were compared to baseline. Only 2.9% of foods consumed had a similar Euromonitor option with a lower Ofcom score. Scenarios 1A, 1B, and 2A had lower Ofcom scores, calorie, sodium, saturated fat, and sugar intakes compared to baseline. Scenario 2B had lower levels of all outcome measures, except for an increase in calories compared to baseline. Selection of foods with more favourable NP scores has the potential to decrease the Canadian intake of nutrients of concern.

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.

Co-Development of Three Dietary Indices to Facilitate Dietary Intake Assessment of Pediatric Crohn's Disease Patients

Literature on dietary behaviours of the pediatric Crohn's Disease (CD) population and the relationship between dietary intake and CD activity is limited. Three dietary indices were developed and tested to conduct dietary pattern analysis in pediatric patients with CD consuming a free diet following remission induction via exclusive enteral nutrition (n = 11). Index scores underwent descriptive and inferential analysis. The mean adjusted scores (out of 100) for the Pediatric Western Diet Index, Pediatric Prudent Diet Index, and Pediatric-Adapted 2010 Alternate Healthy Eating Index (PA2010-AHEI) were 29.82 ± 15.22, 34.25 ± 15.18, and 51.50 ± 11.69, respectively. The mean Western-to-Prudent ratio was 0.94 ± 0.55. A significant correlation (r = -0.71) and relationship (F[1, 9] = 9.04, P < 0.05, R2 = 0.501) between the Western-to-Prudent ratio and PA2010-AHEI was found. The results suggest participants were not following a Western or Prudent diet, and were consuming foods not captured by the indices. More research is needed to describe dietary intake of individuals with CD, validate dietary indices in diverse samples, and explore the utility of these indices in CD assessment and treatment. The co-authors hope this work will stimulate/inspire subsequent interprofessional, dietitian-led research on this topic.

Geographic Comparison of Dietary Intake and Quality in Manitoba Adolescents

Purpose: The Food and Nutrition for Manitoba Youth (FANS) study examined dietary intakes, food behaviours, food security status, health indicators, and body mass index of a cohort of grade 9 students. This paper describes regional differences and similarities in dietary intake (food and nutrients) and quality of youth participants in the FANS study.Methods: Grade 9 students completed a web-based survey on dietary intakes (24-hour recall), food behaviours, self-reported health indicators, and sociodemographic variables. Nutrient intakes were compared with national guidelines and diet quality was assessed using a modified Healthy Eating Index.Results: A total of 1587 students participated from northern, rural, and urban regions in Manitoba. Northern and rural students had higher intakes of sugar, sodium, and saturated fat compared with urban. Northern students consumed fewer grain products compared to urban, and more servings of "other" foods compared with rural and urban. While most participants were classified into the "needs improvement" or "poor" Healthy Eating Index categories, significantly more northern participants were in the "poor" category.Conclusions: Most adolescents in the study are at nutritional risk; however, there are additional vulnerabilities for those in rural and northern communities. Dietitians can use results to advocate for and plan interventions to improve adolescent nutrition.

Development and Evaluation of the Dietary Pattern Calculator (DiPaC) for Personalized Assessment and Feedback

This study aimed to develop and validate a diet assessment screener - the Dietary Pattern Calculator (DiPaC). A scoping review identified currently available short diet quality assessment tools. Twenty-one articles covering 19 unique tools were included. The current tools mainly focused on individual nutrients or food groups or were developed for a specific population, and few ascertained overall dietary patterns. The 24-hour dietary recalls from the nationally representative Canadian Community Health Survey (CCHS)-Nutrition 2015 (n = 13,958) were used to derive and validate a personalized dietary pattern informed by the scoping review using weighted partial least squares. The dominant dietary pattern in CCHS-Nutrition 2015 was characterized by high consumption of fast foods, carbonated drinks, and salty snacks and low consumption of whole fruits, orange vegetables, other vegetables and juices, whole grains, dark green vegetables, legumes, and soy. The dietary pattern assessment was used to create and evaluate DiPaC following an agile and user-centred research and development approach. DiPaC, which demonstrated high validity and intermediate reliability (internal consistency = 0.47-0.51), is publicly available at https://www.projectbiglife.ca/. DiPaC can be used by the public, clinicians, and researchers for quick and robust assessment of diet quality, providing immediate feedback with the advantage of being easy to implement.

The impact of characters like Tony the Tiger and other child-targeted techniques used in food and beverage marketing

Introduction

Food marketing's impact is a function of exposure and power, both of which contribute to children's poor diet quality and obesity risk. Children's exposure to food marketing is well documented, however, few studies have assessed the impact of specific persuasive marketing techniques or aspects of 'power' on children.

Methods

This study administered an online survey to 1,341 Canadian children (9-12 years) aiming to determine the impact of: (1) child-targeted vs. adult-targeted marketing, and (2) licensed characters vs. spokes characters on children's food preferences and behavioral intentions. Participants were randomized to a single condition in each survey part and viewed 3 static food advertisements displaying the features of that condition (e.g., child-targeted advertising or licensed characters), and answered 3 Likert-scale (5-point) questions after each exposure. For each condition within each research question, there were four outcome variables related to the impact of marketing on children: food preference, purchase intent, pester power, and total impact. ANOVA tested the difference in impact (Likert scores) between conditions overall and for each outcome, with Bonferroni post-hoc tests where necessary.

Results

A greater average total impact was observed among children exposed to child-targeted ads (mean Likert score 3.36) vs. adult-targeted ads (mean score 2.75; p < 0.001) or no marketing (mean score 2.81; p < 0.001). Children exposed to ads featuring spokes characters had a higher average total impact (mean score 3.98) vs. licensed characters (mean score 3.80; p < 0.001) and the control (i.e., no characters) (mean score 3.19; p < 0.001), and the total impact of licensed characters was greater than that of no characters. Similar trends were observed for all other outcomes.

Discussion

Overall, this study showed that child-targeted ads and those using characters - especially spokes characters - have a strong overall impact on children's food preferences, purchase intents, and pester power, and support the implementation of comprehensive marketing restrictions to protect children.

Questionable advisability of vitamin and mineral dietary supplement use in adolescents

OBJECTIVE

Present study aimed to assess potential health risk in Slovenian adolescents due to inadequate diet and/or dietary supplement (DS) use.

METHODS

Data on DS use, micronutrient intake (24-h recall), eating habits (FFQ), body height and mass were collected within ACDSi (Analysis of Children's Development in Slovenia) cross-sectional study conducted in 2014. Adolescents enrolled in first year of 15 secondary schools (average (SD) age: 15.4 (0.7) years, N = 342) were included in the sample.

RESULTS

Adolescents' use of DS (especially multivitamins ingested as a popular drink (60%), magnesium (16%), and vitamin C (10%)) significantly contributed to their absolute intake of vitamins/minerals, resulting in higher percentage of DS users meeting reference values proposed by the nutrition societies of Germany, Austria, and Switzerland (D-A-CH recommendation). Simultaneously, DS users did not exceed the upper tolerable level proposed by the European Food Safety Authority for daily intake. With diet alone, adolescents consumed less than recommended amounts of the following vitamins/minerals: the intake was lowest for fat-soluble vitamins A, D, and E; water-soluble vitamins folate, biotin, and pantothenic acid; and minerals fluoride, iodine, chromium, and molybdenum. Suboptimal intake was due to the fact that around ¾ of adolescents consumed less than 54% of the recommended amounts (according to Optimized Mixed Diet (OMD) recommendations) for fruits, vegetables, milk/dairy products, fish, and cereals/cereal products. In contrast, the diet contributed to the consumption of 200-300% of D-A-CH minimum value for sodium. Furthermore, almost ¾ of adolescents exceeded the recommended amount for meat/meat products (320% of OMD) and sweet/salty snacks (453% of OMD).

CONCLUSIONS

Although DS use improved micronutrient intake in adolescents (especially vitamin C and magnesium), activities on public-health interventions should be focus to improve their diets, especially to achieve increased intakes of fruits, vegetables, cereals/cereal products and milk/dairy products, and to reduce consumption of sweet/salty snacks and meat products.

Association of picky eating around age 4 with dietary intake and weight status in early adulthood: A 14-year follow-up based on the KOALA birth cohort study

INTRODUCTION

A relatively common deviant type of eating behaviour among children is picky eating. Research on associations between picky eating and dietary patterns later in life is limited, and studies examining long-term effects on growth have yielded mixed results. The present study aimed to examine longitudinal associations of picky eating in early childhood with consumption of various foods, and weight status (body mass index, BMI) in young adulthood.

METHODS

Data from the Dutch KOALA Birth Cohort was used. Picky eating was determined around age 4 (range 3-6 years) by a questionnaire completed by parents. At follow-up around children's age 18 (range 17-20 years), weekly food intake frequencies, weight and height were assessed with a questionnaire completed by the grown-up young adult children. In total, 814 participants were included. Multiple regression analyses were performed for food intake frequencies and weight status (BMI) with picky eating score as predictor, controlling for parental and child covariates.

RESULTS

The mean picky eating score at age 4-5 was 2.24 (range 1-5). A 1-point higher picky eating score was associated with eating fruit 0.14 days less per week, raw vegetables 0.14 days less per week, cooked vegetables 0.21 days less per week, fish 0.07 days less per week and dairy products 0.23 days less per week (P-values all <0.05). Associations between picky eating and intake frequencies of meat, eggs, various snacks, sweet drinks, and weight status (BMI) were not significant.

CONCLUSION

Picky eating in childhood is associated with lower intake frequencies of various healthy foods among young adults. It is therefore recommended to pay sufficient attention to picky eating in young children.

Mortality and Life Expectancy Lost in Canada Attributable to Dietary Patterns: Evidence From Canadian National Nutrition Survey Linked to Routinely Collected Health Administrative Databases

Using 5 diet quality indexes, we estimated the mortality and life expectancy lost, at the national level, attributable to poor dietary patterns, which had previously been largely unknown. We used the Canadian Community Health Survey 2004, linked to vital statistics (n = 16,212 adults; representing n = 22,898,880). After a median follow-up of 7.5 years, 1,722 deaths were recorded. Population attributable fractions were calculated to estimate the mortality burden of poor dietary patterns (Dietary Guidelines for Americans Adherence Index 2015, Dietary Approaches to Stop Hypertension, Healthy Eating Index, Alternative Healthy Eating Index, and Mediterranean Style Dietary Pattern Score). Better diet quality was associated with a 32%-51% and 21%-43% reduction in all-cause mortality among adults aged 45-80 years and ≥20 years, respectively. Projected life expectancy at 45 years was longer for Canadians adhering to a healthy dietary pattern (average of 5.2-8.0 years (men) and 1.6-4.1 (women)). At the population level, 26.5%-38.9% (men) and 8.9%-22.9% (women) of deaths were attributable to poor dietary patterns. Survival benefit was greater for individuals with higher scores on all diet indexes, even with relatively small intake differences. The large attributable burden was likely from assessing overall dietary patterns instead of a limited range of foods and nutrients.

Advertising expenditures on child-targeted food and beverage products in two policy environments in Canada in 2016 and 2019

BACKGROUND

The food industry advertises unhealthy foods intended for children which in turn fosters poor diets. This study characterized advertising expenditures on child-targeted products in Canada and compared these expenditures between Quebec, where commercial advertising to children under 13 is restricted, and the rest of Canada, where food advertising to children is self-regulated.

METHODS

Advertising expenditures data for 2016 and 2019 for 57 select food categories and five media channels were licensed from Numerator. Products and brands targeted to children were identified based on their nature and the advertising techniques used to promote them. Advertising expenditures were classified as healthy/unhealthy using Health Canada's nutrient profile model. Expenditures per child capita aged 2-12 years were calculated and expenditures from 2016 were adjusted for inflation. Advertising expenditures were described by media, food category, year, and geographic region.

RESULTS

Overall, $57.2 million CAD was spent advertising child-targeted products in Canada in 2019. Television accounted for 77% of expenditures followed by digital media (18%), and the food categories with the highest expenditures were candy/chocolate (30%) and restaurants (16%). The totality of expenditures (99.9%-100%) in both Quebec and the rest of Canada in 2016 and 2019 were considered 'unhealthy'. Across all media channels (excluding digital), advertising expenditures were 9% lower in 2019 versus 2016. Advertising expenditures per capita were 32% lower in Quebec ($9.40/capita) compared to the rest of the country ($13.91/capita).

CONCLUSION

In Canada, millions are spent promoting child-targeted products considered inappropriate for advertising to children. While per capita advertising expenditures for these products are lower in Quebec compared to the rest of Canada, they remain high, suggesting that Quebec's commercial advertising restrictions directed to children are likely not sufficiently protecting them from unhealthy food advertising.

Child-appealing packaged food and beverage products in Canada-Prevalence, power, and nutritional quality

BACKGROUND

Children are frequently exposed to marketing on food packaging. This study evaluated the presence, type and power of child-appealing marketing and compared the nutritional quality of child-appealing vs. non-child-appealing Canadian packaged foods and examined the relationship between nutrient composition and marketing power.

METHODS

Child-relevant packaged foods (n = 5,850) were sampled from the Food Label Information Program 2017 database. The presence and power (# of techniques displayed) of child-appealing marketing were identified. Fisher's Exact test compared the proportion of products exceeding Health Canada's nutrient thresholds for advertising restrictions and Mann Whitney U tests compared nutrient composition between products with child- /non-child-appealing packaging. Pearson's correlation analyzed the relationship between nutrient composition and marketing power.

RESULTS

13% (746/5850) of products displayed child-appealing marketing; the techniques used, and the power of the marketing varied ([Formula: see text] 2.2 techniques; range: 0-11). More products with child-appealing packaging than with non-child appealing packaging exceeded Health Canada's thresholds (98% vs. 94%; p < .001). Products with child-appealing packaging (vs. non-child-appealing) were higher in total sugars (median: 14.7 vs. 9 g/RA; p < .001) and free sugars (11.5 vs. 6.2 g/RA; p < .001), but lower in all other nutrients. There was weak overall correlation between marketing power and nutrient levels. Results varied by nutrient and food category.

CONCLUSIONS

Unhealthy products with powerful child-appealing marketing displayed on package are prevalent in the food supply. Implementing marketing restrictions that protect children should be a priority.

Broadcast Television Is Not Dead: Exposure of Children to Unhealthy Food and Beverage Advertising on Television in Two Policy Environments (Ontario and Quebec). An Observational Study

BACKGROUND

Food marketing can influence children's dietary behaviors. In Canada, Quebec banned commercial advertising to children under the age of 13 y in 1980, whereas advertising to children is self-regulated by industry in the rest of the country.

OBJECTIVES

The objective of this study was to compare the extent and power of food and beverage advertising on television to children (age: 2-11 y) in two different policy environments (Ontario and Quebec).

METHODS

Advertising data for 57 selected food and beverage categories were licensed from Numerator for Toronto and Montreal (English and French markets) from January to December 2019. The 10 most popular stations for children (age: 2-11 y) and a subset of child-appealing stations were examined. Exposure to food advertisements (ads) was based on gross rating points. A content analysis of food ads was conducted, and the healthfulness of ads was assessed using Health Canada's proposed nutrient profile model. Descriptive statistics were tabulated for the frequency of and exposure to ads.

RESULTS

On average, children were exposed to 3.7 to 4.4 food and beverage ads per day, exposure to fast-food advertising was highest (670.7-550.6 ads per year), advertising techniques were used frequently, and the majority (>90%) of advertised products were classified as unhealthy. On the top 10 stations, French children in Montreal were most exposed to unhealthy food and beverage advertising (712.3 ads per year), although they were exposed to fewer child-appealing advertising techniques compared with those in other markets. On the child-appealing stations, French children in Montreal were least exposed to food and beverage advertising (43.6 ads per year per station) and child-appealing advertising techniques compared with the other groups.

CONCLUSIONS

The Consumer Protection Act appears to positively impact exposure to child-appealing stations; yet, it does not sufficiently protect all children in Quebec and requires strengthening. Federal-level regulations restricting unhealthy advertising are needed to protect children across Canada.

Fruit and Vegetable Intake Is Associated with Food Knowledge among Children Aged 9–14 Years in Southwestern Ontario, Canada

Interventions to improve dietary quality and intake of fruits and vegetables (FV) among Canadian children have had modest success, and it has been suggested that food knowledge could be key to improvement. Programs have been criticized for insufficiently connecting food knowledge with food skills and decision making about dietary intake. The objective of this study was to investigate factors associated with FV consumption by elementary school children, aged 9–14 years, in Ontario, Canada, including food knowledge, socioeconomic status, sociodemographic characteristics, and the food environment. In 2017–2019, a cross-sectional survey was administered to 2443 students at 60 elementary schools across Southwestern Ontario (SWO), Canada. A parent survey was used to validate self-reported sociodemographic variables. The mean intake of FV reported by these participants was 2.6 (SD 1.1) and 2.4 (SD 1.2) servings/day, respectively. A FV intake below WHO guidelines was reported by 40.7% of respondents. Knowledge score, child age, and parent employment status significantly predicted higher reported intake of FV. This study shows that FV intake among this population group is low, and increased intake is associated with higher food knowledge. To encourage healthy eating, school-based food and nutrition programs that incorporate multiple components and emphasize food literacy are needed.

Comparing the perceptions and opinions of the 2007 and 2019 Canada's food guides among parents of young children

Background

The Canada's Food Guide (CFG) is recognized as the most prominent authoritative guideline for healthy eating in Canada. In 2019, Health Canada released the latest iteration of the CFG with substantial changes to its messaging and format from the previous 2007 CFG.

Objective

This study compared the awareness, use, knowledge, and opinions of the 2007 and 2019 CFGs among parents with children aged 18 months to 5 years who are participants in a family-based intervention trial, the Guelph Family Health Study.

Methods

The sample consisted of 327 parents (59% women) who responded to questions about the 2007 CFG and 177 parents (60% women) who responded to questions about the 2019 CFG. Parents' awareness and knowledge of the 2007 and 2019 CFGs were compared using Pearson's Chi-Square, while parents' opinions of the two CFGs were compared using Wilcoxon Rank-Sum tests. To describe and provide context about how parents used the 2007 and 2019 CFG descriptive analysis was used. To analyze the open-answer comments parents provided for the 2007 and 2019 CFGs thematic coding was used.

Results

Awareness of the 2007 and 2019 CFGs was high with 94.5 and 90.4% of parents reported having heard about the 2007 and 2019 CFGs, respectively. Knowledge of the plate proportion recommendations in the 2019 CFG was significantly higher than knowledge of the recommended number of servings in the 2007 CFG with 93.4% of parents identifying the Vegetable and Fruit Plate Proportions in the 2019 CFG. Parents identified that the 2019 CFG was a helpful and trustworthy resource, and that it was easier to follow and understand, and more representative of their culture and traditional foods than the 2007 CFG.

Conclusion

Our results suggest that parents' knowledge of the 2019 CFG recommendations was higher than for the 2007 CFG recommendations. Parents also had more positive opinions about the 2019 CFG as compared to the 2007 CFG. Future research is needed to explore whether these higher levels knowledge of the 2019 CFG recommendation translate to healthier eating patterns among Canadian families.

Benchmarking unhealthy food marketing to children and adolescents in Canada: a scoping review

INTRODUCTION

Unhealthy food and beverage marketing in various media and settings contributes to children's poor dietary intake. In 2019, the Canadian federal government recommended the introduction of new restrictions on food marketing to children. This scoping review aimed to provide an up-to-date assessment of the frequency of food marketing to children and youth in Canada as well as children's exposure to this marketing in various media and settings in order to determine where gaps exist in the research.

METHODS

For this scoping review, detailed search strategies were used to identify relevant peer-reviewed and grey literature published between October 2016 and November 2021. Two reviewers screened all results.

RESULTS

A total of 32 relevant and unique articles were identified; 28 were peer reviewed and 4 were from the grey literature. The majority of the studies (n = 26) examined the frequency of food marketing while 6 examined actual exposure to food marketing. Most research focussed on children from Ontario and Quebec and television and digital media. There was little research exploring food marketing to children by age, geographical location, sex/gender, race/ethnicity and/or socioeconomic status.

CONCLUSION

Our synthesis suggests that unhealthy food marketing to children and adolescents is extensive and that current self-regulatory policies are insufficient at reducing the presence of such marketing. Research assessing the frequency of food marketing and preschooler, child and adolescent exposure to this marketing is needed across a variety of media and settings to inform future government policies.

Intake of Fruits, Vegetables, and Sugar-Sweetened Beverages among a Sample of Children in Rural Northern Ontario, Canada

There is evidence to suggest that dietary intake of children differs by rural/urban place of residence: rural children may have a higher intake of foods high in fat and sugar than those living in urban environments. The aim of this study was to examine the intake of fruits and vegetables (FV) and the frequency of sugar-sweetened beverage (SSB) consumption, among a sample of rural children in Northern Ontario, Canada, in two different seasons. Sociodemographic factors and children's FV and SSB intake were measured using two repeated cross-sectional surveys, and seasonal information was based on the month of data collection. Logistic regressions were used to examine the odds of children eating five or more FVs, and the odds of 'frequently or always' consuming SSBs. During the fall, children reported eating five or more FV more often, when compared to winter (53.9% vs. 48.3%). In the fall, 25.8% of children reported 'frequently or always' drinking SSB, compared with 16.9% in winter. Indigenous children were less likely to eat five or more FV (OR 0.34 (95% CI 0.12-0.95)) in the fall when compared to non-Indigenous children. Findings indicate that intake of FV among rural students in this region is low, and the frequency of SSB is high, when compared with national recommendations.

Socioeconomic position and consumption of sugary drinks, sugar-sweetened beverages and 100% juice among Canadians: a cross-sectional analysis of the 2015 Canadian Community Health Survey–Nutrition

Objective

The aim of this study was to describe sugary drink (beverages with free sugars), sugar-sweetened beverage (beverages with added sugars, SSB) and 100% juice (beverages with natural sugars) consumption across socioeconomic position (SEP) among Canadians.

Methods

We conducted a cross-sectional analysis of 19,742 respondents of single-day 24-h dietary recalls in the nationally representative 2015 Canadian Community Health Survey–Nutrition. Poisson regressions were used to estimate the prevalence of consuming each beverage type on a given day. Among consumers on a given day, linear regressions were used to estimate mean energy intake. Models included household education, food security and income quintiles as separate unadjusted exposures. Sex-specific models were estimated separately for children/adolescents (2–18 years) and adults (19 +).

Results

Among female children/adolescents, the prevalence of consuming sugary drinks and, separately, SSB ranged from 11 to 21 and 8 to 27 percentage-points higher among lower education compared to ‘Bachelor degree or above’ households. In female adults, the prevalence of consuming sugary drinks and, separately, SSB was 10 (95% CI: 1, 19) and 14 (95% CI: 2, 27) percentage-points higher in food insecure compared to secure households. In males, the prevalence of consuming 100% juice was 9 (95% CI: − 18, 0) percentage-points lower among food insecure compared to secure households. Social inequities in energy intake were observed in female adult consumers, among whom mean energy from sugary drinks was 27 kcal (95% CI: 3, 51) higher among food insecure compared to secure and 35 kcal (95% CI: 2, 67) higher from 100% juice among ‘less than high school’ education compared to ‘Bachelor degree or above’ households.

Conclusion

Social inequities in sugary drink consumption exist in Canada. The associations differed by SEP indicator. Equitable interventions to reduce consumption are warranted.

Creating "Plates" to Evaluate Canadians' Dietary Intake in Relation to the 2019 Canada's Food Guide

Purpose: Explore Canadians' dietary intake in relation to the 2019 Canada's Food Guide (CFG) Plate using novel volume-based food analyses, by age and meal occasion.Methods: Foods reported in 24-hour recalls by 20,456 Canadians in the 2015 Canadian Community Health Survey - Nutrition were classified as: Vegetables and Fruits, Whole Grain Foods, Protein Foods, Non-Whole Grain Foods or Other Foods (high in fat, sugar, sodium). Food volumes were used to calculate percent contributions of each grouping to total intake, stratified by age (1-6; 7-12; 13-17; 18-64; 65+years) and meal (breakfast, lunch, supper, snack), applying sample survey weights and bootstrapping.Results: By volume, the Canadian population diet included: 29% Vegetables and Fruits, 22% Protein Foods, 7% Whole Grains, 24% Non-Whole Grain Foods, and 18% Other Foods. Intakes of Protein Foods (1-6 years) and Other Foods (7-12; 13-17 years) were higher in children than adults by volume, relative to total intake. Whole Grains intake was highest at breakfast. Other Foods intake was highest at snack.Conclusions: The volume-based population diet of Canadians reported on a single day includes a substantial proportion of non-recommended foods. There are opportunities to design interventions that target specific foods, ages, and meals to align intake with recommendations.

Examining Elementary School Children's Knowledge about Food and Nutrition in Southwestern Ontario, Canada

Purpose: Knowledge is fundamental to helping children make nutritional choices that support lifelong healthy behaviours. This study (i) investigates elementary school children's knowledge about food and nutrition and (ii) identifies sociodemographic factors influencing children's reported knowledge.Methods: In 2017-2019, a survey was administered to 2443 students (grades 5-8) at 60 schools across southwestern Ontario, Canada, and a parent survey was used to validate self-reported sociodemographics. Multiple regression was used to analyse children's knowledge scores and related sociodemographic factors. A total knowledge score was calculated by summing correct responses derived from 46 individual questions in the student survey.Results: Mean total knowledge score was 29.2 out of a possible 46 points (63.5% correct). Students demonstrated some knowledge and awareness of strategies to encourage fruit and vegetable consumption, healthy food selection, nutrition, and food preparation skills, although knowledge of food guide recommendations and locally sourced produce were limited. Female sex, family income, and rurality were associated with higher knowledge scores.Conclusions: Results provide insight regarding strengths and gaps in elementary-school children's food and nutrition knowledge. Poor performance of students on specific food guide-related questions suggests that the general guidance of the 2019 Canada's Food Guide might be better understood by children and adolescents.

Children's measured exposure to food and beverage advertising on television in Toronto (Canada), May 2011-May 2019

OBJECTIVE

Exposure to unhealthy food advertising is a known determinant of children's poor dietary behaviours. The purpose of this study was to quantify and characterize Canadian children's exposure to food advertising on broadcast television and examine trends over time.

METHODS

Objectively measured advertising exposure data for 19 food categories airing on 30 stations broadcast in Toronto were licenced for May 2011 and May 2019. Using ad ratings data, the average number of food advertisements viewed by children aged 2-11 years, overall, by food category and by type of television station (child-appealing, adolescent-appealing and generalist stations), was estimated per time period.

RESULTS

In May 2019, children viewed an average of 136 food advertisements on television, 20% fewer than in May 2011. More than half of advertisements viewed in May 2019 promoted unhealthy food categories such as fast food (43% of exposure), candy (6%), chocolate (6%) and regular soft drinks (5%) and only 17% of their total exposure occurred on child-appealing stations. Between May 2011 and May 2019, children's exposure increased the most, in absolute terms, for savory snack foods (+7.2 ad exposures/child), fast food (+5.4) and regular soft drinks (+5.3) with most of these increases occurring on generalist stations.

CONCLUSION

Canadian children are still exposed to advertisements promoting unhealthy food categories on television despite voluntary restrictions adopted by some food companies. Statutory restrictions should be adopted and designed such that children are effectively protected from unhealthy food advertising on both stations intended for general audiences and those appealing to younger audiences.

Gender plays a role in adolescents' dietary behaviors as they transition to secondary school

Little research explores how changes in adolescents' peer, family and school environments may influence dietary behaviors during the shift from elementary school to secondary school and whether boys and girls experience these changes in similar ways. Drawing on Bronfenbrenner's socio-ecological model and Ridgeway's gendered framework, thematic analysis of twenty-seven semi-structured interviews with parent-adolescent dyads reveals that changes in adolescents' peer, family and school environments affect dietary behaviors following the transition in gendered ways. Within the peer context, food facilitates friendships among girls. Girls use food to forge intimate relationships with their peers whereas boys do not report relying on their peers to influence their dietary choices. In the family environment, gender-based body ideals (i.e., being strong and fit for boys versus being thin for girls) become more apparent and influential over adolescents' dietary behaviors. In some families, parents oppose gender-based body ideals (i.e., food restriction among girls) whereas in others, parents' expectations around food become supportive of gendered norms (i.e., encouraging food consumption among boys to gain muscle or acquiring food literacy skills among girls). Within the school context, socializing emerges as a key priority above eating at lunchtime, but boys and girls engage in this socialization differently. Girls use their lunch hour to socialize with peers through sedentary activities whereas boys socialize through team sports. In summary, gender plays a role in how changes in the peer, family and school environments influence boys' and girls' dietary behaviors as they transition into secondary school. Future public health interventions should consider using a targeted gender approach to encourage adolescents to make healthier food choices.

Obesity prevention in early care and education: a comparison of licensing regulations across Canadian provinces and territories

BACKGROUND

Early care and education (ECE) settings represent an important point of intervention for childhood obesity prevention efforts. The objective of this paper was to compare ECE licensing regulations for each Canadian province/territory to evidence-based, obesity prevention standards.

METHODS

Two authors reviewed existing ECE regulations for each province/territory and examined whether the regulatory text supported standards for nutrition (n = 11), physical activity (n = 5) and screen time (n = 4). Provinces/territories were evaluated on the strength of regulatory language for each standard (i.e. fully, partially, or not addressed) and a total comprehensiveness score (maximum score of 20). ECE centres and homes were examined separately.

RESULTS

The majority of provinces/territories required providers to follow Canada's Food Guide, but few had regulations for specific foods or beverages. Most provinces/territories included standards related to written menus and drinking water, but the strength of these standards was weak. Many provinces/territories required physical activity and outdoor opportunities to be provided daily, but few included a time requirement. Only two provinces included any screen time standards. Total comprehensiveness scores averaged 5.7 for centres and 5.4 for homes.

CONCLUSIONS

Canadian provinces/territories have insufficient obesity prevention regulations in ECE settings, highlighting a potential point of intervention to prevent obesity.

Nutritional quality of the food choices of Canadian children

BACKGROUND

The release of the Canadian Community Health Survey (CCHS), Nutrition 2015 provides a unique opportunity since CCHS 2004 to investigate food choices of Canadian children and adolescents at a national level.

OBJECTIVE

This study examined the quality and quantity of food choices of children ages 2-8 years and adolescents 9-18 years, using Health Canada's Surveillance Tool Tier System 2014. It is hypothesized that Canadian children and adolescents are consuming diets poor in nutritional quality based on evidence from the last national nutrition survey in 2004.

DESIGN

Intakes from CCHS 2015, 24-h dietary recall were categorized into Health Canada's Tiers 1-4, based on CNF/CFG classification system and thresholds for nutrients to limit i.e., total fat, saturated fats, sugars, and sodium to assess quality of food choices. Additionally, dietary intakes were grouped according to Canada's 2007 food guide servings as the 2019 food guide was not available.

RESULTS

Majority of foods reported by children 2-18 years were categorized as Tier 2 and Tier 3 foods. Investigation of energy contributions from the Tier 4 and "other foods" represented 21-25% of daily calorie intake and of these foods, high fat and/or high sugar foods contributed majority of daily calories to these categories.

CONCLUSIONS

This study showed Canadian children 2-18 years are consuming diets high in nutrients recommended to limit. Evidence from this study provides a unique opportunity to improve the nutritional quality of foods, and the food choices of children.

Children's measured exposure to food and beverage advertising on television in a regulated environment, May 2011-2019

OBJECTIVE

To quantify food/beverage advertising on television in Montreal (Quebec), to estimate and characterise children's exposure and to examine trends over time.

DESIGN

Television food advertising data were licensed for nineteen food categories and eighteen stations for May 2011, 2016 and 2019. The frequency of advertisements and the average number viewed per child aged 2-11 years overall, by food category and by station type (i.e. youth-appealing (n 3) and generalist (n 15) stations) were determined. The percent change in advertising frequency and exposure between May 2011 and 2019 was calculated.

SETTING

Montreal, Quebec, Canada.

PARTICIPANTS

This study used media data and did not directly involve human participants.

RESULTS

The total number of television advertisements increased by 11 % between May 2011 (n 41 084) and May 2019 (n 45 406); however, exposure to food/beverage advertisements decreased by 53 %, going from 226 ads/child in May 2011 to 107 ads/child in May 2019. Overall, the most advertised food categories in both May 2011 and 2019 were fast food (29·8 % and 39·2 %, respectively) followed by chocolate (14·2 %) in 2011 and savory snacks (9·7 %) in 2019. In May 2019, children were predominantly exposed to unhealthy food categories such as fast food (41·3 % of exposure), savory snacks (7·5 %), chocolate (5·0 %) and regular soft drinks (4·5 %), and most (89·3 %) of their total exposure occurred on generalist television stations.

CONCLUSION

Despite Quebec's restrictions on commercial advertising directed to children under 13 years, Quebecois children are still frequently exposed to unhealthy food advertising on television. Government should tighten restrictions to protect children from this exposure.

Comparing how Canadian packaged food products align with the 2007 and 2019 versions of Canada's Food Guide

In 2019, Canada's Food Guide (CFG) was updated from the 2007 version. This study developed a food-based nutrient profile model (NPM) to evaluate the alignment of packaged food and beverage products with CFG 2019 and compared it with CFG 2007. Packaged products from the University of Toronto's Food Label Information Program 2017 database were evaluated in terms of their alignment with CFG 2007 (using the Health Canada Surveillance Tool (HCST)) and CFG 2019 (using our newly developed CFG 2019 NPM). Agreement in alignment (e.g., products "in line" according to CFG 2019 NPM and in Tiers 1 or 2 according to the HCST) was calculated and differences in alignment and reasons for differences were quantified and described. Overall agreement in product alignment between CFG 2007 and 2019 was 81.9%, with fewer products aligned with CFG 2019: 16.4% vs. 31.8%, (χ² = 189.12, p < 0.001). Differences in alignment varied across food categories (0.0-73.8%), explained by differences in CFG 2019, reflected in the CFG 2019 NPM (e.g., emphasis on avoiding processed foods, encouraging whole grains and low-fat dairy). This study presents a first step in assessing packaged foods' alignment with CFG 2019; future work is needed to evaluate broader dietary adherence to the updated recommendations. Novelty: A food-based nutrient profile model was developed based on the 2019 CFG and tested on packaged foods by comparing it with the nutrient-based HCST, based on CFG 2007. Most (82%) packaged products were "not in line" with either CFG version.

Diet Quality Is Associated with Cardiometabolic Outcomes in Survivors of Childhood Leukemia

There is little information about how diet influences the health of childhood acute lymphoblastic leukemia (cALL) survivors. This study explores the associations between diet quality indices, cardiometabolic health indicators and inflammatory biomarkers among cALL survivors. Participants were part of the PETALE study (n = 241, median age: 21.7 years). Adherence to 6 dietary scores and caloric intake from ultra-processed foods were calculated. Multivariate logistirac regressions, Student t-tests and Mann-Whitney tests were performed. We found that 88% of adults and 46% of children adhered poorly to the Mediterranean diet, 36.9% had poor adherence to the World Health Organisation (WHO) recommendations and 76.3% had a diet to be improved according to the HEI-2015 score. On average, ultra-processed foods accounted for 51% of total energy intake. Low HDL-C was associated with a more inflammatory diet (E-DIITM score) and higher intake of ultra-processed foods. A greater E-DII score was associated with elevated insulin resistance (HOMA-IR), and consumption of ultra-processed foods was correlated with high triglycerides. Circulating levels of TNF-α, adiponectin and IL-6 were influenced by diet quality indices, while CRP and leptin were not. In conclusion, survivors of cALL have poor adherence to dietary recommendations, adversely affecting their cardiometabolic health.

Evaluating Diet Quality of Canadian Adults Using Health Canada's Surveillance Tool Tier System: Findings from the 2015 Canadian Community Health Survey-Nutrition

The 2014 Health Canada’s Surveillance Tool, Tier System (HCST) is a nutrient profiling model developed to evaluate adherence of food choices to dietary recommendations. With the recent release of the nationally representative Canadian Community Health Survey-Nutrition (CCHS-N) 2015, this study used HCST to evaluate nutritional quality of the dietary intakes of Canadians in the CCHS-N. Dietary intakes were ascertained using 24-hour dietary recalls from Canadians adults ≥19 years (N = 13,605). Foods were categorized into four Tiers based on degree of adherence to dietary recommendations according to thresholds for sodium, total fat, saturated fats, and sugars. Tier 1 and Tier 2 represented “recommended foods”, Tier 3 represents foods to “choose less often”, and Tier 4 represented foods “not recommended”. Across all dietary reference intakes (DRI) groups, most foods were categorized as Tier 1 for Vegetable and Fruits (2.2–3.8 servings/day), Tier 2 for Grain Products (2.9–3.4 servings/day), Tier 3 for Milk and Alternatives (0.7–1 serving/day) or for Meat and Alternatives (1.1–1.6 servings/day). Consumption of foods from Tier 4 and “other foods” such as high fat/sugary foods, sugar-sweetened beverages, and alcohol, represented 24–26% and 21–23% kcal/day, for males and females, respectively. Canadians are eating more foods categorized as Tier 1–3, rather than Tier 4. Adults with the highest intakes of Tier 4 and “other foods” had lower intakes of macronutrients and increased body mass index. These findings can be used by policy makers to assist in identifying targets for food reformulation at the nutrient level and quantitative guidance to support healthy food choices.

Evaluating the Canadian Packaged Food Supply Using Health Canada's Proposed Nutrient Criteria for Restricting Food and Beverage Marketing to Children

Federally mandated restrictions on food and beverage marketing to kids (M2K) have been re-introduced as a national public health priority in Canada by the newly elected government, following the failure to implement a similar policy first proposed in 2016. This study examined the extent to which Canadian packaged foods, including products already displaying M2K on the packaging, would be permitted to be marketed, based on the nutrient criteria for marketing restrictions defined by Health Canada (in December 2018) as part of the previous policy proposal. Products from the University of Toronto Food Label Information Program 2013 database (n = 15,200) were evaluated using Health Canada’s published criteria: thresholds for sodium, sugars and saturated fats that products cannot exceed in order to be M2K. The proportion of products exceeding no thresholds (i.e., permitted to be M2K), the number of thresholds exceeded, and the proportion exceeding each individual threshold were calculated overall and in the subsample of products displaying M2K on the packaging (n = 747). Overall, 18.0% of products would be permitted to be M2K, versus 2.7% of products displaying M2K. Sodium was the most exceeded threshold overall (57.5% of products), whereas sugars was the most exceeded by products displaying M2K (80.1%). Only 4.7% of all products versus 10.4% of products displaying M2K exceeded all three thresholds. These results highlight the importance of reintroducing federal regulations restricting M2K in Canada and including marketing on product packaging in the regulatory scope.

Vegetable/Fruit Intakes of Young Children at Home and in Childcare Centres

Purpose: The vegetable/fruit intakes of a sample of children attending regulated childcare in Nova Scotia was assessed and compared by age groups (3 and 4-5 year olds) and by home and childcare environments. Methods: Seventy-nine children had 3-4-day food records and 58 had records from both environments. The data were coded by the 2007 Canada's Food Guide (CFG) recommendations and the 2014 Classification of Foods in the Canadian Nutrient File according to CFG (CNF/CFG) Tiers. Descriptive statistics and tests of significance were determined. Results: Overall, 56% of children met the CFG vegetable/fruit recommendations but the percentage of older children meeting recommendations was half that of the younger age group; a significant difference. Fruit and juice comprised 65% of vegetable/fruit intakes with more consumed at home. Vegetable/fruit items were mostly from the higher quality CNF/CFG Tiers but more of the lower quality items were consumed at home. Conclusions: The 4-5 year olds may not be increasing their vegetable/fruit intakes as the CFG recommends. While just over half of children met CFG vegetable/fruit recommendations, the vegetable/fruit items were mostly high quality; fruit and juice predominated. Identification of strategies to support increased vegetable/fruit intakes of children in both home and childcare environments is warranted.

The Family Mealtime Observation Study (FaMOS): Exploring the Role of Family Functioning in the Association between Mothers' and Fathers' Food Parenting Practices and Children's Nutrition Risk

This cross-sectional study explores associations between mothers’ and fathers’ food parenting practices and children’s nutrition risk, while examining whether family functioning modifies or confounds the association. Home observations assessed parents’ food parenting practices during dinnertime (n = 73 families with preschoolers). Children’s nutrition risk was calculated using NutriSTEP^®. Linear regression models examined associations between food parenting practices and NutriSTEP^® scores. An interaction term (family functioning × food parenting practice) explored effect modification; models were adjusted for family functioning to explore confounding. Among mothers, more frequent physical food restriction was associated with higher nutrition risk in their children (β = 0.40 NutriSTEP^® points, 95% Confidence Interval (CI) = 2.30, 7.58) and among both mothers and fathers, positive comments about the target child’s food were associated with lower nutrition risk (mothers: β = −0.31 NutriSTEP^® points, 95% CI = −0.54, −0.08; fathers: β = −0.27 NutriSTEP^® points, 95% CI = −0.75, −0.01) in models adjusted for parent education and child Body Mass Index (BMI) z-score. Family functioning did not modify these associations and they remained significant after adjustment for family functioning. Helping parents to use positive encouragement rather than restriction may help to reduce their children’s nutrition risk.

Differences in the Quantity and Types of Foods and Beverages Consumed by Canadians between 2004 and 2015

This study examined differences in food and beverage intake estimated from nationally representative surveys of Canadians in 2004 and 2015 collected through the Canadian Community Health Surveys. Differences in mean daily energy intake and amounts of food consumed were compared between 2004 and 2015 and across age groups for all energy reporters (aged 2 years+) and among only plausible energy reporters. From 2004 to 2015, mean energy intake decreased by 228 kcal/day (all energy reporters) and 74 kcal/day (plausible energy reporters). Canadians reported consuming more daily servings of meat and alternatives but fewer servings of vegetables and fruit and milk and alternatives in 2015 compared to 2004. Analyses of food subgroups revealed that Canadians reported consuming more daily servings of dark green and orange vegetables, dairy products, legumes, nuts and seeds, and eggs but fewer servings of potatoes, other vegetables, fruit juices, fluid milk, and sugar-sweetened beverages in 2015 compared to 2004. While some aspects of the Canadian diet have improved, daily mean intake of other nutritious foods either stagnated or worsened over time. Continued attention is needed to improve population-level intakes of vegetables, fruit, whole grains, and protein foods such as legumes, nuts, seeds, and lower fat dairy products.

Differences in the Quantity and Types of Foods and Beverages Consumed by Canadians between 2004 and 2015

This study examined differences in food and beverage intake estimated from nationally representative surveys of Canadians in 2004 and 2015 collected through the Canadian Community Health Surveys. Differences in mean daily energy intake and amounts of food consumed were compared between 2004 and 2015 and across age groups for all energy reporters (aged 2 years+) and among only plausible energy reporters. From 2004 to 2015, mean energy intake decreased by 228 kcal/day (all energy reporters) and 74 kcal/day (plausible energy reporters). Canadians reported consuming more daily servings of meat and alternatives but fewer servings of vegetables and fruit and milk and alternatives in 2015 compared to 2004. Analyses of food subgroups revealed that Canadians reported consuming more daily servings of dark green and orange vegetables, dairy products, legumes, nuts and seeds, and eggs but fewer servings of potatoes, other vegetables, fruit juices, fluid milk, and sugar-sweetened beverages in 2015 compared to 2004. While some aspects of the Canadian diet have improved, daily mean intake of other nutritious foods either stagnated or worsened over time. Continued attention is needed to improve population-level intakes of vegetables, fruit, whole grains, and protein foods such as legumes, nuts, seeds, and lower fat dairy products.

Nutrient Profile Models with Applications in Government-Led Nutrition Policies Aimed at Health Promotion and Noncommunicable Disease Prevention: A Systematic Review

Nutrient profile (NP) models, tools used to rate or evaluate the nutritional quality of foods, are increasingly used by government bodies worldwide to underpin nutrition-related policies. An up-to-date and accessible list of existing NP models is currently unavailable to support their adoption or adaptation in different jurisdictions. This study used a systematic approach to develop a global resource that summarizes key characteristics of NP models with applications in government-led nutrition policies. NP models were identified from an unpublished WHO catalog of NP models last updated in 2012 and from searches conducted in different databases of the peer-reviewed (n = 3; e.g., PubMed) and gray literature (n = 15). Included models had to meet the following inclusion criteria (selected) as of 22 December 2016: 1) developed or endorsed by governmental or intergovernmental organizations, 2) allow for the evaluation of individual food items, and 3) have publicly available nutritional criteria. A total of 387 potential NP models were identified, including n = 361 from the full-text assessment of >600 publications and n = 26 exclusively from the catalog. Seventy-eight models were included. Most (73%) were introduced within the past 10 y, and 44% represent adaptations of ≥1 previously built model. Models were primarily built for school food standards or guidelines (n = 27), food labeling (e.g., front-of-pack; n = 12), and restriction of the marketing of food products to children (n = 10). All models consider nutrients to limit, with sodium, saturated fatty acids, and total sugars being included most frequently; and 86% also consider ≥1 nutrient to encourage (e.g., fiber). No information on validity testing could be identified for 58% of the models. Given the proliferation of NP models worldwide, this new resource will be highly valuable for assisting health professionals and policymakers in the selection of an appropriate model when the establishment of nutrition-related policies requires the use of nutrient profiling.

The effectiveness of voluntary policies and commitments in restricting unhealthy food marketing to Canadian children on food company websites

Marketing unhealthy foods and beverages to children (M2K) fosters poor dietary patterns, increasing obesity and noncommunicable disease risk. Federal restrictions on M2K have been under development in Canada since 2016; however, at present, M2K is mostly self-regulated by food companies. This study aimed to compare M2K on Canadian websites of food companies with and without voluntary policies or commitments in this area. A systematic content analysis of company websites was conducted in spring/summer 2017 for major packaged food (n = 16), beverage (n = 12), and restaurant chain (n = 13) companies in Canada. M2K policies were sourced from company websites and published corporate documents. Sixteen companies (43%) reported national and/or global M2K policies, while 21 companies (57%) had no published policies. The websites of Canadian companies (n = 154) were scanned for child-directed products and marketing; type and frequency of marketing techniques were recorded. Child-directed marketing appeared on 19 websites of 12 companies (32%), including 9 companies with M2K policies. Websites featured products with unconventional flavours, colours, shapes, or child-oriented packaging, and used promotional characters, contests, games, activities, or lettering and graphics appealing to children. The nutritional quality of products marketed to children was evaluated using a nutrient profile model developed by Health Canada for proposed M2K regulations. Of the 217 products marketed to children, 97% exceeded Health Canada's proposed ∼5% Daily Value threshold for saturated fat, sodium, and/or sugars, 73% of which were products from 9 companies with policies. These findings highlight the limitations of self-regulation in restricting M2K on food company websites, reinforcing the need for government regulations.

A process and outcome evaluation of an in-class vegetable promotion program

OBJECTIVE

Nutrition interventions that target both fruits and vegetables are effective in increasing fruit consumption, but have been limited in their ability to improve vegetable intake. To address the low proportion of children meeting vegetable intake guidelines, approaches specifically targeting vegetables are needed. This paper reports on a mixed-method analysis of a 10-week vegetable promotion pilot project that aimed to increase vegetable intake as part of the existing Crunch&Sip in-class fruit and vegetable break program.

DESIGN

The intervention was designed to promote vegetable consumption through the implementation of vegetable-focused resources, including curriculum resources and parent education materials. Teachers completed pre- and end-of-intervention surveys. Process measures related to the use of resources and teachers' perceptions of barriers to implementation. The outcome evaluation included measures of children's vegetable consumption during Crunch&Sip breaks and teachers' attitudes and confidence relating to educating students about the benefits of consuming vegetables.

SUBJECTS

Twenty-one Western Australian primary schools already participating in the Crunch&Sip program participated in the pilot intervention and evaluation. Coverage included 35 primary school teachers representing 818 students aged 4-11 years.

RESULTS

The proportion of children bringing vegetables for Crunch&Sip more than doubled over the 10-week intervention (21% vs 46%; p < 0.001). Improvements were observed in teachers' perceived knowledge about the nutritional benefits of vegetables (p = 0.001) and confidence to educate students about the benefits of vegetable consumption (p = 0.028).

CONCLUSIONS

Preferentially promoting vegetable consumption as part of an existing school-based nutrition program may be an effective strategy to increase children's vegetable intake.

Assessing the Dietary Habits of Canadians by Eating Location and Occasion: Findings from the Canadian Community Health Survey, Cycle 2.2

Occasion and location of food environment has an influence on dietary habits, nutritional quality and overall health and nutrition-related chronic disease risk. Eating occasion and location was assessed in 20,402 Canadians aged ≥ 2 years, with a focus on energy, saturated fat, added sugars, and sodium intake by age group. Data showed >80% of children, compared to ~60% of adolescents and adults, consumed three meals (breakfast, lunch, dinner) plus snacks in a day. Dinner contributed the most calories [ranging from 395 ± 11 kcal (2–3 year olds) to 952 ± 27 kcal (men 19–30 years)], saturated fat [7.4 ± 0.2% energy (2–3 year olds) to 9.1 ± 0.3% energy (women 31–50 years)], and sodium [851 ± 24 mg (2–3 year olds) to 1299 ± 69 mg (men 19–30 years)], while snacks contributed the most added sugars [22 ± 1 kcal (men >70 years) to 45 ± 1 kcal (2–3 year olds)]. By eating location, most Canadians (>90%) reported consuming food from home. Subsequently, home was associated with the majority of energy [1383 ± 23 kcal (women >70 years) to 2090 ± 35 kcal (boys 9–13 years)], saturated fat [20.4 ± 0.4%E (men 51–70 years) to 24.2 ± 0.4%E (2–3 year olds)], added sugars [77 ± 3 kcal (men 19–30 years) to 117 ± 2 kcal (2–3 year olds)], and sodium [2137 ± 59 mg (women 19–30 years) to 2638 ± 45 mg (men 51–70 years)] intakes. Reported eating behaviours suggest action is needed at individual and population levels to alter food purchasing and consumption habits, specifically with regards to snacking habits and foods prepared at home.

The Ontario Food and Nutrition Strategy: identifying indicators of food access and food literacy for early monitoring of the food environment

INTRODUCTION

To address challenges Canadians face within their food environments, a comprehensive, multistakeholder, intergovernmental approach to policy development is essential. Food environment indicators are needed to assess population status and change. The Ontario Food and Nutrition Strategy (OFNS) integrates the food, agriculture and nutrition sectors, and aims to improve the health of Ontarians through actions that promote healthy food systems and environments. This report describes the process of identifying indicators for 11 OFNS action areas in two strategic directions (SDs): Healthy Food Access, and Food Literacy and Skills.

METHODS

The OFNS Indicators Advisory Group used a five-step process to select indicators: (1) potential indicators from national and provincial data sources were identified; (2) indicators were organized by SD, action area and data type; (3) selection criteria were identified, pilot tested and finalized; (4) final criteria were applied to refine the indicator list; and (5) indicators were prioritized after reapplication of selection criteria.

RESULTS

Sixty-nine potential indicators were initially identified; however, many were individual-level rather than system-level measures. After final application of the selection criteria, one individual-level indicator and six system-level indicators were prioritized in five action areas; for six of the action areas, no indicators were available.

CONCLUSION

Data limitations suggest that available data may not measure important aspects of the food environment, highlighting the need for action and resources to improve system-level indicators and support monitoring of the food environment and health in Ontario and across Canada.

Adherence to Canada's Food Guide recommendations among Alberta's multi-ethnic youths is a major concern: findings from the WHY ACT NOW project

BACKGROUND

Dietary habits formed during youth may result in the development of obesity and chronic diseases in adulthood. We aimed to determine the frequency of the consumption of foods and beverages and the degree of adherence to Canada's Food Guide recommendations among multi-ethnic youths.

METHODS

Participants were recruited from 12 schools in the Edmonton, Alberta area by use of posters, school newsletters and advertisements. A 30-item food frequency questionnaire was administered by a trained interviewer to assess dietary intake in a convenience sample of 557 (328 females and 229 males) youths aged 11-23 years; for the purpose of the present study, only the 14-18 years age group was considered in the analysis. Participants were divided by sex and self-identified ethnicity into four groups [Indigenous, African & Middle Eastern (AME), Asian, and European]. Statistical analysis of the data was undertaken using t-tests, Welch's analysis of variance and Games-Howell tests. P < 0.05 was considered statistically significant.

RESULTS

Vegetables and Fruit recommendations were the least likely to be followed, with 90.7-96.8% of participants in all groups not consuming the recommended number of servings day^-1 . The mean frequency of fruit consumption was lower among Indigenous youths compared to Asian youths (0.90 versus 1.37 times day^-1 ). A greater proportion of males than females (55.9% versus 44.3%) did not meet the minimum recommendations for Meat and Alternatives (P = 0.016). The percentage of youths not adhering to recommendations for Milk and Alternatives was 81.7% for Indigenous, 73.3% for AME, 78.6% for Asian and 63.5% for European youths. Indigenous youths more frequently consumed potato chips and soft drinks compared to other ethnic youths. The most frequently consumed beverage was milk (1.25 times day^-1 ).

CONCLUSIONS

The majority of youths did not consume minimum daily recommended servings of Vegetables and Fruit, Milk and Alternatives, and/or Meat and Alternatives food groups. Evidence-based dietary interventions and public health strategies are needed.

Diet and cardiometabolic side effects in children treated with second-generation antipsychotics

BACKGROUND

Second-generation antipsychotic (SGA) treatment in children is associated with metabolic side effects including weight gain, dyslipidemia, and insulin resistance. The objective of this study is to determine if SGA treatment in children affects dietary intakes and relationship to metabolic side effects.

METHODS

Three-day food records assessed dietary energy and macronutrient intakes in a cross-sectional population of SGA-treated (n = 35) and SGA-naïve (n = 29) children.

RESULTS

SGA-treated children had more overweight/obesity (BMI ≥ 85th percentile for age and sex, p = 0.001); waist circumference (WC) ≥ 90th percentile for age and sex (p = 0.007); waist:height ratio (WHtR) ≥ 85th percentile for age and sex (p = 0.004), greater HOMA-IR, (p = 0.001) and plasma triglycerides (p = 0.017), and lower plasma HDL (p = 0.029). Dietary energy intakes were not different between SGA-naïve and SGA-treated children [1734 ± 486 vs 1971 ± 649 (-135, 408) kcal/day, mean ± SD (95% CI)] after adjustments for sex, age, Tanner stage, psychostimulant use, and height. Similarly, no differences in macronutrient intakes were observed. In models adjusted for SGA treatment and physical activity, no relationships between dietary intakes and BMI were found, but dietary total energy intakes were positively associated with waist circumference z-scores (p = 0.019), systolic blood pressure z-scores (p = 0.028, also adjusted for BMI) and HOMA-IR (p = 0.013, also adjusted for age, sex, BMI). All of the children had poor diets with 87.5% having >7% of daily energy from saturated fat; 62.5% having >20% of daily energy from sugar; and almost 60% having sodium intakes above the tolerable upper intake level.

CONCLUSIONS

SGA treatment is not associated with greater dietary energy intakes in children. However, dietary energy intakes are associated with greater waist circumference and systolic blood pressure z-scores and HOMA-IR in children with mental health conditions.

Adapting the Healthy Eating Index 2010 for the Canadian Population: Evidence from the Canadian National Nutrition Survey

The Healthy Eating Index (HEI) is a diet quality index shown to be associated with reduced chronic disease risk. Older versions of the HEI have been adapted for Canadian populations; however, no Canadian modification of the Healthy Eating Index-2010 (HEI-2010) has been made. The aims of this study were: (a) to develop a Canadian adaptation of the HEI-2010 (i.e., Healthy Eating Index-Canada 2010 (HEI-C 2010)) by adapting the recommendations of the HEI-2010 to Canada's Food Guide (CFG) 2007; (b) to evaluate the validity and reliability of the HEI-C 2010; and (c) to examine relationships between HEI-C 2010 scores with diet quality and the likelihood of being obese. Data from 12,805 participants (≥18 years) were obtained from the Canadian Community Health Survey Cycle 2.2. Weighted multivariate logistic regression was used to test the association between compliance to the HEI-C 2010 recommendations and the likelihood of being obese, adjusting for errors in self-reported dietary data. The total mean error-corrected HEI-C 2010 score was 50.85 ± 0.35 out of 100. Principal component analysis confirmed multidimensionality of the HEI-C 2010, while Cronbach's α = 0.78 demonstrated internal reliability. Participants in the fourth quartile of the HEI-C 2010 with the healthiest diets were less likely to consume refined grains and empty calories and more likely to consume beneficial nutrients and foods (p-trend < 0.0001). Lower adherence to the index recommendations was inversely associated with the likelihood of being obese; this association strengthened after correction for measurement error (Odds Ratio: 1.41; 95% Confidence Interval: 1.17-1.71). Closer adherence to Canada's Food Guide 2007 assessed through the HEI-C 2010 was associated with improved diet quality and reductions in the likelihood of obesity when energy intake and measurement errors were taken into account. Consideration of energy requirements and energy density in future updates of Canada's Food Guide are important and necessary to ensure broader application and usability of dietary quality indexes developed based on this national nutrition guideline.

Identification of dietary patterns associated with obesity in a nationally representative survey of Canadian adults: application of a priori, hybrid, and simplified dietary pattern techniques

Background: Analyzing the effects of dietary patterns is an important approach for examining the complex role of nutrition in the etiology of obesity and chronic diseases.Objectives: The objectives of this study were to characterize the dietary patterns of Canadians with the use of a priori, hybrid, and simplified dietary pattern techniques, and to compare the associations of these patterns with obesity risk in individuals with and without chronic diseases (unhealthy and healthy obesity).Design: Dietary recalls from 11,748 participants (≥18 y of age) in the cross-sectional, nationally representative Canadian Community Health Survey 2.2 were used. A priori dietary pattern was characterized with the use of the previously validated 2015 Dietary Guidelines for Americans Adherence Index (DGAI). Weighted partial least squares (hybrid method) was used to derive an energy-dense (ED), high-fat (HF), low-fiber density (LFD) dietary pattern with the use of 38 food groups. The associations of derived dietary patterns with disease outcomes were then tested with the use of multinomial logistic regression.Results: An ED, HF, and LFD dietary pattern had high positive loadings for fast foods, carbonated drinks, and refined grains, and high negative loadings for whole fruits and vegetables (≥|0.17|). Food groups with a high loading were summed to form a simplified dietary pattern score. Moving from the first (healthiest) to the fourth (least healthy) quartiles of the ED, HF, and LFD pattern and the simplified dietary pattern scores was associated with increasingly elevated ORs for unhealthy obesity, with individuals in quartile 4 having an OR of 2.57 (95% CI: 1.75, 3.76) and 2.73 (95% CI: 1.88, 3.98), respectively (P-trend < 0.0001). Individuals who adhered the most to the 2015 DGAI recommendations (quartile 4) had a 53% lower OR of unhealthy obesity (P-trend < 0.0001). The associations of dietary patterns with healthy obesity and unhealthy nonobesity were weaker, albeit significant.Conclusions: Consuming an ED, HF, and LFD dietary pattern and lack of adherence to the recommendations of the 2015 DGAI were associated with a significantly higher risk of obesity with and without accompanying chronic diseases.

The 2015 Dietary Guidelines for Americans is associated with a more nutrient-dense diet and a lower risk of obesity

BACKGROUND

Dietary pattern analysis represents a departure from the traditional focus on single foods and nutrients and provides a comprehensive understanding of the role of the diet in chronic disease prevention and etiology. Dietary patterns of Canadians have not been evaluated comprehensively with the use of an updated a priori dietary quality index.

OBJECTIVES

We aimed to update the Dietary Guidelines for Americans Adherence Index (DGAI) on the basis of the 2015 Dietary Guidelines for Americans (DGA), to evaluate the construct validity and reliability of the revised index, and to examine whether closer adherence to this index is associated with a lower risk of obesity with or without an accompanying chronic disease.

DESIGN

Data from 11,748 participants (≥18 y of age) in the cross-sectional Canadian Community Health Survey cycle 2.2 were used in weighted multivariate analyses. Multinomial logistic regression was used to test the association between diet quality and obesity risk.

RESULTS

With the use of principal component analyses, the multidimensionality of the 2015 DGAI was confirmed, and its reliability was shown with a high Cronbach's α = 0.75. Moving from the first to the fourth (healthiest) quartile of the 2015 DGAI score, there was a trend toward decreased energy (2492 ± 26 compared with 2403 ± 22 kcal, respectively; ±SE) and nutrients of concern (e.g., sodium), whereas intakes of beneficial nutrients increased (P-trend < 0.05). In the age- and sex-adjusted model, a lack of adherence to the 2015 DGA recommendations increased the OR of being unhealthy obese from 1.42 (95% CI: 1.02, 1.99) in quartile 3 to 2.08 (95% CI: 1.49, 2.90) in quartile 2 to 2.31 (95% CI: 1.65, 3.23) in the first quartile of the 2015 DGAI score, compared with the fourth quartile (healthiest) (P-trend < 0.0001). The odds of being obese without a chronic disease (healthy obese) and having a chronic disease without being obese also increased in the lowest DGAI quartile compared with the highest DGAI quartile, albeit not as much as in the unhealthy obese group.

CONCLUSION

The 2015 DGAI provides a valid and reliable measure of diet quality among Canadians.