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Healthy eating guidelines for a school jurisdiction: collaborative design and implementation.

INTRODUCTION

Healthful eating is a determinant of optimal childhood growth, development, and academic performance (1). Previous studies have shown that nutrition guidelines in schools can improve students' dietary behaviours by changing the school food environment (2-9).

A health authority and a school jurisdiction began working together to develop and implement healthy eating guidelines in 2006 (10). Schools received seed funding and dietitian consultations to meet the guidelines, which were based on each school's identified priorities. Representatives from the jurisdiction, schools, parents, food service vendors, and the health authority were active participants from the start of the Healthy Eating Guidelines Initiative (HEGI) until its conclusion in 2010.

PURPOSE

Because of the limited number of outcome studies related to school nutrition policies in Canada (2,8,9,11), a pilot evaluation was completed to explore the impact of the HEGI on school food environments and students' self-reported diets.

METHODS

Subjects

All 31 schools in the jurisdiction were invited to participate in the evaluation. Schools were categorized according to the food service available: full service (serving food prepared on site in a cafeteria-style setting), limited service (serving prepackaged food in a kiosk-type setting), and no service (having no food service outlets).

Tools

Two tools, a school environment assessment and a student questionnaire, were developed through the use of Ever Active Schools resources (12) and in consultation with the stakeholder groups. Both tools were vetted by stakeholders for face and content validity, as well as suitability in the school setting.

The school environment assessment included interviews with school representatives and an inspection list for school food service facilities. The student questionnaire was completed by students in grades 7 to 12. Students were asked to report the number of times they had consumed vegetables, fruit (not including juices), milk and yogurt, carbonated beverages, and fried potatoes in the previous 24 hours. The foods were chosen because they were available at school and/or of interest to the stakeholders. Juices were not included because stakeholders were concerned that students would not differentiate between sugar-sweetened fruit beverages and 100% juices with a self-administered tool. Student questionnaires were completed during class after the teacher used a standardized script to explain the study to the students. Participating schools completed these tools twice: before the HEGI (September 2007 to December 2008) and following the HEGI (May to June 2010).

The evaluation was reviewed and approved by the Rocky View Schools Research Committee. Ethical implications of the evaluation were considered through the use of the Project Ethics Community Consensus Initiative tools (13).

Data analysis

The student questionnaires were examined overall and by food service provision category (full service, limited service, and no service) for changes that might have occurred during the HEGI. Specific dietary behaviours of interest, based on self-reports of the previous day, included the proportions of students consuming vegetables and fruit five or more times (summation of vegetables and fruit responses), consuming milk and yogurt three or more times, not consuming carbonated beverages, and not consuming fried potato products. The proportions from before and after the HEGI were analyzed with chi square comparisons in SPSS Statistics (version 15, SPSS Inc., Chicago, IL, 2006), using a P value of 0.05. A Bonferroni correction (p=0.013) was used because of multiple comparisons for the analysis examining the potential influence of school food service.

RESULTS

Twenty-two (71%) schools in the jurisdiction participated in the evaluation (Table 1). Seventeen schools served students in grades 7 to 12. Students from all these schools completed the questionnaire. The questionnaire participation rates were 60% (n=3970) before the HEGI and 66% (n=4498) after. Respondents' ages (mean = 14.50 and 14.75) and sexes (female =50.8% and male = 50.2%) were similar to those of the overall student population.

Seventeen of the 22 schools were more supportive of healthy eating at the end of the HEGI. Some examples of their reported changes are presented in Table 2. However, representatives from five schools with limited or no on-site food service reported that they did not make significant changes to the school food environment according to the guidelines because they perceived that their students continued to prefer inexpensive, less healthy foods offered through the kiosk, the vending machines, and/or the hot lunch program.

Students' self-reported eating behaviours are shown in Table 3. Overall, after the introduction of the guidelines, a significantly higher proportion of students reported dietary intakes that met recommendations. Students at schools with full food service reported significant positive changes in comparison with students at schools without this type of service.

DISCUSSION

Challenges of localized decision-making

This project built upon previous school nutrition promotion activities through the use of a collaborative approach to develop and implement jurisdiction-wide guidelines. The finding that only 17 of 22 schools reported taking steps to meet the guidelines highlights the challenges of localized decision-making, as personnel at each school maintained authority over how or whether it would meet the guidelines.

The need for further change

Consistent with previous studies, students reported healthier eating behaviours at the conclusion of the HEGI (4,8). While changes have been made to the beverage vending machines by replacing sugar-sweetened carbonated beverages with plain water, artificially sweetened carbonated beverages, flavoured water, and sports drinks, the contents could be further improved through the provision of only healthier options, such as plain water, 100% juices, and milk. Lower proportions of students reported consuming less healthy items (i.e., fried potatoes or carbonated beverages) after the HEGI; however, room remains for improvement. For example, almost 50% of students reported consuming fried potato products after the HEGI.

Style of food service in schools

Students in schools with cafeteria-style service showed positive changes, but students in other schools did not. This could be a reflection of the number of daily opportunities to influence student food choices through breakfast, snacks, and lunch offered in a cafeteria. Furthermore, schools with cafeterias typically offer a wider variety of foods and have more flexibility in the food preparation areas, so more options are available to change the food served.

Study limitations

This was a pilot evaluation, and the full impact of the HEGI could not be examined. However, the methods and findings can be used to inform future evaluations. To reduce social desirability effects, we did not include identifiers on the anonymous student questionnaires. As a result, within-subject level comparisons could not be made. Because of the potential for confusion between 100% juices and sugar-sweetened juice beverages, the student questionnaire did not include reporting of juice intake during the previous day. The findings therefore may under-represent the consumption of fruit and vegetables (through 100% juices) and other non-carbonated sugar-sweetened beverages. In addition, the food consumption analysis did not take into account potential cluster effects within schools, and it did not permit an examination of student ages and sexes. Further, the student questionnaire did not provide a way for us to examine students' overall diet quality or caloric intake. Findings therefore should be interpreted with caution.

Although the tools did not undergo a rigorous validation process, they were vetted by the advisory group for face and content validity. Since the HEGI, the health authority has made efforts to strengthen evaluations by using validated tools such as the Joint Consortium for School Health tools (14) and by collecting student identifiers to examine individual-level changes.

While this study has limitations, the findings are consistent with those of previous studies. These earlier studies have shown that guidelines implemented throughout a school jurisdiction can have positive impacts on the school food environment and students' food intake.

CONCLUSIONS

Implementing guidelines throughout the school district led to improvements in the school food environment. The HEGI showed promise as a strategy to promote healthy eating among students. Future work should be conducted with a larger sample size and validated methods to determine whether the observed findings from the HEGI can be applied to other settings.

RELEVANCE TO PRACTICE

The HEGI shows promise as a collaborative strategy to support healthy eating behaviours among students through improvements to the school food environment. Further work is needed to evaluate strategies or models to promote healthy food environments at schools and in the community, as well as their potential impacts on students' food choices.

References

(1.) American Dietetic Association. Position of the American Dietetic Association: nutrition guidance for healthy children ages 2 to 11 years. J Am Diet Assoc. 2008;108:1038-47.

(2.) Saksvig BI, Gittelsohn J, Harris SB, Hanley AJ, Valente TW, Zinman B. A pilot school-based healthy eating and physical activity intervention improves diet, food knowledge, and self-efficacy for native Canadian children. J Nutr. 2005;135:2392-8.

(3.) Jaime PC, Lock K. Do school based food and nutrition policies improve diet and reduce obesity? Prev Med. 2009;48:45-53.

(4.) Mendoza JA, Watson K, Cullen KW. Change in dietary energy density after implementation of the Texas Public School Nutrition Policy. J Am Diet Assoc. 2010;110:434-40.

(5.) Foster GD, Sherman S, Borradaile KE, Grundy KM, Vander Veur SS, Nachmani J, et al. A policy-based school intervention to prevent overweight and obesity. Pediatrics. 2008;121:e794-802.

(6.) Van Cauwenberghe E, Maes L, Spittaels H, van Lenthe FJ, Brug J, Oppert JM, et al. Effectiveness of school-based interventions in Europe to promote healthy nutrition in children and adolescents: systematic review of published and 'grey' literature. Br J Nutr. 2010;103:781-97.

(7.) Vecchiarelli S, Takayanagi S, Neumann C. Students' perceptions of the impact of nutrition policies on dietary behaviors. J Sch Health. 2006;76:525-31.

(8.) Veugelers PJ, Fitzgerald AL. Effectiveness of school programs in preventing childhood obesity: a multilevel comparison. Am J Public Health. 2005;95:432-5.

(9.) Mullally ML, Taylor JP, Kuhle S, Bryanton J, Hernandez KJ, MacLellan DL, et al. A province-wide school nutrition policy and food consumption in elementary school children in Prince Edward Island. Can J Public Health. 2010;101:40-3.

(10.) Rocky View Schools. Rocky View Schools healthy eating guidelines; 2009 [cited 2011 May 20]. Available from: http://www.rockyview.ab.ca/programs_services/healthy-eating-initiative/healthy_eating_assets/Dec2008 RockyViewSchoolsHealthyEatingGuidelinesFinal.pdf

(11.) MacLellan D, Holland A, Taylor J, McKenna M, Hernandez K. Implementing school nutrition policy: student and parent perspectives. Can J Diet Pract Res. 2010;71:172-7.

(12.) Ever Active Schools. Health Assessment Tool for Schools (HATS); 2012 [cited 2012 Sep 1]. Available from: http://www.everactive.org/health-assessmenttool-for-schools

(13.) Alberta Innovates Health Solutions. A Project Ethics Community Consensus Initiative; 2013 [cited 2013 Sep 1]. Available from: http://www.aihealth solutions.ca/arecci/

(14.) Pan-Canadian Joint Consortium for School Health; 2013 [cited 2013 Sep 8]. Available from: http://www.jcsh-cces.ca/

FLORA F. STEPHENSON, PhD, Data Integration, Measurement and Reporting, Alberta Health Services, Calgary, AB; J. CYNE JOHNSTON, PhD, Population and Public Health, Alberta Health Services, and Department of Community Health Sciences, Faculty of medicine, University of Calgary, Calgary, AB; THERESA RIEGE, BHumEc, RD, Nutrition and Food Services, Alberta Health Services, Calgary, AB; FARAH BANDALI, MSc, RD, Population and Public Health, Alberta Health Services, Calgary, AB; DEBORAH A. McNEIL, PhD, Population and Public Health, Alberta Health Services, and Faculty of Nursing, university of Calgary, Calgary, AB
Table 1
Characteristics of the participating schools (n=22)

School type                          n            % (a)

Elementary (kindergarten             5            22.7
to grade 4)

Elementary/middle                    7            31.8
(kindergarten to grade 8)

Middle (grades 5 to 8)               3            13.6

Middle/high (grades 6 to 12)         1             4.5

Mixed grades (kindergarten           1             4.5
to grade 6, grades 9 to 12)

High (grades 9 to 12)                5            22.7
                                            (a) Totals 99.8%
                                          because of rounding.

Level of food service

Full (cafeteria serving              5            22.7
food prepared on premises,
vending machines)

Limited (small food store or         6            27.3
kiosk serving prepackaged foods,
vending machines, catered hot
lunch program not taking place
daily)

No (no food service, no daily       11            50.0
catered hot lunch program
except at one school)

Table 2
Examples of changes made at the schools, according to the type of
food service available Schools with full food service (a cafeteria
and vending machines) Cafeteria

* Improved visibility of healthy choices by placing the sandwich
display case prominently

* Added healthy options such as wraps, vegetables, fruit, salad,
baked potato wedges, and soups

* Provided healthier side dishes with hot lunch entrees (e.g.,
salad instead of french fries)

Beverage vending machines

* Removed sugar-sweetened carbonated beverages and replaced them
with plain water, flavoured water, sports drinks, and artificially
sweetened carbonated beverages

Snack vending machines

* Replaced deep-fried potato chips and candies with healthier snack
options, such as nuts, 100% dried fruit, and baked potato chips

Schools with limited food service (a small school store or a kiosk
and vending machines)

School store or kiosk

* Served healthier packaged snack options (e.g., granola bars,
nuts, and dried fruit)

* Introduced smaller package sizes of less healthy snacks (e.g.,
regular potato chips)

* Offered milk daily or weekly through a milk program

Beverage vending machines

* Switched to serving only 100% juices and plain water

Hot lunch programs (variable frequency, from once a week to three
times a year)

* Replaced less healthy entrees with healthier options (e.g.,
switched from pizza to sandwiches)

* Provided healthier side dishes with hot lunch entrees (e.g.,
milk, 100% juices, a piece of fruit, vegetables)

Schools with no food service (only catered hot lunch programs)

Hot lunch programs (variable frequency, from daily to once a
month) (a)

* Replaced less healthy entrees with healthier options (e.g.,
switched from fried chicken and hot dogs to sandwiches and pitas)

* Provided healthier side dishes with hot lunch entrees (e.g.,
milk, 100% juice, a piece of fruit, vegetables)

* Used healthier products in the food preparation process (e.g.,
whole wheat bread instead of white bread for sandwiches)

Other aspects of the school food environment reported in some
schools

* Started a milk program at the school

* Made fruit available to students and staff by placing a fruit
basket in the school office

* Reduced the use of or removed food and candy rewards in the
classroom

(a) Less healthy meal side dishes continued to be offered at some
schools (e.g., sugar-sweetened juice beverages, high-sugar
beverages, chips, or desserts).

Table 3
Students' self-reported dietary behaviours during the preceding
24 hours, before and after the Healthy Eating Guidelines
Initiative

Reported behaviours                   Before     After       P

Overall                               n=3970    n=4458

Consumed vegetables and fruit          48.4%     51.0%     0.017
(not including juices) [greater
than or equal to] 5 times

Consumed milk and yogurt               54.0%     57.7%     0.001
[greater than or equal to] 3 times

Did not consume any                    48.6%     52.8%    <0.001
carbonated beverages

Did not consume any fried              46.3%     51.0%    <0.001
potato products

Schools with full food service        n=1944    n=2630

Consumed vegetables and fruit          49.3%     55.5%    <0.001
(not including juices)
[greater than or equal to] 5 times

Consumed milk and yogurt               53.3%     58.8%    <0.001
[greater than or equal to] 3 times

Did not consume any                    47.3%     52.5%     0.001
carbonated beverages

Did not consume any                    42.7%     49.5%    <0.001
fried potato products

Schools with limited food service     n=1454    n=1360

Consumed vegetables and                46.3%     43.1%     0.089
fruit (not including juices)
[greater than or equal to] 5 times

Consumed milk and yogurt               54.1%     53.7%     0.849
[greater than or equal to] 3 times

Did not consume any                    50.5%     52.8%     0.225
carbonated beverages

Did not consume any fried              51.3%     53.4%     0.258
potato products

Schools with no food service           n=572     n=738

Consumed vegetables and fruit          50.4%     51.0%     0.831
(not including juices)
[greater than or equal to] 5 times

Consumed milk and yogurt               55.9%     61.6%     0.041
[greater than or equal to] 3 times

Did not consume any                    48.3%     53.5%     0.056
carbonated beverages

Did not consume any fried              45.6%     51.3%     0.041
potato products
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Article Details
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Title Annotation:Report/Rapport
Author:Stephenson, Flora F.; Johnston, J. Cyne; Riege, Theresa; Bandali, Farah; McNeil, Deborah A.
Publication:Canadian Journal of Dietetic Practice and Research
Article Type:Report
Geographic Code:1CALB
Date:Jan 1, 2013
Words:2660
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