The Impact of Canadian School Food Programs on Children’s Nutrition and Health: A Systematic Review

The Influence of Educational Determinants on Children's Health: A Scoping Review of Reviews

Objectives: Education is one of the most important social determinants shaping the development and wellbeing of children. The purpose of this review of reviews is to inform policymakers, practitioners and public health stakeholder involved in developing child-friendly policies outside of the healthcare system. Methods: We carried out a scoping review of reviews. It included 32 reviews. Results: We identified four main categories of educational determinants in relation to children's health: 1) the organization and structure of educational activities, 2) the interpersonal relations in the educational facilities and structures, 3) the spatial environment of educational facilities and structures, 4) social inequalities in the educational facilities and structures. This last category highlighted the capacity of education system to act on inequalities derived from the way social structures are organized. Conclusion: We suggest a conceptual framework for action which distinguishes structural determinant (gender, race, social class, etc.) and structuring determinant (public policy, systems of governance, organization of cultures/values consideration). Finally, we discuss on how these social structures and structuring determinants influence the intermediary educational determinants collated in the review.

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 Unpublished data and grey literature were also searched.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.

Applicability of the Socioecological Model for Understanding and Reducing Consumption of Ultra-Processed Foods in Canada

Ultra-processed foods (UPFs) have become a major contributor to the diets of Canadians, with a recent report from Statistics Canada suggesting Canadians are consuming almost one-half of their calories from UPFs. Research has linked UPF consumption with increased risk for chronic diseases such as cardiovascular disease and type 2 diabetes, among others. This paper sought to investigate the popularity of UPFs, particularly among children and teens, utilizing the socioecological model as a framework to illustrate how influences at multiple levels (i.e., public policy, organizational, community, interpersonal, and individual) have played a role in the proliferation of UPFs. Evidence from previous studies is used to identify how factors at different levels may influence UPF consumption and discuss potential strategies for reducing UPF consumption. To meaningfully reduce UPF consumption among Canadians, all levels should be considered, with the goal of creating a healthier Canadian population.

"I was pushed over the edge, but I didn't die" - A qualitative case study of Danish school children's food literacy at FOODcamp

Food literacy (FL) is a goal for many food camps aimed at improving school children's culinary skills and food knowledge. FL in relation to children has been defined as constituting five competencies: "to do" (practical skills),"to know" (knowledge), "to sense" (sensory experiences), "to care" (care for self and others), and "to want" (to be willing to act). However, understanding the processes and mechanisms that relates to school children's FL remain underexplored. The aim of this study was to identify underlying mechanisms operating at a food camp and elucidate how they relate to FL competencies among school children. A qualitative embedded case study design was used to explore this with a Danish food camp programme 'FOODcamp' targeting school-going children aged 12-14 years, constituting an instrumental case. A theory-driven abductive research strategy was used to facilitate analytical generalization. Five schools and nine classes participating in FOODcamp were recruited for the study. Data comprised 10 focus group discussions conducted with children, nine interviews conducted with teachers, and 10 days of observation at FOODcamp. The analysis resulted in 12 conceptually derived mechanisms operating at a food camp namely 'hands-on with food and kitchen utensils', 'use of all senses', 'help and recognition', 'theoretical reflection', 'from farm to table', 'try new and scary things', 'experimenting', 'genuine participation', 'cook from scratch', 'principles', 'meal group community' and 'food group community'. These mechanisms were in various combinations and in a dynamic interplay with contextual conditions related to school children's five FL competencies. The conceptually derived mechanisms may guide future research and practice by highlighting various processes and contextual conditions, given that they are adapted to the specific possibilities of a given context and age group.

A randomized control trial of a Canadian-based school food program on the home food environment

Research provides evidence of take-home effects in school-based nutrition interventions, citing children as important influencers of family nutrition, acting as agents of change in the household and potentially influencing family food consumption. Therefore, the purpose of this randomized control trial was to examine whether implementation of a centrally procured school food program would produce changes in children's home food environment, including fruit and/or vegetable availability and parental modelling of fruit and/or vegetable consumption. A secondary objective was to investigate whether children's fruit and/or vegetable intake predicted their parent's fruit and/or vegetable intake. A total of 60 schools participated in the evaluation, including 2443 students (and their parents) in grades 5-8. Findings indicated that the intervention did not produce take-home effects on children's home availability of fruit (p = 0.52) and vegetables (p = 0.67) or parental modelling of fruit (p = 0.26) and vegetable consumption (p = 0.78), which may be related to the fact that only food provisions were given. However, children's fruit and vegetable consumption predicted parents' fruit and vegetable consumption (p < 0.001), thereby indicating that children may possess the capacity to influence home nutrition. Future school-based nutrition interventions are recommended to be multi-component (e.g. experiential learning, parent involvement) and that encourage nutrition leadership opportunities for children in the home context.

Process evaluation of the Centrally Procured School Food Program (CPSFP) in Ontario, Canada: school-level perspectives

This study explored the implementation of the Centrally Procured School Food Program (CPSFP)-a free, universal, volunteer-led snack program for elementary school children. To assess participants' perceptions and experiences with the CPSFP, interviews were conducted in school-level participants (n = 33) using a semi-structured interview guide. Fifteen on-site visits also were conducted at each school to observe implementation practices. Quantitative data were obtained through a general information form where participants provided school characteristics and weekly logbooks where they described program operations and food quality. Most participants expressed positive perceptions of the CPSFP, identifying it as a valuable program for their students. Successful program implementation was associated with an appreciation for the CPSFP and the participation of the school community. Challenges to program implementation included concerns with the volume and types of food provided, issues with classroom food delivery and distribution and communication challenges. Suggestions for improvement included building capacities and enhancing student engagement in the program. Participants provided an in-depth assessment of the implementation of the CPSFP. The lessons learned and suggestions provided may help not only enhance the reach, feasibility and fidelity of the CPSFP, but inform the best practices for similar programs.

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.

The Good Food for Learning Universal Curriculum-Integrated Healthy School Lunch Intervention: Protocol for a Two-Year Matched Control Pre-Post and Case Study

Background

Good nutrition affects children’s health, well-being, and learning, and schools offer an important setting to promote healthy behaviors that can last a lifetime. Once children reach school age, they spend more of their waking hours in school than in any other environment. Children’s eating habits may be easier to influence than those of adults. In Canada, households with children are more likely to experience food insecurity, and school food programs that are universally available to all children can support the development of healthy eating patterns across groups of varying socioeconomic status. There is a significant gap in the rigorous community-engaged academic research on the impact of school meal programs, especially universal ones.

Objective

The aim of this population health intervention research is to study the impact of a 2-year universal, curriculum-integrated healthy school lunch program in elementary schools in Saskatoon, Saskatchewan, Canada, on food consumption, dietary quality and food and nutrition-related knowledge, attitudes, and practices.

Methods

This population health intervention study will be conducted in 2 intervention elementary schools matched with 2 control schools. We will collect preintervention data, including objective measurements of food eaten at school and food-related knowledge, attitudes, and behaviors. This will be followed by the intervention itself, along with qualitative case studies of the intervention process in the 2 intervention schools. Then, we will collect postintervention data similar to the preintervention data. Finally, we will finish the data analysis and complete the ongoing sharing of learning from the project.

Results

This study was funded in April 2020 but because of the COVID-19 pandemic, data collection did not begin until May 2021. The intervention will begin in September 2021 and end in June 2023, with end point data collection occurring in May and June 2023. The case study research will begin in September 2021 and will be ongoing for the duration of the intervention.

Conclusions

The opportunity we have to systematically and comprehensively study a curriculum-integrated school lunch program, as well as the promising practices for school food programs across Canada, is without precedent.

International Registered Report Identifier (IRRID)

DERR1-10.2196/30899

Children's perceptions of a Centrally Procured School Food Program in southwestern Ontario, Canada

INTRODUCTION

This qualitative study investigates children's perceptions of the influences of a Centrally Procured School Food Program on their dietary behaviours and their recommendations on how to improve the program.

METHODS

The observations of 208 students aged 9 to 14 years (Grades 5-8) at 21 elementary schools were collected through focus groups in 2017/18. The larger intervention consisted of a 10-week program offering daily snacks (i.e. fruit, vegetables, whole grains, dairy, meat alternatives) for elementary school children in southwestern Ontario, Canada.

RESULTS

The participants' overall impressions of the program were positive. They noted reduced hunger, increased energy and improved nutrition. Many children felt that the program changed their dietary patterns at home as well as at school, particularly in terms of eating more fruit and vegetables. The snack program also enabled children to try healthy foods.

CONCLUSION

Most participants considered the program to be beneficial in promoting healthy eating. Participants recommended adding educational activities, expanding the variety of foods and increasing child involvement in selecting and preparing foods.

Current Systems-Level Evidence on Nutrition Interventions to Prevent and Treat Cardiometabolic Risk in the Pediatric Population: An Evidence Analysis Center Scoping Review

Improving and maintaining cardiometabolic health remains a major focus of health efforts for the pediatric population. Recent research contributes understanding of the systems-level nutrition factors influencing cardiometabolic health in pediatric individuals. This scoping review examines current evidence on interventions and exposures influencing pediatric cardiometabolic health to inform registered dietitian nutritionists working at each systems level, ranging from individual counseling to public policy. A literature search of MEDLINE, CINAHL, Cochrane Databases of Systematic Reviews, and other databases was conducted to identify evidence-based practice guidelines, systematic reviews, and position statements published in English from January 2017 until April 2020. Included studies addressed nutrition interventions or longitudinal exposures for participants 2 to 17 years of age who were healthy or had cardiometabolic risk factors. Studies were categorized according level of the social-ecological framework addressed. The databases and hand searches identified 2614 individual articles, and 169 articles were included in this scoping review, including 6 evidence-based practice guidelines, 141 systematic reviews, and 22 organization position statements. The highest density of systematic reviews focused on the effects of dietary intake (n = 58) and interventions with an individual child or family through counseling or education (n = 54). The least frequently examined levels of interventions or exposures were at the policy level (n = 12). Registered dietitian nutritionists can leverage this considerable body of recent systematic reviews to inform a systems-level, collaborative approach to prevention and treatment of pediatric cardiometabolic risk factors.

Fruit and Vegetable Lesson Plan Pilot Intervention for Grade 5 Students from Southwestern Ontario

The purpose was to create and assess the impact of food literacy curriculum alongside a centrally procured school snack program among grade five students in Southwestern Ontario, Canada. Grade five students (N = 287) from five intervention and three controls schools participated in an 8-week food delivery program. In addition to the food delivery program, intervention schools received a resource kit and access to 42 multidisciplinary food literacy lesson plans using the produce delivered as part of the food delivery program. Participants completed matched pre- and post-test online surveys to assess fruit and vegetable intake, knowledge, preferences, and attitudes. Descriptive analyses and changes in scores between the intervention and control schools were assessed using one-way ANOVAs, paired samples t-tests, and McNemar’s tests. In total, there were 220 participants that completed both the pre- and post-test surveys. There was a significant improvement in fruit and vegetable intake (p = 0.038), yet no differences in knowledge of the recommended number of food group servings, knowledge of food groups, or fruit and vegetable preferences or attitudes were observed. Integrating nutrition lesson plans within core curricula classes (e.g., math, science, and literacy) can lead to modest increases in fruit and vegetable intake.

The effect of teacher-delivered nutrition education programs on elementary-aged students: An updated systematic review and meta-analysis

Research shows that schools can make a positive impact on children’s nutritional outcomes. However, it is also reported that schools and teaching staff note many barriers, which may restrict nutritional education programming and delivery. This is concerning, considering the view that teachers are the key agents for promoting health and nutrition within schools. The purpose of the updated systematic review and meta-analysis was to ascertain the impact that nutrition education programs have on elementary-aged students’ energy intake, fruit, vegetable, sugar consumption and nutritional knowledge. A systematic literature search was conducted using electronic databases (The Cochrane Central Register of Controlled Trials (CENTRAL); A + Education; ERIC; PsycINFO; MEDLINE; ProQuest Central, Journals@Ovid and SAGE Health Sciences Full-Text Collection) from 1990 to 31st October 2018. This process yielded 34 studies for inclusion in this systematic review and meta-analysis. Of these studies, seven studies had a focus on energy intake, five had a focus on sugar consumption, 21 of the studies looked at fruit and vegetable consumption and 13 studies focused on nutritional knowledge. The results suggest that the teaching of nutrition education in elementary schools by qualified teachers can make an important contribution to the knowledge and dietary habits of children. The small and medium effect sizes indicate that prudent, evidence-based decisions need to be made by policy makers and pedagogues as to the teaching strategies employed when delivering nutrition education programs to elementary-aged students.

The review is reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (van Sluijs et al., 2007).

Making a Case for "Education for Health Literacy": An International Perspective

In many countries, health literacy research, practice, and policy have been moving away from a focus only on medical care and health-care settings to a much broader conceptualization. In this broader perspective, health literacy can be obtained and used across many other settings (e.g., school, home, workplaces, government) towards achieving health and wellness goals across the life-course for individuals, families, and communities. The education sector is a critical domain towards these achievements and education for health literacy is a fundamental process and outcome. This can help towards important public health goals, including critical health literacy, as oriented not only towards individual actions, but also towards supporting effective social and political action. This Perspective Article describes the importance and utility of the education for health literacy perspective, which, follows a view that health literacy is a key outcome of health education from which improved population health, health promotion and disease prevention could be achieved across diverse contexts. We first describe different educational paradigms to address health literacy and clarify the education for health literacy perspective as a supportive, instructional and capacity-building global resource across the life-course. Then, using specific examples from Canada, America, and Germany, we provide a snapshot of the diverse ways in which the education for health literacy perspective can be found in national policies. These include broad national goals and standards (Germany and Canada) and major health care reform (America). We next consider the tensions and gaps that can arise in the translation and implementation of these policies relative to the ideal education for health literacy perspective, especially related to equity. These include the need for funding, goals of the educational system, and limited evaluation of policy in practice. Finally, we highlight strategic opportunities to achieve education for health literacy and equity especially offering examples from innovative practice in Canada across the lifespan.