Food and eating environments in Canadian schools.
Obesity rates have tripled among Canadian children over the past few decades, and approximately 25% of Canadian children are now overweight or obese (1). This is of concern because obese children are more likely to suffer from a range of mental, physical, and social health problems (2-4), and because obese children are likely to become obese adults (5).
In response to this public health crisis, the coalition of Federal, Provincial, and Territorial (F/P/T) Ministers of Health and Health Promotion has made childhood obesity its leading priority. In November 2011, the F/P/T ministers released their framework for action to curb childhood obesity (6,7). The three policy priorities of this framework are the identification of obesity risk and addressing it early, making social and physical environments more supportive of physical activity and healthy eating, and increasing the availability and accessibility of nutritious foods. The current study focuses on the latter two priorities, particularly as they pertain to healthy eating at school, a place where school-aged children spend approximately 50% of their waking hours and consume approximately one-third of their calories during the school week (8).
The physical or built environment provides the context within which dietary choices occur. Children's dietary choices during the school day are influenced by accessibility and options in school vending machines and cafeterias (9,10), as well as by fast food restaurants and other convenience food retailers within walking distance of the school (11-13). Although no national Canadian data exist on vending machines and cafeterias, United States data suggest that 97% of high schools have vending machines (14). Further, data from 2006 indicate that about 50% of Canadian schools are located within 1 km of a fast food restaurant and that 60% are located within 1 km of a convenience store (15).
The school social environment can also influence students' diets. For instance, children's eating habits can be shaped by school food and beverage policies, educational programs, and meal programs that target healthy eating (9,10,16). Pan-Canadian policies, education requirements, and programs relevant to healthy eating do not exist, and a dearth of national research is available to characterize these aspects of the school environment.
A key strategy within the F/P/T ministers' framework for action to curb childhood obesity is the measurement and reporting of collective progress in addressing the priority areas. Therefore, in this study, we examined the physical and social eating environments of Canadian schools. We also describe variations in these environments by type of school (e.g., elementary or secondary school) and by location (e.g., urban or rural).
The sample included primary and secondary schools that participated in the 2009/2010 cycle of the Canadian Health Behaviour in School-aged Children (HBSC) survey. The Canadian HBSC survey is administered every four years by the Social Program Evaluation Group at Queen's University. The 2009/2010 HBSC included a general health survey completed by students (not reported here), an administrator questionnaire completed by the principal or designate of each school, and geographic measures of the built environment in the neighbourhood surrounding each school. The sample of HBSC schools is representative by school board type (public or separate), language of instruction, urban or rural location, and regional geography. All provinces and territories were represented, except Prince Edward Island and New Brunswick.
The HBSC administrator survey contained questions related to each school's size, demographics, facilities, policies, programs, and surrounding environment. Questions relevant to eating covered the following: healthy eating programs at the school, healthy eating education at the school, and the school food retail environment. Table 1 includes a summary of the survey questions, their response options, and an overview of the point scoring system that we used to create summary scores for the three areas.
Food retail environment
The addresses of the 436 schools were mapped using ArcGIS (version 10.0, Esri, Redlands, CA, 2010) geographic information system (GIS) software, and a 1-km circular radius buffer was constructed around each school. A 1-km radius corresponds to an approximately 10-minute walk, and children can access these retailers during their lunch hour and breaks or while travelling to and from school (13). We geocoded and counted the number of chain fast food restaurants, chain cafes/coffee shops, and convenience stores within the 1-km buffer for each school. The groups of food retailers examined represent outlets that contribute to unhealthy eating and obesity (17). Addresses of the top 200 (by sales) chain fast food restaurants and chain cafes/coffee shops were extracted from the Enhanced Points of Interest database (DMTI Spatial Inc., Toronto, ON) and geocoded in ArcGIS. Online Yellow Pages searches for "convenience store" were performed at the street address of each school. The addresses of convenience stores within 1 km of the school were extracted and geocoded in ArcGIS. The numbers of fast food restaurants, cafes/coffee shops, and convenience stores within each school's buffer were counted. For schools with at least one retailer within their buffer, the road travel distance from the school's main entrance to the closest retailer was calculated.
Characteristics of the schools and their environments were profiled using conventional descriptive statistics. The total sample was described, and schools were described according to grades served (primary, kindergarten to grade 8; secondary, grades 9 to 12; mixed, grades covered by primary and secondary schools) and urban/rural geography (rural, population <10,000; small city, population 10,000 to 99,999; large city, population [greater than or equal to] 100,000). Fisher's exact tests were used to determine the significance of differences in healthy eating programs/policies, education, and food retailers according to grade and geography. Analyses of variance tests were used to determine the significance of differences in the summary scores and distance measures. Statistical analyses were performed using SPSS Statistics Premium (version 20, IBM, Armonk, NY, 2011).
Geographic information system food retailer measures were available for all 436 participating schools. Administrator questionnaire responses were available for 407 (93%) of these schools.
Responses to healthy eating program questions are summarized in Table 2. Within the preceding year, most (67%) schools had initiated healthy eating lunch programs, while a few (18%) had initiated junk food-free days. Between 40% and 58% of schools offered or had initiated the remaining six healthy eating programs (a committee to oversee healthy eating, healthy eating on a school improvement plan, access to fruits and vegetables, a healthy eating breakfast program, Nutrition Month activities, stopping the sale of junk food). Healthy eating summary scores differed significantly between urban and rural schools and types of schools; scores were more favourable in rural and small urban schools than in large urban schools. Scores also were higher in secondary schools than in primary and mixed schools.
Table 2 also shows responses to the healthy eating education items. The majority of schools offered cooking classes (59%) and healthy eating media literacy education (67%), while a minority offered gardening activities (15%), field trips to farmers' markets (27%), and field trips to grocery stores (36%). The summary education score was greater in small urban schools than in rural and large urban schools, and greater in mixed schools than in primary schools.
Table 3 indicates the food retail environment within schools. Fifty-three percent had a school cafeteria, and 89% of these offered healthy menu choices. Most (75%) schools had a tuck shop, and 58% of these offered healthy choices. More than 70% of schools had pop/juice and milk vending machines, but only 41% of these offered healthy food choices in their vending machines. The food retail environment summary scores indicated that rural schools had more favourable environments than did large urban schools, and that primary schools had more favourable environments than did mixed and secondary schools.
Because 63% of schools allowed some or all students to leave school property during school hours, the food retailer environment in the 1-km buffer surrounding schools was relevant for most schools (Table 3). For 50% of schools, a chain fast food restaurant was located within 1 km; for these schools, the average distance to the closest retailer was 0.68 km. Thirty-three percent of schools had a chain cafe/coffee shop within 1 km, and for these schools the average distance to the closest retailer was 0.72 km. Forty-one percent of schools had a convenience store within 1 km, and for these schools the average distance to the closest retailer was 0.77 km. Significant differences existed in food retailer counts across both rural/urban status and type of school; large urban areas and secondary schools had the most food retailers nearby.
The need for improvement
The objective of this study was to describe healthy eating programs, healthy eating education, and the food retail environment of Canadian schools. The findings illustrate the need for improvement in all three areas, highlighted here with a few examples. Only 53% of schools had a committee that oversaw healthy eating and included healthy eating within the annual improvement plan. Only 59% of all schools (77% of high schools) offered cooking classes, and a minority offered special eating education activities such as gardening and field trips to food retailers. Soft drinks were available in vending machines within most schools, and a large percentage of schools were located within 1 km of a chain fast food restaurant (50%), chain cafe/coffee shop (33%), or convenience store (41%).
Access to food retailers
The current study has a novel design because it is national in scope. The ability to compare it with existing descriptive Canadian studies is limited, but achievable for the food retail environment surrounding schools. Results based on 188 schools that participated in the 2006 HBSC indicate that, at the time, 58% of schools were located within 1 km of a convenience store (versus 41% reported here), 31% were located within 1 km of a fast food restaurant (versus 50% reported here), and 34% were located within 1 km of a doughnut/coffee shop (versus 33% reported here) (15). Thus, the findings of the 2006 and 2010 HBSC surveys are fairly consistent. The density of food retailers around schools was greater in urban schools, which makes sense because of the greater population density. By grade level, secondary school students had greater access to all food retailer types than did primary school students. This finding is consistent with those of two American-based studies, in which student fast food access and consumption were found to increase from primary to secondary school (14,18).
The food retail environment surrounding schools has been shown to have a negative influence on Canadian students' eating behaviours during the school day (11-13). Thus, school-aged children in Canada may benefit from the adoption of municipal or regional (e.g., provincial) policies that regulate the number of food retailers located within close proximity of schools. Several local councils in England have banned new fast food retailers from opening within 400 yards of schools (19). Unfortunately, we are unaware of such policies in Canada, and to date no studies have been conducted to assess whether implementing such a policy would be effective.
Availability of healthy foods
Intervention studies have shown that increasing the availability and lowering the price of healthy food choices (e.g., fruits and vegetables) in schools increase sales (20,21), and ecological studies have shown that consumption of unhealthy foods is associated with obesity at the health region level within Canada (22). The availability of healthy foods within Canadian schools has likely been improving as several provinces (e.g., British Columbia, New Brunswick, Nova Scotia, Ontario) have been developing mandatory policies aimed at reducing the sale of unhealthy foods within schools. For instance, British Columbia's Healthy Eating Strategy aims to raise school community awareness of healthy food and beverage guidelines, provides customized support resources (e.g., a toll-free resource line) to school districts, provides a list of "choose most" and "not recommended" food items, and trains food service personnel (23).
Significance of findings for policy-makers
National-level information on education, programs, and policies directed toward healthy eating is lacking for Canadian schools. Therefore, our analyses provide useful results for policy-makers. For instance, healthy-eating breakfast (58%) and lunch (67%) programs had been initiated in the majority of schools surveyed. Nonetheless, additional investments in such programs may be warranted as one in 10 Canadian children are at risk of hunger and food insecurity (24).
Types of schools
Because of the lack of research, we can only speculate on the reasons why differences were seen in education, programs, and policies according to urban/rural status and type of school. Possibly, farmers' markets may not exist in rural areas and/or personnel from rural schools may feel that field trips to such areas are unnecessary because they are in a rural area. A greater level of poverty in rural areas may have stimulated the school programs aimed at increasing access to fresh fruits and vegetables. Primary schools, which tend to be much smaller than high schools, may not have the facilities to support cooking classes, and historically this may not be part of the curriculum in such schools.
This study has some limitations. First, the self-reported responses from the administrator questionnaire were prone to social desirability bias. Second, the validity and reliability of the questionnaire items have not been determined. Third, schools in New Brunswick and Prince Edward Island chose not to participate, which limits the generalizability of our study. Fourth, five of the eight measures in the section on healthy eating programs asked if changes occurred in the preceding year, and, therefore, these questions may not have captured schools that had made changes in their programs more than 12 months before study participation. Finally, the way in which some of the questionnaire items were asked had limitations. For instance, the item on cooking classes did not specify cooking of healthy foods, the healthy breakfast and lunch program items did not assess specific foods and beverages offered, and the vending machine items on healthy foods did not indicate what these foods were.
This national study provides novel descriptive information on food retail environments, both within and surrounding Canadian schools, as well as on the programs and educational policies that influence children's dietary habits. The findings highlight that considerable room for improvement exists in several areas. These findings can be used to provide baseline data for the F/P/T ministers' framework for action to curb childhood obesity, which will be needed to monitor progress, and can inform the development of policies and programs aimed at improving the eating behaviours of school-aged children. While a discussion of previous (11-13) and future research on the HBSC is beyond the scope of this study, such research is linking these school measures to students' specific eating behaviours.
RELEVANCE TO PRACTICE
Because school-aged children spend approximately 50% of their waking hours at school during the school week, school food and eating environments must be considered when dietary counselling is provided for children and their families. Dietitians and other practitioners need to be aware of the significant environmental barriers that many Canadian children face at school, and the lack of education and programs on healthy eating at many schools. Potentially, dietitians could improve this situation by advocating for better food environments at schools and for ways to ensure healthy eating education plays a greater role in the curriculum.
This study was supported by research grants from the Canadian Institutes of Health Research (operating grants MOP 9762 and PCR 101415) and the Heart and Stroke Foundation of Canada. The Health Behaviour in School-aged Children Survey (HBSC), a World Health Organization European Region collaborative study, was funded in Canada by the Public Health Agency of Canada and Health Canada. The international coordinator of the HBSC is Candace Currie (University of Edinburgh). The principal investigators of the 2009/2010 Canadian HBSC are John Freeman and William Pickett. Ian Janssen was supported by a Canada Research Chair position.
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H. FRANCES BROWNING, BA, RACHEL E. LAXER, MSc, School of Kinesiology and Health Studies, Queen's University, Kingston, ON; IAN JANSSEN, PhD, School of Kinesiology and Health Studies and Department of Community Health and Epidemiology, Queen's Universi ty, Kingston, ON
Table 1 Summary of survey items and response options Topic area Survey item Healthy eating Does your school have a committee that programs oversees policies and practices concerning healthy eating at your school? Does your school's improvement plan for the current school year contain any items related to physical activity and healthy eating? Does your school ensure that all students, regardless of ability to pay, have access to fruits and vegetables? During the past 12 months, did your school initiate any of the following activities/programs? - Healthy food choices during breakfast program - Healthy food choices during lunch program - Organized Nutrition Month activities - Stopping the sale of junk food - Junk food-free days Healthy eating Does your school offer any of education the following? - Cooking classes - Gardening (e.g., growing produce) - Field trips to farms/a farmers' market - Field trips to a local grocery store - Media literacy on topics related to healthy eating Food retail Do students have access to the following environment facilities where they can buy foods or at school drinks? If yes, are healthy choices available? - Cafeteria - School shop - Candy and potato chips vending machine - Drinks vending machine Food retail Are students permitted to leave the environment school property during the school day? in school neighbourhood Number of food retailers within 1 km of the schoola - Chain fast food restaurant - Chain cafe/coffee shop - Convenience store Distance from school to closest (a) - Chain fast food restaurant - Chain cafe/coffee shop - Convenience store Topic area Response options (points) Healthy eating Yes (1), No (0) programs Yes (1), No (0) Yes for the entire year (1), Yes but occasional/ short term (0.5), No (0) Yes (1), No (0), N/A (0) Yes (1), No (0), N/A (0) Yes (1), No (0), N/A (0) Yes (1), No (0), N/A (0) Yes (1), No (0), N/A (0) Healthy eating education Yes (1), No (0) Yes (1), No (0) Yes (1), No (0) Yes (1), No (0) Yes (1), No (0) Food retail environment at school Yes (0), Yes with healthy choices (1), No (0.5) Yes (0), Yes with healthy choices (1), No (0.5) Yes (0), No (1) Yes (0), Yes with healthy choices (1), No (0.5) Food retail Yes, No environment in school neighbourhood Continuous variable Continuous variable Continuous variable Continuous variable Continuous variable Continuous variable N/A = not applicable (a) Measures obtained using geographic information systems Table 2 Healthy eating programs and education in Canadian schools (n=407) urban/rural status Small Programs and Total Rural urban education responding (n=176) (n=136) "yes" Healthy eating programs Healthy eating 53.0% 56.25% 50.0% committee Healthy eating items 53.2% 54.5% 55.6% on improvement plan Access to fruits 39.9% 43.9% 46.7% and vegetables Healthy eating 57.5% 64.0% 59.2% breakfast program Healthy eating 66.8% 63.3% 79.3% lunch program Nutrition Month 43.9% 45.1% 43.1% activities Stopped sale 54.5% 57.9% 57.6% of junk food Junk food-free 18.3% 20.1% 14.5% days Summary score 3.8 [+ or -] 4.0 [+ or -] 4.2 [+ or -] (maximum of 8) (a) 1.9 1.9 1.9 Healthy eating education Cooking 58.9% 60.0% 63.4% classes Gardening 15.3% 11.5% 19.5% activities Field trip to 26.5% 14.5% 39.8% a farmers' market Field trip to 35.6% 33.9% 43.9% a grocery store Healthy eating 67.3% 62.4% 69.9% media literacy Summary score 2.0 [+ or -] 1.8 [+ or -] 2.4 [+ or -] (maximum of 5) (a) 1.2 1.0 1.3 (b) Large Programs and urban Primary education (n=124) P value (n=193) Healthy eating programs Healthy eating 51.3% 0.55 54.4% committee Healthy eating items 48.3% 0.64 53.0% on improvement plan Access to fruits 26.1% 0.002 37.9% and vegetables Healthy eating 45.9% 0.014 48.9% breakfast program Healthy eating 57.7% 0.001 65.9% lunch program Nutrition Month 42.5% 0.91 49.1% activities Stopped sale 45.8% 0.12 50.6% of junk food Junk food-free 18.8% 0.50 17.5% days Summary score 3.1 [+ or -] <0.001 3.6 [+ or -] (maximum of 8) (a) 1.9 (b) 2.0 Healthy eating education Cooking 52.2% 0.20 33.0% classes Gardening 15.7% 0.17 14.8% activities Field trip to 28.7% <0.001 36.3% a farmers' market Field trip to 29.6% 0.06 36.3% a grocery store Healthy eating 71.3% 0.24 67.0% media literacy Summary score 2.0 [+ or -] 0.001 1.9 [+ or -] (maximum of 5) (a) 1.3 1.2 (c) Type of school Programs and Mixed Secondary education (n=120) (n=123) P value Healthy eating programs Healthy eating 52.7% 50.5% 0.80 committee Healthy eating items 50.9% 55.5% 0.93 on improvement plan Access to fruits 36.0% 46.7% 0.02 and vegetables Healthy eating 62.4% 66.4% 0.01 breakfast program Healthy eating 73.6% 60.6% 0.13 lunch program Nutrition Month 27.4% 52.0% <0.001 activities Stopped sale 44.9% 70.5% <0.001 of junk food Junk food-free 13.6% 23.7% 0.19 days Summary score 3.7 [+ or -] 4.3 [+ or -] 0.015 (maximum of 8) (a) 1.9 1.8 (c) Healthy eating education Cooking 83.0% 77.1% <0.001 classes Gardening 17.9% 12.8% 0.58 activities Field trip to 20.5% 15.6% <0.001 a farmers' market Field trip to 37.5% 33.0% 0.78 a grocery store Healthy eating 72.3% 62.4% 0.30 media literacy Summary score 2.3 [+ or -] 2.0 [+ or -] 0.009 (maximum of 5) (a) 1.1 1.1 (a) Presented as mean [+ or -] standard deviation (b) Rural schools different from small urban schools (c) Primary schools different from mixed schools Table 3 Food retail environments in Canadian schools and their neighbourhoods (n=407) Urban/rural status Total Small responding Rural urban "yes" (n=176) (n=136) Food retail environments in schools Access to cafeteria 53.1% 58.1% 51.6% to buy food/drink If yes, healthy 89.3% 91.0% 90.0% choices (n=187) Access to school 74.9% 76.3% 73.8% shop If yes, healthy 57.6% 55.3% 56.3% choices (n=99) Access to vending machine Pop/juice 75.8% 83.0% 75.0% Milk 72.7% 83.3% 73.3% Healthy choices 41.3% 39.4% 53.3% (n=155) Summary score 2.1 [+ or -] 2.2 [+ or -] 2.1 [+ or -] (maximum of 4) (a) 0.9 0.8 0.8 Food retail environments in school neighbourhoods Students allowed 63.4% 67.5% 70.2% to leave property Chain fast food restaurants within 1 km 0 49.8% 75.6% 39.7% 1-2 14.4% 11.9% 13.2% 2-3 18.1% 9.7% 24.3% >4 17.7% 2.8% 22.8% Chain cafes/coffee shops within 1 km 0 67.5% 92.6% 55.9% 1-2 20.4% 6.3% 30.1% 2-3 7.8% 1.1% 11.8% >4 4.1% 0.0% 2.2% Convenience stores within 1 km 0 59.5% 79.0% 47.8% 1-2 2.8% 2.8% 3.7% 2-3 10.8% 8.5% 11.8% >4 26.8% 9.7% 36.8% Distance (km) from school to closest (a),(e) Chain fast food 0.68 [+ or -] 0.65 [+ or -] 0.69 [+ or -] restaurant 0.24 0.24 0.26 Chain cafe/coffee 0.72 [+ or -] 0.63 [+ or -] 0.77 [+ or -] shop 0.70 0.23 0.24 Convenience store 0.77 [+ or -] 0.78 [+ or -] 0.74 [+ or -] 0.39 0.39 0.37 Type of school Large urban P Primary (n=124) value (n=193) Food retail environments in schools Access to cafeteria 48.2% 0.26 47.2% to buy food/drink If yes, healthy 86.4% 0.70 92.9% choices (n=187) Access to school 75.0% 0.89 69.2% shop If yes, healthy 64.3% 0.76 50.0% choices (n=99) Access to vending machine Pop/juice 66.7% 0.032 75.6% Milk 58.3% 0.004 81.3% Healthy choices 30.2% 0.09 57.1% (n=155) Summary score 1.8 [+ or -] 0.006 2.2 [+ or -] (maximum of 4) (a) 0.9 (b) 0.7 Food retail environments in school neighbourhoods Students allowed 69.9% 0.88 50.8% to leave property Chain fast food restaurants within 1 km 0 24.2% 65.0% 1-2 19.4% 9.8% 2-3 23.4% 12.2% >4 33.1% <0.001 13.0% Chain cafes/coffee shops within 1 km 0 45.2% 74.8% 1-2 29.8% 13.8% 2-3 12.9% 5.7% >4 12.1% <0.001 5.7% Convenience stores within 1 km 0 45.2% 74.8% 1-2 1.6% 2.4% 2-3 12.9% 8.1% >4 40.3% <0.001 14.6% Distance (km) from school to closest (a),(e) Chain fast food 0.72 [+ or -] 0.10 0.67 [+ or -] restaurant 0.22 0.23 Chain cafe/coffee 0.74 [+ or -] 0.55 0.71 [+ or -] shop 0.22 0.23 Convenience store 0.80 [+ or -] 0.45 0.88 [+ or -] 0.36 0.38 Mixed Secondary P (n=120) (n=123) value Food retail environments in schools Access to cafeteria 18.0% 78.5% <0.001 to buy food/drink If yes, healthy 86.8% 89.7% 0.54 choices (n=187) Access to school 65.7% 84.1% <0.001 shop If yes, healthy 48.6% 79.3% 0.02 choices (n=99) Access to vending machine Pop/juice 32.2% 93.2% <0.001 Milk 45.6% 88.5% <0.001 Healthy choices 65.1% 22.9% <0.001 (n=155) Summary score 1.3 [+ or -] 2.4 [+ or -] <0.001 (maximum of 4) (a) 0.9 (c) 0.5 (d) Food retail environments in school neighbourhoods Students allowed 95.5% 72.5% <0.001 to leave property Chain fast food restaurants within 1 km 0 38.3% 47.2% 1-2 18.3% 15.0% 2-3 20.0% 20.7% [greater than or equal to] 4 23.3% 17.1% 0.004 Chain cafes/coffee shops within 1 km 0 62.5% 66.3% 1-2 20.0% 24.9% 2-3 13.3% 5.7% [greater than or equal to] 4 4.2% 3.1% 0.04 Convenience stores within 1 km 0 62.5% 48.2% 1-2 7.5% 0.0% 2-3 12.5% 11.4% [greater than or equal to] 4 17.5% 40.4% <0.001 Distance (km) from school to closest (a),(e) Chain fast food 0.69 [+ or -] 0.67 [+ or -] 0.31 restaurant 0.24 0.26 Chain cafe/coffee 0.73 [+ or -] 0.70 [+ or -] 0.47 shop 0.26 0.23 Convenience store 0.68 [+ or -] 0.75 [+ or -] 0.035 0.34 0.38 (a) Presented as mean [+ or -] standard deviation (b) Large urban schools differed from rural schools. (c) Mixed schools differed from primary and secondary schools. (d) Secondary schools differed from primary and mixed schools. (e) Limited to schools with at least one retailer within 1 km
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|Author:||Browning, H. Frances; Laxer, Rachel E.; Janssen, Ian|
|Publication:||Canadian Journal of Dietetic Practice and Research|
|Date:||Jan 1, 2013|
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