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Canada's monthly school health report from the Canadian Association for School Health
Volume 6 Issue 4 (Apr-Jun, 2012)
Featuring: A Sobering Assessment of Canadian Obesity Prevention through Schools

As we write about the first quarter of our seventh year publishing these reports, we are pleased to note several web-based activities that continue to generate participation and positive feedback from our 2500+ contacts in Canadian School Health.

Many will recall our previous work with the Canadian Association for Community Education (CACE) in developing a Consensus Statement and a Community of Practice on Schools Serving Disadvantaged Communities. That statement is being taken up by an international discussion group led by a group of experts from around the world and here in Canada. But we are also pleased to announce CACE and other community school networks around the world will be launching a series of webinars on that excellent model of school health and social development which is also well-established here in Canada. The first webinar in that series is on Monday, Nov. 5 at 9:00 (ET). Click here for the webinar schedule and link to the session which will have experts from the UK, the UK, Eastern Europe, Africa and Canada. Add your name to this list of participants to follow the conversations over the next several months.

CASH is also organizing another series of webinars on school substance ab use prevention that will continue this school year. This series is part of a national project funded by Health Canada that CASH is undertaking in partnership with the Council on Drug Abuse and the International School Health Network. Each webinar/web meeting will include a wiki-based discussion (adding comments and editing a draft SAP Glossary Term describing the better practice). As well, participants and anyone else interested in substance abuse prevention can follow our SAP Twitter account providing clippings of research, news and resources. Or, you can visit this page on the CASH SAP Community of Practice web pages for the latest research/news, including our latest Monthly Report.

The three webinars this year have included presentations from leading experts such as Colleen Anne Dell, CIHR/Health Canada project on Indigenous Culture as an Intervention, Peter Scales of the Search Institute (Youth Assets Approach) and William Hansen, a leading researcher and prevention program developer. (Go to the archive for recordings and readings). The next session on November 15 will include Wadih Mallouf of the UN Office on Drugs & Crime. To access the webinar, go to the CASH webinars page and add your name to this List of Participants to receive all of the related information.

Our featured article this month is a long one but it is worth the reading. (You may want to view or use the Download to Print version of this newsletter for easier reading) We have used the information service provided to members of CASH and the International School Health Network (which monitors over 225 journals, 150 media outlets and 100 social media sources and provides “clippings” on a daily, weekly and monthly basis) to do an assessment of progress (or lack thereof) in preventing childhood obesity in Canada. Canada can be considered a world leader in this effort and has numerous government strategies, over 156 million in research and many good projects. But the reality is that we are making almost no progress in reducing overweight/obesity despite 20 years of work. The article suggests some dramatic changes in the approach being used and joins other groups such as Ontario’s physicians, Canada’s business community and nutrition advocates in calling for changes based on an extensive analysis of recent research, reports, news stories and blog-based commentaries found in the last 18 months. The ten action points suggested at the end of the article may not be the final answers but we certainly need to ask some blunt questions and to redirect our efforts before all the funding and attention is drawn elsewhere.

One of the points raised in the article concerns the absence of a monitoring and reporting system that tracks child weights, prevention program capacity at all levels and student learning about nutrition. Readers interested in these M&R systems may want to join a webinar on indicators planned for November 20, 2012. (Go to the ISHN webinars page)

Canadian School Health Knowledge Network News

  • Four Year Knowledge Exchange Program in Substance Abuse Prevention
    CASH is pleased to be working with the Council on Drug Abuse and the International School Health Network in providing knowledge development and exchange associated with a national peer-based program being developed and expanded in schools in three jurisdictions. Go to the webinar archive to access the recordings.

Also visit the CASH Substance Abuse Prevention CoP pages to learn more about the several Wikipedia style summaries that are being prepared as a set of Glossary Terms in school substance abuse prevention. The wiki-based discussion of these terms will continue through to the end of the series of webinars for this year in March 2013. The drafts under discussion are noted within the webinar session descriptions on the webinar archives page. Please add your comments and even edit these documents using the simple editing tools of the web site. All suggestions are welcome, even those posted anonymously.

  • CASH-CODA-CACE Symposium
    The annual conference this year will occur on April 9-10, 2013 in Saskatoon, SK. More details will follow soon.

  • Thanks to our CoP Chairs
    Here is a list of some great people; Eileen Antone (Aboriginal School Health), Judy Hills (Mental Health), Lesley Whyte (Substance Abuse), Mary McKenna (Nutrition), Delphine Melchert & Dwayne Provo (Disadvantaged Schools) and Roselle Paulsen (Sexual Health).

  • Health Teachers Network
    CASH is updating and adding to the extensive collection of lesson plans and educational resources in Health/Personal-Social Development Education (HPSD) (See the extensive list of these resources on substance abuse offered through our Health Canada project). This is in preparation for the creation of a Canadian section of an international HPSD teacher’s network that will include the lesson plan database as well as a Twitter news/research feed and other activities that will be done with similar organizations in the UK and the USA.
  • Sign Up & Sign In:
    We are continuing to transfer the email contacts lists over to our professional networking web site at Agencies, organizations and individuals will be able to control the email they receive from this wiki-based web site through their own profiles. (This occurs by "watching" or "unwatching" selected pages).
  • CASH-ISHN Membership Drive
    The International School Health Network is partnering with CASH and similar organizations in the US, Australia and the UK to offer membership services that include:

- access to the extensive ISHN research/news/resources clipping service monitoring over 150 journals, over 75 media outlets and over 75 social media sources to bring a constant stream of brief info items with web links.
- reduced conference registration fees
- access to CASH and ISHN webinars
- access to updated web pages on SH in all 200 countries and their respective states/provinces including recent reports and articles, key contacts, web sites and policy, planning and educational resources
- customized search engines going only to government web sites around the world and access to shared collections of bookmarks, documents, videos and more.
- Organizational memberships provide access to SH events for up to 15 employees.

Sign up now for a CASH-ISHN membership at:

  • CASH: The Next Generation
    As many will already know, CASH Executive Director Doug McCall has semi-retires and has been working with several chairs of the Communities of Practice so that they can continue their work using a variety of web tools. If you are interested in being involved in the evolution of CASH in the future, contact Doug at or 250.483.6988
Highlights of Canadian Research & News Stories from July-September 2012

With our change to a quarterly format for this newsletter, we are highlighting only selected events over the past three months. Go to the archive of monthly postings for all of the items. If you want to receive an alert every time we finish posting the month’s items, go to, sign in as a member of the web site (no cost, so spam) and use your profile to “watch” this page in that web site. An email will automatically be sent each month when that pages changes once a month.

Highlights From July 2012
  • News Story (Jul 24-12) Crime rate in Canada at lowest level since 1972, Statistics Canada says
  • News Story (Jul 19-12) Experimenting with injection drugs leads to regular use for many youth: B.C. study
  • Report Making Business Case for Investments in Workplace Health and Wellness: Summary Report (Conference Board, Canada)
  • Report Reducing Health Inequalities; A Challenge for our Times (Canada)
  • News Story (Jul 5-12) Reject gay-straight alliances, parents group tells London, ON Catholic trustees
  • Report Nova Scotia Students Eating and Physical Activity Report (May, 2012)
Articles in Issue #3, 2012 of the Canadian Journal of Public Health
  • Have We Lost the War on Obesity?
  • The Daily Physical Activity (DPA) Policy in Ontario: Is It Working? An Examination Using Accelerometry-measured Physical Activity Data
  • Major Initiatives Related to Childhood Obesity and Physical Inactivity in Canada: The Year in Review
See all of the postings for Jul-Aug 2012 here
Highlights from August 2012 See all of the postings for Jul-Aug, 2012 here. Highlights from June 2012

See all of the postings for Sep 2012 here

Feature Article:
Some Sobering Thoughts about Canada’s Efforts to Reduce Childhood Obesity through Schools: A Review based on 18 months of Monitoring Research, News Stories, Reports & Social Media

Prepared by Doug McCall, Executive Director, International School Health Network

Over the past two decades around the world, there has been and continues to be a significant amount of government attention, research, program development and other activities all seeking to prevent obesity and promote related behaviours. Much, if not most of that activity has been focused on childhood obesity and the role that schools can play in reducing or preventing the problem. Yet, as this article will show, the obesity rates and related behaviours such as physical activity and fruits/vegetable consumption have not really changed.

Canada is typical among several high-income countries that have addressed the rising tide of childhood obesity by positioning schools as a primary setting for prevention. In this article, we will discuss many of the Canadian initiatives undertaken in the past decade as an illustration of similar activities in many developed countries. The Canadian efforts are as good as most around the world. Indeed, Canada was asked by the World Health Organization to develop a school policy/program planning document that suggested ways to implement the WHO strategy on diet and physical activity. As we discuss very recent research, news stories, reports and resources that have been found over the past 18 months, we will refer both to previous Canadian efforts made two decades ago to promote heart health as well as announced future Canadian participation on non-communicable disease prevention as part of global actions being taken by many countries through various UN agencies.

However, as the inevitable cycle of public, political and professional support turns and as attention for obesity prevention fades in the face of new priorities and diminished public resources, this article presents some sobering thoughts about what will endure and even what has been accomplished in the past two decades. At a time of huge government cutbacks, and with urgent issues such as mental health, bullying, LGBT students, economic disparities, the return measles/whooping cough and others crowding onto the stage, can we really expect funding and policy attention to continue to focus on obesity and its behavioural risk factors of physical inactivity and over-eating?
Based on our regular monitoring of over 225 health, education, nutrition, physical activity and other journals, news stories over 150 media outlets and over reports/resources from over 100 social media sources provided on a daily, weekly and monthly basis to members of the International School Health Network, this article suggests that the research base for some of the Canadian efforts has been unbalanced and somewhat uncertain, that the policy directions have been ad-hoc and repetitive for most of the two decades and that our attention has been focused on individual interventions/programs with only recently seeing a return to the realization that multi-intervention approaches and programs work better but need close attention to capacity-building. This realization may be occurring in Canada just as the results are showing marginal or no progress and the media is starting to report the negative stories and contradictory studies and while advocates such as physicians and business leaders are calling for more radical action.

Two Decades of Attention on Obesity, Inactivity and Over-eating in Canada

The Canadian Heart Health Initiative (CHHI) was a 15-year national and provincial/territorial initiative consisting of five core phases that began in 1989 and ended in 2004. The Initiative used a population health approach to a major chronic disease (heart disease) and represented a systematic approach to implementing a countrywide policy at the national, provincial and community levels. Around 2005, these efforts were regrouped into “healthy living” strategies across Canada after a large scale consultation that essentially re-invented the population health approach for healthy living/chronic disease prevention. The focus was on obesity and physical inactivity was a primary target. Both of these national initiatives received wide spread support.

The 2005 strategy coincided with other events in Canada that were also used to bolster the obesity efforts. These included an historic agreement (2004 Health Care Accord) between the First Ministers of the provinces, territories and the federal government that included agreements to promote physical activity and to pursue inter-sectorial cooperation through joint work on healthy schools. At the same time, Canada’s education ministers approached their health counterparts to form an inter-governmental consortium on school health promotion that was to take the lead on these types of issues. A new research/knowledge agency was also formed and this Canadian Council on Learning included funding for a number of activities, including a national Community of Practice on school nutrition. These new entities joined a solid history of school health activities starting with a 1990 Consensus Statement published by over 30 of the country’s non-governmental organizations as well as applications of this multi-intervention approach to nutrition and physical activity. Also in 2005, a major research study on comprehensive approaches to school nutrition based on 15 schools in Nova Scotia replicated the work done in the US on similar school multi-intervention programs and approaches.

A few years later, in 2011, federal and provincial/territorial health ministers announced yet another national dialogue on obesity. But this time the announcement from Ministers was met with criticism from stakeholders and from the media. More recently, the efforts on obesity have been merged with other chronic diseases internationally as well as in Canada under the rubric of non-communicable or chronic diseases. Throughout all of these lofty documents and high sounding action plans, Canada and other countries have been asking schools to do more to promote activity and healthy eating. It is this turn of events in March of 2011 that prompted the writing of this article.
This article uses a unique information service provided to the members of the International School Health Network (ISHN) that monitors over 225 journals, over 150 news media outlets and over 100 social media sources to identify and briefly analyze the recent research, news and commentary. We have listed the items from the past two months (Sept-Oct, 2012) in a detailed manner and also created another list at a more general level of the highlighted items we noted since March 2011 (an 18 month period).

This monitoring of these recent sources over the past 18 has found that:
  • The prevalence of obesity has not changed or has increased in many jurisdictions around the world. A recent report from the Johnson Foundation says that if the United States doesn't start getting its obesity problem in check, 13 states could have adult-obesity rates higher than 60 percent by 2030, according to a reportreleased Tuesday by the Trust for America's Health (TFAH) and Robert Wood Johnson Foundation (RWJF). Similar national and provincial reports in Canada (PEI, Nova Scotia) also report little or no progress.
  • The research basis for seeking to prevent childhood obesity through schools seems faulty, with major assessments done by the relevant evidence assessment bodies in the United States and the United Kingdom expressing caution and with several Cochrane and similar reviews suggesting that there has been too much focus on physical activity as a weight loss strategy and too little focus on diet, mental health and work life factors that structure our families/daily lives as well as higher risk situations caused by poverty, discrimination and genetics.
  • Much of the recently funded research on obesity has focused on prevalence and on the risk and protective factors, most of which already known in earlier research studies. These studies have replicated studies demonstrating the impact of various social influences such as parents, peers and the media and have even “discovered” the fact that poor people usually have poorer diets.
  • Similarly, the policy documents being approved by governments look much the same as previous ones written decades earlier. As is often the case, they don’t specify how progress will be measured in terms of food consumption and physical activity patterns. In Canada, there have been some specifics done in 2011 after over two decades of various national and provincial initiatives. In terms of the school-related progress, there have been some national and provincial reports on these behaviours but they are often part of research projects rather than government-funded, monitoring programs that provide regular reports to the public. As well, there is little reporting on the capacity of health, education and other systems to deliver the necessary multi-intervention programs or on the actual learning achieved by students in Canadian schools about nutrition and health in classrooms,
  • Most of the focus in Canada’s obesity initiative has been on the link between physical activity and weight, seeking to achieve a caloric energy balance. Research reviews noted in this article show that this is a somewhat tenuous connection. It is now increasingly understood that unless we all have personal trainers and very accommodating schedules, we cannot burn off enough calories to make a difference. As well, only recently has some of the research on the “social construction of eating” led to greater regard to mental health (loneliness, boredom, body image), and work-life factors (unsafe neighbourhoods, two working parents, walkable neighbourhoods) and the use of food as a reward or compensation. Key concepts such as mental health, work-lifestyle, parental influence, parent concerns about safety, working parents, pressure on schools to perform academically have been largely ignored in school policy-making/advocacy in favour of the physical activity-energy balance approach. This has led to an unbalanced research basis for many of the long term policy initiatives.
  • The approach has also been disease or deficit oriented, seeing the prevention and management of obesity as being caused by the “inactivity epidemic” and “over-eating”. Many other issue-focused strategies have moved past this deficit approach to look for strengths, assets and resilience and it is time for the obesity movement to do so as well.
  • Much of the discussion has focused on single interventions (e.g. regulating or restricting school food sales, providing fresh fruit & vegetables, increased time for physical education) and only more recently on multi-intervention programs and approaches. In many ways, Canadian and many other country efforts have re-invented multi-intervention approaches that, two decades ago, used to be called “active schools” and “nutrition-friendly schools”. And, now, just as the funding is drying up, the research is now turning to implementation and capacity issues associated with these multi-intervention approaches.
  • As well, as is often the case with multi-intervention approaches on specific health issues, the researchers and program developers are calling their new, shiny models “healthy schools” or “healthy school communities” that ignore most of the 25+ other health and social issues that are part of human health in favour of a selected few issues related to obesity. Further, despite now using the language of “ecological approaches” much of the discourse is on the school and educators and ignores the roles of local health authorities, school boards, municipalities as well as health, family/social service, agriculture, consumer and education ministries.
  • Our monitoring over the past 18 months identified several media reports that indicate changing public opinion on the issues. Much of this has been negative in nature, citing student dissatisfaction with the food, over-zealous use of BMI in student report cards, controversies with celebrity chefs and more.
On a more positive note, the items found in our 18 month window of searches has noted that
  • A wide variety of planning guides, educational resources and tools have been published. The reference documents with the lists of items noted above have identified over 25 specific tools that can easily be adapted for high income countries such as Canada.
  • Food producers and processers have created educational materials and programs for kids and parents that are quite appropriate despite their potential for commercial abuse.
  • Researchers are now focusing on specific results and will be better able to estimate cost effectiveness and cost benefits. We have identified some articles that have specifically noted the number of activity minutes gained in different types of interventions and others have reviewed articles examining the cost-benefits of school physical activity and nutrition programs.
  • There are some recent attempts to work across ministries and systems, with exploration of interventions such as municipal by-laws restricting the location of fast food outlets near schools and a convergence of interest from safety officials, educators and public health on safe/active routes to school. However, in our conclusions, we will add some cautions about these innovations, especially in communities where the streets and neighbourhoods are already well-established and not likely to change substantially in re-zoning.
Method for this Review

As a former teacher trained to teach history, it is my inclination to look for patterns and cycles in daily events while referring to similar trends in the past. As the Executive Director of the International School Health Network, it is my task and pleasure to monitor over 225 journals, over 150 media outlets and over 100 social media sources as well as numerous web sites in order to post, each week, the titles of over 250 articles, news stories, reports, blog posts and planning/educational resources. Using Twitter and a Blog, it is easy for ISHN to create and post weekly and monthly reports on a wide variety of health/social issues and different aspects of school-related work. We do so on health topics such as substance abuse prevention and mental health, as well as more generic aspects such as teacher education or implementation/capacity issues and by context such as disadvantaged communities or developing countries. As well, we post items by geographical area such as Europe, the United States or Canada. We have used the Canadian and the international lists for this article.

We started this ISHN member service in 2007 but have used the items collected only between March 2011 and September 2012, an 18 month time period, for this article. Readers of this article can go to a list of Obesity & Schools: Highlights & Twitter Posts (Mar-2011 to July-2012) and to a more detailed Sample Report on Research-News-Resources on Obesity listing all items (identified in August and September, 2012).

Once we identified an item in that 18 month time frame, we did additional searches to locate related reports, articles, resources or news stories that led up to or came after the particular items found in the 18 month period.

This article has placed these numerous news stories, research articles, reports and resources into an evidence-based and experience-tested outline that ISHN uses to collect these items on broad health issues like obesity. The broad headings of this outline are:

A. Understanding the Problem: (Prevalence, nature, aspects, importance of the problem, behaviour theories that explain it)
B. Impact, Role of the School on the Problem (Influence of the physical and social environment, school organization & practices)
C. Effects of Multi-Intervention Approaches, Programs, Strategies including Comprehensive Approaches (Multi-issue, multi-level, multi-system programs) Coordinated Programs and Services (School-Agency
Programs and Whole School (Educator-only Strategies)

D. Effects of Individual Evidence-based and Experience-tested Interventions (Including Policy, Instruction, Services, Social Support, Physical Environment Interventions)
E. Implementation, Capacity, Sustainability and Systems Change (Including Evidenced-based, Practical and Strategic Implementation Strategies, diffusion or education change theories, Capacity-building/Continuous
Improvement and Strategic Consideration of System/Agency/School Characteristics

F. Consideration of Local Community Contexts (Including rural, cultural, disadvantaged, faith communities etc)
G. Consideration of and Integration within the Constraints and Educational Mandate of the School
H. Questions related to Future and Current Research (Methods, link to educational outcomes, cost-effectiveness etc.)

Readers can see how we have used these headings to collect items into extensive Bibliographies/ Toolboxes on topics such as nutrition, substance abuse and mental health. As well, we have drawn from the ISHN World Encyclopedia on School Health, Safety, Equity, Social and Sustainable Development, a Wikipedia style web site and knowledge exchange program, that includes several summaries of better practices and other aspects that we have used as introductory references in many sub-sections in this review. Those items appear in italics at the beginning of many sub-sections, often with web links to selected ISHN summaries.

In some ways, this lengthy review is a test of the outline noted above and its underlying synthesis of the wisdom gained from over 25 school-based and school-linked approaches, models and frameworks on different aspects of health and social development. As we collate the many items that cross our desks each day, we need a mental paradigm and practical outline within which we can post the items for future review. We hope that you will agree that this ISHN outline, inspired by the work of many, many people on many school-related models, can provide this outline and therefore lead to some useful observations about previous, current and emerging trends and issues.
In addition to the observations made in these categories noted above, this article provides a description of the many activities undertaken by a wide variety of organizations, universities and governments that relate directly to obesity, over-eating and physical inactivity. Please note that we do not include many aspects of healthy eating/nutrition such as food safety, allergies, salt, and other aspects but do include school meal and fruit & vegetable programs because they provide healthier food. Similarly, we look solely at increasing moderate and vigorous physical activity but do not address related topics such as motor skills, sports, fair play and other aspects of active living.

Limitations of this Review

One of the obvious limitations of this review is that we did not cover all of the potential time back to the early 1990’s and selected only that between the latest national policy/strategy announcement issued by Canada’s Health Ministers in March 2011 and today. We did this solely because of the time/resource limits of our daily work schedule. Further, in the document listing the items between March 2011 and July 2012, the reader will find only the highlights that we noted during those weeks rather than the full detail of the last two months provided in the second document. As well, in our searching of the journals, news media and other sources, we may have missed items that could be relevant here.

As well, all of the research articles, new stories, blog articles and more were identified by one person, the author of this paper. Other people, reviewing the same items may have identified other items or highlighted different items. That is one of the reasons why we have extracted the lists of items for all to see, so that any of the readers can scan them from their own perspective.

Significance of this Review

This review presents a good picture and trend analysis of Canadian and international efforts (research, policies, initiatives, reports, news stories and resources) to reduce or prevent obesity. The Canadian efforts discussed here are similar to those of many other countries and therefore offer some comparisons and insights relevant to them.
As well, the review presents, in a detailed and thorough format, the many reasons why researchers, practitioners, officials and policy-makers need to find better ways to know what is occurring in other jurisdictions, what is emerging in terms of research and public concern, and what has preceded today’s efforts in the recent past. We all work in silos and boxes and need to look up and look around at what others are doing much more often.
In many ways, Canada and likely several other countries have once again reached a high point in the issue management cycle for diet and physical activity. Unfortunately, we will likely see reductions in obesity prevention in order that school systems can address emerging issues such as mental health, LGBT bullying, the return of whooping cough and measles, girls education, food safety and more. In many ways, we are now at the point where we have been before on this issue of heart health/healthy living/obesity. We are once again looking for ways to coordinate multiple interventions going into the school, for ways to sustain those programs and multi-intervention approaches without external support from research grants or government funding and for ways of integrating this specific health problem within a truly holistic approach to health.

An Introduction to this Article

This review was prompted in part by a couple of articles and reports identified in our regular monitoring of research and news. These articles and reports suggested we are not making much progress in Canada:
  • In the May-June 2012 Issue of the Canadian Journal of Public Health, the editorial asks: Have we lost the war on obesity?
  • In that same CJPH issue, a small study reports on the implementation of the Ontario Daily Physic al Activity policy in 16 schools (stipulating a minimum of moderate or vigorous activity 20 minutes per day) and notes that not a single child in all of those had met or exceeded that minimum and that half of the students were not getting daily activity opportunities.
  • Another article in that same CJPH issue reported that over half of BC schools were located within a ten minute walk of a fast food outlet, with larger schools in urban areas and less advantaged areas more likely to be closer.
  • A regular PEI study done in schools reports that the survey found 30 per cent of students are considered overweight or obese for their age, a number that has remained steady since 2008. Only about 45 per cent of students meet national physical activity guidelines of 60 minutes per day, the survey found, results which are also relatively unchanged since 2008. However, the survey did note a drop of seven per cent in students who reported eating and drinking unhealthy foods and beverages excessively, down to 23 per cent from 30 per cent.
  • The preliminary results of a similar Nova Scotia, Canada study done in 2003 and 2011 found that Childhood obesity rates have continued to rise over the last eight years, with approximately one third of Grade 5 students were either overweight or obese, about one third of Grade 5 students meeting Canada’s Food Guide recommendations for vegetables and fruit intake, the average daily consumption of sugar sweetened beverages (including pop and fruit drinks) decreased from 2003 to 2011. Most Grade 5 students exceeded recommendations for screen time (less than 2 hours per day). In 2011, students reported watching less TV but more computer and video game usage. The full report from the Nova Scotia project puts a positive spin on the results between 2005 and 2010, saying that the increases in obesity rates are slowing. It also should be noted that the agreement between the sponsoring school board and local health authority on this Healthy Schools program has been modified in the light of budget cutbacks throughout the province.
Internationally, we have seen similar news stories and reports. These include:
Thoughts on Overall Policy and Approach

Here are some observations about an overall approach and macro policy considerations based on some of the items we encountered in our 18 month window of monitoring various sources.

1. Start with the end in mind. An analysis of European healthy eating policies noted that of the 107 national and state strategies on nutrition and physical activity, only 27 were being evaluated for an effect on consumption, only 16 on the basis of improved health status and only three were using a cost-benefit analysis. The authors also noted the lack of comparability of these European evaluations. Canada launched its obesity discussions in 2005 and had the previous Canadian Heart Strategy before that which started in 1989. It is only in 2011 that we find an attempt to develop indicators of progress relative to behaviour and health status.

2. School Health Policy-making involves more than one system. McKenna (2001), an expert who has analyzed efforts to introduce comprehensive school nutrition approaches (noted as “policies” in some nutrition documents) reports that “in Britain, Canada and the United States, the impetus for initiating school nutrition policies has come primarily from health, not education, agencies. These agencies define the nutrition problems of school students as both under- and over-nutrition, and, to solve them, advocate the development and implementation of policies to combat health and learning problems associated with poor nutrition. Health, rather than educational, agencies are also more likely to formulate school nutrition policies; such policies commonly address the dietary principles of access, adequacy, and moderation. Within countries, the adoption of school nutrition policies varies considerably. Moreover, the degree to which such policies have been implemented is unclear, because of a lack of research to evaluate their process and impact. To enhance the successful development and implementation of school nutrition policies, greater partnership between health and education agencies is recommended throughout the policy process”.

3. Use a Systems-based Approach that includes multi-level Actions. A recent NGO report from Ontario, Canada illustrates how systems thinking and knowledge exchange are now considered in advocacy and policy development. The report; Moving Forward on Provincial Action Plan on Obesity: Ontario, Canada 's Action Plan for Healthy Eating and Active Living (HEAL) was developed to address an epidemic of overweight and obesity in Ontario and as part of a world-wide response to reduce chronic disease by targeting nutrition and physical activity. It is a consultative report which describes four priorities for action which need to take place in order to move the HEAL strategy forward. This report builds on OCDPA's "Thinking Like A System: the way forward to prevent chronic disease in Ontario", and offers a clear and concise blueprint on how to implement the four priorities for action. These include; establishing a HEAL Expert Panel to recommend a comprehensive agenda for action, establish a research and policy engagement agenda, developing a comprehensive HEAL knowledge exchange plan and developing a plan to build regional capacity to implement effective HEAL programs and policies.

4. Follow up on Stated National Commitments rather than making New Statements. The 2004 Health Care Accord between First Ministers of the provinces, territories and federal government was an historic document, setting out several broad national goals for health care and a few specific references to health promotion, including one in regard to inter-sectorial collaboration on healthy schools and another on inactivity. For Canada, with its tendency to safeguard provincial policy interests (especially the right to govern school systems) at the expense of common sense, this document was a bit of a breakthrough. However, as one might have expected, there is no mention of healthy schools, activity or even health promotion in the 2012 Progress Report of the Health Council on the progress made in implementing the accord. The criticism and lack of interest in the 2011 Health Ministers statement on Health Promotion and Prevention can be seen as a natural response to their lack of follow up on joint promises made in 2004.

Collating the Identified Items into an Evidence-based, Experienced-tested Outline

The remainder of this article places the many articles, news stories, reports and resources that we identified over the past 18 months within our outline used to collate items relating to health and social issues. This outline is based on a synthesis of effective approaches to school-based and school-linked health and social development and consequently helps us to see the relevance and potential importance of the items. The text in italics at the start of each sub-section explains that part of the outline.
A. Understanding the Problem
This sub-section covers several aspects including the prevalence (size, burden, trends) of the problem, the nature of the problem/relevant or key aspects, risk/protective factors, social influences such as parents, peers, the media, social determinants such as poverty, cultural isolation/discrimination, genetic factors including intelligence and personality, the impact of different stages in the life course and transitions at those different stages, the identification of specific populations/behaviours/conditions causing more risk from the problem/issue, intersections with other health and social issues/conditions/behaviours and the use of behavioural theories that explain the problem or potential solutions. These several aspects are used most often to understand the problem and [potential solutions and are most often explored in correlational research.

(Size, burden, trends)

The prevalence of the problem of overweight and obesity has been documented many, many times on the past 20 years and in particular over the more recent five years. The appropriate weight for a child’s height (BMI) has been the criteria used most often. The proportion of children whose BMI is overweight or obese is usually what is reported in the media.
In recent research articles there has been criticism of this measure and suggestions for others. In recent news stories, we have noted that some US states and school boards have backed off their practice of reporting children’s BMI to parents as part of the school reporting process.

Canada, like many other countries, has been tracking bodyweight and related factors through national surveys such as the Health Measures Survey and the Canadian Community Health Survey, with different types of data reported every two years. The items being tracked relevant to bodyweight include BMI, consumption of fruits and vegetables, and daily activity and sedentary behaviours.

An average lay person reading the releases from Statistics Canada might end up being confused by the various reports. For example, the June 3, 2010 release of the BMI for 2007-09 reported that 26% of children over 6 fall into the overweight (17%) or obese (9%) category. Two years later in a Sep 20, 2012 release, the BMI reported for both overweight and obese children from 2009-11 was 31%. This apparent jump in weight problems in young Canadians over that two year period occurred at a time when physical activity and fruit/vegetable consumption among all Canadians appeared to be quite stable according to the same Statistics Canada reports. In September 28, 2011 release, baseline data on the physical activity and fruit/vegetable consumption of Canadian children and youth is presented, with only 7% saying that they achieving an average of 60 minutes per day/six times per week in 2007-09 and about half of 12-19 year olds saying that they that they consumed five servings of fruits & vegetables in 2010.

As well, if one reads the four reports of the Canadian results of the Health Behaviours in School-age Children (HBSC), one learns that obesity levels of Canadian children have remained stable since 2002, through 2006 and 2010. In 2002, 24% of boys and 16% of girls were overweight or obese. In 2010, those numbers were 25% and 17%, both of which were likely within the margin of error for the surveys. As well, the HBSC reports note that the physical activity levels in those same three time periods stayed at 18 and 19 per cent for all three cycles (with an improvement noted between 2002 and 2006 for physical activity. As well, the young people trying to lose weight stayed within one per cent for all three surveys.

These crude measures obviously need explanation and are likely the subject of explanatory articles and analyses elsewhere. However, and just as obvious, is the need for indicators that not only track long term outcomes such as body weight but also contexts (types of communities), inputs (child and family assets, access to healthy foods and playgrounds/sports), processes (exposure and participation in prevention and health promoting programs) and short term outputs such as knowledge, skills, attitudes/beliefs that lead up to the outcomes. This will be discussed further in the discussion of monitoring and reporting within the sub-section on systems capacity.

However, this author, for one, was struck by the apparent slowness in Canada to develop any baseline statistics for the strategies that have been articulated and developed as early as 1990. Does it really take twenty years to decide on how such strategies, which were being pursued in separate physical activity and nutrition strategies both federally and in the provinces before 2001 and that were consolidated in the 2005 Healthy Living strategy and its provincial/territorial counterparts, to set up some basic baseline data? Earlier in this article we noted that most of the European initiatives also did not include health status or behavioural outcomes, so this policy-making deficit may be endemic in nature to large scale government initiatives.

The Nature of the Problem and its Different Aspects

As is often the case with health issues, the news media has published several stories, usually based on research studies that have different or repetitive explanations of the problem of overweight and obesity.

Old Ideas about social influences

In the two lists of identified items used as data sources for this article, you will find repetitive research studies about the social influences that affect the eating and activity patterns of young people. We already knew, but have been told again by yet more research studies that parent practices such as family meals and attitudes/habits about physical activity will affect their children’s patterns of behaviour. Exposure to television advertising is also explored again in various research studies. Easy or convenient access to healthy foods and playgrounds/sports venues at a reasonable price is also pretty obvious as a factor but you will find several studies showing correlations between neighbourhoods with difficult access and overweight problems.

A Canadian news story published in September 2012, based on an analysis of Ontario Child Health data, tells us that the “Obesity journey pretty much etched in stone by childhood experiences, environment”. Another Canadian news story again tells us the obvious, that children can be influenced by their peers in their food choices and that “peer pressure can hurt healthy eating habits”.

There are repeated studies about the role of parents in encouraging healthy eating and physical activity but they may not delve deep enough into the role, challenges and other factors within modern, stressful family life today. Here are some newer stories that appeared in the media, often based on published research studies:
  • In one news story identified in our monitoring we read that researchers at Oregon State University have confirmed what we knew all along – children in this country (USA) are increasingly sedentary, spending too much time sitting and looking at electronic screens. But it’s not necessarily because of the newest gee-whiz gadgets – parents play a major factor in whether young children are on the move. Overall, they found that children who had “neglectful” parents, or ones who weren’t home often and self-reported spending less time with their kids, were getting 30 minutes more screen time on an average each week day. While all the children in the sample of about 200 families were sitting four to five hours in a typical day, parents in the more neglectful category had children who were spending up to 30 additional minutes a day watching television, playing a video game or being engaged in some other form of “screen time.”
  • In another news story citing another research study, researchers found that mothers who were employed full time “reported fewer family meals, more frequent fast food for family meals, less frequent encouragement of their adolescents’ healthful eating, lower fruit and vegetable intake and less time spent on food preparation, compared to part-time and not-employed mothers,
  • Food ads may outweigh parents' diet advice. Food ads influence what children want to eat but healthy messages from parents may help to temper the influence, researchers have found. In the experiment, children were allowed to choose a coupon for apple slices or french fries that they saw advertised during cartoons. The parents were randomly assigned to follow a script that advised the children to select the healthier food or the food the child wanted the most. Among the children who saw the commercial for fries, 71 per cent chose the coupon for french fries if their parents remained neutral, compared with 55 per cent who opted for the fries coupon if their parents encouraged them to choose the healthy food.
We also came across a 2012 report on American family assets done by the Search Institute. The Family Assets Index assesses how families “measure up” against the aspirational ideal we strive for in healthy, asset-rich families. Families fit into four groups based on their Index score: Poor, Fair, Good, or Excellent. Scores on the Index approximate a normal bell curve, such that the majority of families score in the middle 50th percent only 11% of families score ‘Excellent’. The average score of 47 is on the high-end of ‘Fair’, but still equates to less than half of the aspired family assets. Thus, while all families have some assets, there is still room for growth. The average American family with a 10- to 15-year old scores 47 out of 100. The study notes that the number of assets in families does not vary by parent education or household income or even by single or dual parents in the home. Black and Hispanic families have different and more assets than White, Asian or other ethnicities. Families living in urban communities have more assets than suburban or rural families. The more assets a family has the more likely they are to like maintaining a balanced diet and getting a balanced diet and getting adequate amounts of sleep, exercise, and “down time.”

In addition to the obvious and repetitive studies noted above, our monitoring of the research, reports and news identified these new insights:
  • Bag Lunches vs school prepared meals A study reported in the April 2011 issue of Infant, Child and Adolescent Nutrition confirms other findings that the quality of lunches brought from home is far less than the meals prepared and sold at schools. (Other studies report that a minority of students purchase food at school). The obvious implication from this article is that there are significant limits on the reach of public policies regulating food sold and prepared at school. Since most of the action taken in schools with regard to school nutrition and obesity has been to restrict or regulate food sales, we may be affecting only a minority of students.
  • Fatness Causes Inactivity in Children, Not the Reverse A startling conclusion is presented in an article in the October 2011 issue of Archives of Childhood Diseases. Fatness leads to inactivity, but inactivity does not lead to fatness: a longitudinal study in 202 children. The authors suggest this reverse causality may explain why attempts to tackle childhood obesity by promoting activity have been largely unsuccessful. It is noteworthy that this cause-effect relationship is also noted in Canadian reports. Tremblay & Wilms (2003) in their analysis for the Canadian Institute for Health Information stated that” Caution must also be used when speculating on causation. It may be that children who are prone to overweight and obesity may also be prone to living a more sedentary lifestyle; that is, obesity and overweight can discourage children from participating” .
  • Targeting sedentary behaviour to reduce weight: Meta-analysis A meta-analysis published in the May 2012 issue of the International Journal of Behavioral Nutrition and Physical Activity reports that multiple and individual interventions targeting sedentary behaviors as well as multiple behaviors can result in significant decreases in sedentary behaviour. Studies need to increase follow-up time to estimate the sustainability of the intervention effects found. No differences were found between single and multiple health behaviour interventions.
  • Cutting down TV time doesn't help kids lose weight: Study Trying to help children lose weight by cutting back on the time they spend in front of a TV or video game doesn’t have much of an impact, according to a Canadian study. Interventions designed to reduce overall screen time, including individual and family counselling, automatic monitoring of screen time and classroom curricula, have all been largely unsuccessful, wrote Catherine Birken of the Hospital for Sick Children Research Institute in Toronto.
  • A large longitudinal study in the US that (Hook & Altman, 2012) examined the relationship between junk food sales and weight found that such sales in schools had no effect on students’ weight. The authors report that “The relationship between consumption of sugar-sweetened drinks and snacks and childhood obesity is well established, but it remains unknown whether competitive food sales in schools are related to unhealthy weight gain among children. The authors examined this association using data from the Early Childhood Longitudinal Study, Kindergarten Class. Employing fixed effects models and a natural experimental approach, they found that children’s weight gain between fifth and eighth grades was not associated with the introduction or the duration of exposure to competitive food sales in middle school”. They offer various explanations for this finding, including the lack of time for children to eat much as school. Another may be that most children at that age bring lunches from home to eat at school.
A Presentation Leads Us into several Research Reviews

One of the more significant findings of our monitoring of research, news and social media sources is that physical Activity alone does not have much effect on body weight. This important point, still contested or glossed over in some articles, was first identified by our coming across a presentation made by a Canadian physician (Note: Free registration with Medscape required to access article) at the 2008 Academy of Pediatrics conference, where he reported a meta-analysis of almost 400 studies and concluded that that “BMI is not affected by school-based physical activity interventions”. Note: The lead researcher, Dr. Harris, did make great efforts to point out several other benefits of physical activity, including blood pressure, bone density and flexibility.

We then found that the Centre for Reviews and Dissemination of the National Institutes of Health Research in the UK expressed similar cautions about physical education and weight loss when it assessed the validity of a 2007 review done by Connelly et al (2007) that uses what the authors themselves call a “novel” approach to reviews. The CRD assessment states that “the conclusion regarding the decisive role of compulsory physical activity should perhaps be regarded more as hypotheses-generating rather than definitive”. Digging deeper, we found that the 2011 report Obesity in Canada presents only one article as the basis for this part of the obesity strategy related to activity and weight loss.

Matson-Koffman et al (2005) from the CDC Center on Chronic Disease Prevention found seven studies that suggested increased time in physical education classes with better trained teachers are among the studies that “can increase physical activity or improve their nutrition” (not necessarily reduce weight) but they also suggest that “further research is needed to determine the long-term effectiveness of different policy and environmental interventions with various populations and to identify the steps necessary to successfully implement these types of interventions”.

We also tracked down the advice from another evidence review organization within the Centers for Disease Control and Prevention in the US who have stated that school-based programs alone may not be effective in reducing or maintain weight. This cautionary finding was reported by the Community Guide, the evidence-synthesis organization of the Centers for Disease Control & Prevention in the US. “TheCommunity Preventive Services Task Forcefindsinsufficient evidenceto determine the effectiveness of school-based programs to prevent or reduce overweight and obesity among children and adolescents because interventions varied and reported outcomes that were not comparable”.

A Canadian Cochrane review of the research on school physical activity programs (Dobbins et al, 2009) concluded that “Generally, school-based interventions had no effect on leisure time physical activity rates, systolic and diastolic blood pressure, body mass index, and pulse rate”.

Khambalia et al (2012), in their review of the school-based literature, found that while there have been severalreviewson the topic, findings remain mixed. They suggest that intervention components in theschoolsetting associated with a significant reduction of weight in children included termlong-term interventionswith combined diet and physical activity and a family component. Hendrie et al (2012) also suggest that obesity prevention programs should combine multiple interventions in the school with other interventions in the home. Effective studies used about 10 behavior change techniques, compared with 6.5 in ineffective studies. Effective interventions used techniques including providing general information on behavior-health links, prompting practice of behavior, and planning for social support/social changes. Different behavior change techniques were applied in the home and school setting. This finding about combined home and school programs makes sense to us, however, we also there has not been a strong focus on parent participation in Canadian studies or initiatives.

Other articles we noted in our monitoring noted that reviews of the impact physical activity on other long term conditions such as diabetes and cholesterol were sometimes mixed. We conclude this brief discussion of the impact on physical activity and weight loss with a summary of an article prepared by Canadian researchers as part of a series of articles presenting evidence informing the revision of Canada’s physical activity guidelines. Janssen & LeBlanc (2010) conclude that physical activity is “associated with numerous health benefits” and that 60 minutes per day of moderate or vigorous activity is recommended. However, they conclude that “These studies tended to report weak to modest relationships between physical activity and overweight/ obesity, with many risk estimates being non-significant”.

Much of the attention in the obesity strategies in Canada to date has emphasized physical activity as the primary buffer against overweight (as do some popular television shows). However, the evidence appears to suggest that attention should be focused elsewhere on factors such as work-lifestyles (time starved parents buying fast or processed foods, living in suburbs without safe routes to schools, concern about safety in neighbourhoods leading to sedentary activities among children staying alone at home after school and emotional/mental health factors such as loneliness, boredom, stress and bullying that can lead to overeating. In respect to nutrition, the earlier “Vitality” campaigns that focused on social aspects of eating may also be more worthy of our attention once again.

Overview of Canadian Efforts related to Obesity, Healthy Living & Heart Health

· -5 projects funded on obesity management.
These 2011-13 funded projects can be linked with a similar set of local projects funded under the Healthy Living Fund that operated between 2004 and 2007. This list of eleven funded projects that were organized in cooperation with provinces included three school-linked or school-based projects.

Other findings related to Research

Our monitoring activities also found some frustrating and interesting research reports.
  • Some systematic reviews clumped together a variety of interventions with little regard for the delivery mechanisms required. As is often the case with systematic reviews of research, we found reviews that combine various types of school-based and school-linked interventions in summary type reviews and then fail to distinguish their respective effectiveness. For example Waters et al (2011) provide a “synthesis” of potential or promising interventions (curriculum that includes activity, nutrition and body image, increased activity during the school week, improved food quality and more) but then add that the results of the review should be viewed cautiously because of the heterogeneity of the data and small size of the studies. Other reviews wander off on other outcomes, such as Story et al (2009) reporting on schools and obesity prevention. They note that fast foods are sold in schools and are largely responsible for high intake of calories (ie the point of the review) and then cite the “emotional and social” benefits of physical activity.
  • An article in Issue #4, 2012 of Critical Public Health opens the door to a discussion of how public health systems need to divest themselves of terms, practices, structures and underlying assumptions imported from the health care system. The authors note that "Public Health specialists have increasingly deployed the concept of ‘dose–response’ in areas such as diet (‘five-a-day’), alcohol (‘21 weekly units’) and physical activity (‘150 minutes of weekly activity’). Using these examples and a case study that sought to establish an optimal dose of physical activity for mental health gain, this article offers a critical assessment of the nature, robustness and function of ‘dose’ in public health. Drawing from a ‘sociology of knowledge’, the article argues that dose–response can best be considered an analogy that does not necessarily translate favourably from its original expression in toxicology to some public health domains. Rather than having technical robustness, its attractiveness and utility is seen to lie in it possessing ‘cultural capital’ (ie sounding medical). Here, the ability to link behavioural concerns to clinical practice, to simplify complex ideas and to act as a regulatory form of behavioural governance. The article is skeptical of further empirical pursuits in identifying optimal doses and offers an alternative course for public health framing.The discussions of obesity have been inundated with this dose-response, intensity, duration type thinking derived from medicine rather than behavioural science. We used to have calls for “150 minutes of physical education per week”, now it is for “60 minutes of MVPA” per day. We remind everyone to eat at least “five servings” of fruit & vegetables per day. We tell our young people that more than “two hours of screen time per day” is unhealthy (as we return from jobs with seven or eight hours of screen time per day).
  • A couple of articles were identified in our monitoring that clarified the concept of “behavioral intention” A Canadian study provides a picture of the frequency and some of the characteristics of children who use active routes to go to school. Pabayo et al (2011) report that “longitudinal analyses (from the cohort study National Longitudinal Survey of Children and Youth) indicated that as children aged, the likelihood of using active transportation to school increased, peaked at the age of 10 years, and then decreased. Urban settings, households with inadequate income, living with one parent and having an older sibling living at home were significant predictors of active transportation to school at baseline and carried through across time.
  • Another Canadian study (O’Loghlen et al, 2011) was one of several recent studies that have recognized that active and safe routes to school offer a good opportunity for increased physical activity. This study reported on a survey of the practices of 400 Canadian accompanied by a GIS analysis. The authors report that “Greater than 70% of schools had passive policies (e.g., skateboards permitted on school grounds) and facilities (e.g., bicycle racks in secure area to avoid theft) to encourage bicycle and small-wheeled vehicle use. Less than 40% of schools had active programs designed to encourage active transportation, such as organized ‘walk to school’ days. Garbage in the streets, crime and substance abuse were barriers in most school neighbourhoods. Approximately 42% of schools were located on high-speed roads not amenable to active transportation and 14% did not have a sidewalk leading to the school. Secondary schools had less favourable active transportation policies/programs and neighbourhood safety/aesthetics compared to primary schools. Rural schools had less favourable built environments than urban schools”.
Recognize Complexity, Context and Competition

We also encountered a fledgling discussion in the obesity, nutrition and physical activity research over the past 18 months about “ecological approaches”, an emerging trendy topic in much of the recent health promotion research. We can start this discussion with a traditional article that we identified in the 18 month time frame that is actually the opposite of this new ecological approach and illustrates how far we need to go in its application.

Leeman et al (2012) present a framework or logic model for evaluating policy interventions on obesity that simultaneously fits with and ignores a systems-based, ecological approach. The framework was developed by the CDC-funded Center of Excellence for Training and Research Translation (Center TRT) to build public health practitioners’ capacity to evaluate policy. The framework is designed for use by practitioners working as partners and evaluators in public policy initiatives (legislation, regulations, or funding allocations) at the state or local level. The example chosen to illustrate the use of the framework is the implementation of a single intervention, school-based food gardens. The article does a great job in explaining how the inputs, activities, outputs and long term outcomes can be organized using a linear logic model that looks for feedback from the environment, practitioners and other sources in the implementation of the program. However, the trouble with this school garden model is that it ignores the rest of the world insofar as the many, many other competing demands on schools (and their systematic propensity to respond because they are open, adaptive systems) and the complexity of the inter-actions within such large systems that have demands created both externally, across multiple systems and at many different levels within the system itself. Not only will this single intervention on school gardens compete with other nutrition issues (food safety, food allergies, hungry children, eating disorders etc), it will compete with 25 other pressing health and social issues challenging today’s young people. If we continue to focus only on one pre-determined solution, rather than helping the people identify their own needs based on good local data and analysis, then we will continue to misunderstand the “ecological approach”.

An article by prominent Canadian researchers (Alvaro et al, 2011) has succinctly explained the case for this shift in thinking and doing health promotion. Their paper “explores why Canadian government policies, particularly those related to obesity, are ‘stuck’ at promoting individual lifestyle change. Key concepts within complexity and critical theories are considered a basis for understanding the continued emphasis on lifestyle factors in spite of strong evidence indicating that a change in the environment and conditions of poverty isare needed to tackle obesity. Opportunities to get ‘unstuck’ from individual-level lifestyle interventions are also suggested by critical concepts found within these two theories, although getting ‘unstuck’ will also require cross-sectoral collective action. Our discussion focuses on the Canadian context but will undoubtedly be relevant to other countries, where health promoters and others engage in similar struggles for fundamental government policy change”.

Another article located in our 18 month scan emphasized that the complexity of factors causing obesity requires us to use a multi-level, multi-faceted response. In an editorial in the International Journal of Public Health, Rutter (2012) quotes a Canadian researcher to argue that “obesity is the result of a complex web of social, cultural, environmental, biological and cultural influences”. He suggests that “there is a fundamental epistemological difference between the rigorous EBM (evidence based methods) that can differentiate between two treatments and the kinds of research that are able to identify effective, sustainable approaches within complex, adaptive systems”.

Ecological action vs ecological analysis

It is now trendy to say that our health promotion efforts are based on an ecological approach but we often really mean ecological analysis rather than ecological action. In other words, we don’t really change our intervention strategies to take action in an ecological way. To use the language and wisdom of ecology, we ate still trying to train the fish and birds and rodents to behave differently rather than modifying or protecting their habitats, seeding the process and then letting nature take its course.

Articles on ecological approaches to physical activity and nutrition are now appearing quite regularly in the journals. But few of them actually discuss things such as multi-level change in systems, the boundary protecting role of middle managers, ensuring that ministry structures and budget lines are focused on health promotion goals such as populations and settings and interventions instead of organizing their work around diseases.
We have now recognized through ecological analysis that behaviour of individuals is caused by different, daily interaction s between the traits of the individual, with the characteristics of the family/home, the conditions in the neighbourhood and what occurs in the several micro-environments within the school (classrooms, hallways, cafeterias, bathrooms etc). In Canada, a CIHR grant developed and applied this concept to school health promotion. But the analysis idea has been around a long time. In a paper prepared for the CIHI on obesity in 2005, it was noted that former Canadian Brian Flay had described this as early as 2002. Members of the Canadian School Health research Network have applied an ecological and systems based approach to school nutrition in a discussion paper developed for the Office of Nutrition Policy, Health Canada.

It is in the taking of ecological action that we need to learn much more. Linear thinking, highly focused attention to individual programs, concentration only on the front-lines of multi-level systems are all no longer appropriate. Ecological action really means more attention to context, capacity and change processes in large systems and multiple, over-lapping systems.

Although most of the items found in the past 18 months did not truly reflect an understanding ecological action, our monitoring did locate these examples:
  • The interaction between the home food environment, school programs and individual characteristics on eating habits is explained in another recent article identified in this review. Lippevelde et al (2011) Changes in home-related determinants were significantly related to changes in fat intake from snacks; therefore, school-based obesity programmes on adolescents should try to address these determinants. In the Lippevelde et al study, one of the three investigated home-related factors, namely parental support, was affected by the parental component intervention.
  • Use of Complexity Framework to Assess PA Programs An article in the latest issue of Health Promotion Practice identifies the barriers and facilitators in adopting, implementing, and maintaining a school-based physical activity intervention using RE-AIM as a theoretical evaluation framework. It was concluded that interventions that consider complexity and compatibility with the school setting are more likely to be adopted, implemented, and maintained.
  • An article in Issue #4, 2011 of Critical Public Health demonstrates how a socio-ecological perspective was deployed during an exploratory study into the role of primary school dining halls in improving children's nutrition-related behaviour. This study revealed how policies at local and school levels reflected national objectives with respect to nutritional guidelines, but were also influenced by multiple, competing interests at other socio-ecological levels. These included pupils’ food preferences; organisational objectives such as protecting school meal uptake; and the practices of school meal staff. It is argued that higher level policy interventions may have limited effectiveness if undermined by lack of attention to lower level factors. The use of socio-ecological frameworks as theoretical, methodological and evaluative tools to support a consistent, holistic approach during the design, implementation and evaluation of health improvement policies is recommended.
Truly Consider Social Determinants

As with many other health issues, the obesity movement has recently turned its attention to social determinants.

This blog post from Australia summarizes the need to focus much more on disadvantage, disparity and determinants in preventing or reducing obesity.” Firstly, diseases commonly attributed to obesity are more prevalent amongst marginalised populations regardless of their weight. Despite this, anti-obesity campaigns seek only to change the attitudes rather than the circumstances of those people deemed most at risk. By focusing on weight as the problem and weight loss as the solution, social and economic inequalities are made invisible. Health disparities between groups are blamed on individuals for not making “healthy” choices, ignoring the ways that the choices available to comfortably middle-class white Australians are often very different to those available to people on low incomes, to recent immigrants, or to Indigenous Australians. What’s more, the emphasis on individual responsibility amounts to a sort of victim blaming that allows structural inequalities to remain unaddressed. Individuals who don’t or aren’t able to lose weight are branded as non-compliant. Fat people are seen as having a “bad” attitude. And they are seen as undeserving of respect, dignity, or even access to medical treatment, since they apparently have only themselves to blame. If you don’t believe me, just look at the comments section of any story on “obesity”.

A Dutch article (van Rossem et al, 2012) notes that disadvantaged young children are more likely to engage in sedentary behaviours from an early age. An article in one of the major Canadian newspapers, The Globe & Mail, has described how difficult it is for kids in deprived neighbourhoods to access sports and other activities, thereby contributing to the obesity and related epidemics.

Although it is not surprising, it is still nevertheless heartening to note that several international as well as Canadian news reports, articles and resources are addressing the issue of overweight/obesity from the perspective of social determinants. Food insecurity will drive down food quality and food choices, so this needs to be a consideration in national and state/provincial strategies.

This is not to say that current Canadian or international obesity strategies have yet truly adjusted their focus from middle class concerns about body image and optimal fitness to more basic concerns such as a secure, high quality supply of nutritious food. An article in August 2012 Issue of the International Journal for Equity in Health examines the "healthy living" strategies in two Canadian provinces using several policy documents for the analysis. The authors report that "initiatives active between January 1, 2006 and September 1, 2011 were found using provincial policy documents, web searches, health organization and government websites, and databases of initiatives that attempted to influence to nutrition and physical activity in order to prevent chronic diseases or improve overall health. Initiatives were reviewed, analyzed and grouped using the descriptive codes: lifestyle-based, environment-based or structure-based. Initiatives were also classified according to the mechanism by which they were administered: as direct programs (e.g. directly delivered), blueprints (or frameworks to tailor developed programs), and building blocks (resources to develop programs). Sixty (60) initiatives were identified in Ontario and 61 were identified in British Columbia. In British Columbia, 11.5 % of initiatives were structure-based. In Ontario, of 60 provincial initiatives identified, 15 % were structure-based (ie addressed social determinants). Ontario had a higher proportion of direct interventions than British Columbia for all intervention types. However, in both provinces, as the intervention became more upstream and attempted to target the social determinants of health more directly, the level of direct support for the intervention lessened.

There is a growing body of knowledge indicating that poverty or “food insecurity” is a contributing factor to obesity, despite its counter-intuitive logic. Some of these articles were identified in our monitoring over the past 18 months. This is true of young people and is therefore relevant to schools. Widome et al (2009) note that “s. Compared with food-secure youths, food-insecure youths were more likely to perceive that eating healthfully was inconvenient and that healthy food did not taste good. Additionally, food-insecure youths reported eating more fast food but fewer family meals and breakfasts per week than did youths who were food secure”. The Johnson Foundation (2012) has argued that schools can play a role in reducing food insecurity and therefore obesity in deprived children through school meal and snack programs providing nutritious foods. The Dieticians of Canada have also taken the position that disadvantage affects access to high quality food and therefore can cause overweight/ obesity. This disadvantage includes the lack of convenient access to healthy foods in low income, urban neighbourhoods as well as isolated rural and aboriginal communities.

Hossain et al (2007) have noted that “the growing prevalence of type 2 diabetes, cardiovascular disease, and some cancers is tied to excess weight. The burden of these diseases is particularly high in the middle-income countries of Eastern Europe, Latin America, and Asia, where obesity is the fifth-most-common cause of the disease burden — ranking just below underweight. Phipps et al (2006) did an analysis of poverty and obesity in Canada, Norway and the US and found that “In Canada and especially in the US, we find a much greater extent of obesity for poor than non-poor children. However, when we compare only non-poor children in the three countries, although the magnitude of difference is smaller, it remains clear that Norwegian children are much less likely to be obese. Policy and research directed towards reducing the extent of child obesity in both Canada and the US should pay particular attention to issues of child poverty”.

A news story in May of 2012 caused consternation within Canadian circles as a UN Envoy said that Canadian food policies are hurting the poor. Olivier De Schutter, the UN special rapporteur on the right to food, said 800,000 families -- nearly two million people -- in Canada don't always know where their next meal is coming from. He said one in 10 families with kids under the age of six is 'food insecure,' meaning they don't have physical and economic access to an adequate amount of nutritious and safe food. In particular, the remoteness drives up the price of food and the new national program to subsidize food prices in remote communities isn't being monitored properly to ensure the savings are passed on to the consumers, he said. As well, access to traditional food, including hunting, fishing and trapping, is becoming less accessible due to flooding, environmental contamination and government policies that restrict or prevent aboriginal control over their own land. The federal government was harshly critical of De Schutter's visit. Health Minister Leona Aglukkaq called him "uninformed" and criticized him for discussing nutrition in the north without visiting the Arctic

The Center for Science in the Public Interest (Canada) has called for a national school meal program in Canada that would match those offered in most other countries such as the UK and the USA but, to date, there has been little response. In England, the national school meal program is very popular with school boards and is used as a way to ensure disadvantaged children have a healthy meal each day.

An analysis of Ontario Child Health data (Gonzales et al, 2012) reports that “several prospective studies highlight the importance of childhood socioeconomic disadvantage as a major predictor of obesity [5-8]. For example, Power et al. (2003) showed that family SES in early childhood (birth to age 7) was significantly associated with obesity at age 33; this finding was not explained by parental BMI or the individual’s own education. These prospective studies illustrate that childhood SES has long-lasting effects that are not easily reversed by changes in SES occurring in adulthood [6]. Other family indicators, closely linked to SES, have been identified as risk factors for obesity in childhood. Children from single parent households have significantly higher BMIs compared to those from dual parent households [9]. In addition, parental educational attainment is inversely associated with adulthood BMI [10]”.
Another article found in our August monitoring activities might provide an easy, practical, albeit small part of the pathway towards redirecting our attention to disadvantaged children and obesity. Breslin & Brennan (2012), writing in a social work journal, report on the success of a project that assigned aspiring PE teachers to schools in disadvantaged communities. The researcher s are predicting changes in physical activity among the students but the experience, which includes a visit to the university by the students, may also alter the beleifs and attitudes of both the student teachers as well as the students in other ways.

Often when addressing health or social problems that are caused or aggravated by poverty, the answers point to the need for increasing the incomes of economically disadvantaged families through social assistance and taxation adjustments. While this is part of the long term answer, it may be that the school provides an opportunity for direct provision of healthier foods through breakfast, snack, lunch and after school programs offering healthy foods to deprived children. This policy option for lunches is being actively pursued in England and several European countries. Canadian pilots in BC and in northern territories have demonstrated that school snack programs can result in increased consumption of fruits & vegetables.

Neighbourhood Safety: Can Safe Schools Initiatives Prevent Obesity?

Neighbourhood safety, often congruent with disadvantaged communities, is also a factor in physical activity and therefore overweight/obesity. Canadian researchers Caron & Janssen (2012) found that “high social and physical neighborhood disorder combined was associated with approximately 40-60% increased likelihood of high television, computer, and video game use.

A news story from Wales and other regions in the UK, (Wales Online, Aug 1-12) reports that concern was being expressed by public authorities as parents' safety fears 'stop outdoor play'. The research, which involved 1,000 parents in Wales, Scotland, Northern Ireland and England, showed that 49% reported a fear of strangers stopping their children from playing outside, while 46% said traffic was a concern, and 31% highlighted fear of accident and injury as barriers to outdoor play. The study was part of the legislated national “Play Day” established in the UK.

The most recent report on child and adolescent physical activity in Canada noted that 58 per cent of Canadian parents say they are very concerned about keeping their children safe and feel they have to be over-protective. The news story citing this Canadian parental concern then quoted Judith Down, director of the Alberta Centre for Active Living, says parents can try organizing play dates in the parks with a rotating shift of parent supervisors, or making a buddy system. This is often the same idea for used organizing safe routes to school, with parents shouldering the burden for the school in mobilizing parent volunteers. In these days of waning parent volunteerism for many youth activities, in these days of increased liability and concern about screening for potential child abusers, in these days of heightened litigation and civil suits, let alone the over-arching concern about bullying, we have to question whether parent volunteers are a viable option for many schools, particularly those in neighbourhoods with fewer advantages and more crime.

Healthy Eating as a social construct

Another trend in the research identified through this 18 month review is the re-emergence of the notion that eating is primarily a social behaviour and that people are motivated to eat more or less based on their social interactions with others.

Child-rearing practices with regard to children’s bedtimes is one of those changing social behaviours that is having an effect on eating habits and weight gain. One of the new areas of investigation of obesity has been the influence of adequate sleep on weight gain. A Quebec study also made this connection between too little sleep and obesity. (Chaput et al, 2011) observed a “U-shaped relationship between sleep duration and all adiposity indices. None of energy intake, snacking, screen time or physical activity intensity differed significantly between sleep categories. After adjusting for age, sex, Tanner stage, highest educational level of the parents, total annual family income, and parental BMI, only short-duration sleepers (<10 hours) had an increased odds of overweight/obesity (OR 2.08, 95% CI 1.16-3.67). Addition of total energy intake and physical activity to the model did not change the association substantially (OR 2.05, 95% CI 1.15-3.63). They concluded that the study provides evidence that short sleep duration is a risk factor for overweight and obesity in children, independent of potential covariates. These results further emphasize the need to add sleep duration to the determinants of obesity”. A 2011 study done for the Sleep Council in England The study found that today's seven to 14-year-olds go to bed almost 40 minutes later than their grandparents. They also eat later, watch TV or play computer games and get less fresh air that their grandparents. These three factors could be having a detrimental effect on their ability to sleep well, according to The Sleep Council.
Another social construct, the working mother, is also creating a new pressure on the quality of meals. A news story entitled “Working moms spend less time daily on kids’ diet, exercise, study finds” led us to a study documenting the fact that when it comes to cooking, grocery shopping and playing with children, American moms with full-time jobs spend roughly three-and-half fewer hours per day on these and other chores related to their children’s diet and exercise compared to stay-at-home and unemployed mothers. Male partners do little to make up the deficit. Employed fathers devote just 13 minutes daily to such activities and non-working fathers contribute 41 minutes, finds the study. The researcher suggested that noted that schools should shoulder a greater burden for supporting healthy lifestyles, through healthier lunches and more activity.

Parent perceptions about the weight, activity levels and eating habits of their children was also examined in several news stories and research articles located in our 18 month review. Corder et al, 2012 found that most parents incorrectly classified their child as active when their child was inactive. Other stories described parents as being reluctant to talk to their children about their weight because they thought that it would lessen their self-esteem and raise the risks of their being bullied at school.

Intersections with other health and social issues/conditions/behaviours

Researchers are increasingly looking for correlations between the disease they are studying and other health/social issues and obesity is no exception to this general rule. We found three such stories/studies in our 18 month time period that linked obesity with sexual risk taking, mental health problems and drug use as well as bullying, both as the bully and the victim.
  • The social consequences and correlates between obesity and risky behaviours such as substance abuse and sexual activity as well as mental health problems are described in a special issue in the January 2012 Issue of Journal of Youth & Adolescence
  • A Canadian study found that obese teens not only make easy targets for bullies, in the case of girls, they're more likely to turn into bullies themselves, according to the findings of a Canadian study on the social fallout of being overweight. Researchers who followed more than 1,700 Ontario high school students for one year found that overweight and obese boys were twice as likely than their healthy-weight peers to be hit, kicked, pushed or shoved around. They also were two-times more likely to suffer "relational" bullying -- being shunned or excluded from groups and activities. Obese girls, meanwhile, were three times more likely than healthy-weight girls to become the perpetrators of relational bullying -- a kind of psychological torment that can cut as deeply as any physical wound
  • A Canadian news story, reporting on a BC parents meeting, quoted a study saying that obese kids were far more likely to be bullied than LGBT youth.
Use of behavioural theories that explain the problem or potential solutions

Our monitoring of research and news identified a couple of examples of researchers explicitly using behavioural theories to explain eating and activity patterms and to develop interventions.
Quebec researchers (Beaulieu & Godin, 2012) developed a “theory-based intervention programme aimed at encouraging high school students to stay in school for lunch. Intervention Mapping and the Theory of Planned Behaviour served as theoretical frameworks to guide the development of a 12-week intervention programme of activities addressing intention, descriptive norm, perceived behavioural control and attitude. It was offered to students and their parents with several practical applications, such as structural environmental changes, and educational activities, such as audio and electronic messages, posters, cooking sessions, pamphlets, improvisation play theatre, quiz, and conferences. The programme considers theoretical and empirical data, taking into account specific beliefs and contexts of the target population.

Plotnikoff et al (2012) used the theory of Planned Behavior to explain physical activity in a large sample of adolescents in Alberta, Canada. The authors note that “TPB explained 59% and 43% of the variance for intention and behavior respectively, in a sample of over 4000 students. Moderating (by gender) and mediating tests were supported and is therefore useful in understanding physical activity in this population. The articles we identified in the last 18 months also added more insights on the concept of behavioral intention.

The concept of “behavioural intention” is the premise for teaching students how to develop and implement a personal health action plan. This is a premise of many health education curricula in many parts of the world. An article in Issue #6, 2012 of The Journal of Social Psychology examines the connections between behavioural intention to implement personal health practices and affect and cognition. The authors emphasize that behavioural intentions are more emotional than intellectual and report that "results did not support the hypothesis that a shift from a reliance on affect to a reliance on cognition would occur as temporal distance increased. Within-participants analyses revealed a decrease in the contribution of cognition to behavioral intention formation when forming attitudes in the future condition". This might have significant implications about behavioural messages related to obesity insofar as they may be more successful emphasizing the benefits and fun of activity and healthy eating rather than the logic of balancing caloric intake and output.

Ickes & Sharma (2011) underscore the importance of behavioural intentions to eat in a healthy manner in another article identified in our monitoring. They argue that “The theory of planned behavior (TPB) proposes that the single best predictor of a person’s behavior is intention to perform that behavior. Successful application of the TPB supports that attitudes, subjective norms, and perceived behavioral control are predictive factors of behavioral intention (BI)”. Since many instructional programs seek to develop personal health action plans or "behavioural intentions", this study reported in the February 2011 Issue of Infant, Child and Adolescent Nutrition is encouraging. In a similar way, Widemann et al (2010) in another article identified as a result of our monitoring suggests that the more individuals develop personal health action plans (behavioural intentions), the more likely they are to change behaviour, even if they don't always follow through.

Impact, Role of the School on the Problem
This section examines the impact of the natural social and physical environment of the school on the problem or behaviour. This sub-section is not focused on interventions that can be delivered through the school but rather on the regular features of the school in its normal state or operations. The social environment of the school includes student and teacher conduct & relationships, co-curricular and after-school clubs and activities, staff morale, relationships between the school and parents, overall school climate/ethos and more. The physical environment of the school and nearby neighbourhood includes school grounds, transportation routes to school, gymasia and playgrounds, lighting, proximity to fast-food restaurants, exposure to advertising, municipal parks, busy city streets, high crime areas or natural green areas, access to municipal and other cultural facilities, age of the building, natural light, easy access to and quality of the water. School organization and practices include age/grade groupings, physical size, location and facilities of the school, age/experience/mobility of the teachers, basic school operations such as transportation/busing, lunches, recesses, and important social rituals in the school such as school assemblies, proms, graduation ceremonies, parent/teacher nights and more. School-related transitions include transitions from other schools, family/pre-school into primary school, between primary and secondary schools, secondary schools to post-secondary education/training or into the work force.

Our monitoring of research, news and other sources also found several items that discussed the impact of regular school practices and routines as well as the school’s social and physical environment on obesity. Here are some of the items noted in our postings:
  • Childhood Obesity Prevention Focus on the School
    Reflecting the reality of many national and state childhood obesity prevention initiatives, Issue $4, 2012 of Childhood Obesity focuses almost entirely on the school setting as the way to prevent obesity. Three editorials are presented, there are articles examining the impact (or lack thereof) of state and school district policies on food sales, a thorough look at farm-to-school programs and more.

  • A news story identified in this review noted that cutting short lunch time in school may lead to obesity (USA Today, Aug 17-2011). Citing a national survey done by the US-based School Nutrition Association, which shows elementary kids have about 25 minutes for lunch; middle school and high school students about 30 minutes. That includes the time students need to go to the restroom, wash their hands, walk to the cafeteria and stand in line for their meals. Many students may have only about 10 to 15 minutes left to eat their meals, school nutrition directors say. But students should have at least 20 minutes to eat their lunch, the government recommends.
  • In some countries such as the UK and in some states in the US, there are or were policies to add body weight or BMI to student report cards so that parents and students would know that their children are overweight. Our monitoring of the news media over the past 18 months found several articles that were very critical of adding BMI to student report cards, with really negative reports coming out of the UK from Kingshurst, Birmingham and Selly Oak, Birmingham. This practice never found favour in Canada but we do know that many school jurisdictions no longer benefit from the confidential basic health screening that local health authorities used to do for children beginning school (which examined weight, height, vision, hearing, vaccinations etc.) This type of screening is now often done by teachers in some school boards in a circuitous way through their participation in a widespread university-led early childhood assessment test.
Effects of Multi-Intervention Approaches, Programs, Strategies
This section includes research items that specifically report on multi-intervention approaches and programs only. Many research reviews do not differentiate between multi-intervention and single intervention programs which are discussed in the next sub-section. Please note the differences between comprehensive approaches (multi-issue, multi-level, multi-agency programs at all levels in several systems), coordinated agency-school programs (involving personnel from local agencies working with school boards at the regional level and whole-school strategies (Health Promoting Schools) involving only school-based personnel. This section begins with a discussion of whether the issue has been addressed in formal Consensus Statements or Multi-Intervention Plans, Frameworks or Models. The impact of the three types of multi-intervention approaches/ plans/programs is assessed in relation to overall health as well as on the issue or different aspects of the issue.

Multiple interventions: An Overview

As we all know, the knowledge and understanding that multiple intervention approaches and programs promoting health, healthy eating and physical activity are more effective than single intervention strategies has been with us for many years in Canada and in most other countries.

In 1997 Health Canada and the Canadian Association for School Health published Food for Thought, which was a nutrition-focused application of the Comprehensive School Health (CSH) approach (which had been developed, published marketed by CASH and HC earlier in the 1990 Canadian Consensus Statement on Comprehensive School Health. Similarly, and about the same time, the Canadian Association for Health, Physical Education, Recreation and Dance had published a similar statement on “active schools”, also recommending a multi-intervention approach for physical activity.

With all of this well-known to many for decades, it was both heartening and frustrating to read a recent systematic research review identified through our monitoring that essentially repeats the same conclusion. A review (Wang & Stewart, 2012) is cited by the Evidence Awareness program of the National Health Service in England. They conclude that “the evidence indicates that nutrition promotion programmes using the HPS approach can increase participant consumption of high-fibre foods, healthier snacks, water, milk, fruit and vegetables. It can also reduce participant breakfast skipping, as well as reduce intakes of red food, low-nutrient dense foods, fatty and cream foods, sweet drinks consumption and eating disorders. It can help to develop hygienic habits and improved food safety behaviours”. We also found similar articles once again making the argument for “whole school” strategies to promote physical activity.

Surely, the value of multiple intervention approaches or programs is not the question of today. That was resolved a long time ago. The real questions of today are similar to these:
  • How do we implement these multi-intervention approaches and programs in complex, ever-changing environments?
  • How can we tailor the various interventions and combinations to suit different local circumstances, conditions and most importantly, different resource levels within communities and countries?
  • Who will be assigned to coordinate the various interventions?
  • How can we ensure that the participating agencies and systems will continue to be there supporting school systems after the research and demonstration projects are complete?
  • How do we encourage researchers to spend less time publishing copyrighted programs and worrying about fidelity (in order to maintain a funding source and research credibility) and spend more time in examining issues of evolution, adaptability and sustainability of their programs in real world conditions.
  • What happens when the normal cycles of teacher and principal turnover occur? Who inducts new teachers into the principles and practices of the multi-intervention approach? How do we enable systems to respond to new demands and issues without abandoning what has been established already?
A Clear View and Shared Vision of the School Level Actions Required

One of the important things in initiating change is to have a clearly stated, practical view of what is being proposed. The International School Health Network, as part of its synthesis of better practices for over 25 comprehensive approaches to working with schools for health and social development purposes suggests that authorities and practitioners need to select or develop a shared vision of model that combines multiple interventions. In our monitoring activities from the past 18 months, we can state that this view is well established among Canadian groups concerned with obesity at least for the school-level actions that are seen as valid and practical.

The Canadian Childhood Obesity Foundation has identified several school-level interventions that can be delivered by educators in a “whole school strategy” which we have adapted below with several additions. This practical list matches the research and advice from Canadian reports and international publications such as Obesity in Canada (Public Health Agency of Canada) and the trans-national report on the Health behaviours of School-Age Children report. It is a pretty good school-level checklist, even though it is very similar to the earlier checklists published 10-15 years earlier by Health Canada, the Canadian Association for School Health and the Canadian Association for Health, Physical education, Recreation and Dance.

Action at the School Level: A Whole School Strategy
  • Implement a whole school planning strategy (eg Active Schools, Nutrition Friendly Schools) that includes action on physical activity and nutrition and has components such as parent involvement, PE and health instruction, changes to the school environment such as recess, lunchroom facilities and reverse order lunch hours, extra-curricular activities and other factors.
  • Implement an instructional program (eg Healthy Buddies) that addresses mental health, nutrition and physical activity.
  • Encourage teachers to use updated lists of lesson plans and resources (eg BC Curriculum Supplement)
  • Follow the guidelines or requirements of the provincial policies on food sales in cafeterias and canteens (eg BC Guidelines).
  • Discourage school, external groups and parental practices or activities that use food or activity as rewards or punishment, or that use unhealthy food or overly competitive sports in fund-raising or athletic activities.
  • Provide 5or more servings of fruit and vegetables per day to students.
  • Work with local food producers to organize Farm to School programs or activities.
  • Seek support and community involvement in delivering fruit and vegetables to schools in disadvantaged communities
  • Ensure school cafeterias offer attractive salads and vegetable sides
  • Limit screen time per day to less than two hours. Educate and encourage parents and students to restrict their screen time, discourage any TV before two years of age and do not provide TV’s in children’s bedrooms. (Eg ScreenSmart program).
  • Ensure one or more hours of moderate or vigorous physical activity per day.
  • Make use of the Active, Safe Routes to School resource for planning and suggested activities. Work with safety, crime prevention and environmental groups to make this happen.
  • Use “reverse lunches” that have children play outside for the first part of the lunch hour and then eat afterwards.
  • Use “active recess” strategies to encourage children to be active during the break.
  • Encourage regular classroom teachers to incorporate physical activity into their classes wherever possible.
  • Encourage zero consumption of sugar sweetened beverages per day. Encourage parents to pack water or milk in their child’s lunch. Consider using the SipSmart or Drop the Pop programs in your school.
Coordinated Agency & School Programs

This school checklist is a good one. It has several Canadian examples of programs. All of these interventions are within the reach of most schools in Canada. But there is something missing. It is the similar list of ongoing actions that school boards, health authorities, sports and recreation departments and nutritionists in the community need to be doing to support schools every year in “coordinated agency and school programs”. The action list could include:
  • Active support and funding for parent education programs
  • Ongoing community awareness activities and funding for community-based groups
  • Regional planning mechanisms to ensure that sports, recreation and nutrition services are available to all schools
  • Regional planning and funding for farm to school programs
  • Coordinated municipal policies regulating sales of junk food at sports centres and hockey rinks
  • Inter-agency agreements making it easier for schools and community groups to share sports and recreation facilities
  • Regular funding of joint in-service activities for nurses, teachers and others
Comprehensive, Multi-Level, Multi-System Approaches Linked with other Issues

Similarly, we need lists of actions to be taken at provincial/territorial ministry/whole of government level to support local agencies and local schools through “comprehensive approaches” linking multiple interventions delivered by multiple systems at multiple levels. These include:
  • Policy requiring school boards, health authorities and other agencies to establish inter-agency protocols and committees
  • Establishing inter-ministry committees to develop, oversee implementation and conduct regular evaluations of progress
  • Requiring health ministries to report on activity and diet of young people in regular reports to the public
  • Requiring education ministries to report on the health, nutrition and physical education knowledge, skills, beliefs, intentions and attitudes of students as they leave primary and secondary schools
  • Ensuring that all children in their jurisdiction have access to a healthy breakfast, lunbch and snacks through equitable provision of school meal programs
In our monitoring of research articles we did find an increase in research attention on the leadership role required of ministries. We cite one of those items here and more studies below in the policy section of this paper. Four articles in the June 2012 Issue of Journal of School Health focus on correlations between ministry and school district policies and school actions on health issues such as tobacco, nutrition and healthy eating. Another article shows how the CDC School Health Index can be used to monitor such policies. The policy index approach facilitates the consideration of the effect of school policy change in a holistic, aggregated way. School characteristics influence policy adoption, and thus, should be taken into consideration in the promotion of policy change.

In federal countries such as Canada, there is also a more transparent and explicit role for federal departments, research agencies and other organizations. These include:
  • Departments responsible for industry and consumer protection (eg Industry Canada) need to take stronger action on protecting consumers from processed foods through regulations, consumer awareness advertising and more
  • Departments responsible for agriculture (eg Agriculture Canada) should invest in farm-to-school programs, fruit & vegetable programs in disadvantaged areas
  • Departments responsible for families and citizen welfare (Human Resources and Skills Development Canada) should be investing in school meal programs and, adding nutrition supplements to head start programs and investing more for food stamps and similar programs
  • Departments responsible for citizen health (eg Health Canada, Public Health Agency of Canada and the Food Inspection Agency of Canada) need to invest in food supplement programs for isolated communities that include schools as distribution mechanisms
  • Research and knowledge development agencies (eg Canadian Institutes for Health Research, Canadian Best Practices Portal, Health Evidence Canada and others) need to coordinate their efforts around an explicit and shared research and knowledge development agenda. This should include the formation of as well as ongoing support for links and knowledge exchange activities between university-based research centres, professions such as the Dieticians of Canada, advocacy and service groups such as the Centre for Science in the Public Interest and Breakfast for Learning, intergovernmental mechanisms such as the federal-provincial Nutrition Working Group and the Joint Consortium for School health and in national conferences, communities of practice and web-based knowledge exchange activities.
Our monitoring of the news and reports over the past 18 months has noted that the Public Health Agency of Canada has funded 37 projects on obesity prevention. The call for proposals included children and youth as a priority. However, after searching on the PHAC web site, we found only news releases about only two of these projects, without any listing of funded projects and contact information. Indeed, the changes in the various contributions and granting programs in PHAC has resulted in having outdated information (latest being 2001) and confusing and broken links on the PHAC web site.

As well, we also noted that the CIHR Institute on Nutrition, Metabolism and Diabetes has included obesity intervention research as among its strategic priorities for 2010-14. We conducted a search of the CIHR database for previously funded decisions and through a helpful search page using “obesity” as the key word search noted that $156,747,909.00 has been provided to 629 projects related to obesity. A search using “obesity and schools” located 24 funded projects totalling $4,269,552.00. All of these projects are now completed. Five of these 24 projects were evaluating the impact of interventions and the remainder were investigating risk/protective factors, social influences and determinants.

We could make more complete lists at the three other levels of action in obesity prevention, namely the local agency/school board, provincial/territorial ministry and federal/national levels but the point has been made. We don’t need more checklists and self-assessment tools for individual schools. We need them for health authorities and school boards. We need them for health and education ministries and for the whole of provincial/territorial governments and for federal departments and agencies.

At the international level, there are and have been several published consensus statements and multi-intervention models or plans on physical activity and nutrition. These include:
- Healthy nutrition: an essential element of a health-promoting school (WHO, 1998)
- Promoting physical activity in schools: an important element of a health-promoting school (WHO, 2007)
- Global Strategy on Diet, Physical Activity and Health (WHO, 2004)
- Nutrition Friendly Schools Initiative (WHO, 2005)
- School Policy Framework: Implementation of the WHO Strategy on Diet, Physical Activity & Health (WHO, 2008)
- Toronto Charter on Physical Activity (Global Advocacy for Physical Activity, International Society for Physical Activity and Health, 2010)
- School Meal Programs (UN World Food Programme)
- School Nutrition in Developing Countries (Partnership for Child Development)

Effects of Individual Evidence-based and Experience-tested Interventions
The items in this section Include Policy, Instruction, Services, Social Support, Physical Environment Interventions.
Policy Interventions
Policy interventions include policies, regulations or professional guidelines established by whole of government as well as individual ministries, local agencies and school boards and professions. Policies established by non-educational authorities usually position their school-related actions within a broader framework on youth or community.

Most Canadian provinces and territories introduced policies regulating food sales in schools from 2006 to 2010. In some cases, these mandatory policies would be part of suggested multiple intervention approaches, coordinated programs or whole school strategies on nutrition. However, it was usually the case that only the regulation of food sales was mandatory and the other activities were optional.
Reading the news stories and articles on policy that were located in our 18 month search, it would appear that most jurisdictions are currently implementing school food sales policies and regulations in most jurisdictions but the impact of those policies on actual food consumption has not yet been firmly demonstrated.
  • An article in the July-August 2012 issue of Canadian Journal of Public Health would suggest that the school food sales policy in Quebec appears to have changed meal offerings since 2002. (71% of primary schools, 71% of public secondary schools, and 54% of private secondary schools did not offer cold-cut dishes, stuffed pastry, or a fried food on their daily menus. But sugared beverages and whole grain breads were still problems).
  • Two studies report on the effect of policies regulating school meal offerings in England in the February 2011 Issue of Public Health Nutrition. The studies report that schools complied with the policies and that students who purchased meals at school made healthier choices. Both studies noted that food provided by parents for consumption at school was not affected. In the same issue, a New Zeal study noted that family-provided food was the mainstay for school children.
  • Having a good policy does not ensure change in school nutrition An article in Issue #4, 2012 of Childhood Obesity examines the impact of well-written state and school district "local wellness policies” (LWP) (actually addressing only nutrition and healthy eating in schools) as measured by perceived actual implementation of healthier reimbursable meals and sales of competitive (ie fast foods) in schools. "Data was collected from school districts in California, Iowa, and Pennsylvania included district LWPs and online surveys at the district (n = 23) and school levels (n = 76). Overall LWP and component strength scores did not consistently predict perceived implementation of LWP reimbursable school meals or nutrition guidelines for competitive foods offered or sold in school settings. These findings are similar to a recent report by Kubik and colleagues, where school district nutrition policies were not associated with less “junk” food in vending machines and school stores. That study suggests neither state policy nor district policy influence the availability of junk food in high schools; however, state policies did influence junk food availability in elementary and middle schools. Conversely, these results contrast those of Schwartz and colleagues,24 who reported higher LWP strength scores were predictive of implementation among schools in Connecticut. Collectively, results of this study and those reported previously suggest LWP scores, which indicate comprehensiveness or strength of a LWP, may not result in greater perceived or actual implementation.
  • State Laws on PE affect Elementary, Middle but not High School PE time A study reported in Issue #8, 2012 of the American Journal of Public Health examined the actual time for PE classes in elementary, middle and secondary schools. The US states with stringent laws requiring PE time had 27 & 60 more minutes per week in elementary and middle schools than states with general laws and 40 & 60 more minutes than states with no laws for those schools. High school results were non-significant.
  • Questions and Pushback on Effect of Regulating School Food Sales. There are several items in this week reporting on questions and push back on the effectiveness of regulations affecting food sales in schools. A longitudinal study points out that the sale of fast foods in schools has much less effect on weight than other factors, primarily the home environment and parent lifestyle. Canada's national newspaper questions the value of regulations when children can go to food outlets nearby. A blog post reviews the recent changes made in Los Angeles, Seattle and other cities when students rebelled against tasteless healthy meals.
  • A research study reported in a news story (Aug 13-12) found that “ School snack laws may help prevent weight gain” Students gained less weight over three years if they lived in states that restricted the sale of unhealthy snacks at school than kids in states without those laws, a study has found. The study did not examine the impact of food sales in cafeterias. Students in states with strong laws all three years gained an average of 0.44 fewer BMI units and were less likely to remain overweight or obese than their peers in other states. That’s about 2.25 fewer pounds for a child who is 5 feet tall and weighed 100 pounds.
  • Bans on sugared beverages reduce in-school access but not consumption An article in the March 2012 issue of the Archive of Pediatric and Adolescent Medicine reports on an analysis of students across 40 states The proportions of eighth-grade students who reported in-school SSB access and purchasing were similar in states that banned only soda (66.6% and 28.9%, respectively) compared with states with no beverage policy (66.6% and 26.0%, respectively). In states that banned all SSBs, fewer students reported in-school SSB access (prevalence difference, −14.9; 95% CI, −23.6 to −6.1) or purchasing (−7.3; −11.0 to −3.5), adjusted for race/ethnicity, poverty status, locale, state obesity prevalence, and state clustering. Results were similar among students who reported access or purchasing SSBs in fifth grade compared with those who did not. Overall SSB consumption was not associated with state policy; in each policy category, approximately 85% of students reported consuming SSBs at least once in the past 7 days. Supplementary analyses indicated that overall consumption had only a modest association with in-school SSB access.
  • School sales of sweetened beverages has no effect on weight We find almost no evidence that availability of sweetened beverages for sale at school leads to heavier weight or greater risk of overweight or obesity among children. We also find limited evidence that availability of sweetened beverages for sale at school leads to higher total consumption of these beverages. This startling conclusion is based on a large US longitudinal study of young children. Go to this article in the Nov/2011 issue of Social Science & Medicine.
Tunnel Vision in Analyzing Policy Implementation

Most studies of policy implementation focus almost entirely on the adoption and implementation process in the front lines of the system. This tunnel vision ignores the multiple levels of the large, bureaucratic, complex, loosely-coupled, systems that actually are or should be responsible for the wide-spread implementation of a policy in their system or in another system to which they have been assigned. Budd et al (2009) illustrate this type of narrow focus when they examine the implementation of School Wellness policies in 300 high schools in the US.

Budd et all report that “most respondents (82%) indicated their school made their staff aware of policy requirements; 77% established a wellness committee or task force, 73% developed administrative procedures to guide policy implementation, and 56% trained staff to implement the policy. Only 26% had acquired funding for implementing the SWP.

The most commonly cited challenges to implementation were lack of time or coordination of policy team (37% of respondents) and lack of monetary resources (33%), followed by “not a priority” (26%), lack of staff cooperation or support (24%), lack of student acceptance (24%), “no consequences of noncompliance” (20%), lack of training, technical assistance, or resources (20%), “lack of knowledge or unsure how to proceed” (17%), lack of leadership (10%), and lack of appropriate food or beverages available from vendors and suppliers (6%).

Five of the 7 policy core domains were reported as being implemented by more than 80% of the schools (nutrition education, nutrition standards for USDA child nutrition programs and school meals, nutrition standards for competitive and other foods and beverages, physical education, and physical activity). The core domains least likely to be implemented were communication and promotion (63% of respondents) and evaluation (54%).
Only 33% of schools were held accountable for implementing communication and promotion; 85% were held accountable for implementing nutrition standards for USDA child nutrition programs and school meals. For 3 domains (physical activity goals, communication and promotion, evaluation), most respondents reported they were either unsure or that there was no accountability for SWP implementation”.
Budd et al conclude that organizational capacity within the school (such as procedures, staff awareness, setting up a committee, etc) were instrumental in the success of policy implementation. They also note that the vast number of challenges to implementation (noted above) had to be addressed if implementation were to succeed. And then, somewhat typically for researchers, they turn to arguing that enhanced “accountability” for policy implementation would be needed to implement the policies effectively.

Their analysis is typical of most and ignores the fact that the higher levels in the school system (school district administrators and education ministry officials) would likely give almost exactly the same answers to the survey in regards to their work on school wellness policies. Can anyone tell us that these problems would not be faced by these two levels of school administrators: were lack of time or coordination of policy team, lack of monetary resources, “not a priority” lack of staff cooperation or support, lack of student or parent acceptance and political/media backlash, “no consequences of noncompliance”, lack of training in systems change, lack of technical assistance, or resources, “lack of knowledge or unsure how to proceed” , lack of leadership from above, and lack of appropriate food or beverages available from vendors and suppliers.
Further, if we looked into the offices of local health authority managers, community nutritionists, and health ministry officials, we would likely find the same challenges plus a long debate about food quality from a variety of vested and special interest groups.

Instructional Interventions
Instructional interventions seek to develop general as well as specific skills, specific functional knowledge, normative beliefs, self-knowledge, behavioural intentions, normative beliefs and self-concept and more. Health and social development goals are usually pursued in three major curricula; health/personal and social development, family studies/home economics and physical education but are often pursued through career/life planning courses, moral or spiritual education and other specific programs. Three levels of student achievement are often sought including basic health literacy for all students, a more optimal life-long learning and interest in health and social development for most students and health/social services career exploration and training for some students. The curricula established by government ministries are implemented in instructional programs that require specific and general teacher skills, support for instruction, better scope/sequence of curricula, teaching/learning materials, teaching methods, teacher education and training, parent involvement in at-home learning, web-based learning and more.

The quality of the Instruction in physical education and nutrition education classes was questioned by some of the articles identified in this review. This is a bit of a change from the tradition of most studies which examine only the quantity or time spent in such instruction.
  • Time spent being active in Australian PE Classes An article in Issue #3, 2012 of Journal of Science & Medicine in Sport reports on another small study of time spent in moderate or vigorous activity in PE classes; this time from Australia. Systematic direct observation of Year 7 PE classes over a six-month period. Eighty one (81) PE lessons across six schools were observed. The mean (SD) percentage of class time spent in moderate to vigorous physical activity (MVPA) was 56.9% (18.7). However, only 60% of the 81 met the recommended 50% of class time spent in moderate to vigorous physical activity (MVPA). Just over 6% of class time was spent in skill instruction. Game play made up nearly half of the lesson context (44%) and teachers spent just under one-third (31%) of class time promoting PA
  • Less than Half of Time in PE Classes is Active An article in the May 2012 Issue of Physical Activity & Health reports on a detailed Texas study of time spent in PE classes in actually being moderately to vigorously active. Students engaged in less than half their PE class time in MVPA (38%), while approximately 25% of class time was spent in classroom management. Percent time in MVPA was significantly higher in outdoor classes.
  • In a similar vein, the use of renewed popularity of dance on television has coincided with a “Dance, Dance Revolution” in PE programs. An increased focus on dance in PE may be one way to encourage adolescent females and males to be more active. However, an article identified in our August monitoring (Gao, 2012) suggests that although junior high students are definitely motivated to dance, they lack the movement skills necessary to participate and therefore, the PE classes teaching dance end up with students not achieving moderate or vigorous activity levels. A Canadian analysis of girls’ experiences and involvement with physical activity (Clark et al, 2012) concluded that “unstructured play that occurred in girls’ free time and dance appeared as important forums, which allowed girls to engage in activities they enjoyed and explore their physicality”.
  • The American food guide MyPlate discussed Several articles and summaries of poster presentations at a recent nutrition conference in Issue #4 (Supplement), 2012 of Journal of Nutrition Education and Behavior report on and evaluate the US food guide program called MyPlate. Canada has changed its icon when it released its new set of nutrition guidelines and produced educator materials as well. The American articles discuss the impact of the new icon but the issue to be raised here is this: do these guidelines encourage teachers to teach the facts (food groups, nutrients, portion size, balance etc. about nutrition rather than emphasize the skills (reading labels, making healthy snacks, etc) and the practical knowledge (advertising tricks, weight loss gimmicks etc.) One of the conclusions often reached when reviewing the impact of health education classes in schools is that curricula and instruction should be as specific and practical as possible in encouraging students to follow specific behaviours. Our monitoring of the research and news located some items that suggested this kind of specificity.
  • Programs to Encourage Eating Breakfast Articles from the February issues of the European and American Journals of Clinical Nutrition can be combined to show the value of nutrition education on eating breakfast. The article in the American journal notes that eating breakfast can have a positive impact on food choices and eating later in the day. The European article reports that a school educational program affected the number of children eating breakfast each day.
  • Cooking Skills, not nutrition facts are best: Study. A new study published in the Journal of Nutrition Education and Behavior shows that having cooking classes alongside subjects such as math and science may promote healthier eating habits as well as curb the childhood obesity epidemic. Researchers at Colorado State University Department of Food Science and Human Nutrition wanted to find out whether nutrition education had any positive effect on students. Using the Cooking with Kids program as a model, they interviewed 178 fourth graders to evaluate children’s attitudes towards cooking and experiences at school and home following a series of cooking plus tasting or just tasting classes alone.
Another typical finding in health education research is that teaching knowledge or facts without addressing skills, attitudes, beliefs and intentions is not likely to change health behaviours, although practical knowledge about the issue may be a pre-requisite for such changes in behaviour.

  • Knowledge alone does not change behaviour A study reported in Issue #4, 2012 of the Journal of Nutrition Education & Behavior reports that a classroom nutrition education program combined with parent involvement and teacher training improved knowledge but did not change consumption. This is hardly a surprise, since we have similar studies on many health issues over the past two decades. The real questions before us are whether such knowledge is a prerequisite for behaviour change, how to teach practical skills related to food selection and preparation, understand social influences and modify normative beliefs about food and eating.
Incorporating physical activity into regular elementary school classrooms

A Canadian study (Stanec & Murray-Orr, 2011) has identified some of the barriers for elementary teachers who want to bring physical activity and physical literacy into their regular classroom. They conclude that “elementary generalists have reported feeling overwhelmed with crowded schedules, inadequate space, a lack of administrative and specialist support, and the pressures of standardized tests. As well, physical educators have shared feelings of both isolation and alienation from those who teach solely in the classroom. The findings also showed that teachers place a high priority on their students’ health and want to help provide them with opportunities to be physically literate”.

An American study (Dunn et al, 2010) of the effect of teacher training of regular elementary teachers is reported in the September 2012 of Preventing Chronic Disease. Three hours of training motivated the teachers to increase the average time spent in activity with students from 2.4 minutes to 9.5 minutes (a gain of 7.1 minutes) and is presented as one way of achieving the goal of having children be active at least 60 minutes per day. However, these seven minutes represent the time that the class is engaged in activity and there may be differential levels of activity among the individual students.

Health & Other Services
This sub-section includes school-based and linked clinics, screening services, early identification and referral, coordination with schools in treatment, individual educational programs, alternative schools and classes, in-school management of the illness/condition, coordination with the school from family, social, youth, addictions, mental health, early childhood, police, sports/recreation and employment services, coordination with the school during rehabilitation/re-integration etc. The over-arching goals for the school-linked delivery of these services is to be convenient and accessible for youth from school or within the neighbourhood, to be youth-friendly in nature, to have minimal wait-times for the children/ youth/families involved and to coordinate effectively with the schools in terms of early identification/referral, assistance in managing the disease at school and re-integration after treatment. In regards to obesity, the roles of the community nutritionist and programs in local health authorities and the sports/recreation coordinators and programs in local municipalities and recreation departments are very important.

As is often the case with school health research, we did not identify many studies that examined the effectiveness of service delivery in regards to obesity and overweight. Two exceptions to this general pattern of focusing solely on what educators can do, rather than others in the community are noted below.
  • A review of the research (Branscum & Sharma, 2012) on the impact of after school programs on obesity/overweight reports that such programs have little impact on weight or the antecedents of overweight/obesity. A total of 20 interventions were found from 25 studies. Children in the interventions ranged from kindergarten to middle schoolers, however a majority was in the 4th and 5th grades. Most of the interventions targeted both physical activity and dietary behaviors. Among those that focused on only one dimension, physical activity was targeted more than diet. The duration of the interventions greatly varied, but many were short-term or brief. Many interventions were also based on some behavioral theory, with social cognitive theory as the most widely used. Most of the interventions focused on short-term changes, and rarely did any perform a follow-up evaluation. A major limitation among after school interventions was an inadequate use of process evaluations. Overall, interventions resulted in modest changes in behaviors and behavioral antecedents, and results were mixed and generally unfavorable with regards to indicators of obesity.
  • News Story (Jul 20-11) No point in telling parents about children's weight: Study. School policies that let parents know when their children are overweight or obese appear to have little impact on the problem, according to a U.S. study (Madsen & Linchey, 2012). In the last decade, almost all public schools in California collected information about the height and weight of fifth, seventh and ninth graders, but only some schools opted to send the results to parents -- giving Kristine Madsen, at the University of California, San Francisco, a chance to evaluate the impact of that notification. She found that, years later, children whose parents were told they were overweight were no more likely to have lost weight at that point than children whose parents were not notified, according to a report published in the Archives of Pediatric Adolescent Medicine.
Social Support
This sub-section includes school staff/volunteer awareness of the issue, parent information, education and support, student leadership programs, peer helper programs, student clubs, working with community-based organizations, programs and campaigns, working with local media outlets, working with social media and more.

Many countries have organized and delivered media and community awareness campaigns on physical activity, healthy eating and a combination of both. In Canada, there have been several such campaigns on physical activity in the past decade from groups such as Participaction.

A recent Research Review on Physical activity mass media campaigns in several countries (Leavy et al, 2011) found that seven out of 18 studies reported changes in physical activity levels as a result of the campaigns. However, the reviewers expressed caution about the limitations of the evidence used in most evaluations. The authors also suggest a process and evidence-based framework for designing such campaigns.

The 18 month monitoring time frame selected as the basis of this article did identify some articles reporting on process evaluations or initial descriptive studies of the Participaction campaign in Canada.
The Sip Smart! BC™ is an educational program that was developed and introduced in BC and introduced in Quebec. The program teaches children in grades 4 to 6 about sugary drinks and about making healthy drink choices. Sip Smart! BC™ was created and developed by the BC Pediatric Society and the Heart and Stroke Foundation of BC & Yukon with funding from the BC Healthy Living Alliance. Families can download fun and engaging resources to help children learn more about sugary drinks and healthy drink choices. To get started, click Families, and follow the links.

The Drop the Pop Campaign was developed in the Northwest Territories and spread to other northern territories and provinces in Canada. The Drop the Pop Campaign is to encourage students and their families to consume healthier beverages and foods, to learn new skills and knowledge and to foster long-term healthy food intakes in order to maintain and improve overall well-being. The Yukon program has evolved and now sponsors other school, family and community activities to promote healthy eating.

Changes to Physical Environment or Resources
This sub-section includes school grounds, facilities, transportation to and from school, provision of specialized or other equipment and more.

Our time frame for identifying articles, stories and resources related to the physical environment of the school and its surrounding neighbourhood did include articles on this aspect of school health promotion. They included:
  • Renovating School Yards for Physical Activity Two studies in the April 2011 Issue of International Journal of Behavioral Nutrition & Physical Activity report that renovating playgrounds on school grounds can increase their use and physical activity. Shade, cleanliness & safety seem to be important.
  • Evaluation of USDA Fresh Fruit & Vegetable Program: The 10-year-old Fresh Fruit and Vegetable Program, which began with four states and the Zuni tribe in New Mexico, now operates in all 50 states and several U.S. territories. More than 4,000 elementary schools participate, and the program has an annual budget of $150 million—or nearly $1 billion each time the federal Farm Bill is renewed. An evaluation of the programlast year found that students at schools participating in the Fresh Fruit and Vegetables Program ate an average of a quarter cup more fresh produce per day than students at schools without the program, and consumed almost no additional calories in the process.
  • School snack programs work in isolated indigenous communities: The impact of a school snack program on the dietary intake of grade six to ten First Nation students living in a remote community in northern Ontario, Canada was reported in Issue #3, 2012 of Rural and Remote Health. The authors report that "Students participating in the snack program during the 2004 data collection (37%; n=23) compared with those who did not (63%; n=40) had significantly (p<0.05) higher mean intakes from the ‘Vegetables and Fruit’ food group (7.5 vs 3.4 servings), folate (420 vs 270 µg), dietary fiber (18 vs 8 g), vitamin C (223 vs 94 mg), calcium (1055 vs 719 mg) and iron (16.5 vs 11.7 mg). For the 2007 data collection, snack program participants (52%; n=26) had higher intakes from the ‘Milk and Alternatives’ food group (3.3 vs 2.2 servings), vitamin A (697 vs 551 RE [retinol equivalents]), calcium (1186 vs 837 mg), and vitamin D (6.9 vs 4.4 µg) and significantly lower intakes of 'Other' foods (6.0 vs 7.2 servings) compared with non-participants (48%; n=24). Given the positive impact of the program on the food and nutrient intake of school snack program participants, qualitative feedback will be used to enhance the program and participation. Clearly, school snack programs can be an important venue to address the nutritional vulnerability of First Nation youth living in remote communities."
These positive studies about the impact of providing fruit & vegetables to disadvantaged students may be usefully correlated with an analysis of a systematic review done by the Centre for Reviews and Dissemination (CRD) on a review of behavioural interventions to increase fruit & vegetable consumption. The research review concluded that behavioural interventions had a modest effect but the CRD analysis suggests that this conclusion should be treated with caution because of limitations in the review methods. Another review (Ganann et al, 2012) points to the need for systematic reviews of interventions that increase access to Fruits & vegetables and provides a preliminary look at such research.

Another topic that has arisen in recent months in the published research is the idea of establishing boundaries surrounding schools so that students cannot easily leave the school at lunch hour to purchase junk or fast food or to prevent advertising aimed at young people to affect their immediate purchasing decisions. There were several articles that addressed this new topic, including several Canadian researchers:
  • Seliske et al (2012) examined Canadian data in the Health behaviours in School-Age Children Survey and suggested that a buffer zone of 1000 metres was the preferred distance to deter students from leaving the school. Students who had at two or more food retailers within 750 m of their schools had a 2.74 times greater relative odds of purchasing food at those locations.
  • Black & Day (2012) did a similar analysis in British Columbia and found that “in 2010, over half of the public schools in BC (54%) were located within a 10-12 minute walk from at least one limited service food outlet. The median closest distance to a food outlet was just over 1 km (1016 m). Schools comprised of students living in densely populated urban neighbourhoods and neighbourhoods characterized by lower socio-economic status were more likely to have access to limited service food outlets within walking distance. After adjusting for school-level median family income and population density, larger schools had higher odds of exposure to food vendors compared to schools with fewer students.
  • A Canadian webinar recently addressed the topic of school zoning by-laws.
  • The Association pour la santé publique in Quebec has published a planning guide for municipalities. .
It is appropriate here to inject an observation about Canadian communities in regards to the feasibility of re-zoning neighbourhoods in order to situate fast food outlets far enough away from schools, particularly secondary schools which are often located in central points in the communities and cities. In growing communities and suburbs, where new roads and neighbourhoods are being built, it is likely feasible to incorporate such considerations. However, in most Canadian communities and likely in many other countries, there are fewer communities who are building in that manner. Most neighbourhoods will be already established, with major routes, bus lines and rail lines, commercial centres and secondary schools already built. It would likely be quite challenging for municipal authorities to change those existing arrangements unless there was an urgent, more short term threat to public safety like increased road accidents or crime.

There were also several Canadian and international articles on another relatively new topic in physical activity and schools, the use of active and safe transportation routes to school. Here are some of the Canadian articles:
There are also several international articles that were identified in our snapshot of the last 18 months. Chillion et al (2012) report that bicycling to school is associated with improvements in physical fitness over a 6-year follow-up period in Swedish children. Southward et al (2012) calculate the valuable contribution of the school journey to daily physical activity in children aged 11–12 years. We also noted several articles discussing the “walkability” of neighbourhoods as a factor in activity patterns of young people and adults in communities.

In Canada and in other countries, there are several organizations promoting active and safe routes to school. A national web site provides some information and some excellent planning resources. The ASRTS programs have benefitted from a previous national program between Health Canada and Environment Canada that promoted walking to school as an environmental and active process. As well, it looks like several local health authorities are coordinating the programs in cooperation with schools.

However, we should again inject some caution. One of the articles in the February 2011 Issue of International Journal of Behavioral Nutrition & Physical Activity (Chillion et al, 2011) is a review of the research on active school transportation. The 14 studies reviewed had varying methods and results, so the authors concluded that insufficient evidence is available at this point to conclude that these programs increase physical activity. However, there is considerable attention in Canada and in other countries.

As well, we would again suggest that older, established communities and cities face significant challenges in creating safe pathways to and from schools. Further, as we read through the web sites here in Canada, we noted that many of the “participating schools” were actually noted as such because they took part in at least one event per year, mostly being the school participating in the annual International Walk to School Day. This is entirely different than finding volunteers or paying staff (other than street safety workers at major streets) to organize ongoing active and safe route to school activities every day.
Based on the Canadian HBSC data from the recent survey, it looks like about one third of Canadian students walk to school. This is likely to remain the same unless a considerable amount of funding is provided to schools to sustain more active programs to attract more students and parents.

To end this sub-section on a more positive note, we should also note that our 18 month snap shot of changes in Canadian school practices did include stories and articles on innovative and low cost interventions such as reverse lunches, active recess, changes to lunchroom décor and providing more time for students to eat their lunches.

Implementation, Capacity, Sustainability and Systems Change
(This sub-section Includes evidenced-based, practical and strategic Implementation strategies, diffusion, dissemination or education change theories, capacity and capacity-building/ continuous improvement, sustainability and understanding the characteristics of systems, organizational development and systems change theories and approaches in order to effect wide-spread and enduring change)

Implementation/On-going Operation Issues

In the recent past, researchers, officials and practitioners were primarily concerned with the quality of the program and its initial adoption. As we have learned, often the hard way, that “implementation” is not a process that is ever finished in an open, complex and adaptive system, we now think of implementation both in terms of maintaining an ongoing operation as well as a complex process that will ultimately affect the outcomes of a program, regardless of external controls and concerns about fidelity. Indeed, researchers have turned their attention to the implementation and on-going operation of multiple programs as part of a comprehensive, multi-level approach involving multiple systems at multiple levels.

Much of the discussion about implementation/operations of programs and approaches on a variety of health issues has focused on practical and fairly obvious factors. Teacher training in the program (which is distinct and different from teacher education and development in generic skills and knowledge about the issue) has been the big favourite, with most studies concluding that teachers trained in the program did a better job in implementation. Other fairly obvious factors include stakeholder involvement, parent involvement, youth engagement, clear assignments of tasks and roles, feedback during implementation, having support from administrators and so on. The ISHN has called these “local mechanisms in implementation” and has drafted a Wikipedia style summary of these factors)

Our 18 month time frame for locating studies and stories did identify some examples of this kind of practical implementation planning. For example, Cardon et al (2012) found that when implementing a set of physical activity interventions in 111 elementary schools and 125 secondary schools that “better knowledge of community schools and having attended in-service training were associated with higher implementation scores in elementary and secondary schools. Better implementation of the strategies was found in larger schools. Participation in activities from the School Sports Association and more perceived interest from parents and the school board were also associated with higher implementation scores”.

A newer idea regarding implementation/on-going operation that is appearing in the research on some issues is the use of an evidence-based planning model to plan, implement and operate programs or multi-intervention approaches. (This use of evidence-based models is complementary to the use of evidence-based interventions.) Jacobs et al (2012) have identified eleven such evidence-based dissemination/planning models. Examples include the Re-AIM framework, PRECEED-PROCEDE, the Mariner Model and others.

Our list of items over the past 18 months did identify one example of the use of a planning model. Coleman et al (2012) suggest that the use of an “evidence-based public health approach”may be more effective in achieving positive outcomes when trying to change school environments and policies” . They note a variety of issues hampering the implementation of school nutrition policies: “These issues included 1) difficulty in implementing school nutrition environment changes (vending, cafeteria food sales, other sources of foods/beverages, etc.) due to the pressure that nutrition services faced for financial stability; 2) failure to limit unhealthy foods brought from home into a variety of school settings (classrooms, playgrounds, cafeterias); 3) lack of integration of the intervention into daily school practice because of delivery by research staff; and 4) reliance on curriculum that was difficult to implement within the context of standardized academic performance testing”.

They report that “As hypothesized using an implementation-focused EBPH approach to change nutrition environments and policies significantly decreased outside foods and beverages on campuses. The change was primary seen for unhealthy foods and beverages, although healthy foods were also reduced in the morning snack recess/playground environment. Conversely, healthy food items increased during lunch in intervention schools only”.
Canadian researchers (Masse et al, 2012) monitoring the implementation of the Action Schools program in British Columbia used “constructs from the theories of organizational change, social cognitive theory and Rogers's diffusion of innovation model to examine characteristics of teachers and schools and attributes of the innovation associated with implementation. Teacher self-efficacy, outcome expectation, training received, organizational climate/support, level of institutionalization, environmental influence, and attributes of the innovation were associated with implementation. In multivariate analyses, teacher self-efficacy, training, and level of institutionalization remained significant.

A third idea in the emerging discussion of implementation/operation issues focuses on the factors that are almost never considered in controlled trials of various programs. ISHN calls these “local drivers/barriers in implementation/operations”. They include factors such as inter-personal relationships between the leaders of key stakeholders, recent incidents, the history of the issue within the organization or community, the actions or priorities of key gatekeepers and more. The articles, stories and resources we identified in the time frame used for this article did not locate any items addressing this aspect of implementation/ongoing operations of obesity prevention programs.

Capacity and Capacity-Building
The International School Health Network, in its Wikipedia style web site has gathered the thoughts of many experts, practitioners and officials about the concepts of capacity and capacity-building. These include “baseline capacity” such as minimum staffing/budgets, time in the curriculum, wait times for services delivery as well as “operational capacity” in systems and institutions (developed from a WHO model by Canadian researchers) that includes (1) coordinated policy and senior leadership at all levels, (2) assignment of coordinators at all levels, (3) formal and informal mechanisms for cooperation and coordination, (4) ongoing knowledge development and exchange, (5) ongoing workforce development (6) strategic and joint management of emerging issues and priorities (7) regular monitoring and reporting on systems capacity, processes/programs, outputs and outcomes (8) explicit planning for sustainability and renewal and “absorptive capacity” that understands that the size of the change (innovation or reform) and the readiness/ability of the system to absorb that change in a realistic timeframe will have an enormous impact on the ongoing effect of the approach or the program . This includes the notion that if a system or organization is pre-occupied with another threat or major reform, it is less likely to adopt, implement, operate and maintain other changes, however desirable.

Baseline capacity

The ISHN defines baseline capacity as follows: The basic or baseline capacity of health, school and other systems to promote learning, health, safety and social development requires an essential number of staff, minimal financial resources and legislative/policy authority to operate a minimally effective and coordinated school-based or school linked approach or to implement a defined number or type of programs, services and policies. These basic capacities include the physical aspects of the schools, social supports such as parent and community involvement, essential preventive health and other services, core instruction in health, family studies, physical education, environmental studies, social studies and moral/spiritual/religious instruction and essential policies requiring schools, agencies and ministries to work together. Although there are many organizations who have advocated for particular capacities such as staffing ratios for school nurses or minimum time to be devoted to health education learning in mandated curricula, the evidence base and the actual experiences with these specific baseline capacities is not well researched nor often discussed by systems decision-makers.
Although there was only one item addressing obesity among the reports, research articles or news stories about baseline capacity levels in schools or other systems in our 18 month monitoring window, there are some related items that can be mentioned here.

Time Available in the School Curricula in Canada

We did not locate any analysis of the health education or physical education curricula in Canada with regard to nutrition or physical activity per se. Lu & McLean (2012) did an analysis of the curricula in Canada and found that all or most of the 13 sets of curricula have positioned the curriculum and instruction within a broader multi-intervention approach, that they are using a holistic view of health and health promotion and that only a few jurisdictions are using basic health literacy as a focus. They also comment on the pros and cons of combining health education and physical education or delivering them as separate curricula. (Ontario, Manitoba and Quebec have combined HE and PE, and Alberta is planning to do so soon. The remainder of jurisdictions combined HE with career and life planning in a manner similar to most European countries).
One of the drawbacks noted by Lu & McLean is that there will be less time for the 25+ health and social issues other than physical activity which are currently addressed in the health education curricula. A preliminary analysis of the Canada curricula done in the Spring of 2012 by this author found that in Manitoba and Ontario, approximately 2/3 of the learning outcomes in the HPE curriculum are devoted to physical activity in secondary grades, leaving about 17 hours of instructional time for health topics, including nutrition, sexual health, drugs, child abuse, family violence, gender equity, oral health, family life, character education, human rights, social responsibility, human health and environmental health, infectious diseases, sanitation, growth and development, mental health, bullying, cyber bullying, media literacy and more. In the Quebec HPE curriculum, which is almost entirely focused on activity, there is approximately two hours of instructional time available for these topics within the health component. In curricula that combine health, personal-social development with life/career planning there is about 40 hours of instructional time available for health and social content.

One article we found did examine this conflict between health and physical activity to be quite competitive and harmful to both subject areas. A study of PE schools in four provinces in South Africa (Van Deventer, 2012) reports that the qualifications of PE teachers declined after the post-Apartheid government combined PE with a "Life Orientation" course in secondary schools. Fifty-eight per cent of LO teachers in the Senior Grades and 40% in the Further Education & Training grades who facilitated the movement component of LO were not qualified to present PE.

A series of articles in Issue #5, 2012 of the International Journal of Consumer Studies has several articles re-stating the case for values-based financial education that promotes basic "financial literacy" and "sustainable financial behavior". Years ago, we used to call this "home economics" but in the intervening years, this curriculum has disappeared from most school systems. These articles once again make the case for adding more home economics and financial literacy in the high school curriculum to counter the lack of basic financial literacy underlying the overspending habits of many Canadian, American and citizens in other countries who have taken on far too much household debt. Family life skills such as cooking, basic home repair, child rearing and other similar topics were also a focus in these home economics/family studies courses and would provide reinforcement of messages about nutrition and diet.

Sufficient Staffing Required

An article in the September 2012 Issue of the Journal of School Health (Bruce et al, 2012) analyzes the 159 submissions made to a 2009 Parliamentary Inquiry into "the opportunities for schools to become a focus for promoting healthy community living. Submissions to the Inquiry varied widely in their positions about school health promotion. The aim of this review was to identify core themes in the debates about school health promotion and how stakeholders saw schools becoming a focus for promoting healthy communities. Emergent themes included barriers and enablers to school health promotion including the need for stronger leadership from the Departments of Health (DoH) and Education and Early Childhood Development (DEECD). Rather than supporting the idea that schools could have a wider role in communities, submissions pointed to the acute need for increased resource allocation to support health promotion in schools, and for coordinated approaches with stronger leadership from the health and education sectors. Without these structures, schools can only address health in an ad hoc manner with limited resources, capacity, and outcomes.

An article in Issue #2, 2012 of Health Education Research (Dreisinger et al, 2011) describes the conditions or capacities required to implementing a community-wide obesity prevention program. The factors include strong intervention planning and an existing sustainability plan; physical space available for the intervention; staff and monetary resources; administrative buy-in; community buy-in and engagement; a strong partner base and an agency with a healthy and active mission.

This discussion about basic staffing levels available in schools and in the health, nutrition or recreational sports systems to prevent obesity should include consideration of staff required to do such coordination at ministry, health authority/social agency/school board and school levels.

School nurses are one potential source of on-site staff support for school nutrition programs but recent news stories from the UK and US have identified pending school nurse shortages as a major issue in the delivery of school health programs. School nurses can do many things in schools including nutrition and physical activity programs as well as management/support of obese students.

The past few years has seen the introduction and then the withdrawal of Canadian staffing programs for community nutritionists and community/sports coordinators. In our monitoring of the journals, we have seen several recent articles defining and advocating for coordination staff in whole school physical activity programs (Heidorn & Centeino, 2012) and in school-community nutrition programs. Hills and Hollis (2011) report that the presence of a nurse in the school results in fewer early releases of students missing school, increased communication, less time spent on health issues, students with chronic illnesses are safer, and there is a resource available for health information.
The recent news about school nursing captured in our monitoring has also included recent reports from Alberta, Ontario and Quebec about considering more investments in school nursing and there are provinces (New Brunswick) with established school nurse programs. However, there are real shortages and there will be competition for the nurse time between re-emerging infectious diseases such as measles and whooping cough and the assignment of nurses to new mental health initiatives. If school nursing programs are not the ones to coordinate obesity prevention, who will?

Operational Capacity
Operational capacity includes (1) coordinated policy and senior leadership at all levels, (2) assignment of coordinators at all levels, (3) formal and informal mechanisms for cooperation and coordination, (4) ongoing knowledge development and exchange, (5) ongoing workforce development (6) strategic and joint management of emerging issues and priorities (7) regular monitoring and reporting on systems capacity, processes/programs, outputs and outcomes (8) explicit planning for sustainability and renewal.

This sub-section identifies several items from our 18 month window of observations of the media reports, journals, social media and other sources. In many ways, current Canadian initiatives have ended up back at where they were in 2004, having gone through the cycle of defining the problem and identifying many interventions that can be inserted into schools, we are again realizing that system operational capacity is required if any of these interventions are to survive at levels where they can make a difference.

The Canadian Heart Health Initiative (1986-2004) ended up with several serious research-based discussions of capacity (Renaud et al, 1997; O’Loughlin et al, 1998; Joffres et al, 2004; Dressendorfer et al, 2004; Riley et al, 2001). Researchers in the 15 provincial/territorial test sites reported consistently that greater system, institutional, professional and community capacities were required in order to sustain the improvements gained in the pilot-testing of various strategies.

However, despite the well-articulated findings of its predecessor strategies, the current generation of obesity/healthy living strategies in Canada has not yet firmly addressed the issues associated with capacity. Such a focus would shift the conversation away from the implementation of specific programs primarily or solely in schools towards systems change and capacity issues that address issues such as community context, multi-level action across several systems, social and economic factors such as poverty and community safety, employment practices that provide for better work-life balance, values that reduce consumption and substitution of food to replace a lost sense of family and meaning in our lives.

Capacity through Coordinated Policy and Senior Leadership at all Levels in Several Systems

Usually, matters relating to school health policies are focused solely on the school and ignore other agencies, ministries of government and regulations or practice guidelines for non-educational professionals. We are pleased to note that some of the articles located in our monitoring of the research, news and other sources broadened that usual focus. In particular, the role of state/provincial governments was examined in a couple of US studies.

Several articles in August 2012 Issue of Public Health Nutrition critically examine national policy-making on nutrition and healthy eating. One article examines the eventual policy options selected by the New Zealand government and found that government policy favoured the food industry position (vs the public health position) in all realms except when it came to schools, where sales were regulated. Another article noted the absence of research on how food is sold and marketed to children in sports venues. A third article documents how television food commercials target children in Germany, despite an industry pledge to the contrary. A fourth article suggested that a 20% tax on the sales of sugar-sweetened beverages would affect consumer purchasing practices. Another paper suggests that advocates need to address underlying social norms, as was done in regard to cigarettes, if public policy on beverage sales is to change. Finally, an analysis of national healthy eating policies and strategies in Europe notes that of the 107 strategies, only 27 were being evaluated for an effect on consumption, only 16 on the basis of improved health status and only three were using a cost-benefit analysis. The authors also noted the lack of comparability of these European evaluations.

Three articles in the May, 2012 Issue of Journal of School Health report on the effect of state level leadership in regulating school food sales, in farm to school programs and in monitoring BMI. Not surprisingly, those states that had passed laws and shown active leadership had more school districts and schools implementing those policies and programs.

As we were writing this review, we received an email pointing to yet another action (a report on nutrition after school) taken by a group that has demonstrated national and provincial/territorial leadership on school nutrition for many years; the Federal/Provincial/Territorial Working Group on Nutrition. With Canada being a federal country, national initiatives can often be bogged down in jurisdictional squabbling. This FPT committee was largely responsible for the work and sharing that went into the development of school food policies across the country. Other organizations were helpful, including the intergovernmental Joint Consortium for School Health in publishing a self-assessment tool and special journal tool and the Canadian Association for School Health in organizing an active national Community of Practice of officials, practitioners and researchers between 2006 and 2010 but the FPT Nutrition group has been real policy leader from beginning to end.

Capacity by Assigning Coordinators at all levels

The need for systems and agencies to assign staff to the critical role of coordination at all levels has appeared in articles related to school-based and school-linked physical activity but there have not been recent, similar discussions about comprehensive approaches to nutrition. In several cases, multiple intervention strategies originally focused on physical activity have been expanded to include a nutrition component but the inverse has not happened. In some jurisdictions, the role of the community or public health nutritionist has been clarified to include working with schools but there has not been any recent discussion of the coordination role needed in comprehensive approaches such as “nutrition-friendly schools”.

To illustrate the recent focus on coordination of whole school PA programs, we can note that several articles in September, 2012 Issue of the Journal of Physical Education, Recreation and Dance provide the second part of two special issues on the role of Directors of Comprehensive School Physical Activity Programs. The role, training, potential activities and more are described in the series of articles in the two issues of the journal. They provide an excellent description of this important aspect of capacity for such whole school strategies.

Capacity for Ongoing Knowledge Development and Exchange

Ongoing knowledge development and exchange is a vital component of operational system/organizational capacity. The Canadian Association for School Health mapped out how knowledge is developed and dispersed in countries such as Canada in a complex diagram that includes the processes, products and players involved. These include:
  • Research funding agencies, research programs and individual researchers creating or developing knowledge based on studies while administrators create other forms of knowledge base on administrative data sources and practitioners experiences
  • A number of organizations gathering and synthesizing knowledge from research reviews, studies, reports, and other sources
  • Other practitioner organizations, government funded organizations and university centres translating knowledge into different print, media and web formats for a wide variety of audiences
  • Other national and state/provincial organizations and publications disseminating knowledge through journals, newsletters, conferences, webinars and other formats
  • Other national, state and local organizations, professional associations, program developers and others exchanging knowledge in two way or multiple directions through conferences, communities of practices and other means
  • Local managers, individual professionals, parents, officials and others taking up knowledge based on their particular needs, biases, experiences
  • Local managers, senior managers, researchers and others reflecting on knowledge acquired through implementing specific programs or approaches as well as their on-going professional assignments
Researchers and government officials would like to think that their knowledge products and processes lead local agencies and practitioners to better practices and programs but this is often not the case. Very often, highly qualified professionals at the local level review the research directly or make selections about programs based on their own urgent needs, particular circumstances or profession al experiences. As well, we would all like to think that the knowledge developed in regard to one health issue or aspect of school health promotion is shared easily and widely across multiple systems and professions but this is often not the case. Experts work on select bodies of knowledge in isolation from each other or even competition with each other.

Having briefly described this propensity for knowledge dispersal (likened to a crowded dim sum restaurant with many menu choices), the CASH report suggested that knowledge managers seek to establish communications channels and ongoing knowledge exchange mechanisms among the various players described above in relation to their shared interest areas. We looked for such ongoing knowledge development and exchange capacity in Canada in respect to obesity prevention.

We noted that the Canadian Institutes for Health Research has renewed its strategic plan for 2010-14 and it includes a continued focus on obesity and a specific reference to “focusing on solutions to promote healthy body weights at the population level (e.g., school-based approaches, intervention research)”. This represents a bit of a shift in that previous work with this Institute focused more on metabolic and clinical nutrition issues. As noted above, a search of the CIHR database over $156 million has been spent by CIHR on obesity research in 629 projects. A search using “obesity and schools” located 24 funded projects totalling over $4 million. All of these projects are now completed. Five of these 24 projects were evaluating the impact of interventions and the remainder were investigating risk/protective factors, social influences and determinants.

The items collected in this 18 month period, along with our related searching, suggest that the physical activity movement in Canada has benefitted from its lead position in the obesity fight. Existing PA knowledge management organizations have been strengthened or created in the past few years using the obesity related funding. These include:
The nutrition/healthy eating sector has not benefitted as much from the increased interest in obesity. The changes include:
With regard to the topics of obesity, there are a few specific mechanisms that have been established within Canada and internationally to facilitate knowledge exchange about this issue. The Childhood Obesity Foundation based in BC has worked with the collaborative initiative of several organizations to prevent obesity and another to promote healthy eating, physical activity and tobacco use prevention that were funded by the Canadian Cancer Strategy between 2009 and 2012. (Note: Three of seven projects funded by Cancer Strategy will continue in 2012-17, but it is not clear which ones). The Canadian Best Practices Portal has compiled several background and policy documents on overweight/obesity and a search of their evaluated intervention sections identifies 56 programs, 32 of which were focused on schools.

Knowledge Management Matters

Having this knowledge development and exchange infrastructure is very important to the long-term success of national strategies. Our monitoring of articles during the 18 months identified several, including two articles in Issue #3, 2012 of Preventing Chronic Disease report on the Healthy Schools program, a support to the US federal law requiring funded schools to implement nutrition and activity programs. The article on the role of the Technical Assistance component of the HSP shows that training, assistance and coordination matter in the implementation and operation of the program.

Capacity: Monitoring, Reporting, Evaluation, Self-Assessments

Our monitoring over the last 18 months has identified reports, articles and news stories that relate to the capacity to monitor and report on system/agency/school capacity to prevent obesity, two program evaluations done on multi-intervention programs in PEI and Nova Scotia and the development/use of a national school-self-assessment tool. For more background on the different types of assessment activities and their uses, readers can go to this ISHN overview on Monitoring, Reporting & Evaluation in School Health & Social Development.

Reporting on Childhood Obesity as part of a National, Provincial/Territorial, Local Monitoring and Reporting System
The ISHN has defined and described effective School-Linked Monitoring and Reporting Systems in a summary developed after a series of international webinars. "A Monitoring and Reporting (M&R) System uses carefully selected indicators based on reliable data sources to produce regular reports on system/organizational performance over time as a tool to focus system reform and improvement. The goals of monitoring/reporting systems are to assess the effectiveness and efficiency of a system, agency or coordinated set of programs in order to improve performance as well as provide a mechanism for accountability. M&R systems provide enhanced information for improved planning, policy, practice and decision-making. Effective M&R systems record changes over time in the local context, inputs, processes (programs, policies, practices) and outputs (short term health/social status, behaviours, knowledge, skills, attitudes). These outputs can lead to positive lifelong outcomes in health, social development and education provided that similar supportive conditions or interventions are available over the life course."
The type of data collected and who collects it is also important. We need health status, determinants, social influences, behaviours, belief outputs data at certain selected ages over the life course. This should be collected or funded by the health and social service sectors. Education systems should collect data on knowledge, skills, attitudes, beliefs, intentions etc. that can be taught in health education classes and be responsible for reporting that as part of their academic reporting. School reporting should also collect data on topics such as school climate, parental and student involvement etc. All systems need to work together to report on capacities in various systems at various levels. Governments need to develop plans for sharing existing data sources among themselves (usually not done) and then opening that data up to researchers, advocates and the public. Governments also need to harmonize the many surveys being some in schools.

After over 20 years of national strategies, over 20 million dollars of research and many, many initiatives, projects, programs and activities at the national, federal and provincial/territorial level promoting physical activity, healthy eating and healthy weights, Canada has finally taken the step of writing down some measurable targets for its obesity prevention efforts in a report called ACTIONS TAKEN AND FUTURE DIRECTIONS 2011: Curbing Childhood Obesity: A Federal, Provincial and Territorial Framework for Action to Promote Healthy Weights. This document was published on November 25, 2011 and contains two annexes that could form a start but certainly not a complete basis for developing some of the outcome and process indicators needed for a truly effective national strategy.

Annex F of the document contains some weight and behavioural outcome indicators to curb childhood obesity. The indicators seem reasonable and cover areas such as unhealthy weight (BMI), amount of daily physical activity, family-based activity, walking/cycling to school, sedentary activity, fruit/vegetable consumption, breakfast consumption, and sugared beverage consumption. The Annex also includes environmental factors including; household food insecurity, child exposure to food advertising, school policies on active transportation, amount of PE classes per week and parent opinions on child access to public facilities for physical activity. Data sources for these indicators include some baseline data from the Canadian Community Health Survey (CCHS), a Nielson Media Research report, the Physical Activity Monitor and the Canadian Health Behaviours in School-Age Children (HBSC) survey.

This article is not the place to offer a full analysis of these indicators but our initial reactions include these:
  • Many of the indicators selected are focused on physical activity despite the research review evidence cited above that presents a consensus that increasing physical activity does not lead to weight loss among children. We may want to track activity levels for other reasons but obesity prevention does not really offer a strong scientific rationale.
  • Other behavioural indicators relating to nutrition should be added, including the frequency of family meals, composition of school lunches packed by parents, amount of time spent by children in unsupervised time at home after school, availability of televisions and computers in bedrooms and others.
  • Other environmental indicators should include the number of students who purchase or who are provided lunches at school, the composition and frequency of snacks purchased at school, the number of schools following school food sales regulations, the amount and nature of food advertising permitted by schools, the reported parent views on the safety of their neighbourhoods and routes to school, the number of family meals consumed outside of the home and the nature of those restaurants, the estimated number of students who leave school at lunch hour etc
  • The data sources for these 2011 indicators appear to vary in regards to their continuity and nature. The Physical Activity Monitor is actually a report prepared by a research institute using various surveys. The HBSC survey data is actually controlled by a university and is not easily and automatically available to other researchers or inquiries. The only data source that has guaranteed life from one survey to the next is the CCHS.
  • How do these data sources relate to others noted in this article? Is this data coordinated with the Canadian Health Measures Survey? Is there duplication with the provincial data collection done in several provinces?
Annex D of the federal/provincial/territorial monitoring plan includes a “summary of existing initiatives with various levels of PT involvement”.
Setting aside this vagueness for a moment (which is clearly inappropriate for a monitoring and reporting system to Canada) we note that the indicators include:
  • For early childhood, about half of provinces/territories are “involved” in baby-friendly initiatives, publishing infant feeding guidelines for professionals, early prevention/intervention, food guidelines for day care centres, developing a screening tool for pre-school children at risk from nutrition problems, and adapting WHO growth charts
  • For schools, almost all provinces/territories are “involved” in active, safe routes to schools, comprehensive school health initiatives, publishing school food sales guidelines and promoting physical activity after school
  • In urban and rural planning, a few provinces/territories are “involved” with community design initiatives, professional development for planners, age-friendly initiatives, healthy community initiatives
  • In other areas and sectors, a few provinces/territories are “involved” with activities such as comprehensive overweight strategies, engaging stakeholders in vulnerable communities, and efforts to decrease marketing of food to children and youth.
Again, without taking too much time, it would seem obvious that we need to track the status and reach of several more interventions at a provincial. Health authority and school level in order to truly monitor what is happening in school-based and school-linked obesity prevention. These could include:
  • The status, content and objectives and actual time spent teaching of nutrition education objectives in the K-12 health curricula
  • The status, content and objectives and actual time spent in active play in physical education curricula
  • The involvement of parents in school-sponsored and school-linked parent education programs that include nutrition
  • The provisions and supports provided by other agencies in coordination with schools for obese students
  • The degree to which school food sales restrictions are being observed in schools
  • The proportion of students who eat lunches from home at school
  • The proportion of students leaving schools at lunch time
  • Etc.
The Joint Consortium for School Health (JCSH) was supposed to address this confusion, incoherence and lack of coordination among child/youth health surveys as well as help to establish a system for reporting on child and youth health that would enhance reporting but also reduce the number of requests to schools to participate in surveys. It held three workshops, contracted a review of data sources and conducted a consultation with provinces/territories but did not publish a plan or even some initial steps towards a data collection/monitoring reporting plan for child/youth health. Instead of sorting out this confusion, JCSH created a school-based self-assessment tool on nutrition and physical activity which now includes a section on mental health. Monitoring of child/youth health nor coordination of surveys has not been mentioned in its recent annual reports. As a consequence, we now have three or four national surveys and several provincial surveys all tracking obesity, weight, activity and diet (sometimes with other health aspects and sometimes not) with different but similar results.

A Proliferation of School Self-Assessment Tools

While the use of self-assessment tools does not constitute a monitoring and reporting system, (indeed, the two are often confused by many), Canada does have an over-abundance of checklists and self-assessment tools relevant to the prevention of obesity. These include school self-assessment tools in PEI, Nova Scotia, British Columbia and Alberta. As well, there are other more extensive self-assessment tools that include diet and activity issues available from other credible sources such as the Association for Supervision and Curriculum Development, various UN agencies, Health Canada and others. The effective use of self-assessment tools can be a real support to school, agency and ministry planning but the proliferation of such tools focused on obesity/overweight in Canada has led to duplication of efforts. Further, our searching done in the preparation of this article could not readily locate any accurate reports on the uptake and impact of these tools in the development of Canadian obesity prevention efforts.

Building on a similar university-led self-assessment on tobacco that was developed on tobacco, two other sections have been added to the document and republished as a Healthy School Planner. The web site housing this tool is currently under revision. It is not stated on the web site how many schools are using or have used this tool at least once to assist in their planning. The questions in the planning tool are well founded and based on solid research. The web site does state that the list of participating schools will be published on the web site but our searching of the site did not locate any such page. This tool is based on a similar tool developed in the US state of Michigan.
The Healthy School Planner is similar to the more extensive Voices & Choices on-line school self-assessment tool developed by Health Canada that also includes questions on nutrition and physical activity. In 2003,Voices and Choiceswas developed in collaboration with the Centre for Addictions and Mental Health (CAMH) as a practical, do-it-yourself, strategic planning process for secondary schools in Canada. It is based on the international Health Behaviours in School-Age Children survey and creates a PDF report for participating schools. The program was discontinued due to low uptake among schools. The V&C tool was briefly considered as a mechanism for monitoring and reporting on school capacity in health promotion in 2005-06 but was rejected.

The Healthy School Planner is also similar to the more extensive Healthy School Report Card published by the international organization representing school district administrators (ASCD). The ASCD has developed and field-tested a Canadian version of their report card which also includes nutrition and physical activity questions as part of an overall approach to educating the whole child. The ASCD report card was also considered briefly as a possible tool by the intergovernmental Joint Consortium for School Health but was rejected.

One of the research articles identified in our 18 month monitoring time frame did locate an Irish study (Chroinin et al, 2012) that assessed the impact of using a school self-assessment tool in physical activity. An analysis of the responses from a small sample of 21 schools revealed that the resulting approaches were apparently more structured, inclusive and more feasible. The authors suggest that the “long-term impact of the self-evaluation process merits further investigation”.

Regular National Reports Needed

The Canadian Institute for Health Information did issue a first report on child and youth health in 2005 and it indicated that it would report regularly on all aspects of child and youth health but CIHI has not done so recently. CIHI is a more appropriate body to do the reporting since it is a shared mechanism of governments, it is independent and it is able to report directly to Canadians. CIHI focused on childhood obesity as a priority topic in its health promotion activities between 2004 and 2007. The CIHI activities included a 2006 report on obesity prevention that examined the role that schools and other settings could play in such prevention.

Comparisons Over Time, Across Provinces and Countries Needed

Government officials and others in administration are often reluctant to do this but reasonable comparisons offer an excellent way for us to understand monitoring and reporting, especially when it comes to complex outcomes and outputs derived from school-based and school-linked programs.

Simple data can often be very helpful. For example, a news story on August 9, 2012) reported on a study showing that England, Wales and Northern Ireland, along with the Netherlands and part of Belgium, were the only countries that did not have a recommended annual PE teaching time.

The best comparisons, however, are those made of the same institutions or organizations over time, with regular, reliable, transparent reports being issued, publicized, analyzed by many using different perspectives and discussed with a view to making system improvements. Other comparisons that examine similar approaches/programs in similar communities or countries are also useful, provided that important differences in context are taken into account and explained in the reporting.

That is why it is discouraging to see how the regular survey, the Health Behaviours in School-Age Children (HBSC), is misused or under-used in respect to obesity/overweight and several other issues. This survey is that started in Europe and is now done regularly in Canada and the United States. The most recent data collection in Canada was done in 2009-10, with reports going back to 2001-02. There are many excellent questions in this survey of 11-15 year-olds that pertain to weight, activity and diet as well as many other topics. Canada participated, for the first time, in the 1989-90 HBSC Study cycle, as an associate member, along with 11 other European countries and produced the reportThe Health of Canada's Youth(1992). Canada was subsequently accepted as a full member of the HBSC study team and has participated in three further HBSC surveys in 1993-94, 1997-98 and 2001-02.
With four national HBSC reports now completed for Canada, it is possible to do comparisons over time. This has not been done for most health issues or topics within the reports, although there a couple of observations in subsequent reports (cited above) with the exception of the first report in 1999. This could be easily done and would add value, history and context to any Canadian discussions. As well, each of the three Canadian reports published to date has included a different focus for the narrative. In the latest report it was on mental health, perhaps signalling a shift in the attention of that part of the Public Health Agency of Canada away from overall health towards a single issue. The international report for the same survey period focused on social determinants.

As well, unfortunately, we understand that an agreement between the researchers and the Public Health Agency of Canada discourages any researchers except those working with Queens University to have easy, direct access to the data. The last analytical report noted on the Queens web site is dated 1999, and although it is likely that these researchers have published other articles since then, there is no ongoing open researchers discussion of the Canadian HBSC data as there has been on other studies such as the National Longitudinal Survey of Children and Youth.

Secondly, the Canadian sample size for the 2009-10 survey was expanded to include samples from all of the provinces and the three territories. However, it does not appear that the provincial reports will be published together, thereby making it impossible to compare among Canadian jurisdictions. These provincial/territorial reports may also not be published separately. Some jurisdictions may have published their results independently but our Google searches found only one report from the Yukon.

Thirdly, the recent Canadian reports made every cycle do not include comparisons with other similar jurisdictions such as those in Europe and the US as they did in the first report issued in 1999. Indeed, for the latest report, we have to go to the WHO-Europe web site to obtain the international results. The Canadian results in the last report compare quite favourably with all of Europe (including the countries with fewer resources) in regard consumption of fruits and vegetables, drinking sugar-sweetened beverages and physical activity but not as well in regards to sedentary behaviour and in the relative differences due to socio-economic status. However, it would be much better if independent researchers could examine the data in more depth, perhaps selecting only countries with stronger similarities to Canada and doing other types of secondary data analysis.

Canadian Program Evaluations

As noted elsewhere in this review, our timeline for collecting reports and articles did identify two program evaluations on multi-intervention programs in Prince Edward Island and Nova Scotia. It should be noted that the initial pilot study in Nova Scotia (Veuglers & Fitzpatrick, 2005) involving a small sample of self-selected schools did report changes in body weight. However, the larger sample, longer term evaluations in the Maritime provinces are showing little or no impact on body weight. A similar large scale evaluation is underway in Alberta and there is an ongoing evaluation in British Columbia. The Apple Schools project in Alberta has reported that in the initial 2008 results of their study showed a significant increase in the number of children who were overweight or obese as reported by the 2004 Canadian Community Health Survey. The next set of results and reports is due in October, 2012. Fung et al (2012) report that the participating Alberta Apple Schools ”in 2010 relative to 2008, students attending APPLE Schools were eating more fruits and vegetables, consuming fewer calories, were more physically active and were less likely obese. These changes contrasted changes observed among students elsewhere in the province”.

The pilot evaluations of the Action Schools BC program done in 2003-04 for activity and in 2006 for diet reported positive results. A similar small scale evaluation (Naylor et al, 2006) involving 10 schools reported increased levels of physical activity among students (+67 minutes in schools in schools receiving the materials and some training and +55 minutes for schools receiving the materials and more training) but do not report on weight loss or other physical measures. However, the web site does not list any published large scale evaluations since then, except to note that evaluation of the program is ongoing. A cursory search using Google Scholar and the search term “Action Schools” did not identify any evaluation reports after those describing the initial pilots.

Another BC-based program, the Healthy Buddies Program, combines healthy eating, physical activity and mental health components. The pilot study (Stock et al, 2007). A cursory search using Google Scholar and the search term “Healthy Buddies Program” did not identify any evaluation reports after those describing the initial pilot. The Healthy Buddies program was also piloted in Manitoba in the 2009-10 school year. The ministry sponsored evaluation of the program had ten intervention and ten control schools. The students in the intervention schools experienced healthy declines in BMI and waist circumference compared to students in control schools. The program was not effective in increasing physical activity or fitness levels among students. Students in Grades 1-3 experienced more gains in self-esteem, healthy living knowledge and behaviours than students in grades 4-6. Teachers were positive about the quality of the materials (21 lesson plans) and teacher training.

Summing up the Canadian evaluations to date, it would appear that the initial pilot studies in several locations in Canada reported that multi-intervention programs promoting physical activity and/or healthy eating did have a short term impact on activity and diet but the larger and longer term evaluations are not showing any significant improvements in overweight or obesity rates. The program that included a mental health (friendship) component did report changes in body weight in the small scale controlled trial.

Canadian School Recognition & Incentive Programs

Effective use of school recognition and small incentives programs is another tool that can be used to prevent obesity. Our 18 month window of observations did identify several examples of this approach in Canada in regard to promoting healthy weights through schools.

The province of Ontario operates a Healthy School Recognition Program that includes healthy eating and physical activity criteria. To be recognized, the school must commit to organizing at least one activity. The program accepts applications from individual schools and school boards on behalf of their schools. The Ontario Ministry web site includes a web page listing all schools participating in the recognition program (There were 702 schools out of 4,500 schools (15.6%) in the province participating in 2011-12).

The Community Use of Schools program in Ontario provides funding to all school boards to help offset the cost of providing not-for-profit community groups access to school facilities outside of school hours, so that those groups can provide affordable programming for the community. Additionally, the Priority Schools Initiative provides funding to schools in high-needs neighbourhoods so that boards can offer space there free of charge to not-for-profit groups. Approximately 45 new Priority Schools will be added in the 2011-12 school year bringing the total number to 220across the province.

The Manitoba Healthy Schools program runs two incentive funding campaigns each year that encourage schools to undertake activities to receive small incentive grants of $100 plus $0.35 per student. The program has been operating since 2003. Healthy eating or physical activity has been the subject of the campaigns several times. To be eligible, the school must organize at least one activity on the theme of the campaign.
The province also provides a Healthy Schools Grant to local school divisions as part of a series of categorical grants. The HS grant was included in this list of grants as of 2011-12. School divisions are required to submit plans and administrative reports for these grants.

British Columbia provides small grants to schools that become members of the BC Healthy Schools Network. To be a member, schools must form a team, conduct an assessment, develop an inquiry question (which must be student drive in 2012-13), share with a partner school, complete the inquiry and submit a case study report. In 2010-11, 66 schools out of approximately 2100 (3.1%) in the province completed the activities, a slight decline from previous years.

British Columbia also supports its Action Schools BC program, which provides a wide variety of free and updated teaching/learning materials, school activities, parent information and teacher training to elementary schools on physical activity and healthy eating. As of the end of 2012 after eight years of operations, 1,455 (92%) of target schools were registered and 1,360 (86%) had received workshops. There is no data supplied on the ASBC web site as to if and how registered schools continue to participate each year and it is assumed that the small ASBC staff are able to deliver about 200 workshops per year and alert all registered schools to new materials by email as they are produced. This program does require an annual report from each school according to the forms on the web site but no compilation or analysis of those reports is provided. This is in keeping with the slightly different format of the ASBC program which is not really a school recognition or accreditation program.

The physical and health education teachers association in Canada has operated the Quality Daily Physical Education recognition program. QDPE is a well-planned school program of compulsory physical education provided for a minimum of 30 minutes each day to all students (kindergarten to grade 12) throughout the school year. A QDPE program includes; daily curricular instruction for all students (K-12) for a minimum of 30 minutes, well planned lessons incorporating a wide range of activities, a high level of participation by all students in each class, an emphasis on fun, enjoyment, success, fair play, self-fulfillment and personal health, appropriate activities for the age and stage of each student, activities which enhance cardiovascular systems, muscular strength, endurance and flexibility, a participation based intramural program, qualified, enthusiastic teachers, reative and safe use of facilities and equipment. The current number of schools in Canada that have been recognized as QDPE schools was not readily found on the PHE Canada web site.

Capacity: Explicit Planning for Sustainability

Among the various multi-intervention programs around the world that promote physical activity and healthy eating is the Child & Adolescent Trial for Cardiovascular Health program which is likely one of the largest and most evaluated programs anywhere in the world. Most readers will know that the multi-intervention program was successful. But they may also know that the CATCH program is no longer operating in most of the areas to which it spread despite the fact that its value was demonstrated in many studies.

Hoelscher, et al. (2004) reported on the maintenance of the Child and Adolescent Trial for Cardiovascular Health (CATCH) coordinated program. An institutionalization study was undertaken five years after the end of the main trial. This study compared 56 former CATCH and 40 former control schools as well as 12 new schools defined as unexposed control group. The “Institutionalize” term was defined as the longer-term viability and integration of a new program within an organization. Institutionalization was measured by the routine use of CATCH program components and ongoing achievement of CATCH program goals. The measures to determine the institutionalization included a school health survey for principals, menu documentation, a survey of food service staff, observations of PE instruction time and school staff surveys, including a classroom practice survey for elementary schools. The results reported from this analysis were:
  • The school menus for former CATCH schools contained less total fat content than former control schools but no difference with the new unexposed group of schools. Training of school food service personnel had no lasting effect.
  • There were no differences among all of these groups of schools on the proportion of PE time spent on vigorous physical activity.
  • PE teachers in former CATCH schools reported that they used CATCH activities 33% of the time. Former control schools used CATCH activities 30% of the time. Unexposed schools used CATCH activities 10% of the time.
  • Classroom instruction using CATCH materials were low in all schools. Former CATCH schools reported using 2 out of the 15 lessons. Teaching time was also low in all schools.
  • The CATCH family component was used infrequently in all three groups of schools.
  • Time spent teaching about tobacco did not vary and was low in former CATCH and former control groups.
  • CATCH training was associated with continued use of CATCH materials.
  • The maintenance of the school menus was deemed to be likely due to a state decision to mandate such menus.
The researchers developed a composite score for institutionalization and found that former CATCH schools scored significantly higher in ongoing maintenance of the CATCH program. However, despite this difference between the groups, all schools had disappointing levels of ongoing implementation. These levels were unlikely to result in behaviour change. Further in looking at the composite score assigned by the researchers, we might consider the discussion of sustainability presented by St. Leger (2005) when he raises the question of a passing mark or minimum threshold in sustainability. Who decides what the acceptable minimum threshold should be? If programs can be diluted as much as the CATCH program has been since it was ended in the study described above, is it realistic to expect that their positive results would be maintained?

Training was seen as important factor in maintenance but only if it is maintained over time to include new staff brought in from staff changes. The most frequently cited obstacles in maintaining the program were similar in former CATCH and control schools, lack of time in the school day, low priority for health education, state or district requirements for other subjects and lack of materials. Hoelscher et al use diffusion theory to explain their results. The interventions within the CATCH program that were maintained were seen as being more compatible to organizational goals. The researchers also suggest that classroom materials that are more flexible and that can be used outside of a sequential program are more likely to have continued use. However, this may result in lowered fidelity and effectiveness.

Many countries have replicated or done similar studies to that of the CATCH study in the United States (De Bourdeaudhuij et al, 2011). As noted above, Canada has had several studies very similar to the CATCH program in several provinces. However, we need to look very seriously at the fate of the CATCH program in the US, after it used up its research funding, support from private foundations and ran out of steam in selling its materials and training to other locations. Will our programs suffer the same fate, especially since they seem to be failing in meeting their original promise of reducing or preventing obesity ?

To finish up our brief discussion of sustainability planning, we turn to yet another article located in our search time frame that provides an idea or an approach to this vital capacity of explicit sustainability planning.
Saunders et al (2011) assessed the sustainability of the Lifestyle Education for Activity Program (LEAP), a comprehensive that targeted change in instructional practices and the school environment to promote physical activity (PA) in high school girls. In their paper, the seven steps used to assess sustainability in LEAP are presented. These features of the LEAP sustainability model include assessing sustainability of changes in instructional practices and the environment, basing assessment on an essential element framework that defined complete and acceptable delivery at the beginning of the project, using multiple data sources to assess sustainability, and assessing implementation longitudinally. This article may very well be a basis for further discussions on how program developers, officials and others can plan in advance for sustainability.

Consideration of System Characteristics/System Change
This sub-section considers the characteristics of large, multi-level, “complex” systems such as education, health, social services, justice/law enforcement and others and how they will affect the adoption, implementation, operation and sustainability of programs and multi-intervention approaches. These systems are “open” to external influences and demands, “adaptive” and responsive to those demands if they are small innovations while being resistant to large scale reforms that seek to alter their “core functions”, “loosely-coupled” and “non-rational’ in their decision-making, comprised of “professional bureaucracies” in which “structures”, “routines”, “informal social networks” and certain “forms of knowledge” are influential, comprised of different types of employees whose “concerns as adopters” will influence potential changes and where “middle managers” will protect “boundaries” and front-line workers (teachers, nurses) will identify often with more valued disciplines (science, math, medicine) rather than health education or promotion and whose “scarce professional prerogatives”, will ensure that they will fight to retain their right to make some decisions and whose “preoccupations” and “professional-social norms will affect changes within the context of their organization’s “readiness to adopt” innovations or overall “adsorptive capacity” of the system. The ISHN has started an international discussion group on these topics with an agenda that includes these systems change topics, an introductory webinar and a Twitter-based news/research feed on organizational development.

The organizational development concepts noted in quotations immediately above, as well others, are just being now considered in the research related to school health promotion and so it is not surprising that our monitoring over the past 18 months has identified only a few items that relate directly to these concepts. Here are a couple of noteworthy items that reflect these new understandings that are so vital to our ability to sustain individual programs and multi-intervention approaches in schools and other systems that must work with schools on an ongoing basis.
  • Understanding the Characteristics of School Food Services: A recent article noted in our August 2012 monitoring of research articles identified an analysis of “competitive food sales” in the US by Guthrie et al (2012). The researchers delved into the US situation in order to examine the fears of reduced revenues from food sales that are often expressed by school administrators. They found that the schools who profited most from such sales were secondary schools from affluent districts which had fewer school meals subsidized by the federal government or the state. They also found that revenues from vending machines most often went directly to the school rather than to the food service. They suggest that increasing student participation in USDA school meals may be one of the strategies used to offset potential losses from such sales. However, the larger point is that by better understanding the segments of the audience (ie types of schools and characteristics of the food services within those schools) more effective strategies to promote, adopt and sustain healthier school meals might be more likely.
  • Social networks within and between bureaucracies & system/policy change: Several articles in Issue #3, 2012 of Policy Studies Journal examine how informal social networks within and across government ministries as well as among organizations and sectors can affect policy development. Five of the articles discuss how to track the influence of these networks within systems using various statistical analysis tools. One article examines how such networks can be used in rebuilding communities after disasters and another examines inter-organizational cooperation via networks or competition during economic development programs. These informal social networks are one of the characteristics that need to be considered when pursuing systems change and sustainability.
  • Adopter Concerns as a focus for Implementation: Five articles in Issue #3, 2012 of Evaluation & Program Planning use adopter concerns or perceptions as a lens in delving more deeply into implementation and program sustainability issues. The articles examine the concerns and perceptions of NGO educators in program evaluation, researchers at university centers in organizing site visits from external evaluators, junior high school teachers in using web-based in-service programs, public health staff in implementing environmental/systems change strategies and educators in implementing an after school program physical activity program for under-served students. The unifying message from these articles is that practical concerns of adopters will ultimately determine the fate of any intended change in their practices.
  • Obesity and School Counselors: An American study (Laurier et al, 2012) of the perceived barriers and facilitators to involving school counsellors more on student obesity issues reported that “About two-thirds of the professional school counselors in this study reported that working with students who present with obesity-related issues was part of their role and function. Another 81.3% stated that among three major barriers, lack of time was the most significant factor that prevented PSCs from working with students with obesity related issues. On the other hand, 90% of the PSCs in this study stated that they would be more involved in prevention/treatment of obesity related issues if they received more requests from parents, teachers and students with obesity related issues.
Consideration of Local Community and Country Contexts (Including rural, cultural, disadvantaged, faith etc)
This sub-section considers the impact of the country or local community context on the capacity of the school and neighbourhood to adopt, implement and sustain individual programs and multi-intervention approaches. More importantly, the ISHN suggests that the issues to be addressed, the programs and multi-intervention approaches selected and the evolution of the whole process should begin with the needs and strengths of the local community being considered. This radical reversal of the process, from the traditional approach whereby higher authorities decide that an issue is to be addressed, a program (s) be developed and then adaptations are to be made for context, to the situation where local communities and schools/neighbourhoods determine their own priorities is still far off in the future, so we include the adaptations in this section. In high-income countries, there will be a variety of local communities or neighbourhoods, including indigenous/aboriginal communities, disadvantaged communities, rural, suburban and urban communities, multi-ethnic and cultural/religious minority communities and affluent communities, all with different needs and strengths. In low and middle income countries, there will be urban slums, rural areas and relatively affluent communities. In countries that have been disrupted by war/conflict, disasters and epidemics, there are a different set of needs. The ISHN is facilitating discussions on school programs in indigenous communities, disadvantaged communities and low income countries. The Inter-Agency Network Emergencies in Education brings together many organizations concerned with relief programs in disrupted communities.

Once again, this context-driven approach to school health and social development is new and therefore our monitoring over the past 18 months has identified only a few items of direct relevance. Immediately below, we discuss a couple of examples we located and then offer a discussion about how Canadian efforts in obesity prevention have addressed disadvantaged communities.
A systematic review (Verstraeten et al, 2012) published in the August 2012 issue of the American Journal of Clinical Nutrition reports that school-based obesity prevention programs can reduce the risk of obesity/overweight in low income countries. From a total of 7218 unique references, they retained 22 studies. Most of the interventions (82%) had a positive effect on dietary behavior and physical activity behavior (effect size ranged from −0.48 to 1.61). BMI decreased in 8 studies (effect size ranged from −0.7 to 0.0). Effective interventions targeted both diet and physical activity, involved multiple stakeholders, and integrated educational activities into the school curriculum. This article would be a good starting point for subsequent discussions about this particular context of developing countries.

For rural communities, the obesity prevention movement might be well advised to work with organizations and networks such as 4-H clubs, university extension programs and community education/schools networks that have a long history in such communities. University-based extension programs have long served rural communities and helped them to address health, equity, social and environmental issues as part of well-grounded community development programs. Issue #4, 2012 of the Journal of Extension illustrates how the other aspects of human development pursued through schools can benefit from and cooperate with these long-standing programs. Articles in the issue address topics such as school gardens, the evaluation of youth development programs, building community coalitions and networks, training of community-based coordinators and an assessment of 14 leading parent programs

Canadian Obesity, Nutrition and Physical Activity Strategies & Poverty
We identified several articles, papers, reports and news stories over the past 18 months that suggest Canada should focus more in children and youth in disadvantaged communities as a way to decrease obesity rates. There is considerable consensus in these items suggesting that a focus on poverty will increase the food quality and activity opportunities and, consequently, decrease or prevent overweight/obesity.

Most Canadian jurisdictions have explicit strategies on obesity and overweight, most of which are aimed more generally at healthy eating and physical activity or “healthy living”. The Canadian Best Practices Portal has listed those strategies in its collection of background materials on obesity/overweight.

An article in August 2012 Issue of the International Journal for Equity in Health (Gore & Kothari, 2012) examines the "healthy living" strategies in two Canadian provinces using several policy documents for the analysis. The authors report that "Initiatives active between January 1, 2006 and September 1, 2011 were found using provincial policy documents, web searches, health organization and government websites, and databases of initiatives that attempted to influence to nutrition and physical activity in order to prevent chronic diseases or improve overall health. Initiatives were reviewed, analyzed and grouped using the descriptive codes: lifestyle-based, environment-based or structure-based. Initiatives were also classified according to the mechanism by which they were administered: as direct programs (e.g. directly delivered), blueprints (or frameworks to tailor developed programs), and building blocks (resources to develop programs) 60 initiatives were identified in Ontario and 61 were identified in British Columbia. In British Columbia, 11.5 % of initiatives were structure-based. In Ontario, of 60 provincial initiatives identified, 15 % were structure-based (ie addressed social determinants). Ontario had a higher proportion of direct interventions than British Columbia for all intervention types. However, in both provinces, as the intervention became more upstream and attempted to target the social determinants of health more directly, the level of direct support for the intervention lessened.

A recent Canadian article (Tremblay, 2012) lists ten national initiatives to promote physical activity and obesity. A glaring omission from that list is a national initiative to feed hungry children in Canada. Canadian advocates have tried in vain to get one national initiative on school meals, but instead, we leave the feeding of hungry children to the voluntary sector such as the Breakfast for Learning program while having multiple strategies on sports and activities. We even provide tax breaks for middle class families so that they can send their children to organized sports and arts programs.

In other words, the only national program seeking to ensure that disadvantaged children have nutritious meals (or any meals at all) is also left up to the voluntary sector instead of federal or provincial/territorial policy or program. Since starting in 1992, Breakfast for Learning has nourished over 2.9 million children with the provision of over 367 million meals and snacks. In the 2011-2012 school year, Breakfast for Learning funded 4,431 breakfast, lunch and snack programs operating within over 2,400 school/community sites, supporting more than 430,000 children and youth with the provision of over 67 million nourishing meals and snacks.

Canadian tax policy modified was modified in 2006 to assist Canadian middle class families be active through a Children’s Fitness Tax Credit but, again, the initiative to help poor children have an opportunity has to come from the voluntary sector with private sector support (Canadian Tire JumpStart program) . The effectiveness of the tax credit scheme has been criticized by Spence et al (2010). Their analysis states that “parents in the lowest income quartile were significantly less aware and less likely to claim the CFTC than other income groups. Among parents who had claimed the CFTC, few (15.6%) believed it had increased their child's participation in PA programs. The authors conclude that “more than half of Canadian parents with children have claimed the CFTC. However, the tax credit appears to benefit the wealthier families in Canada”.

The Canadian Tire Jumpstart is a national charitable program that helps financially disadvantaged kids participate in organized sport and recreation. We help cover registration, equipment and/or transportation costs. The program has an extensive, national network of more than 310 local chapters. Chapter members are volunteers who are committed to helping get kids active and healthy. Since its launch in 2005, Canadian Tire Jumpstart has given 473,792 kids across Canada the chance to play.

Everybody Gets to Play, Canadian Parks and Recreation Association is a product of a national project which has evolved into a national program for supporting low income communities in providing sports and recreation to children. The program includes an adapted program for aboriginal communities.

A British report on the uptake of the school lunch program in England would suggest that it may be possible to expand the numbers of students purchasing school lunches/ (Some European countries provide free lunches to all students). The fifth annual report of the School Food Trust and LACA survey on the take-up of school meals in 2009-2010. The results include these findings; (1) catered or contracted provision accounted for 80%, 39% and 72% of primary, secondary and special school lunch provision, (2) Take up of school lunches was 41.4% in primary schools and 35.8% in secondary schools. This represents an increase over 2008-2009 of 2.1 percentage points in the primary sector and 0.8 percentage points in the secondary sector. This equates to around 100,000 more pupils taking school lunch. (3) Average school lunch prices were £1.83 in the LA catered primary sector and £1.94 in the LA catered secondary sector, an increase of 3% on the preceding year in both sectors. (4) Over 94% of primary and secondary LA catered school lunch provision was thought to be compliant with the food-based standards for school lunches, 93% and 71% respectively with the nutrient-based standards, and (5) Two-thirds of LAs indicated that pupil attitudes to healthier meals in had improved in the primary sector compared with last year, and 34% in the secondary sector. The remainder thought attitudes were about the same, and under 5% in the secondary sector (but none in the primary sector) that attitudes were worse.
To conclude this sub-section, it is high time that governments in Canada stop abdicating their responsibility for the feeding of hungry children and provide a national school food program that provides breakfasts, lunches and snacks to these children as is done in most other western nations.

Consideration/Integration within the Constraints, Pre-Occupations, Norms & Educational Mandate of the School
This sub-section is another new area for school health and social development. It is based on the dawning realization that individual programs and multi-intervention approaches must fit within the pre-occupations, priorities, organizational structures & processes, core mandates, governing ideologies and socio-professional norms of the school systems if they are to be sustainable. The ISHN has started a discussion group on this “integration within education systems” theme that is led by Peter Paulus of Germany, a country that started their school health model by linking a “healthy school” with a “good schools”. Paulus suggests that this fundamental re-thinking is needed because the growth in the numbers of healthy schools in many countries continues to be slow, difficult and fragile, that educational policy debates still exclude health promotion (and social development) considerations and remain focused on academic and vocational priorities, the concept of the healthy school did not originate in the education sector and health continues to be seen as an “add-on” to the mission of the school and quite secondary to its true purpose. Many people around the world are now working on this integration within education theme. Many have begun that work by paying greater attention to the educational benefits of improved health/social development, increased safety and reduction of disparities. A recent paper from the European office of the World Health Organization (Suhrcke &de Paz Nieves, 2011) has captured much of the latest evidence in this regard.
While this documentation is useful, we should recognize that this discussion should not really be about persuading educators to do more or do better because it helps children learn. Rather, this discussion should be about how health, social service and other agencies/professionals can alter their approach and work within schools to better address the preoccupations of educators, serve the basic mandates prescribed for schooling and recognize the social, financial, ideological/normative and other constraints that educators face every day. We illustrate this new approach with just a couple of examples. (1) The school’s fundamental role in accreditation of student learning means that some students will fail in school and this will cause a disconnect with the institution and possible lead to health and social problems. (2) Teachers must respect the privacy of parents and students and therefore they place themselves at risk in addressing controversial issues, even those such as bodyweight and the composition of lunches brought to school. (3) Teachers are biased towards the traditional teaching of facts and this is often linked up with health professionals traditional desire to convey medical facts about risks, thereby ignoring more important teaching about skills, norms, beliefs, intentions and self-concept. (4) One of the few professional decisions remaining within the purview of teachers is the selection and development of lesson plans to suit their particular group of students but health experts want teachers to follow precisely the lessons prescribed in their research-tested programs.

Once again, this being a new area of investigation in school health studies, we did not identify many items in our 18 month time frame, but there are a few that can illustrate this important new understanding about working with schools.
  • Pressure on Recess: One of the unintended consequences of pressuring schools to do better on standardized tests may be the loss of recess as a valuable play time, an essential part of the learning process at school. A blog post (DeWitt, 2012) that was identified in our 18 month scanning process noted that ``Recess has traditionally served as the one outlet during the school day when kids get to recharge their bodies and minds. But those minutes have been steadily eroding. Up to 40 percent of U.S. school districts have reduced or eliminated recess in order to free up more time for core academics, and one in four elementary schools no longer provides recess to all grades"(Zygmunt-Fillwalk and Bidello, 2005; McKenzie and Kahan, 2008. Robert Woods Johnson Foundation, 2010). That blog post also quoted a report from the Johnson Foundation that states: “When most people talk about how to improve education, they tend to focus only on what happens in the classroom. But the most unexpected opportunity to boost learning lies outside the classroom: on the playground at recess"(The State of Play. Robert Wood Johnson Foundation).In Canada, the Council of Ministers of Education, Canada has developed a formal statement supporting play-based learning which is apparently more concerned with the content of early childhood education programs (ensuring that they do not become too focused on academic skills). Perhaps we can persuade the same education ministers that other parts of the school experience are equally important for older students.
  • Don't Mess with My Lesson Plans: Teachers Strike Over Professional Autonomy: An article in Issue #4, 2012 of Educational Policy (Jacoby & Nitta, 2011) helps us to understand how much teachers value their professional autonomy in selecting lesson plans and learning activities. Striking for nine days in 2008, teachers in Bellevue, Washington State, USA carved a distinctive path through the contradictory movements for professional reform unionism and national accountability. In addition to compensation, Bellevue’s teachers struck over the top-down prescriptive management epitomized by the Gates Foundation supported “Curriculum Web.” Where district administrators envisioned the web as a community resource, teachers complained that its detailed daily lesson plans hamstrung their ability to teach effectively. Teachers returned to work only when a memorandum of understanding was signed recognizing their authority to deviate from the district’s web-based curriculum.
  • PE in Irish Education: A National Case Study: All of the articles in Issue #3, 2012 of Irish Educational Studies address the theme of a special issue on physical education. The articles include a research review and two other articles on the role of the generalist primary school teacher and the teaching of PE as well as critical look at school self-evaluation as a means to review progress in whole school PA programs.
  • Professional Norms and Ideologies: One of the things that we have learned about teachers is that they often identify with the discipline which they are teaching. Math teachers consider themselves mathematicians, science teachers and scientists, etc.) Our recent monitoring of the journals has identified one such article that examines the expectations or normative beliefs about overweight people that are currently health by PE teachers who may consider themselves to be athletes. Peterson et al (2012) note that “Findings indicate that physical educators' expectations, attributions, and attitudes regarding students may be negatively influenced by youth body weight, and differ by student gender. They then discuss the potential effect of the physical educators' weight bias on adolescent participation in physical activity and its implications for students' physical health, academic achievement, and social development. The issue of normative beliefs among teachers is well-examined in the research on teacher education and development but is not really examined in health except in relation to substance abuse, so this article may be a start of this discussion in relation to activity.
  • Prevailing social norms that see food as a reward. Teachers are selected for their jobs because they reflect the dominant values and social norms of their communities. This is so that parents will be comfortable in send ing their children to these teachers every day. I am finishing this paper the day after Halloween is celebrated in North America, a custom that now equals Christmas in its spending and that glorifies candy. Last week, I watched out local television news that reported that cake was served at a celebration of an expansion of a school famous for its healthy lunches. Yes, both of these were special occasions and food should be part of the celebration. But don’t we all have many of those special occasions almost every week? And exactly how and with what funds should teachers replace food as the reward at student birthday parties in class, class outings and more?
Questions related to Future and Current Research
This sub-section considers new methods in research (rather than just controlled trials and systematic reviews of these trials), studies that link prevention/promotion programs with improved educational outcomes and studies that report cost-effectiveness or cost-benefits, the reliability of various measures and the emergence of formal research agendas and research-focused centres/programs.

The value of examining trends and new approaches to school health research enables us to judge the maturity of the research in a given area, to avoid duplication of research that already has been done quite often before (a common problem in research funding) and to identify new insights into the issues. In our monitoring of obesity in our selected 18 month timeframe, we were pleased to note studies that examined cost-effective and cost-benefits issues. These items are listed below:

Better ways to increase physical activity

Earlier in this paper, we discussed two studies that reported that physical education classes often have many if not most students standing around while a skill is taught or while other students play more vigorously. Dudley et al (2011) report on a small Australian observational study to note that the average proportion of class time spent (not the actual or all students) in moderate or vigorous activity was 56%. In a similar, larger Texas study, Skala et al (2012) reported that only 38% of the PE class time was spent being active.

Southward et al (2012) noted that active school transportation accounted for almost one/third of the moderate physical activity of students in a school in Bristol England. The authors report that "Physical activity levels during journeys to and from school were highly similar, and contributed 22.2 minutes (33.7%) of total daily MVPA. In addition, MVPA on the journey did not differ between boys and girls, but because girls have lower levels of daily physical activity than boys, the journey contributed a greater proportion of their daily MVPA (35.6% vs 31.3%).

Lilian et al (2010) did an analysis of the strategy of increasing activity time spent in regular classrooms and found that a three hour training program for elementary teachers can result in a gain of 7.1 minutes of activity per week, going from an average of 2.4 minutes of active class time to 9.5 minutes per day. Again, this was the time spent by the entire class and did not differentiate among students who may be participating at different activity levels.
A Dutch study (Slingerland et al, 2012) reports that active transportation to school and after school activities are far more significant than PE classes in the total physical activity of children. Active transport and PE contributed 30.0% and 17.4%, respectively, to school-related activity levels. Active transport to and from school contributed 15% to the total activity levels of children in all aspects of their day.

A recent Canadian study found in our scanning of journals (Fuller at al, 2011) suggests that intra-mural sports are more effective than competitive inter-school sports in raising activity levels for all students. The authors report that “Regardless of whether or not they reported participating in intramural sports, adolescents in schools with more intramural sports engaged in 3.6 (p = .03) more total, and 1.3 (p = 0.03) more vigorous activities per week than those attending schools with fewer intramural sports. Number of extramural sports was not statistically significantly associated with physical activity, regardless of whether or not individual students participated”.

Given the above studies, it is not surprising that one of the leading school-focused research programs on obesity in Canada (Pabayo et al, 2012) has suggested that active transportation to school be a central part of school-based and school-linked efforts to reduce obesity. Also given the above studies and previous discussions, it may be time for Canadians to consider a shift away from trying to find more PE time during the school day and focus on other interventions to achieve the goal of 60 minutes of activity per day.

Cost-Effect among Different Interventions for Childhood Obesity

In a similar vein, Kuhle et al (2010) examined the “prevention potential” of various behaviours in reducing childhood overweight. These included increasing physical activity, reducing sedentary activity (often combined with unhealthy snacking), maternal smoking and pre-pregnancy weight of mothers. They concluded that “Excess screen time and maternal pre-pregnancy weight offer the greatest potential for prevention of childhood overweight at 11 years of age”.

Drake et al (2012) report that team sports and active commuting were linked to obesity reduction but did not comment on PE classes. Their telephone-based survey of about 2000 New Hampshire students correlated team sports and active commuting to school with lower risk of obesity or overweight. Although PE classes are included in the survey, those specific results are not cited in the abstract of the article. Does PE make a difference in weight loss?
Cost-benefits Studies
Cost-benefits studies are different than cost-effectiveness studies because they try to examine the long-term benefits to quality of life and other factors such as health care costs or lost work days. Given that most of this work extrapolates from short term intervention studies and uses economic modelling, it is understandable that there are fewer studies.

Our scanning of the research and related web sites identified two reviews of studies on the cost-benefits of nutrition (Ubido et al , 2011) and physical activity interventions (Lewis et al, 2010) through schools. The nutrition review found several studies that calculated that school-based healthy eating programs had cost-savings (ie a health benefit above the cost of the program). However, the pay-off was a long time in coming, as long as 40-50 years. The cost-benefits for physical activity programs in schools were less conclusive.

A detailed cost analysis (Ohinmaa et al, 2011) of a healthy eating and physical activity program in a Nova Scotia school board reported that on average, to $7,830 per school and $22.67 per student. Of the public funding, $140,500 was for CSH, $86,250 for breakfast programs, $28,750 for school food policy programs, and the remainder for other subsidized programs. Grants, donations and fundraising were mostly locally acquired. They totaled $127,235, which translates, on average, to $2,892 per school or $8.37 per student. The value of volunteer support was estimated to be equivalent to the value of grants, donations and fundraising combined. Of all grants, donations, fundraising and volunteers, 20% was directed to physical activity programs and 80% to nutrition programs.

A news story about a national US Study on school meal programs across that country shows healthy school lunches don't cost more. The study focused on middle schools in low-income neighborhoods across the country, where at least half the students were eligible for free or reduced-price meals. Half the schools had to meet nutritional goals that included reducing fat, offering more fruits and vegetables, and eliminating high-calorie desserts and sugared beverages. The other schools did not. In the end, those schools offering healthier meals saw an average profit of $3.5 million over the three-year study, while those that didn't had a profit of $2.4 million — a difference the researchers said was not significantly different.

Summing up this sub-section, we can conclude that the research on obesity prevention is benefitting from recent studies showing that there are good and feasible alternatives to increasing activity times in schools without having to find yet more time for physical education classes. Indeed, given the time allocations in those classes, it might be more productive to focus on active travel, recess and increased time in regular elementary classes.
However, these alternatives will require careful consideration of the findings of the previous sub-sections, where we noted the powerful influences of professional norms and the pre-occupations/priorities of educators generated from other pressures aimed at increasing academic standards.


This review and analysis of Canadian and similar international research articles, news stories, reports and social media sources has provided some sobering thoughts about the past and current efforts o prevent obesity.
Canada can be considered a world leader in obesity prevention through schools. This has been demonstrated by a large number of the items that we located over the past 18months, between March 2011 and October 2012.
There is a strong and wide spread consensus about effective individual programs and multi-intervention approaches to obesity prevention, healthy eating and physical activity. These statements, models and programs have been articulated and replicated or initiated in Canada. This consensus has been in place for over 25 years in Canada in different formats and articulated in several long term initiatives, strategies and policy documents in Canada dating back to the 1990’s. Canada has even been a host for two key international documents on diet/physical activity and on physical activity alone.

Canada has spent over 156 million on obesity research, including four million on school-based obesity prevention. There has been considerable federal/provincial/territorial cooperation, a sometimes rare commodity in Canadian decision-making as a federal country. Our review has identified numerous projects and activities, also adding up to millions of dollars of expenditures.

However, despite these many nice-sounding and lengthy policy documents, the several models of multi-interventions approaches and programs and many, many exhortations aimed at schools to take up the burden, the only required action for all schools in Canada and most other countries has been limited primarily to restricting and regulating food sales and intervention affecting only the minority of students who purchase or who are provided lunches at schools. These restrictions on food sales have caused older students to leave schools for lunch if they have a fast food restaurant within 850 metres and are having little impact on food sales in high schools but so well at the elementary school level.

The emphasis on physical activity as a weight loss strategy has been misguided and not based on science, as we learned by reading the various research reviews. Physical activity surely has many other benefits but it should not be the cornerstone of obesity prevention. Instead, we need to focus on nutrition and diet, on work-life conditions that dictate that working parents often feed their children with convenient fast food and processed food. We need to work with safe schools advocates to reduce the fear of crime and violence in our neighbourhoods. We need to focus on families and children living in poverty and raise the quality and quantity of their food. We need to address the mental health issues of boredom, loneliness, stress among children that often lead to over-eating.

There have been numerous pilot projects and small scale efforts to increase active and safe routes to schools, to promote greater awareness about sugared beverages, to reverse the order of activities at lunch hour and to make recess periods more active. We also learned about school recognition programs and about several major program evaluations underway in Canada. However, we also learned that the number of schools and students participating in those activities represent only small percentages of the overall number of schools and that some of the “recognized” schools were only doing one activity per year to qualify. We also learned that the programs being tested in several jurisdictions are showing minimal or no positive results in terms in weight loss.

Most importantly, we learned from the many, actually too many surveys of childhood obesity currently being done in Canada that the obesity/overweight rates have not declined at all, despite almost two decades of efforts and an abundance of national, federal and provincial/territorial strategies. We also learned about the rudimentary, incomplete and overlapping methods that have just now, after 20 years of activity, been devised to track obesity rates in the future.

With these Canadian childhood obesity rates being essentially unchanged and perhaps deteriorating, it is not surprising to see recent calls from Canadian physicians and business people that are demanding more action. This review of recent research, news, reports and analyses provided from social media sources suggests strongly that we also need some quite different strategies and emphasis. These include

  1. We need to understand that eating and physical activity are socially constructed behaviours, like all other human behaviours and not simply a matter of caloric intake and expenditures. Our behaviours can be better understood by ecological analysis, a concept that has been around for several years. But we need to restructure our interventions to be based on ecological action, and therefore use a systems-based, multi-level, cross sectorial, economic, political, social and institutional approach.
  2. We need to shift attention to health authorities, social service agencies, school boards and employers rather than the front lines comprised of teachers, nurses and nutritionists. We have lots of checklists for schools. We need to develop similar checklists for provincial/territorial ministries and governments and hold them accountable. We need to ensure that federal departments (Health Canada, Industry Canada, Agriculture Canada) do their part as well as federally CIHR research institutes. We need to ensure that the Council of Ministers of Education, Canada (CMEC) reports regularly on the nutrition knowledge and skills being acquired as part of the mandatory health education curricula in all provinces, as they do foer science and math and reading. We need to have the inter-governmental committees on nutrition and school health continue their work, with the Nutrition Working Group developing national, inter-governmental policy options on school meal/snack programs in schools and the Joint Consortium for |School health completings its work to harmonized the many child health surveys. We need the Canadian Institute for Health Information to resume their child health monitoring and regular reports.
  3. We need to refocus, with less emphasis on physical activity, more emphasis on diet, sleep, mental health, poverty.
  4. We need more focus on the work-lives, safety concerns, daycare and transportation needs that create huge constraints on parents. But we need to be realistic about what can be achieved in terms of rezoning and moving fast food restaurants away from schools, or creating walkability in older established neighbourhoods. We also need to alter parent perceptions about the weight of their children and their health beliefs about their ability to influence the weight of their children.
  5. We need to establish a national school snack and meal program for schools serving disadvantaged schools and join the rest of the western world in using schools to provide healthy food that helps to ensure that no child in Canada is hungry. We need cost benefit studies of offering a universal school lunch program to parents at all other schools.
  6. We don’t need to try to maximize physical education time in schools. We have learned that better, more active use of the current time available in PE classes is needed. Instead, we need to worry about the time available for nutrition education in health curricula that have been combined with PE, resulting in less than 17 hours of secondary health instructional time in two jurisdictions to cover over 25 health issues and less than two hours of time available in one jurisdiction. We need to consider bringing back mandatory Home Economics/Family Studies curricula where students used to be taught basic skills like cooking healthy meals and managing home budgets. Indeed, this renewed curricula could be combined with recent calls for better financial literacy education through a return to consumer education and other content, including parenting skills.
  7. We need to extend the school day to allow for more time at recess and lunch. Many jurisdictions and school boards are experimenting or expanding with pre-school education, so the extension of the school day to include after school child care should be considered for older children.
  8. We need to decide who will do the coordination at all levels across the education, health and other systems. School nurses can be the backbone for obesity preventon and management at the school level and should be considered as several jurisdictions review their role. Increased nurse capacity would also be critical for many other issues coming at schools, including renewed outbreaks of measles, whooping cough and other infections as well as increased trauma from bullying.
  9. We know that advertising works, so we need to ban it when it comes to marketing food to children.
  10. We need to restrict and regulate food sales in hospitals, municipal sporting facilities and other publicly funded venues where children gather
Most of all, we need to be both radical and realist. Radical in pursuing the ten actions noted abive and realistic in terms of what schools, even when working with other community agencies and truly supported by governments can accomplish. We have to ask how many students will truly be affected by an intervention? What proportion of parents who have children of school-age will continue to make their school lunches? How many parents will agree to have their children walk to school, even when there are well-meaning volunteers trying to organize these safe routes? Can we fight the technology of tablets and computers when parents admit they use them to keep their kids calm or amused or should we go with it and invest in active games using the TV screen? Do we recognize the social taboos and limits of schools in regard to parental and child privacy? Do we really want teachers checking kids lunches for their nutritional value? Will parents truly accept teacher comments on their child’s weight or lunch quality?

There are definitely several things that can and they have been identified in this review. Canada, as well as other countries, is seeing schools play an active part. So there is definitely hope for the future. But let’s realize that schools will always be an ultimate follower of the norms and wishes of their communities rather than a leader. So, our true leaders, in government, in business and in local health authorities and other agencies need to stop leading from behind and get out in front of schools,,,now, rather than later.

To conclude, this review of research articles, news stories social media sources and various reports has identified several actions that should be considered id countries like Canada are to make any real progress in preventing obesity through school-based and school-linked programs and multi-intervention approaches. Although an 18 month scan does not replace more in-depth searches and studies, it does provide a sense of direction based on the latest information.

By keeping up with the research articles, news stories, reports and analyses being produced, we can more easily identify emerging trends and significant events. We all want to keep up with the news and research and allof us struggle to do so in our busy work days.

This process requires diligent, regular monitoring, careful and ongoing selection of items and a number of perspectives as well as a solid framework of outline for cataloguing the items in an organized way. We hope that this example shows how the extensive information collected by the International School Health Network each day, each week and each month can be organized and examined quickly.
It took only a few hours to extract the information from our posted regular sources and only a few days to post and analyze those items within the framework/outline developed from a synthesis of school-based and school-linked health and social development models and frameworks.

We believe this review and analysis of current events and trends offers several insights and a good overview of a typical country response to childhood obesity through its schools. It offers some lessons, some ideas worthy of further consideration and others, no doubt, that should be discarded or re-analyzed.

The ISHN information service provides this for its members, giving them daily, weekly or monthly reports depending on their preferences. In cooperation with several other organizations and senior associates, we also produce regular analyses in shared blogs, twitter accounts and widgets that can be published simultaneously on several web sites. As well all of this information is now flowing into several discussion groups and, eventually, the best items will be posted in shared bibliographies/toolboxes. We also hope that the ISHN outline used for this review, one which is based on a synthesis of the accumulated wisdom of over 25 school-based and school-linked strategies, is a valid and useful way to collate he ongoing flows of evidence, experience and commentaries. Our next step is to find the means whereby this type of analysis can be done by several experts and organizations in smaller and more timely reports.

If you would like to learn more about these current and planned knowledge exchange activities, contact Doug Mccall at

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