Welcome!Enhancing nutritional

environments through access to fruit & vegetables in schools and homes among children & youth:

What's the Evidence?

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What’s the evidence? • Ganann, R., Fitzpatrick-Lewis, D., Ciliska, D.,

Peirson, L., Warren, R., Fieldhouse, P., et al. (2014). Enhancing nutritional environments through access to fruit and vegetables in schools and homes among children and youth: a systematic review. BMC Research Notes, 7:422. DOI: 10.1186/1756-0500-7-422

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Participant Side Panel in WebExHousekeeping

Welcome!Enhancing nutritional

environments through access to fruit & vegetables in schools and homes among children & youth:

What's the Evidence?

The Health Evidence Team

Maureen Dobbins

Scientific Director

Heather HussonManager

Susannah WatsonProject Coordinator

Robyn TraynorPublications Consultant

Research Assistants

Yaso Gowrinathan

Kelly Graham

Kristin Read

Emily Sully

Alice Wang

StudentsReza Yousefi Nooraie PhD candidate)

Jennifer YostAssistant Professor

What is www.healthevidence.org?

Evidence

Decision Making

inform

Why use www.healthevidence.org?

1. Saves you time

2. Relevant & current evidence

3. Transparent process

4. Supports for EIDM available

5. Easy to use

A Model for Evidence-Informed Decision Making

National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

Stages in the process of Evidence-Informed Public Health

National Collaborating Centre for Methods and Tools. Evidence-Informed Public Health. [http://www.nccmt.ca/eiph/index-eng.html]

Review

•Ganann, R., Fitzpatrick-Lewis, D., Ciliska, D., Peirson, L., Warren, R., Fieldhouse, P., et al. (2014). Enhancing nutritional environments through access to fruit and vegetables in schools and homes among children and youth: a systematic review. BMC Research Notes, 7:422. DOI: 10.1186/1756-0500-7-422

Importance of this Review

• Low fruit and vegetable (FV) consumption is a risk factor for morbidity and mortality

• Adequate FV consumption can play a protective role in chronic disease and cancer

• Increasing consumption of FV:• Need to focus upstream and beyond individual level

education and behaviour modification

• Interventions to improve availability and accessibility of FV (upstream of the individual) may increase consumption

Systematic review lead author

Rebecca Ganann is a registered nurse, PhD student, and Assistant Clinical Professor in the School of Nursing at McMaster. She was the recipient of a CIHR Vanier Canada Graduate Scholarship and is currently a Strategic Training Fellow in Interdisciplinary Primary Health Care Research.

Rebecca’s research interests include primary health care, addressing health inequities, service accessibility, chronic disease prevention and management, knowledge translation, and evidence-informed decision-making.

Poll Question #1

Who has heard of PICO(S) before?

1.Yes

2.No

Searchable Questions Think “PICOS”

1. Population (situation)

2. Intervention (exposure)

3. Comparison (other group)

4. Outcomes

5. Setting

Review Focus:

• P Any person or institution that can change FV environment for school aged children (5-18 yr. olds)

• I Aimed at modifying population level FV environment

• C Different interventions or no intervention

• O Change in food environment to increase FV accessibility

• S Community-based settings

Where did we search for evidence?

• 19 databases– Peer-reviewed literature– Grey literature

• Targeted internet search

• Hand search – target journals & conference proceedings– reference lists

• Advised by experts, authors, researchers, and relevant policy-makers

How did we select studies to include?

1. Title and abstract

2. Full text review

• Two independent reviewers with third reviewer to resolve disagreements regarding inclusion

Articles were included if:

• In English, French and Spanish

• From high-, middle-, and low-income countries

• Delivered to anyone who could bring about change in FV environment for 5 to 18 year olds

• Randomized and non-randomized study designs that provided before-after comparisons, with or without a control group

• Primary outcomes of interest were measures of FV availability

Data extraction - Characteristics

• Study design

• Participants, setting(s), & intervention(s)

• Outcomes– Primary: FV supply, change in food

environment, FV transition– Secondary: consumption of FV, awareness,

attitudes, general health measures, adverse/ unintended outcomes

Risk of Bias (RoB)

• Cochrane Collaboration’s tool for RoB– Sequence generation– Allocation concealment– Blinding of participants and personnel

– Blinding of outcome assessment

– Incomplete outcome data– Outcome reporting– Other: validated & reliable tools, intention-to-treat,

intervention integrity, statistical approaches

• Ratings: low, unclear, high RoB

Study characteristics

• ~23,000 citations resulted in 23 unique studies included (1.2% of retrieved)– Research from USA, South Africa,

Netherlands, UK, France– Quasi-experimental, cluster-controlled,

before-after (no control group)– Conducted in schools, some home-based

components, Boy Scout troop, Internet settings

Risk of bias assessment

• Quality of study is inversely related to risk of bias– High quality = low risk of bias– Low quality = high risk of bias

• All 23 included studies were rated as having high risk of bias– Less confidence in findings

What did we find?

• Two intervention types– Policies– Programs

• Target audience(s)– Children– Children and parents– General population– School teachers

Target of interventions

• Policies:– School food service– Price of FV– School and broader food environments

• Programs:– School food service– Home and families– Communities or community programs

What did we learn?

• Interventions targeting local school food policies were most promising for improving food environment

• More conservative or mixed impact:– State of federally mandated policies or

educational programs for food service providers and decision makers

– Family interventions

Hartstein et al., 2011

Methods Randomized controlled trial

Participants 30 middle schools

Interventions Dieticians worked with school to change in-school vending machine offerings

Comparison No dietician

Outcomes Number of vending machine slots allocated to fruit juice, sugar-added beverages, and dessert offering

Number of vending machine slots:

•Intervention schools decreased from 31% to 0%.

•Control schools increased from 13% to 43%.

Haroun et al., 2011

Methods Before-after study

Participants 139 primary schools at baseline

136 schools at follow-up

Interventions New food-based standards (FBS) for catering provision of lunchtime in-school services

Outcomes FV provision before and after change in FBS (2005 vs. 2009)

School under new FBS providing significantly more vegetables and salad (4.0%), fruit (3.0%) and fruit juice (1.2%)

Cassady et al., 2006

Methods Before-after

Participants 44 public elementary schools; ~ 8,000 children in after-school program

Interventions New school-based policy to increase servings of FV offered within an after-school program to be consistent with “5 a day” guidelines from new organizational policy

Outcomes Changes in average daily FV servings from old menu to new menu

Fruit servings: Increased from 0.6 to 1.1

Vegetable servings: No change (0.0 to 0.0)

Unintended result: Milk provision decreased after intervention

Goldberg et al., 2009Methods Before-after

Participants Elementary school food service staff, students, parents, teachers, and school leaders

Interventions School food service intervention consisting of school meal menu changes, professional development and capacity building and communication strategies.

Outcomes FV availability in school meals before and after intervention

Menu changes (frequency per week):

•Fresh fruits and breakfast: Increased from 2 to 5

•Fresh fruits at lunch: Increased from 2 to 5

•Entree salads at lunch: Increased from 2 to 3

•Side salads at lunch: Increased from <1 to 1

Cullen et al., 2009

Methods Before-after

Participants 47 schools:

•19 primary schools; 28 secondary schools

•23 schools in small districts; 24 schools in large districts

Interventions School Nutrition Policy that restricts the portion sizes of high-fat and sugar snacks, limits the fat content of milk, provides guidelines for the fat content of foods served, and sets limits on the frequency of serving high-fat vegetables such as french fries

Outcomes Change in FV servings before and after intervention

No significant improvement in fruit servings between school years (pre and post implementation)

Cullen et al., 2006

Methods Before-after

Participants 3 middle schools (2,970 students)

Interventions Food Service Director implemented local school food policy changes including removal of snack chips, candy, sweet desserts and sweetened beverages from snack bars and removal of vending machines from the cafeterias

Outcomes Changes in FV sales and intake of FV.

No change in FV sales

No change in daily intake of fruit and juice

Small reduction in daily servings of vegetables (0.3 to 0.2)

Considerations

• Difficult to classify interventions because of multiple components– Policy vs. program– School vs. municipal vs. state-wide vs. federal– Target of intervention

• Different outcome measures– Change in FV environment– Changes in FV supply– Food sales

What do we need?

• Controlled study designs

• Studies focused on low- and middle-income contexts

• Standardized measurement tools of food environment, access, and consumption– Reliable and validated

• For population-based interventions, should report subgroup analyses (e.g., by age)

Summary of author findings

• There are promising strategies to improve the FV environment for children, particularly through local school food service policies

• Broader state or federally mandated programs had mixed or small impact

• Family interventions had no or small impact on home accessibility

A Model for Evidence-Informed Decision Making

National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

Poll Question #2

Did you find the information presented today helpful?

1.Yes

2.No

Poll Question #3

Was this information new to you?

1.Yes

2.No

Questions?

Thank you!

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