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School nutritional capacity, resources and practices are associated with availability of food/beverage… Mâsse, Louise C; de Niet, Judith E Feb 19, 2013

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RESEARCH Open AccessSchool nutritional capacity, resources andpractices are associated with availability of food/beverage items in schoolsLouise C Mâsse* and Judith E de NietAbstractBackground: The school food environment is important to target as less healthful food and beverages are widelyavailable at schools. This study examined whether the availability of specific food/beverage items was associatedwith a number of school environmental factors.Methods: Principals from elementary (n = 369) and middle/high schools (n = 118) in British Columbia (BC), Canadacompleted a survey measuring characteristics of the school environment. Our measurement framework integratedconstructs from the Theories of Organizational Change and elements from Stillman’s Tobacco Policy Frameworkadapted for obesity prevention. Our measurement framework included assessment of policy institutionalization ofnutritional guidelines at the district and school levels, climate, nutritional capacity and resources (nutritionalresources and participation in nutritional programs), nutritional practices, and school community support forenacting stricter nutritional guidelines. We used hierarchical mixed-effects logistic regression analyses to examineassociations with the availability of fruit, vegetables, pizza/hamburgers/hot dogs, chocolate candy, sugar-sweetenedbeverages, and french fried potatoes.Results: In elementary schools, fruit and vegetable availability was more likely among schools that have morenutritional resources (OR = 6.74 and 5.23, respectively). In addition, fruit availability in elementary schools washighest in schools that participated in the BC School Fruit and Vegetable Nutritional Program and the BC Milkprogram (OR = 4.54 and OR = 3.05, respectively). In middle/high schools, having more nutritional resources wasassociated with vegetable availability only (OR = 5.78). Finally, middle/high schools that have healthier nutritionalpractices (i.e., which align with upcoming provincial/state guidelines) were less likely to have the following food/beverage items available at school: chocolate candy (OR = .80) and sugar-sweetened beverages (OR = .76).Conclusions: School nutritional capacity, resources, and practices were associated with the availability of specificfood/beverage items in BC public schools. Policies targeting the school environment are increasingly beingconsidered as one of the strategies used to address childhood obesity, as a result it is important to furtherunderstand the factors associated with the availability of specific food/beverage items at school.Keywords: Nutrition, School environment, Organizational support, School policy, Availability of food, Availability ofsweetened beverages, Fruit, Vegetables, Junk food, Less healthful food* Correspondence: lmasse@cfri.ubc.caUniversity of British Columbia, School of Population and Public Health,F508-4480 Oak Street, Vancouver, BC V6H 3V4, Canada© 2013 Masse and deNiet; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of theCreative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,distribution, and reproduction in any medium, provided the original work is properly cited.Mâsse and de Niet International Journal of Behavioral Nutrition and Physical Activity 2013, 10:26http://www.ijbnpa.org/content/10/1/26BackgroundOverwhelming evidence demonstrates a worldwide in-crease in childhood obesity [1] and Canada is no excep-tion to this trend [1]. In 2004, one quarter (26%) ofCanadian children aged 2 to 17 years were either over-weight or obese, representing a sharp increase from acombined prevalence of 15% in 1978/1979 [1]. Whileobesity is a complex and multi-factorial problem, manyhave suggested focusing on the school food environmentas part of a comprehensive multi-setting approach to ad-dress childhood obesity [2].The availability of less healthful food and beverages inschools is widespread [3-5]. Despite recent changes to im-prove the school food environment, the availability ofsome high fat food such as pizza and hamburgers, remainsalarmingly high in U.S. schools (73.9% and 82.6%, respect-ively for elementary and middle/ high schools) [5]. Similarto U.S. schools, Canadian elementary schools have fewervending machines; however, less healthful food andbeverages are widely available to all grades as they aremade available through other outlets (e.g., cafeteria, schoolstores) [3].The school food environment has been shown to influ-ence student eating behaviors [6-12]. In schools whereless healthful food and beverages are widely available,students have higher intake of these items, consumefewer fruit and vegetables, and have higher total fat in-take [7-11]. In addition, increasing the availability ofhealthful food and beverages in schools has beenassociated with improved dietary intake [13,14]. Al-though evidence linking the school food environmentwith student Body Mass Index (BMI) is mixed [6], boththe frequency at which fruit and vegetables are availableand the availability of less healthful food in vendingmachines or other venues at school have been associatedwith higher BMI in students [14]. As the school food en-vironment may influence the eating behaviors of chil-dren in that context, it is important to understand thefactors associated with the availability of specific food/beverage items at schools.The school food environment may be influenced by sev-eral factors, such as policies/guidelines that limit the avail-ability of certain food/beverages items, restricting the useof food as rewards in the classroom, setting standards fornutrition education, restricting certain marketing prac-tices, having adequate resources and capacity at the schooland district levels, having a supportive school community,having access to nutritional expertise locally, having accessto nutritional programs that promote healthy eating,and having a favorable socio-demographic profile [15-22].With the exception of school food policies/guidelines,where emerging data links policies with students’ dietaryintake and BMI [18,23-27], the extent to which otherschool factors are related to the availability of specificfood/beverage items at school has received little attention.However, uptake of nutrition and health programs in theschool setting have been found to be highest in schoolsthat have more supportive policies; better organizationalclimate, capacities and resources; and have more supportfrom school principals [28-30]. This suggests that these en-vironmental factors might be associated with the availabil-ity of specific food/beverage items in the school setting.Therefore, the purpose of this study was to determinewhether the availability of fruit, vegetables, pizza/ham-burgers/hot dogs, chocolate candy, sugar-sweetened beve-rages, and french fried potatoes was associated with anumber of school environmental factors: (1) policyinstitutionalization of nutritional guidelines at the districtand school levels, (2) climate, (3) nutritional capacity andresources, (4) nutritional practices at school, and (5) schoolcommunity support for enacting stricter nutritionalguidelines at school. These associations were examinedseparately for elementary schools and middle/high schools.Differences were expected given that food and beveragesare more likely available in higher grades [5,31].Note we examined these associations in schools locatedin British Columbia (BC), Canada which has a markedlydifferent school food environment than other countries.Unlike other countries, Canada does not have a federallysubsidized school meal program [32]. Some school districts,through funding from the Ministry of Education, enableschools to offer school meal programs to vulnerablestudents (breakfast program, hot lunch program, bag lunchprogram, or snack program). School meal programs areoften managed through partnerships and donations schools/districts have negotiated with external agencies. As manyschools do not have on-site cooking facilities, schools cancontract food vendors to prepare the school meals followingthe non-mandated guidelines published by the province/state for administering the program. In addition, in ourcontext the availability of permanent food outlets is muchlower in elementary schools than in middle/high schools(45% versus 95% have permanent food outlets, respec-tively); however, 82% of elementary schools have externalvendors contracted to bring in A La Carte lunch options(e.g., pizza, hamburgers, hot dogs), varying from multipletimes a week to a few times per month [3]. Importantly,food and beverages made available or sold to studentswere not mandated to meet any nutritional guidelinesuntil the 2008/2009 school year, as the province/stateenacted guidelines to support healthy eating at schoolswhich aligned with the 2007 Canada Food Guide [33].MethodsParticipantsPublic school principals in BC were targeted for this study.Given the relatively small number of Francophone,Independent, First Nations, and alternative schools inMâsse and de Niet International Journal of Behavioral Nutrition and Physical Activity 2013, 10:26 Page 2 of 12http://www.ijbnpa.org/content/10/1/26BC, principals of these schools were excluded as thisstudy could not address their specific issues of theseschools. Study approval was received in 43 of the 59school districts (73% response rate); however, threedistricts were excluded as they were participating in an-other study conducted by the same research team. Ofthe 1067 eligible principals, 513 principals completedthe school environment survey (48% response rate).Respondents from schools that included all grades (i.e.,elementary, middle, and high schools n = 13) or had lessthan 50 students (n = 13) were excluded. In total, 369elementary schools and 118 middle/high schools from38 districts provided data for the analyses.ProceduresThis study was approved by the University of BritishColumbia Research Ethics Board. Prior to data collec-tion, school district approval was obtained. In January of2008, principals received a package that included aninvitational letter, consent form, a hard copy of theschool environment survey (which took 30 minutes tocomplete), and a pre-paid self return envelope. Approxi-mately two weeks after the invitational package wasmailed, a research staff member contacted the principalsto determine if they had specific questions about thestudy. Principals who did not return the school environ-ment survey received a second mailing. If completedsurveys were not received within a 3-week period,principals received a reminder email with a link to the on-line survey as an alternative way of completing the survey.Principals were encouraged to seek out the expertise oftheir staff if assistance was needed for filling out sectionsof the survey (e.g., the nutrition environment section).Data collection ended in June 2008. Principals received a$10 gift card for completing the survey.MeasuresOperationalization of the measures integrates centralconstructs from the Theories of Organizational Changeand elements of Stillman’s Tobacco Policy Frameworkadapted for the context of this study (see Figure 1).From the Theories of Organizational Change, our assess-ment framework incorporates assessment of policyinstitutionalization (e.g., school and district policies,guidelines, or requirements) as well as measures oforganizational climate, capacity and resources, andpractices to support healthy eating and nutrition educa-tion at schools. From Stillman’s Tobacco Policy Frame-work [34], our measurement framework includesassessment of internal and external influences that mayimpede or facilitate implementation of healthy eatingpractices or policies at school. Whenever possible,existing measures were used to assess the constructs ofinterests. Content review of our measures was conductedby having relevant provincial Ministry staff and schoolprincipals review the relevance of the items in the contextof BC. A description of the measures follows as well as adescription of the psychometric properties of the scalesused to measure these constructs.School characteristics (independent variables)Policy institutionalization measured the extent to whichdistricts and schools had nutritional policies/guidelines/requirements related to the availability of food andbeverages, qualifications of food personnel, and nutri-tion education at school. Two scales assessed policyinstitutionalization: [1] District guidelines is a 3-itemscale that assessed whether principals perceived theirdistrict’s guidelines to be average, above average, orbelow average compared to other districts with respectto food and beverages sold or made available tostudents, staffing requirements for school food per-sonnel, and nutrition education requirements; and [2]School guidelines is a 7-item scale that measuredwhether schools have guidelines in place that ban foodadvertizing, prohibit use of less healthful food as re-ward, require healthier food choices be subsidized, pro-vide educational requirements for the school foodFigure 1 School environmental factors hypothesized to beassociated with availability of specific food/beverage items.Mâsse and de Niet International Journal of Behavioral Nutrition and Physical Activity 2013, 10:26 Page 3 of 12http://www.ijbnpa.org/content/10/1/26personnel, and include requirements for nutrition edu-cation. Response options for these items included “no”,“in the process of developing guidelines”, and “yes”.These options were dichotomized for analysis purposes(“0” for “no” and “in the process” and “1” for “yes”). Inaddition, the scale included two items that measuredwhether the school incorporates the Canada’s FoodGuide into the curriculum with “yes” and “no” as re-sponse options.Climate assessment was derived from Hoy’s school cli-mate measure [35-38]. The scale, using seven responseoptions, includes 10 semantic differential items thatmeasured whether the overall school climate is collegial,supportive, conciliatory, friendly, warm, open, welcom-ing, accepting of change, accommodating, and trusting.Capacity and resources measured two dimensions: nu-tritional resources and program participation. Nutritionalresources is a 5-item scale based on Hoy’s organizationalHealth Inventory of elementary schools [39]. The scaleassessed whether principals perceived their school’s nutri-tional resources to be average, above average, or belowaverage compared to other schools with respect to thenumber of staff involved in food preparation and manage-ment, eating facility, access to a local nutritionist, accessto caterers and vendors that offer healthier food options,and opportunities to make healthy food choices at school.Program participation was measured with two items: oneassessing participation in the BC Milk Program and theother assessing participation in the BC School Fruit andVegetable Nutritional Program (BCSFVNP), with “yes”and “no” as response options. The BC Milk programsubsidizes the costs of milk to students in K-12 and inelementary schools the milk can be delivered in theclassroom instead of the cafeteria. The BCSFVNP waslaunched in 2005 and provides K-12 schools with 14free deliveries of at least two servings of locally grownfresh fruit and/or vegetables for every student through-out the school year. Both programs are run by schoolvolunteers.School nutrition practices is a 3-item index thatassessed whether current school practices are alignedwith next school years’ upcoming mandated provincial/state guidelines that eliminate the availability of lesshealthful food and beverages in schools and follows the2007 Canada’s Food Guide eating recommendations[33]. Specifically, this index assessed whether schoolsimplemented the guidelines for food and beverages soldor made available to students in the following locations:snack bar/school store(s); vending machine(s); and cafe-teria. Response options for these items included “no”, “inthe process of developing requirements”, and “yes”.These options were dichotomized for analysis purposes(“0” for “no” and “in the process” and “1’ for “yes”) andaveraged across the three items.School internal and external influences (independentvariables)Internal and external support is a 7-item scale thatassessed perceived support from parents, staff, students,and the larger community for eliminating less healthfulfood and beverages in schools as well as assessingwhether principals believed schools can play a role inaddressing childhood obesity. All items were measuredon a 4-point Likert-scale (strongly disagree to stronglyagree).School socio-demographic characteristics (covariates)School size (total number of students) and school setting(categorized as inner city/urban, suburban, or rural)were included in the analyses as covariates.Availability of specific food/beverage items (dependentvariables)The School Health Policies and Programs Study (SHPPS)questions were used to assess availability of specific food/beverage items at school for lunch in a typical week [40].The availability of the following food/beverage items weremeasured: [1] fruit; [2] vegetables; [3] pizza/hamburgers/hot dogs; [4] chocolate candy; [5] sugar-sweetened beve-rages (e.g., pop, iced tea, sport drinks or fruit drinks thatare not 100% fruit juice); and [6] french fried potatoes.Psychometric properties of the measuresThe psychometric properties of the scales were assessedin the larger sample using exploratory factor analysis.We extracted a 5-factor solution using the principalcomponent extraction method with a promax rotation.Results from the factor analysis showed that a 5-factorsolution replicated the hypothesized factor structurewith the exception of two items: one item (the internaland external support item that measured whetherprincipals believed schools can play a role in addressingchildhood obesity) cross-loaded on two factors (internaland external support and policy institutionalization –school guidelines); and another item had a low factorloading (.24) (the policy institutionalization – schoolguidelines item that measured requirements for nut-rition education in schools). The 5-factor solutionexplained 58% of the total variance and each scale hadadequate internal consistency (Cronbach alpha (α)), al-though one was slightly less than the acceptable cut-offof .70 (Policy institutionalization – district guidelinesα = .79 with factor loadings ranging from .78 to .89;Policy institutionalization – school guidelines α = .64with factor loadings ranging from .50 to .68 (except oneitem had a loading of .24); Climate α = .94 with factorloadings ranging from .63 to .88; Capacity & resources –nutritional resources α = .72 with factor loadings rangingfrom .62 to .73; and Internal and external supportMâsse and de Niet International Journal of Behavioral Nutrition and Physical Activity 2013, 10:26 Page 4 of 12http://www.ijbnpa.org/content/10/1/26α = .72 with factor loadings ranging from .30 to .73).Correlations among factors were low (less than .30).Statistical analysesAll analyses were conducted using the STATA softwareversion 11.1 (StataCorp, Texas USA). Nine hierarchicalmixed-effects logistic regressions (xtmelogit) were employedto address the research questions. To account for the nestedstructure of the data, the district code was entered in theanalyses. Multivariate associations were examined by includ-ing the covariates and all the independent variables in themodel. Separate analyses were conducted for elementaryschools and middle/high schools. Analyses for the elemen-tary schools were restricted to food and beverages withmore than 10% availability. To account for multiplecomparisons, significance level was set at a stringent alphalevel of .01 and trends toward significance were set at analpha level of .05.Missing data were imputed using multiple imputationtechniques (missing data ranging from 0.6 to 15.8%). Allmissing data were imputed on the raw data using STATA’sExpectation Maximization method which assumes thedata is missing at random and unrelated to the outcome[41]. The dependent variables were included in the imput-ation model but only missing data on the covariates andindependent variables were imputed. A total of fiveimputations were used.ResultsSchool environmental factorsParticipating middle/high schools were significantly largerthan the elementary schools (Table 1). Schools located inTable 1 Descriptive information about the elementary (N = 366) and middle/high (N = 116) schools that participated inthe studyElementaryschoolsMiddle/highschoolsGroupcomparisons% or mean (SD) % or mean (SD) χ2 or t-test[range] [range] p-valueNumber of schools per district 9.7 3.1[1 - 38] [1 – 11]School socio-demographic characteristicsSchool size 283 (146) 838 (424) t(1) = 21.44(Nelementary schools (Ne) = 379;Nmiddle/high schools (Nmh) = 117) [50 - 1062] [121 - 2100] p < 0.001**School setting (Ne = 361;Nmh = 116) Urban 36.8% 31.9% χ2 (1) = 0.98Suburban 35.2% 37.1% p = 0.614Rural 28.0% 31.0%School characteristicsPolicy institutionalization – District guidelines 2.1 (0.4) 2.1 (0.4) t(1) = 1.01(Ne = 314; Nmh = 102) [1.0 – 3.0] [1.0 – 3.0] p = 0.312Policy institutionalization – School guidelines 0.4 (0.3) 0.4 (0.2) t(1) = 0.29(Ne = 254; Nmh = 89) [0.0 – 1.0] [0.0 – 1.0] p = 0.773Climate 2.4 (0.5) 2.2 (0.6) t(1) = -3.00(Ne = 352;Nmh = 113) [1.0 – 3.0] [1.0 – 3.0] p = 0.003**Capacity & resources – Nutritional resources 1.8 (0.4) 2.0 (0.5) t(1) = 4.64(Ne = 306; Nmh = 104) [1.0 – 2.8] [1.0 – 3.0] p < 0.001**Capacity & resources – Program participation (Ne = 335; Nmh = 93) BCSFVNP (% yes) 43.3% 25.8% χ2 (1) = 9.31p = 0.002**BC Milk Program (% yes) 38.2% 25.8% χ2 (1) = 4.89p = 0.027*School nutrition practices 7.4 (2.1) 5.6 (4.1) t(1) = -6.26(Ne = 359;Nmh = 117) [0 – 10] [0 – 10] p < 0.001**School internal and external influencesInternal and external support 2.8 (0.3) 2.7 (0.4) t(1) = -2.59(Ne = 273; Nmh = 104) [1.9 – 3.9] [1.7 – 3.9] p = 0.010*BCFVNP = British Columbia Fruit and Vegetable Nutritional Program; BC = British Columbia.** Significant at p < .01.* Trend towards statistical significance at p < .05.Mâsse and de Niet International Journal of Behavioral Nutrition and Physical Activity 2013, 10:26 Page 5 of 12http://www.ijbnpa.org/content/10/1/26urban, suburban, and rural areas were well represented.Four of the six school characteristics differed significantly(p < .01) between elementary and middle/high schools(Table 1). Specifically, elementary schools had a better cli-mate, less nutritional resources, higher participation in nu-tritional programs (BC Milk Program and the BCSFVNP),and better nutritional practices which align with upcom-ing provincial/state nutritional guidelines. In addition,elementary schools had significantly more support (in-ternal and external) for enacting stricter nutritionalguidelines at school than did middle/high schools.Availability of food and beveragesThe availability of fruit, vegetables, and pizza/hamburgers/hot dogs was significantly lower in elementary schoolscompared to middle/high schools (Table 2). Chocolatecandy, french-fried potatoes, and sugar-sweetened beve-rages were either not available or rarely available in elem-entary schools than compared to middle/high schools.School environmental factors associated with availabilityof specific food/beverage itemsTables 3 and 4 summarize the results of the hierarchicalmixed-effect logistic regression analyses examining whichschool environmental factors were associated with theavailability of specific food/beverage items in elementaryand middle/high schools.Associations with demographic characteristicsOverall, the school demographic variables were not sig-nificantly associated (p < .01) with availability of specificfood/beverage items in schools. However, the school set-ting showed a trend towards statistical significance(p < .05) with fruit availability in elementary schools andwith pizza/hamburger/hot dog availability in middle/high schools. Elementary schools located in suburbanareas were less likely than those located in urban areasto report fruit availability (Odds Ratio (OR) = 0.39,p = .015). In addition, middle/high schools located inrural areas were less likely than those located in urbanareas to report pizza/hamburger/hot dog availability(OR = 0.24, p = .032).Associations with school characteristicsIn elementary schools, fruit and vegetable availability wasmore likely among schools that have more nutritionalresources (OR = 6.74 and 5.23, respectively), participate inthe BCSFVNP (OR = 4.54 and 2.71, respectively althoughonly a trend towards statistical significance was observedfor vegetable availability (p = .029)), and participate in theBC Milk Program (OR = 3.05 for fruit availability; however,no significant association was observed for vegetable avail-ability). Associations with fruit and vegetable availabilitydiffered markedly among middle/high schools. Havingmore nutritional resources was the only school character-istic associated with vegetable availability in middle/highschools (OR = 5.78). In contrast, no school characteris-tics were significantly associated with fruit availability inmiddle/high schools. In addition, none of the schoolcharacteristics were associated with availability of pizza/hamburgers/hot dogs in elementary and middle/highschools. Finally, middle/high schools that have healthiernutritional practices (i.e., which align with upcom-ing provincial/state guidelines) were less likely to havethe following food/beverage items available at schoolchocolate candy (OR = .80), sugar-sweetened beverages(OR = .77), and french fried potatoes (OR = .80, althoughonly a trend towards statistical significance was observedp = .019).Associations with school internal and external influencesSchool internal and external influences were notassociated with availability of any food/beverage itemsexamined in this study.DiscussionUnderstanding environmental factors associated withthe availability of specific food/beverage items at schoolis an important first step to ensure students have the op-portunity to make healthy nutritional decisions atTable 2 Percent of elementary (N = 369) and middle/high schools (N = 118) reporting availability of specific food/beverage itemsAvailability of ElementaryschoolsMiddle/highschoolsGroup comparisons χ2p-valueFruit 27.9% 74.6% χ2 (1) = 81.67 p < 0.001**Vegetables 9.2% 69.5% χ2 (1) = 179.03 p < 0.001**Pizza, hamburgers, or hot dogs 13.8% 63.6% χ2 (1) = 115.33 p < 0.001**Sugar-sweetened beverages (pop, iced tea, sport drinks or fruit drinks that are not100% fruit juice)5.4% 62.7% χ2 (1) = 188.41 p < 0.001**French fried potatoes 0% 41.5% χ2 (1) = 170.37 p < 0.001**Chocolate candy 0% 37.3% χ2 (1) = 151.26 p < 0.001**** Significant at p < .01* Trend towards statistical significance at p < .05.Mâsse and de Niet International Journal of Behavioral Nutrition and Physical Activity 2013, 10:26 Page 6 of 12http://www.ijbnpa.org/content/10/1/26Table 3 Factors associated with availability of fruit, vegetables and pizza/hamburgers/hot dogs in elementary (N = 369)and middle/high schools (N = 118)Availability of fruit Availability of vegetables Availability of pizza/hamburgers/hot dogsElementaryschoolsMiddle/highschoolsElementaryschoolsMiddle/highschoolsElementaryschoolsMiddle/highschoolsCoefficient Coefficient Coefficient Coefficient Coefficient Coefficient[95% CI] [95% CI] [95% CI] [95% CI] [95% CI] [95% CI]p-value p-value p-value p-value p-value p-valueConstant -2.03 -2.77 -7.76 -1.03 -4.55 3.25[-5.32; 1.27] [-8.33; 2.80] [-12.70; -2.83] [-5.43; 3.37] [-8.42; -0.67] [-1.42; 7.92]p = .055 p = .329 p = .002** p = .647 p = 022* p = .170School socio-demographic characteristics (Covariates)School size-0.79 -0.12 -0.41 0.32 0.01 -0.10[-1.61; -0.02] [-0.57; 0.34] [-1.44; 0.61] [-0.11; 0.76] [-0.79; 0.80] [-0.48; 0.27]p = .055 p = .619 p = .429 p = .143 p = .984 p = .580School settingUrban 1 (reference) 1 (reference) 1 (reference) 1 (reference) 1 (reference) 1 (reference)Suburban-0.94 0.87 -0.31 0.41 -0.56 0.23[-1.69; -0.18] [-0.81; 2.55] [-1.49; 0.87] [-0.84; 1.66] [-1.55; 0.43] [-0.86; 1.31]p = .015* p = .310 p = .607 p = .521 p = .270 p = .682Rural-0.03 0.15 .26 -0.51 0.30 -1.42[-0.87; 0.82] [-1.51; 1.82] [-1.05; 1.56] [-1.86; 0.84] [-0.73; 1.33] [-2.72; -0.12]p = .953 p = .858 p = .701 p = .461 p = .565 p = .032*School characteristicsPolicy institutionalizationDistrictguidelines-0.97 -0.08 -0.95 -0.49 0.04 -0.08[-2.00; 0.07] [-2.07; 1.92] [-2.22; 0.31] [-2.13; 1.14] [-0.98; 1.05] [-1.60; 1.45]p = .068 p = .940 p = .139 p = .553 p = .944 p = .920Schoolguidelines0.87 -0.55 -0.03 -0.03 -0.61 1.05[-0.24; 1.98] [-3.53; 2.44] [-1.57; 1.51] [-2.46; 2.39] [-1.88; 0.67] [-1.48; 3.58]p = .124 p = .716 p = .966 p = .978 p = .350 p = .408Climate-0.48 0.48 0.07 -0.57 0.35 -0.32[-1.04; 0.08] [-0.42; 1.38] [-0.71; .86] [-1.42; 0.27] [-0.33; 1.03] [-1.07; 0.42]p = .092 p = .292 p = .852 p = .183 p = .316 p = .396Capacity & resources – Nutritional resources1.91 1.49 1.65 1.75 0.85 0.09[0.99; 2.82] [-0.14; 3.12] [0.42; 2.89] [0.42; 3.09] [-0.16; 1.87] [-1.01; 1.19]p≤ .000** p = .073 p = .009** p = .010** p = .098 p = .871Capacity & resources –Program participationBCSFVNPNo 1 (reference) 1 (reference) 1 (reference) 1 (reference) 1 (reference) 1 (reference)Yes1.51 -0.35 1.00 -0.20 -0.11 0.75[0.89; 2.14] [-1.78; 1.08] [0.10; 1.90] [-1.35; 0.96] [-0.86; 0.64] [-0.33; 1.83]p≤ .000** p = .629 p = .029* p = .738 p = .773 p = .171BC MilkProgramNo 1 (reference) 1 (reference) 1 (reference) 1 (reference) 1 (reference) 1 (reference)Yes1.12 1.71 0.52 -0.35 0.08 -0.39[0.51; 1.72] [-0.50; 3.93] [-0.41; 1.44] [-1.88; 1.17] [-0.64; 0.80] [-1.62; 0.85]p≤ .000** p = .124 p = .270 p = .636 p = .827 p = .528School nutrition practices-0.08 0.03 0.05 -0.01 -0.07 -0.06[-0.22; 0.06] [-0.12; 0.18] [-0.16; 0.25] [-0.15; 0.12] [-0.22; 0.08] [-0.18; 0.05]p = .282 p = .695 p = .649 p = .833 p = .383 p = .292Mâsse and de Niet International Journal of Behavioral Nutrition and Physical Activity 2013, 10:26 Page 7 of 12http://www.ijbnpa.org/content/10/1/26school. As previously found, the availability of food andbeverages was much lower in elementary schools than inmiddle/high schools [3-5]. Overall, three school environ-mental factors were associated with the availability ofspecific food/beverage items at schools: (1) having morenutritional resources, (2) participation in provincial/statenutritional programs, and (3) having nutritional prac-tices that align with upcoming mandated provincial/statenutritional guidelines. Associations among these envir-onmental factors with availability of specific food/bever-age items were complex as they varied by the type offood/beverage items examined and differed by grade.We found that fruit and vegetable availability was sig-nificantly higher in elementary schools that have morenutritional resources. To better understand these fin-dings, it is important to highlight the nutritional contextof Canadian schools in BC. Unlike other countries,Canada does not have a federally mandated school meal/breakfast program [32]. As a result, many elementaryschools in BC lack the amenities to refrigerate and storefresh fruit and vegetables and to prepare (cook or re-heat) school meals. This partly explains why the avail-ability of fruit and vegetables in BC elementary schoolswere found to be much lower than U.S. elementaryschools (27% versus 68%, respectively [4]). In the contextof BC, our findings might highlight the need to equipelementary schools with an appropriate refrigeration sys-tem to enable them to provide more fruit and vegetablesto their students. Furthermore, fruit and vegetable avail-ability may be limited to being available as snacks onlyas many of the permanent food outlets (i.e., schoolstores, cafeteria, or vending machines) in elementaryschools are not preparing meals. However, many elem-entary schools (82%) have external vendors bringing ALa Carte school lunch options (e.g., pizza, hamburgers,and hot dogs) at varied frequencies (e.g., multiple timesa week to once a month) [3]. Potentially, fruit and vege-table availability might be increased by having externalvendors change their offerings which could be achievedthrough policy strategies or incentive programs. Inaddition, nutritional resources were found to influenceavailability of food in middle/high schools; however, onlyan association with vegetable availability was observed.While food and beverages are more widely available inmiddle/high schools [3], there are still a large number ofschools that do not offer lunch options. This might ex-plain why we observed an association between vegetableavailability and school nutrition resources in middle/high schools. Unlike elementary schools, middle/highschools reported greater availability of fruit at schoolswhich may explain why we did not find an associationbetween fruit availability and nutritional resources inthese schools.We found that participation in the BCSFVNP wasassociated with fruit availability in elementary schools.These findings may suggest that fruit availability in elem-entary schools is a result of participating in the BCSFVNP.If this were the case, it would not reflect the broader avail-ability of fruit on a daily basis since the BCSFVNP doesnot provide enough servings of fruit and vegetables tomeet the required daily for each student. While the intentof the program is to encourage students to eat fresh fruitand vegetables, participation in such programs while im-portant, is not enough to ensure that students eat freshfruit and vegetables every day while at school. Alterna-tively, fruit availability in elementary schools might behigher in schools that participate in BCSFVNP as theyhave greater capability to store fresh fruit snacks. As thenutritional context of elementary schools in BC may bebetter equipped to provide fruit and vegetables as snacksrather than integrating them into the lunch meal (as lunchmeals are often brought by external vendors), it might ex-plain why we did not find an association with vegetablesas fresh fruit snacks might be easier to sell since they re-quire little or no preparation. Lack of significant asso-ciations in middle/high schools may have resulted sinceparticipation in the BCSFVNP is much lower in theseschools. Although the program is equally available to allgrades, more elementary schools than middle/high schoolsparticipate in this program (43% versus 26%, respectively).Participation in the program is free; however, it requiresschools to identify a volunteer to administer and managethe distribution of these food every other week. Therefore,participation might be easier to manage in elementaryschools, as these schools are typically smaller and have lesscomplex schedules. Finally, the difference in associationsbetween elementary and middle/high schools may be re-flective of the fact that the availability of all food andTable 3 Factors associated with availability of fruit, vegetables and pizza/hamburgers/hot dogs in elementary (N = 369)and middle/high schools (N = 118) (Continued)School internal and external influencesInternal and external Support0.21 0.03 1.02 0.08 0.26 -0.54[-0.85; 1.26] [-1.42; 1.48] [-0.43; 2.47 [-1.16; 1.33] [-0.84; 1.36] [-1.66; 0.57]p = .700 p = .969 p = .169 p = .896 p = .643 p = .339CI = Confidence Interval; BCSFVNP = BC School Fruit and Vegetable Nutritional Program; BC = British Columbia;** Significant at p < .01.* Trend towards statistical significance at p < .05.Mâsse and de Niet International Journal of Behavioral Nutrition and Physical Activity 2013, 10:26 Page 8 of 12http://www.ijbnpa.org/content/10/1/26Table 4 Factors associated with availability of chocolate candy, sugar-sweetened beverages, and french fried potatoesin middle/high (N = 118) schoolsAvailabilityof chocolatecandyAvailability of sugar-sweetenedbeveragesAvailability of french friedpotatoesCoefficient Coefficient Coefficient[95% CI] [95% CI] [95% CI]p-value p-value p-valueConstant 4.58 -1.11 -0.80[-0.75; 9.11] [-7.17; 4.96] [-6.82; 5.23]p = .092 p = .720 p = .795School socio-demographic characteristics (Covariates)School size0.10 0.28 0.40[-0.34; 0.53] [-0.19; 0.75] [-0.11; 0.92]p = .654 p = .239 p = .123School settingUrban 1 (reference) 1 (reference) 1 (reference)Suburban-0.50 0.40 0.14[-1.87; 0.87] [-1.20; 2.00] [-1.41; 1.68]p = .474 p = .620 p = .862Rural-1.51 1.44 -0.30[-3.17; 0.15] [-0.40; 3.28] [-2.32; 1.72]p = .074 p = .126 p = .771School characteristicsPolicy institutionalizationDistrictguidelines-0.28 -0.77 0.11[-2.02; 1.47] [-2.58; 1.03] [-1.52; 1.73]p = .756 p = .899 p = .400Schoolguidelines0.56 2.05 -0.36[-2.18; 3.30] [-0.63; 4.72] [-3.26; 2.54]p = .687 p = .133 p = .808Climate0.03 0.55 -0.23[-0.86; 0.92] [-0.36; 1.45] [-1.29; 0.82]p = .947 p = .234 p = .667Capacity & resources - Nutritional resources-0.05 0.19 1.53[-1.38; 1.29] [-1.04; 1.41] [0.08; 2.98]p = .945 p = .766 p = .039*Capacity & resources - ProgramparticipationBCSFVNPNo (reference) 1 (reference) 1 (reference)Yes1.02 0.43 0.32[-0.71; 2.74] [-1.02; 1.88] [-1.28; 1.91]p = .234 p = .552 p = .690BC MilkProgramNo 1 (reference) 1 (reference) 1 (reference)Yes0.19 -0.36 -0.71[-1.12; 1.51] [-1.65; 0.92] [-2.17; 0.75]p = .773 p = .580 p = .343School nutrition practices-0.23 -0.27 -0.22[-0.37; -0.08] [-0.42; -0.11] [-0.40; 0.04]p = .002** p = .001** p = .019*Mâsse and de Niet International Journal of Behavioral Nutrition and Physical Activity 2013, 10:26 Page 9 of 12http://www.ijbnpa.org/content/10/1/26beverages in middle/high schools is markedly higher thanin elementary schools [3]. Furthermore, we found thatelementary schools participating in the BC Milk Programhad more fruit availability. This finding can be explainedby the nutrition environment of elementary schools in BC.Participation in the BC Milk Program requires schools tohave an appropriate refrigeration system. Once they areequipped with such a system, they are in a better positionto store food items. Again, finding an association with fruitmight reflect that it is easier to sell fruit as snackscompared to vegetables. Freshly prepared vegetables re-quire more preparation and appropriate storage whilemany whole fruit do not. Fresh fruit snacks may also bemore appealing than vegetable snacks and are, therefore,more likely to be purchased. This association was onlyobserved in elementary schools and may be explained bythe fact that middle/high schools participate less in theprogram (38% versus 26%, respectively).Finally, we found that middle/high schools that havehealthier nutritional practices aligning with upcomingmandated provincial/state guidelines were less likely tohave chocolate candy, sugar-sweetened beverages, andfrench fried potatoes (although the latter was a trend).Our data was collected 6-months prior to the deadlineat which BC schools were expected to comply with themandated guidelines introduced in 2005. While we donot know whether the schools have changed their envir-onment as a result of the mandated guidelines, limitingavailability of less healthful food and beverages throughpolicy change has been associated with improved dietaryintake in students [42-44]. As policies are increasinglybeing used to modify the school environment, it is im-portant to assess the extent to which schools haveimplemented these guidelines/policies as intended to en-sure decreased availability of less healthful food andbeverages in schools.The findings of this study should be interpreted inlight of the limitations of the study. Firstly, associationswere examined in a cross-sectional sample which pre-cludes us from identifying factors that predict availabilityof food and beverages at schools. Secondly, we did notexamine the extent to which the school environmentalfactors influenced dietary intake as this study focussedon availability as an important first step in ensuring ahealthier nutritional environment. Thirdly, all measureswere assessed with self-report which is known to beassociated with a number of limitations. As many of themeasures were developed or adapted for this study, wehave limited information about the validity of thesemeasures and whether the constructs we used were op-timally operationalized. We evaluated the psychometricproperties of these measures to improve the validity ofour findings; however, future studies should furtherexamine the properties of these measures. Furthermore,the availability of food and beverages was measuredwith an established measure [40]; however, the measuredoes not distinguish whether or not healthier versionswere served. As schools are increasingly encouraged toprovide healthier versions of less healthful food (e.g.,pizza, hamburgers, and hot dogs), future studies areencouraged to incorporate this distinction in theirmeasurement. Lastly, the food environment in publicschools in Canada can vary greatly by province/state aspolicies or mandated guidelines are primarily set at theprovincial/state level. Therefore, our findings may notbe generalized to other provinces/states and countrieswith different structures governing the school foodenvironment.Students have widespread access to less healthful foodand beverages at school. Therefore, there is strong sup-port for developing school food policies/guidelines toinfluence the school environment. The extent to whichschools can implement mandated policies/guidelineswill depend to a certain extent upon factors within theschool environment. This study found three environ-mental factors were associated with the availability ofspecific food/beverage items at school: having more nu-tritional resources, participation in provincial/state nu-tritional programs, and having nutritional practices thatalign with upcoming mandated provincial/state nutri-tional guidelines. As school policies/guidelines are in-creasingly being considered to modify the eatingbehavior of children at school, it is important to gain abetter understanding of the factors associated withTable 4 Factors associated with availability of chocolate candy, sugar-sweetened beverages, and french fried potatoesin middle/high (N = 118) schools (Continued)School internal and external influencesInternal and external Support-1.38 -0.28 -0.11[-2.84; -0.07] [-1.75; 1.19] [-1.80;1.58]p = .063 p = .706 p = .901CI = Confidence Interval; BC = British Columbia; BCSFVNP = BC School Fruit and Vegetable Nutritional Program.** Significant at p < .01.* Trend towards statistical significance at p < .05.Mâsse and de Niet International Journal of Behavioral Nutrition and Physical Activity 2013, 10:26 Page 10 of 12http://www.ijbnpa.org/content/10/1/26availability of certain food/beverage items at school tobetter understand factors that may facilitate attempts tochange the school food environment.Competing interestsNone of the authors have any competing interests.Author’s contributionsLCM contributed to the design, data collection, data analyses, datainterpretation, the drafting of the paper, and main writing to the paper. JEdNcontributed to the data analyses, data interpretation, and drafting sections ofthe paper. All authors have read and approved the final manuscript.AcknowledgementsThis work was conducted with establishment funds from the Michael SmithFoundation for Health Research (MSFHR). Dr. Louise C. Mâsse received salarysupport from the MSFHR (senior scholarship), the Child and Family ResearchInstitute located at the Children’s and Women’s Health Centre of BritishColumbia, and the Sunny Hill foundation. Dr. de Niet received post-doctoralsalary support from the Child and Family Research Institute located at theChildren’s and Women’s Health Centre of British Columbia and the Heartand Stroke Foundation. The authors would like to acknowledge MariaValente and Louis Wong for coordinating the data collection and data entry.Received: 4 August 2012 Accepted: 6 February 2013Published: 19 February 2013References1. 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Am J PublicHealth 2005, 95(3):432–5.doi:10.1186/1479-5868-10-26Cite this article as: Mâsse and de Niet: School nutritional capacity,resources and practices are associated with availability of food/beverage items in schools. International Journal of Behavioral Nutrition andPhysical Activity 2013 10:26.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitMâsse and de Niet International Journal of Behavioral Nutrition and Physical Activity 2013, 10:26 Page 12 of 12http://www.ijbnpa.org/content/10/1/26


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